Sexual Health Counselling - Pain During Intercourse

Dyspareunia – ‘bad or difficult mating’ ie pain assoc. with sexual intercourse- Describes a symptom rather than a disorder- Can happen just before, during or after sex - Physical stimulation of pelvic structures during vaginal intercourse can

lead to pain preventing sexual intercourse. Anxiety and fear increase the perception of pain!!!

- May have a physical or psychogenic (emotional) cause and these may overlap.

- More commonly assoc. in connection w female sexual dysfunction HOWEVER small subset of Male population also suffers from dyspareunia

- Women do not often bring this up in the consult – Swedish Study (uptodate- http://0-www.uptodate.com.library.newcastle.edu.au/contents/differential-diagnosis-of-sexual-pain-in-

women?source=search_result&search=pain+during+intercourse&selectedTitle=1%7E150#H1) reported only 28% of women w a hx of prolonged and severe pain with sex consulted a physician for their symptoms.

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Females - Pain at the vulva, inside vagina or in lower belly

- Don’t Miss:o Malignancies

Frank cervical cancer Vaginal Neoplasia Pelvic tumour – any Vulvar, uterin or ovarian carcinoma

o Ectopic pregnancyo Appendicitis, cholecystitis, diverticulitis IBDo Acute or chronic pyelonephritiso Pelvic abscess secondary to surgery, diverticulitis.o Serious psychogenic causes (inc depression, past traumatic

experiences and others)

- Common causes o Insufficient Foreplayo Vulvar Pain Syndromes

Localised provoked vulvodynia – formerly vestinulodynia Generalised vulvodynia

o Urogenital atrophy Most common cause of dyspareunia in peri and

postmenopausal women Hypo-oestrogenism- Vulvar, vaginal and urinary tract

epithelium express large no. of oestrogen receptors hence are susceptible to decreasing levels of oestrogen that occur w ovarian failure (natural ie menopause, or otherwise). Hypo-oestrogenism causes changes in the vagina and lack

of adequate vaginal lubrication w sexual arousal – both result in dyspareunia.

Mild hypo-oestrogenism – decreased levels of oestrogen are also seen in other conditions and can cause atrophy inc post partum period, breastfeeding, certain meds (low oestrogen OCP, tamoxifen, GnRH agonists and depot medroxyprogesterone acetate- progestin contraceptive) and hypothalamic pituitary disorders.

Unrelated to hypo estrogenic states – in younger women assoc. with inhibited arousal resulting from inadequate foreplay technique, relationship issues, interpersonal conflict, and some meds used to r high BP or depression. Other meds w signif. Effect inc first ge H1 blockers (antihistamines) and anticholinergic agents. Sjogren’s Syndrome.

Other clinical manifestations inc vaginal dryness, burning, pruritis, discharge possible vaginal bleeding.

o Vaginismus Traditionally defined as a ’muscle spasm’ of pelvic floor

muscles surrounding vaginal orifice preventing insertion of an object (penis, digit, instrument) – this definition now being called into question though (see Uptodate).

Primary vaginismus usually related to psychological issue, Secondary vaginismus usually represents a conditioned response to pain from a physical cause or new relationship issues.

o Hypertoncity of local musculatureo Urinary Tract Disease – ask about bladder and urinary symptoms

Interstitial Cystitis (painful bladder syndrome) Cystitis Urethral Diverticulum

o Vulvovaginitis Inflam or irritation around vulva and vagina Common, may cause superficial genital pain during

intercourse. Can be infectious causes eg C albicans or Group B and D

strep or non infectious eg dermitis from contact with bubble baths or perfumed toilet papers.

Common causes inc Candida albicans or Trichomonas vaginalis, dermatitis (common cause for vulvitis)

o Post partum Research suggests 7-10% of women have dyspareunia 12

months post partum Distortion of anatomy, persistent inflamed granulation

tissue or development of a trigger point are poss causes. Rx depends on aetiology.

o Endometriosis Deep dyspareunia is a commo symptom esp if uterosacral

ligaments or rectovaginal septum are involved.

o Pelvic Adhesions o Uterine retroversion

Although a normal position variant of the uterus, some women have pain on deep penile thrusting.

