Painful Sex or Dyspareunia

Introduction to Painful Sex or Dyspareunia

Definition: Dyspareunia is pain during sexual intercourse or pain with sexual activity that involves penetration.

Dyspareunia can occur in men and women who are sexually active, regardless of age. The majority of dyspareunia or painful sex is seen in women, but men can suffer with this diagnosis too.

Physiology of Painful Sex or Dyspareunia

When intercourse is painful, our muscles naturally contract to protect from the pain, and in anticipation of pain. This anticipation can lead your nervous system to react with a cascade of events leading to even tighter muscles, vaginal dryness, and loss of lubrication. When this happens, intercourse becomes even less comfortable, resulting in more pain. This becomes a vicious cycle that needs to be broken, which can be done with pelvic physical therapy.

Types of Painful Sex or Dyspareunia (in Women)

1. Superficial Dyspareunia

Pain at the entrance of the vagina during attempted penetration is superficial dyspareunia. Causes of dyspareunia can include:

• Dryness of the vagina, due to inadequate foreplay or hormonal imbalance (as in perimenopausal or breastfeeding women)
• Urinary tract infection (UTI)
• Injuries to the genital area
• Vaginismus
• Vulvodynia, involuntary contraction of the vaginal muscles
• Surgery that narrows the vaginal opening, such as episiotomy and its repair post-childbirth
• Congenital tight hymen

2. Deep Dyspareunia

Pain post-penetration during the thrusting movement is deep dyspareunia. Causes can include:

• Retroverted uterus: normally the uterus tilts forward on the bladder, but it can tilt back, which can cause dyspareunia. This can be surgically corrected if severe.
• Vaginismus
• Pelvic inflammatory disease (PID), an infection of the cervix, uterus, or vagina
• Endometriosis
• Gynecological cancers: ovarian, uterine, and fallopian tube cancers
• Scarring from radiation, chemotherapy, or surgical scars

Diagnosis for Painful Sex or Dyspareunia

Subjective history: The diagnosis depends on the symptoms the patient reports, such as when and where the pain occurs, for example:

• When do you have pain during intercourse? Is it at the entrance of the vaginal opening or during thrusting?
• How long does the pain last?
• Was there ever a time when intercourse was not painful?
• Any history of sexual abuse or genital trauma?
• Any history of sexually transmitted diseases?

Pelvic exam: This may be followed by a gentle but thorough pelvic exam to assess hypersensitivity to touch and any increased inflammation. The pelvic area may be touched with a cotton swab to assess pain and sensitivity externally. The pelvic muscles may be assessed internally by gently inserting a gloved and lubricated finger through the vagina.

Pelvic Physical Therapy for Painful Sex or Dyspareunia

Physical therapy intervention will include:

• Massage techniques and myofascial release
• Relaxation training, with diaphragmatic breathing and reverse Kegels
• Stretching
• Strengthening of weak muscles
• Postural training and coordination of the muscles that support your core

I evaluate the back, hips, and possibly the rib cage region to see if there are any imbalances in those regions contributing to your pain. I also teach self-care techniques for you to use at home, and possibly with your partner. PT is a process that takes patience. If you're wondering how soon you can expect results, read this article on that topic.

Painful Sex or Dyspareunia in Men

Dyspareunia in men is defined by the International Continence Society (ICS) as penile discomfort occurring during intercourse, which may be caused by penile disease, altered vaginal anatomy in a partner (vaginal tightening and scarring), or positions during intercourse that cause impingement of the uterine cervix.

Chronic dyspareunia is recurrent or continuous pain in the pelvic and genital area that occurs during and after sexual intercourse for three months or more. Pain in the penis may be accompanied by a burning sensation.

Psychological causes can include sexual abuse, anxiety, stress, and fear.

Medical causes can include phimosis (tight foreskin), sexually transmitted disease, testicular cancer, tears in the foreskin, Peyronie's disease, and bladder infections or UTIs that cause painful ejaculation.

Conclusion

Painful sex is a common occurrence, but it is not normal. It is treatable, and there is a solution to the problem. Pelvic physical therapy can effectively treat this condition in most cases with success.