Dyspareunia ( ) is painful

sexual intercourse Sexual intercourse (also coitus or copulation) is a sexual activity typically involving the insertion of the Erection, erect male Human penis, penis inside the female vagina and followed by Pelvic thrust, thrusting motions for sexual pleasure ...

due to somatic or psychological causes. The term ''dyspareunia'' covers both female dyspareunia and male dyspareunia, but many discussions that use the term without further specification concern the female type, which is more common than the male type. In females, the pain can primarily be on the external surface of the

genitalia A sex organ, also known as a reproductive organ, is a part of an organism that is involved in sexual reproduction. Sex organs constitute the primary sex characteristics of an organism. Sex organs are responsible for producing and transporting ...

, or deeper in the pelvis upon deep pressure against the

cervix The cervix (: cervices) or cervix uteri is a dynamic fibromuscular sexual organ of the female reproductive system that connects the vagina with the uterine cavity. The human female cervix has been documented anatomically since at least the time ...

. Medically, dyspareunia is a pelvic floor dysfunction and is frequently underdiagnosed. It can affect a small portion of the vulva or vagina or be felt all over the surface. Understanding the duration, location, and nature of the pain is important in identifying the causes of the pain. Numerous physical, psychological, and social or relationship causes can contribute to pain during sexual encounters. Commonly, multiple underlying causes contribute to the pain. The pain can be acquired or

congenital A birth defect is an abnormal condition that is present at childbirth, birth, regardless of its cause. Birth defects may result in disability, disabilities that may be physical disability, physical, intellectual disability, intellectual, or dev ...

. Symptoms of dyspareunia may also occur after menopause. Diagnosis is typically by

physical examination In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a Disease, medical condition. It generally consists of a series of ...

and

medical history The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is a set of information the physicians collect over medical interviews. It involves the patient, and ev ...

. Underlying causes determine treatment. Many patients experience relief when physical causes are identified and treated. In 2020, dyspareunia has been estimated to globally affect 35% of women at some point in their lives.

Signs and symptoms

Those who experience pelvic pain upon attempted vaginal intercourse describe their pain in many ways. This reflects how many different and overlapping causes there are for dyspareunia. The location, nature, and time course of the pain help to understand potential causes and treatments. Human female inner genitalia 2

Some describe superficial pain at the opening of the vagina or surface of the genitalia when penetration is initiated. Others feel deeper pain in the vault of the vagina or deep within the pelvis upon deeper penetration. Some feel pain in more than one of these places. Determining whether the pain is more superficial or deep is important in understanding what may be causing the pain. Some patients have always experienced pain with intercourse from their very first attempt, while others begin to feel pain with intercourse after an injury or infection or cyclically with menstruation. Sometimes the pain increases over time. Pain may distract from feeling pleasure and excitement. Both

vaginal lubrication Vaginal lubrication is a naturally produced fluid that lubricates the vagina. Vaginal lubrication production increases significantly during sexual arousal in anticipation of sexual intercourse. Vaginal dryness is the condition in which this lub ...

and vaginal dilation decrease. When the vagina is dry and undilated, penetration is more painful. Fear of being in pain can make the discomfort worse. Pain may continue despite the original source being removed, due to the learned expectation of pain. Fear, avoidance, and psychological distress around attempting intercourse can become large parts of the experience of dyspareunia. Physical examination of the vulva (external genitalia) may reveal clear reasons for pain including lesions, thin skin, ulcerations or discharge associated with vulvovaginal infections or vaginal atrophy. An internal pelvic exam may also reveal physical reasons for pain including lesions on the cervix or anatomic variation. When there are no visible findings on vulvar exam that would suggest a cause for superficial dyspareunia, a cotton-swab test may be performed. This is a test to assess for localized provoked vulvodynia. A cotton tip applicator is applied at several points around the opening of the vagina; the patient reports the resulting pain on a scale from 0–10.

