Painful Intercourse is known by the term” dyspareunia” (pronounced dis pa roo ne a). Every woman has probably experienced it once or twice in her life, either due to a yeast infection, perhaps after childbirth, or due to vaginal dryness. When intercourse is always painful, even sometimes impossible, and there is no clear identifiable medical cause, women are often made to feel that perhaps the problem is “psychological”. This feeling is even further strengthened by the fact that dyspareunia is considered a mental health, rather than medical diagnosis, as evidenced by the fact that it is listed in the DSM IV psychiatric diagnosis manual.
There is no doubt this condition greatly affects a woman’s psychological state, the relationship with her partner, and her sex life, but whether or not painful intercourse should be considered a sexual dysfunction rather than a pain disorder which affects sexuality (amongst other functions) is under debate. After all, someone with chronic back pain who is unable to work isn’t said to have a work dysfunction. In fact, a group of researchers at McGill University has been working on reclassifying dyspareunia as a painful condition that limits sexual activity, rather than a sexual disorder per se.
The fact remains, however, that more often that not, pain with intercourse has a physiological source. Among the possible medical causes of painful intercourse are vulvar vestibulitis, vulvodynia, and interstitial cystitis. Other causes can be painful stitches after childbirth, pressure on spinal nerves or nerves in the pelvis, such as the pudendal nerve, or hormonal changes leading to vaginal dryness and even narrowing of the vaginal entrance. Tight muscles of the pelvic floor, the muscles inside the vagina that help to control bladder and bowel function and are normally active during sexual excitement, may be a source of pain as well.
{mosbanner:id=1:right:0}Vulvar vestibulitis, named as a disease only in the mid 1980s, is probably one of the most common causes of pain with intercourse. It is a diagnosis based on the patient’s complaint, as well as physical findings, which include pain at certain points along the vestibule (the vaginal “entrance”) when touched with cotton swab. Because the appearance of the vulva is often normal, and because not all gynecologists actually look at or examine the outer vulva, it is a diagnosis that may often be missed.
While the causes of vestibulitis are not well defined, it is understood that multiple systems are involved. These include the pelvic floor muscles, which are often tight and unstable, the vascular system, the nervous system, and the mucosal system. Studies have found a proliferation of both nociceptors (cells which receive pain signals) and mast cells (cells which react to inflammation) in the vestibular tissue. Because the tissues are actually inflammed, women may react to pain by contracting the pelvic floor, a condition know as pelvic floor hypertonus. Overly contracted pelvic floor muscles perpetuate the painful condition by preventing healing and making attempted intercourse even more painful.
Vulvodynia, of which vulvar vestibulitis is a subset, refers to vulvar pain, which is often chronic and unremitting. Interstitial cystitis is a condition of urinary urgency, frequency and bladder and pelvic pain, of which dyspareunia is often a feature. Vaginismus is defined as a condition whereby vaginal penetration is prevented by “spasm of the outer two thirds of the vagina” although presence of muscle spasm has never actually been substantiated.
Patients who present with a great deal of anxiety regarding penetration, are unable to insert a finger or a tampon, or undergo a gynecological exam are often given this diagnosis. While vaginismus has historically been treated almost exclusively by sex therapists and may exist as an isolated condition, it is now understood in many cases to be a secondary reaction to the presence of primary vestibulitis.