Positional change during coitus is usually helpful Laparoscopic uterine suspension is another possible rx.

o Pelvic organ relapse Usually not a cause of pain – but can cause pain on marked

descent.o Post Op. dyspareunia

Inc hysterectomy and surgery for repair of pelvic relaxationo Leiomyomata

Benign tumours of smooth muscle- think here we are referring to uterine leiomyomatas

Women w leiomyomatas do not have a higher prevalence of dyspareunia than women without these tumours, however in an individual person a leiomyomata can be a source of pain – esp if large and impacted during intercourse.

o Adnexal pathology Eg ovarian cyst Deep dyspareunia usually

o Seminal Plasma allergy Characterised by post coital vulvovaginal itching, burning,

oedema, and erythema w or w/o systemic signs and symptoms (eg dyspnoea, dysphagia, rhinoconjuctival complaints, generalised uticaria, angioedema and more).

Women usually most affected are <40yrs w a fam hax of atopy.

Onset immed or within 1 hr of contact w seminal plasma.o Psychogenic Dyspareunia

Various causes/ ideas behind what causes this, inc sexual abuse, prev painful sexual experience, ‘faulty learning,’ and more.

Described as a hysterical or conversion symptom symbolising an unconscious intrapsychic conflict.

o Dermatological Lichen Planus – (pic from UptoDate)

Most common type of vulvar lichen planus- often involves vagina as well.

Desquamative, erosive, chronic dermatitis

Lichen Scleroisis – (pic from UptoDate) White atrophic papules that may coalesce into

plaques. Labia minora and/or labia majora are most commonly

affected.

Men - Subject to significantly less research than female dyspareunia

o Few long term stat significant studies have been published- Pain in the penis, testis, belly and sometimes rectum.- Prevalence seems to be less but whether this is a reflection of the social

stigma assoc. w male sexual disorders or a true reflection is unknown. o An increase in open discussion regarding sexuality among men in

recent yrs has resulted in larger no. of men discussing dyspareunia w clinicians.

o Suggested prevalence in 2008 in Australia (UptoDate) – 5% of men suffer pain assoc. w sexual intercourse.

- Should always ask patient if pain occurs with non coital sexual activity inc masturbation – an underlying psychological basis should be considered for patients with no pain on masturbation.

- Causeso Main dyspareunia is UNLIKELY to have an INFECTIOUS aetiology.

(from UptoDate – would have thought that it would be MOST COMMON aetiology though??) – I think it is to do with the definition of dyspareunia as being for >/= 3 months in duration – see above.

o Hence perhaps why STIs had been left of the list?? (or perhaps they don’t cause dyspareunia?- think perhaps some don’t cause dyspareunia)

o One way of classifying causes of dyspareunia in men is by x4 broad categories

Isolated painful ejaculation - One of the ejaculatory dysfunctions (can have anejaculation, delayed,

retrograde, premature and painful).- Only ejaculatory condition where PAIN is the main complaint- Incidence in men age >/=50yrs is 1.0-6.7%- Multiple causes see table below inc inflam, surgical, drugs etc- Common presentations inc:

o Penile pain, perineal ache or suprapubic discomfort occurring during or after the ejaculatory period.

o Can be sometimes experienced in testicular or glans area of the penis immed post ejaculation, or result from perineal muscle spasm.

o Atypical pain w ejaculation can also occur in the abdomen, urethral meatus or rectum.

Chronic prostatitis/chronic pelvic pain- Frequently assoc. w male dyspareunia- Both inflam and non inflam conditions of the prostate have been assoc. w

chronic pelvic pain and painful intercourse.- Medical Causes- Peyronie’s Disease

o Formation of inelastic scar or plaque of the turnia auginea that may cause a pathological curvature of the penis and painful eerrections.

o Common cause of dyspareunia in men.- Phimosis

o Leads to inability to retract the foreskin in the uncircumcised male and can cause discomfort w attempted intercourse.