Causes

Dyspareunia in women

The cause of the pain may be anatomic or physiologic, including but not limited to lesions of the vagina, retroversion of the uterus, urinary tract infection, lack of lubrication, scar tissue, abnormal growths, or tender pelvic sites. Some cases may be psychosomatic, which can include fear of pain or injury, feelings of guilt or shame, ignorance of sexual anatomy and physiology, and fear of pregnancy. Common causes for discomfort on vaginal penetration include: #

Infections An infection is the invasion of tissue (biology), tissues by pathogens, their multiplication, and the reaction of host (biology), host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmis ...

. Infections that mostly affect the labia,

vagina In mammals and other animals, the vagina (: vaginas or vaginae) is the elastic, muscular sex organ, reproductive organ of the female genital tract. In humans, it extends from the vulval vestibule to the cervix (neck of the uterus). The #Vag ...

, or lower urinary tract like

yeast infections Candidiasis is a fungal infection due to any species of the genus '' Candida'' (a yeast). When it affects the mouth, in some countries it is commonly called thrush. Signs and symptoms include white patches on the tongue or other areas of the ...

chlamydia Chlamydia, or more specifically a chlamydia infection, is a sexually transmitted infection caused by the bacterium ''Chlamydia trachomatis''. Most people who are infected have no symptoms. When symptoms do appear, they may occur only several w ...

trichomoniasis Trichomoniasis (trich) is an infectious disease caused by the parasite ''Trichomonas vaginalis''. About 70% of affected people do not have symptoms when infected. When symptoms occur, they typically begin 5 to 28 days after exposure. Symptoms ca ...

urinary tract infection A urinary tract infection (UTI) is an infection that affects a part of the urinary tract. Lower urinary tract infections may involve the bladder (cystitis) or urethra (urethritis) while upper urinary tract infections affect the kidney (pyel ...

s, or

herpes Herpes simplex, often known simply as herpes, is a viral infection caused by the herpes simplex virus. Herpes infections are categorized by the area of the body that is infected. The two major types of herpes are oral herpes and genital herp ...

tend to cause more superficial pain. Infections of the

, or

fallopian tube The fallopian tubes, also known as uterine tubes, oviducts or salpinges (: salpinx), are paired tubular sex organs in the human female body that stretch from the Ovary, ovaries to the uterus. The fallopian tubes are part of the female reproduct ...

s like

pelvic inflammatory disease Pelvic inflammatory disease (PID), also known as pelvic inflammatory disorder, is an infection of the upper part of the female reproductive system, mainly the uterus, fallopian tubes, and ovaries, and inside of the pelvis. Often, there may be no ...

tend to cause deeper pain. # Cancer of the reproductive tract, including the ovaries, cervix, uterus, or vagina. # Tissue Injury. Pain after trauma to the pelvis from injury, surgery or

childbirth Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy, where one or more Fetus, fetuses exits the Womb, internal environment of the mother via vaginal delivery or caesarean section and becomes a newborn to ...

. # Anatomic variations. Hymenal remnants, tight hymenal ring, vaginal septa, thickened undilatable hymen,

hypoplasia Hypoplasia (; adjective form ''hypoplastic'') is underdevelopment or incomplete development of a tissue or organ.introitus,

retroverted uterus A retroverted uterus (tilted uterus, tipped uterus) is a uterus that is oriented posteriorly, towards the rectum in the back of the body. This is in contrast to the typical uterus, which is oriented forward (slightly "Anteversion, anteverted") t ...

or uterine prolapse can contribute to discomfort. # Hormonal causes: #*

Endometriosis Endometriosis is a disease in which Tissue (biology), tissue similar to the endometrium, the lining of the uterus, grows in other places in the body, outside the uterus. It occurs in women and a limited number of other female mammals. Endomet ...

and

adenomyosis Adenomyosis is a medical condition characterized by the growth of cells that proliferate on the inside of the uterus (endometrium) atypically located among the cells of the uterine wall (myometrium), as a result, thickening of the uterus occurs. ...

