The problem of painful intercourse (dyspareunia) requires a sensitive and understanding approach by professionals. An accurate diagnosis, with a detailed explanation, and prompt treatment will allay fears, prevent marital disharmony and increase quality of life.
Many women suffer painful intercourse (dyspareunia) on one or two occasions. This information is for those who have a recurring problem with an underlying cause. The aim is to give a comprehensive outline of these causes, to mention the sorts of therapy available and to advise where to seek help.
Most women are unaccustomed to talking about this aspect of life and find it difficult and embarrassing. Consequently individuals may not come forward with their complaint and may simply stop having sexual intercourse. Delay in seeking help has, in the past, led to avoidable breakdown in family relationships.
The causes of painful intercourse can be divided into two groups:
- those which result in pain on penetration (insertion of the penis)
- those giving rise to pain during, and sometimes continuing after, intercourse.
Those conditions responsible for deeper pain during intercourse often result in apprehension about sex. A reflex spasm of the sphincter like muscle in the wall of the vagina, accompanied by lack of secretion, make penetration impossible. Consequently the two groups overlap considerably.
Pain on penetration (superficial dyspareunia)
The causes are usually easily diagnosed following discussion of the symptoms and past events and a simple examination. They seldom require any further tests. Both the woman and her sexual partner will experience pain on intercourse in most of these situations. The causes are:
- lack of vaginal secretions,
- infection in the vulva and vagina,
- spasm in the vagina muscle (called “vaginismus”),
- pain from the scars of giving birth or having had vaginal surgery,
- in rare circumstances, incomplete formation of the vaginal tube.
Lack of vaginal secretions
The excitement phase of the female sexual response is accompanied by release of fluid by the vaginal skin.
Prolongation of this ‘foreplay’ is rewarded by an increase in secretions. However, in the same way as fear leads to a dry mouth, the vaginal fluid is not released unless the woman is relaxed and confident in her love-making.
The vaginal fluid has a role in preventing the ascent of infection through the vagina. Its effectiveness depends on harmless bacteria that promote a mildly acidic environment. These conditions prevent growth of most other microbes. Cervical mucus alters through the normal cycle, being more copious and characteristically ‘stringy’ at the time when eggs are released at mid cycle. Some women learn to use this sign to control their fertility, but it makes little contribution to lubrication.
The amount of vaginal fluid produced varies from person to person, as mentioned before, according to the degree of stimulation and to women’s habits with respect to vaginal hygiene. A fastidious approach to hygiene may paradoxically lead to reduction of anti microbial protection and loss of natural lubrication. For a few days after using vaginal tampons secretions are often reduced.
Women approaching, or after, the menopause (the last period) often suffer from vaginal dryness. The vaginal skin is thinned and produces a reduced amount of fluid, and intercourse may be painful.
In all situations of reduced vaginal secretion the problem is remedied by the use of lubricating agents. Water-based agents (K-Y jelly) are rapidly absorbed and give transient relief from painful intercourse. More effective is Replens, a cream that binds to the skin of the vagina, holding water between its molecules and at the same time increasing anti-bacterial vaginal acidity. Replens is now licensed and can be prescribed for vaginal dryness, itching, irritation and dyspareunia in post menopausal women. It can also be purchased without a prescription from most retail pharmacies.
A long-term answer in menopausal women is the use of hormone replacement in the form of implants, tablets, patches, vaginal creams or pessaries. These medicines are available on prescription. Your general practitioner, family planning clinic or well-woman clinic will be able to advise you on safe treatment.
Infections in the vulva and vagina
1. Candida and trichomonas
The vulva is the area externally surrounding the vagina. Infection with candida (thrush) will cause discharge (typically resembling cottage cheese), inflammation and pain on intercourse. Treatment is with anti-fungal cream or pessaries. If recurrent, the sexual partner, who may not have symptoms, should be treated. Similarly, trichomonas infection causes inflammation and superficial pain on intercourse. The vaginal discharge is usually light green in colour and is frothy.
2. Herpes virus
Herpes infection is manifest as small, extremely painful blisters on the vulva and sometimes around the bladder outlet. Affected individuals should not have sexual contact until the ensuing scabbed over areas have completely healed, as the infection will be passed on. Attacks last for between one and two weeks. Your sexual partner should be checked and you both need to be seen in your local sexually transmitted diseases (STD) clinic. Saline baths may ease the pain and a drug, Acyclovir, may reduce the length of attacks. The disease is often recurrent and the same drug administered to the skin early in an attack can prevent its return.