- Frenulum breveo Shortened frenulum which may restrict the glans in the erect stateo Leads to pain w erections and attempts at intercourse.

- Hernia Repair- Pudendal N entrapment - Infections

o STIs- eg gonorrhoea, Herpes Simplex virus.o Infection of prostate, bladder seminal vesicle or urethra

- Interstitial Cystitis o May experience intense pain at moment of ejaculation and w

intercourseo Compression of bladder during intercourse causes pain sufficient

enough to inhibit intercourse.- Dermatological

o Inc STIso Linchen planuso Lichen Sclerosiso Zoon’s (plasma cell) balanitiso Balanoposthitiso Penile carcinoma

- Medicationso Inc antidepressantso Antipsychotics.

Othero Relationship problems (about partner or self)/psychologicalo Anodyspareunia – pain w receptive anal intercourse was found to

occur in MSM in 14% in one study.

Summary Tables Women

Common Don’t MissInsufficient foreplay Malignancy – various, see sheetPost partum Ectopic PregnancyVulvar pain Syndromes A[[emdicitis, cholecystitis,

diverticulitis, IBDUrogenital Atrophy – oestrogen lack (ususally) – very common in peri and post menopausal women

Acute or chronic pyelonephritis

Vaginismus Pelvic Abscess secondary to surgery or diverticulitis

Hypertonicity of local musculature Serious psychogenic causes – eg Depression, past traumatic experiences.

UTI (inc badder infections)Vulovaginitis – inflam of vulva and vagina (can be just vulvitis or vaginitis though) – can be infectious or non infectious causes.EndometriosisPelvic adhesionsUterine retroversionPelvic organ relapsePost opLeomyomata (benign tumour of smooth muscle)Adnexal Pathology – eg ovarian cystSeminal plasma allergyDermatological – common is lichen planus or lichen SclerosisPsychogenic- important, remember problem doesn’t have to be psychogenic OR physiolocial, there can be elements of BOTH (explore both!!)

Men

Isolated Painful ejaculation (one of the ejaculatory dysfunctions)

Incidence - >/= 50yrs is 1.0-6.7%

Inflam – eg urethritis, prostatis, epididymitisMalignancy – eg bladder cnacer, prostate cancerBenign – eg inguinal hernia, vesical calculi, benign prostate hyperplasiaSurgical – eg radical prostatectomy, vasectomy, hernia repairMedications – eg tricyclic antidepressants, SSRIs, MAOIs, AntipsychoticsPsychogenic

Chronic Prostatitis/chronic pelvic pain Frequently assoc. w male dyspareuniaMedical Causes

Peyronie’s Disease (plaques of turnica auginea)PhimosisFrenulum BreveHernia RepairPudendal N entrapmentInfections – STIs, prostate, bladder, urethra or seminal vesicle.Interstitial cystitisDermatological – inc STIs, lichen planusMedications- inc antidepressant and antipsychotics

OtherRelationship ProblemsAnodyspareunia – pain w repective anal intercourse – found to iccur ni MSM in 14% in one UptoDate study.

References - http://0-www.uptodate.com.library.newcastle.edu.au/contents/

dyspareunia-painful-sex-the-basics?source=search_result&search=dyspareunia&selectedTitle=4%7E150

- http://0-www.uptodate.com.library.newcastle.edu.au/contents/ differential-diagnosis-of-sexual-pain-in-women?source=search_result&search=pain+during+intercourse&selectedTitle=1%7E150#H1

- http://0-www.uptodate.com.library.newcastle.edu.au/contents/ approach-to-the-woman-with-sexual-pain?source=search_result&search=pain+during+intercourse&selectedTitle=2%7E150#H1

- http://0-www.uptodate.com.library.newcastle.edu.au/contents/male- dyspareunia?source=search_result&search=pain+during+intercourse&selectedTitle=14%7E150

- Good for malignancies that can be a cause of dyspareunia - http://0-www.mdconsult.com.library.newcastle.edu.au/das/pdxmd/body/444818285-4/1520365327?type=med&eid=9-u1.0-_1_mt_1014319

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