Estrogen Estrogen (also spelled oestrogen in British English; see spelling differences) is a category of sex hormone responsible for the development and regulation of the female reproductive system and secondary sex characteristics. There are three ...

deficiency is a particularly common cause of sexual pain complaints related to vaginal atrophy among postmenopausal patients, and may be a result of similar changes in menstruating patients on hormonal birth control. Estrogen deficiency is associated with

lubrication Lubrication is the process or technique of using a lubricant to reduce friction and wear and tear in a contact between two surfaces. The study of lubrication is a discipline in the field of tribology. Lubrication mechanisms such as fluid-lubr ...

inadequacy, which can lead to painful friction during intercourse. Vaginal dryness is often also reported alongside lactation. Patients undergoing radiation therapy for pelvic malignancy often experience severe dyspareunia due to the atrophy of the vaginal walls and their susceptibility to trauma. # Pelvic masses, including

ovarian cyst An ovarian cyst is a fluid-filled sac within the ovary. They usually cause no symptoms, but occasionally they may produce bloating, lower abdominal pain, or lower back pain. The majority of cysts are harmless. If the cyst either #Cyst rupture, br ...

tumor A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...

s, and uterine fibroids can cause deep pain. # Pain from bladder irritation: Dyspareunia is a symptom of

interstitial cystitis Interstitial cystitis (IC), a type of bladder pain syndrome (BPS), is chronic pain in the Urinary bladder, bladder and pelvic floor of unknown cause. Symptoms include urinary urgency, feeling the need to urinate right away, urinary frequency, ...

(IC). Patients may struggle with

bladder The bladder () is a hollow organ in humans and other vertebrates that stores urine from the kidneys. In placental mammals, urine enters the bladder via the ureters and exits via the urethra during urination. In humans, the bladder is a distens ...

pain and discomfort during or after sex. For an IC patient with a penis, pain occurs at the moment of ejaculation and is focused at the tip of the penis. If the IC patient has a vagina, pain usually occurs the following day and is the result of painful, spasming pelvic floor muscles. Interstitial cystitis patients also struggle with urinary frequency and/or urinary urgency. # Vulvodynia: Vulvodynia is a

diagnosis of exclusion A diagnosis of exclusion or by exclusion (''per exclusionem'') is a diagnosis of a medical condition reached by a process of elimination, which may be necessary if presence cannot be established with complete confidence from history, examination o ...

involving either generalized or localized vulvar pain most often described as burning without physical evidence of other causes on exam. Pain can be constant or only when provoked (as with intercourse). Localized provoked vulvodynia is the most recent terminology for what used to be called vulvar vestibulitis when the pain is localized to the vaginal opening. # Conditions that affect the surface of the vulva including LSEA (lichen sclerosus et atrophicus), or xerosis (dryness, especially after the

menopause Menopause, also known as the climacteric, is the time when Menstruation, menstrual periods permanently stop, marking the end of the Human reproduction, reproductive stage for the female human. It typically occurs between the ages of 45 and 5 ...

). Vaginal dryness is sometimes seen in Sjögren's syndrome, an autoimmune disorder that characteristically attacks the exocrine glands that produce saliva and tears. # Muscular dysfunction: For example,

levator ani The levator ani is a broad, thin muscle group, situated on either side of the pelvis. It is formed from three muscle components: the pubococcygeus, the iliococcygeus, and the puborectalis. It is attached to the inner surface of each side of the ...

myalgia Myalgia or muscle pain is a painful sensation evolving from muscle tissue. It is a symptom of many diseases. The most common cause of acute myalgia is the overuse of a muscle or group of muscles; another likely cause is viral infection, espec ...

# Psychological, such as vaginismus. Most vaginal pain disorders were officially discovered or coined during a time when rape was more normalized than it is now (marital rape was criminalized in all 50 US states in only 1993). Some in the medical community are now starting to take into account factors like rape/sexual assault/ fear of rape/sexual harassment as strong enough psychological stressors to cause such pain disorders.

