Sexual Pain Disorder

Definition
Dyspareunia refers to pain in the pelvic area during or after sexual intercourse. This can occur in both men and women.
Vaginismus refers to an involuntary spasm of the musculature surrounding the vagina causing it to close, resulting in penetration being difficult and painful, or impossible.
Symptoms
Postmenopausal women and those on medications that produce a general drying effect on body secretions are at particular risk for dyspareunia. Other causes in women include vaginal infections, cystitis or urethritis, orthopedic problems, and chronic constipation.
The most common causes of pain during male ejaculation are prostatitis and urethritis. This is often associated with a recent reduction in frequency of sexual activity. Pain occurring while obtaining an erection may be associated with inflammation of the foreskin, trauma to the penis, infections, genital allergies, or Peyronie's disease.
Difficulty or the inability to allow vaginal penetration for intercourse is the primary symptom of vaginismus. Vaginal pain during intercourse or pelvic exams is common.
Causes
Aggressive or impatient partner
Premature lovemaking following surgery (episiotomy) or childbirth
Menopause, due to decreased levels of female hormones (vaginal lining loses its normal moisture and becomes dry)
Hemorrhoids
Genitourinary tract infections (such as a bladder infection)
Vulvar vestibulitis (inflammation of the vestibule of the vagina—the area of the perineum between the labia minora including the opening of the vagina and the urethra) is among the most common causes of dyspareunia in women, and is commonly overlooked
Herpes sores (see genital herpes)
It is believed that dyspareunia is caused by physiological factors at least 75 percent to 80 percent of the time. Pain at entry that decreases over time is commonly caused by inadequate lubrication. This is oftentimes due to lack of sexual arousal and effective stimulation, and sometimes due to medication that decreases vaginal lubrication (such as antihistamines).
Psychological factors are infrequently involved and will most commonly be associated with feelings of guilt, negative attitudes toward sex, or previous sexual trauma.
Vaginismus, which only occurs in less than 2 percent of women, is considered a sexual dysfunction. It is a complex condition with several possible causes: past sexual trauma or other psychological factors, or a long history of discomfort with sexual intercourse related to another disorder. Sometimes no cause can be determined.
Women with varying degrees of vaginismus often develop anxiety regarding penetration, and intercourse is generally painful. However, this does not mean that these women cannot achieve or sustain sexual arousal. Many are very sexually responsive and may achieve orgasms through clitoral stimulation. Women with vaginismus may enjoy sexual contact as long as vaginal penetration is avoided.
Complications
Vaginismus is a common cause of female sexual dysfunction that may lead to serious dissatisfaction in intimate relationships, including unconsummated marriages. It can also lead to male erectile dysfunction after repeated unsuccessful attempts at intercourse
Treatment
The nature of treatment and outcome of dyspareunia depends on the cause of the pain.
Women
For painful intercourse in women after pregnancy, gentleness and patience should be exercised. Wait at least three weeks after childbirth before resuming sexual relations.
For painful intercourse in menopausal women, use lubricants and estrogen-containing creams or medications as prescribed.
For painful intercourse caused by endometriosis, medications can be obtained. Surgery, which might give total relief, may also be an option.
For painful intercourse due to other complications, disease, or psychological factors, see your health care provider. Vulvar vestibulitis may be very successfully treated with surgical intervention.
Men
For painful intercourse caused by penile skin infections, use antibiotics as prescribed.
For painful intercourse caused by herpes, follow your health care provider's advice.
For painful intercourse caused by prostatitis, sitz baths provide some soothing. Avoid alcohol and caffeine. Antibiotics, as prescribed by the doctor, will help fight infection. Prostatitis and urethritis can be quite successfully treated.
When no organic cause of the pain can be found, and the cause is suspected to be psychological, sex therapy may prove helpful.
What To Expect
Your medical history will be obtained and a physical examination performed.
Detailed medical history questions documenting difficulty with intercourse may include:
When did it develop?
Is intercourse painful every time that it is attempted?
Has it always been painful?
Is it painful for your spouse, also?
Where is the pain? (Labia, vagina, entire pelvic area?)
What are your attitudes towards sex?
Does the pain occur during entry?
Has there been a significant traumatic event in the past (rape, child abuse, or similar)?
What illnesses, diseases, and disorders are being treated?
What medications are being taken?
Has there been a significant emotional event recently?
What have you done to try to make intercourse less painful?
How well has it worked?
What other symptoms are present?
Unless the problem is clearly caused by one person's physical issues, the couple involved should see the doctor together. Physical examination may include a pelvic exam (for women), a prostate exam (for men), and a rectal exam. If a physical problem is suspected, tests will be ordered. Antimicrobial or anti-inflammatory medications may be administered.
Prevention
Good hygiene and routine medical care will help to some extent. Adequate foreplay and stimulation will aid in ensuring proper lubrication of the vagina. The use of a water-soluble lubricant like K-Y Jelly may also help. Vaseline should not be used as a sexual lubricant since it is not water-soluble and may encourage vaginal infections.
Treatment of Vaginismus
Dyspareunia inhibits sexual interest as well as responsiveness. In some situations vaginismus may occur, causing the vaginal muscles to involuntarily contract and clamp down as a self-protective way of avoiding the anticipated discomfort.
The treatment of choice with vaginismus is an extensive therapy program combining education and counseling with behavioral exercises. Exercises include pelvic floor muscle contraction and relaxation (Kegel exercises) to improve voluntary control.
Vaginal dilation exercises are recommended using plastic dilators, and should be done under the direction of a sex therapist or other health care provider. Treatment should involve the partner. This should include gradually more intimate contact culminating in intercourse.
Educational treatment should provide information about sexual anatomy, physiology, the sexual response cycle, and common myths about sex.
Prognosis
When treated by a specialist in sex therapy, success rates are usually very high
Sources:
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders
Aurora Healthcare Dyspareunia Fact Page
American Family Physician: Evaluation and differential diagnosis of dyspareunia
Griffith's 5-Minute Clinical Consult, Lippincott Williams & Wilkins
Kistner's Gynecology & Women's Health A comparison of urinary and sexual outcomes in women experiencing vaginal and Caesarean births
National Institutes of Health - National Library of Medicine. Medical management of endometriosis-associated pain