Dispareunia; quando il rapporto sessuale fa male.

Dyspareunia (pronounced dis-par-oo-nee-ar) is the medical term for difficult/painful sexual intercourse. This condition affects 10-20% women at some point in their lives. Women don’t often come forward with this problem to clinicians due to feelings of embarrassment and therefore, avoid examination, remaining undiagnosed and untreated.

Unfortunately, it is also true that many clinicians in primary care, and often in secondary care are not sufficiently experienced in the management of dyspareunia. Sexual intercourse isn’t something that should be painful for women. We asked our gynaecologist Mr Paul Carter about dyspareunia, how to tackle it and what causes it in the first place.

There are two types of dyspareunia: superficial (pain on penetration) and deep (pain in the pelvis).

Superficial dyspareunia is associated with discomfort and pain around the vulva on penetration during intercourse. This discomfort usually goes away once intercourse has stopped. Women who suffer from this are likely to have a history of thrush, genital herpes or another dermatological condition.

Deep dyspareunia is experienced as discomfort/pain deep within the pelvis or the lower abdomen that can persist for a variable time after sexual intercourse. There may be a history of previous pelvic inflammatory disease ( chlamydia, gonorrhoea) or endometriosis interna ( adenomyosis ) or externa (outside the uterus) in women with deep dyspareunia.

What causes dyspareunia?

There are different causes in pre-menopausal and post-menopausal women.

Pre-menopausal causes

Post-menopausal causes

How is dyspareunia investigated?

Upon clinical examination, to test for superficial dyspareunia, your gynaecologist will take a microbiological swab, do a vulval biopsy and may perform a colposcopy (a procedure to closely look at the vagina, vulva and cervix if abnormal cells are found in the cervix). They will look for signs of infection, inflammation and abnormalities in the vulva and look at vulval tenderness when pressure is introduced (allodynia). Some people suffer from allodynia, a feature of many painful conditions, whereby extreme pain can be felt from stimuli that don’t normally cause pain, like a slight touch. This condition can cause them to feel much pain during intercourse.

While investigating deep dyspareunia, your gynaecologist will see if there is extreme pain when moving the cervix from side to side (cervical excitation) and will look at pelvic tenderness. Reduced mobility of the pelvic organs and pelvic mass (such as an ovarian cyst, (endometriosis) or hydrosalpinx (blocked fallopian tube), might be causing deep dyspareunia. A swab test, ultra-sound scan and laparoscopy can be used when investigating deep dyspareunia.

How is dyspareunia treated?

Superficial dyspareunia can be treated with:

• Lubrication
• Local anaesthetic ointment
• Soap substitutes, to avoid aggravating the vagina and vulva
• Topical steroids
• Topical oestrogen (if post-menopausal)
• Psychosexual counselling

Surgery is a last resort, in extreme cases where the opening of the vagina is too narrow. In cases of deep dyspareunia, where the underlying cause is endometriosis or pelvic inflammatory disease, these conditions will be addressed first.

What does the future look like after diagnosis?

In most cases, women respond well to treatment. In pre-menopausal women, the symptoms often resolve, sometimes even spontaneously. The more persistent cases may need further evaluation, and psycho-sexual counselling and discussion can greatly help on the road to recovery.

If you suffer from a form of dyspareunia and would like help and support, contact our gynaecologist Mr Paul Carter.