Dyspareunia in men

There are a number of physical factors that may cause sexual discomfort. Pain is sometimes experienced in the testicular or glans area of the

penis A penis (; : penises or penes) is a sex organ through which male and hermaphrodite animals expel semen during copulation (zoology), copulation, and through which male placental mammals and marsupials also Urination, urinate. The term ''pen ...

immediately after

ejaculation Ejaculation is the discharge of semen (the ''ejaculate''; normally containing sperm) from the penis through the urethra. It is the final stage and natural objective of male sexual stimulation, and an essential component of natural conception. ...

. Infections of the

prostate The prostate is an male accessory gland, accessory gland of the male reproductive system and a muscle-driven mechanical switch between urination and ejaculation. It is found in all male mammals. It differs between species anatomically, chemica ...

, bladder, or seminal vesicles can lead to intense burning or itching sensations following ejaculation. Patients with

may experience intense penis pain at the moment of ejaculation.

Gonorrhea Gonorrhoea or gonorrhea, colloquially known as the clap, is a sexually transmitted infection (STI) caused by the bacterium ''Neisseria gonorrhoeae''. Infection may involve the genitals, mouth, or rectum. Gonorrhea is spread through sexual c ...

l infections are sometimes associated with burning or sharp penile pains during ejaculation. Urethritis or prostatitis can make genital stimulation painful or uncomfortable. Anatomic deformities of the penis, such as exist in Peyronie's disease, may also result in pain during coitus. One cause of painful intercourse is due to the painful retraction of a too-tight

foreskin In male Human body, human anatomy, the foreskin, also known as the prepuce (), is the double-layered fold of Human skin, skin, Mucous membrane, mucosal and Muscle tissue, muscular tissue at the distal end of the human penis that covers the glans ...

, occurring either during the first attempt at intercourse or subsequent to tightening or

scar A scar (or scar tissue) is an area of fibrosis, fibrous tissue that replaces normal skin after an injury. Scars result from the biological process of wound repair in the skin, as well as in other Organ (anatomy), organs, and biological tissue, t ...

ring following inflammation or local infection. Another cause of painful intercourse is due to tension in a short and slender frenulum, frenulum breve, as the foreskin retracts on entry to the vagina irrespective of lubrication. In one study frenulum breve was found in 50% of patients who presented with dyspareunia. During vigorous or deep or tight intercourse or masturbation, small tears may occur in the preputial frenulum and can bleed and be very painful and induce anxiety, which can become chronic if left unresolved. If stretching fails to ease the condition, and uncomfortable levels of tension remain, a frenuloplasty procedure may be recommended. Frenuloplasty is an effective procedure, with a high chance of avoiding circumcision, giving good functional results and patient satisfaction. The psychological effects of these conditions, while little understood, are real, and are visible in literature and art.

Diagnosis

Differential diagnosis

Dyspareunia is a condition that has many causes and is not a diagnosis of itself. It is combined with vaginismus into genito-pelvic pain/penetration disorder in the

DSM-5 The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the '' Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiat ...

. Criteria for genito-pelvic pain/penetration disorder include multiple episodes of difficulty with vaginal penetration, pain associated with intercourse attempts, anticipation of pain due to attempted intercourse, and tensing of the pelvis in response to attempted penetration. To meet criteria for this disorder, a patient must experience the symptoms for at least six months and experience "significant distress". The differential diagnosis for dyspareunia is long because of its complicated and multifactorial nature. Often there are physiologic conditions underlying the pain, as well as psychosocial components that must be assessed to find appropriate treatment. A differential diagnosis of underlying physical causes can be guided by whether the pain is deep or superficial: # Superficial dyspareunia or vulvar pain: infection, inflammation, anatomic causes, tissue destruction, psychosocial factors, muscular dysfunction # Superficial dyspareunia without visible exam findings: When no other physical cause is found the diagnosis of vulvodynia should be considered. Vaginal atrophy may also not be seen clearly on exam but commonly affects postmenopausal patients and is generally associated with

estrogen Estrogen (also spelled oestrogen in British English; see spelling differences) is a category of sex hormone responsible for the development and regulation of the female reproductive system and secondary sex characteristics. There are three ...

deficiency. # Deep dyspareunia or pelvic pain:

endometriosis Endometriosis is a disease in which Tissue (biology), tissue similar to the endometrium, the lining of the uterus, grows in other places in the body, outside the uterus. It occurs in women and a limited number of other female mammals. Endomet ...

s, pelvic adhesions, inflammatory diseases (interstitial cystitis, pelvic inflammatory disease), infections, congestion, psychosocial factors,

Treatment

The treatment for pain with intercourse depends on what is causing the pain. After proper diagnosis one or more treatments for specific causes may be necessary. For example: * For pain due to yeast or fungal infections, a clinician may prescribe mycogen cream (nystatin and triamcinolone acetonide), which treats both a yeast infection and associated painful inflammation and itching because it contains both an antifungal and a steroid. * For pain that is likely due to post-menopausal vaginal dryness, estrogen treatment can be used. * For patients with diagnostic criteria for endometriosis, medications or surgery are possible options. In addition, the following may reduce discomfort with intercourse: * Clearly explain to the patient what has happened, including identifying sites and causes of pain. Make clear that the pain, in almost all cases, disappears over time, or at least greatly lessens. If there is a partner, explain the causes and treatment and encourage them to be supportive. * Encourage the patient to learn about her body, explore her own anatomy and learn how she likes to be caressed and touched. * Encourage the couple to add pleasant, sexually exciting experiences to their regular interactions, such as bathing together (in which the primary goal is not cleanliness), or mutual caressing without intercourse. Such activities tend to increase both natural

and vaginal dilation, both of which decrease friction and pain. Prior to intercourse, oral sex may relax and lubricate the vagina (provided both partners are comfortable with it). * For those who have pain on deep penetration because of pelvic injury or disease, recommend a change in coital position to one with less penetration, such as missionary position. A device has also been described for limiting penetration. * Recommend water-soluble sexual or surgical lubricant during intercourse. Discourage

petroleum jelly Petroleum jelly, petrolatum (), white petrolatum, soft paraffin, or multi-hydrocarbon, CAS number 8009-03-8, is a semi-solid mixture of hydrocarbons (with carbon numbers mainly higher than 25), originally promoted as a topical ointment for i ...

. Lubricant should be liberally applied (two tablespoons full) to both the penis and the orifice. A folded bath towel under the receiving partner's hips helps prevent spillage on bedclothes. * Instruct the receiving partner to take the penis of the penetrating partner in their hand and control insertion themselves, rather than let the penetrating partner do it.

History

Etymology

The word ''dyspareunia'' comes from

Greek Greek may refer to: Anything of, from, or related to Greece, a country in Southern Europe: *Greeks, an ethnic group *Greek language, a branch of the Indo-European language family **Proto-Greek language, the assumed last common ancestor of all kno ...

δυσ-, ''dys-'' 'bad' and πάρευνος, ''pareunos'' 'bedfellow', meaning 'badly mated'.

Classification

The previous ''Diagnostic and Statistical Manual of Mental Disorders'', the ''

DSM-IV The ''Diagnostic and Statistical Manual of Mental Disorders'' (''DSM''; latest edition: ''DSM-5-TR'', published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a com ...

'', stated that the diagnosis of dyspareunia is made when the patient complains of recurrent or persistent genital pain before, during, or after sexual intercourse that is not caused exclusively by lack of

or by vaginal spasm (vaginismus). After the text revision of the fourth edition of the DSM, a debate arose, with arguments to recategorize dyspareunia as a pain disorder instead of a sex disorder, with Charles Allen Moser, a physician, arguing for the removal of dyspareunia from the manual altogether. The most recent version, the DSM 5, has grouped dyspareunia under the diagnosis of Genito-Pelvic Pain/Penetration Disorder.

References

* ''The original text for this article is taken from a

public domain The public domain (PD) consists of all the creative work to which no Exclusive exclusive intellectual property rights apply. Those rights may have expired, been forfeited, expressly Waiver, waived, or may be inapplicable. Because no one holds ...

CDC documen
PDF
.

External links

{{Authority control Noninflammatory disorders of female genital tract Sexual dysfunctions Pain