3. Bartholin’s cysts and abscesses and infected sebaceous cysts
Bartholin’s cyst is a benign (non cancerous) cyst caused by blockage of a gland at the back of the vagina. The resulting swelling is regular and varies in size from pea sized to egg-sized. It becomes very painful when infected. sebaceous cyst is a cyst containing the greasy fluid that keeps skin moist. Blockage leads to a cyst in the skin.
A gland, which produces mucus, and its duct are present in the fold of skin at the back of the vulva. The duct may become blocked and a mucus filled cyst appears. While this is usually not painful, if infection occurs an abscess forms. The operation for a non-infected cyst involves opening up the duct and maintaining drainage through this opening until healing occurs. Dealing with an infected cyst is considered an emergency because of the severity of the pain. Unfortunately, infected cysts often recur, especially if the drainage hole heals over too early. The surgery occasionally results in painful intercourse. Other infected cysts in the area are likely to be sebaceous cysts or boils and a urine test for diabetes should be performed when these are dealt with.
Muscle spasm in the pelvic floor
The vagina has a weak sphincter muscle that is usually relaxed before penetration. If contracted when penetration is attempted, severe pain will prevent insertion of the penis. In extreme cases the inner thigh muscles will not relax. Fears of becoming pregnant, despite contraception, sexual abuse or fear of recurrence of pain experienced during previous sexual intercourse may be responsible. The advice of a specialist in psychosexual medicine is essential. Therapy will be directed at the couple together and includes exploring the cause of anxiety, counselling and understanding of the normal human sexual response.
Pain from the scars of childbirth
There is no evidence of an increased tendency to painful intercourse when episiotomy is done, compared to allowing natural tearing, when assessed at three months after childbirth. Either can heal with a painful scar, a web of tissue towards the back or an area of granulation tissue (see below). Occasionally a cyst may form as a result of trapping surface cells underneath the skin. This is termed an inclusion cyst or an epidermoid cyst.
Ordinarily resumption of sexual intercourse is possible within six weeks of vaginal delivery. Breast-feeding mothers have reduced levels of vaginal fluid and will notice the vagina is drier and less compliant while this method of feeding continues. If pain occurs, artificial lubrication is often helpful. Careful perseverance is recommended as the dilating effect of intercourse itself seems to assist with many problems. Should pain persist, this should be reported at the six-week check and the area examined.
If scar tissue is the problem, special smooth glass dilators will be helpful. These are passed into the vagina several times each morning and evening. They are available in different sizes. Dilation starts with the largest tolerable and continues with small increases in size until intercourse is again painless. A further check-up will be organised.
If a small web of skin forms at the back of the entrance to the vagina, this can be painful. It will usually respond to regular massaging with a well lubricated finger, pushing backwards.
A raised area, sometimes frond-like, that is red and bleeds easily is granulation tissue. If present at six weeks it can be removed by cautery to the surface. The cause is overgrowth of the healing process either in response to low-grade infection or irritation by suture material. A few sessions of treatment may be required to remove it.
Painful intercourse after vaginal operations
Intercourse is usually not recommended until six weeks after vaginal operations to allow healing. Often the surgeon will want to do a check-up at this time. The success of operations performed for prolapse of the vaginal walls or womb depends on tightening the muscles and tissues around the vagina. An inevitable consequence of an effective operation is a narrowing of the vagina. In younger women, and older women who wish to remain capable of intercourse, a compromise can be reached. The desire to retain this function is discussed before the operation, but sometimes slight narrowing is unavoidable. The use of vaginal dilators (see above) will help and, if not totally successful, a small operation can be performed.
Incomplete formation of the vaginal tube
This problem is extremely rare. It varies from the vagina being represented by a shallow pit, to the presence of two vaginal tubes. It includes narrowing of the tube and lumps or cysts in the wall of the vagina. Your general practitioner will be able to tell if the vagina has developed normally. If it has not, the treatment is a very specialised area and you should be referred initially to a consultant gynaecologist. Modern therapy involves giving support to the couple. Often no more than regular perseverance with sexual intercourse will improve or produce a functional vaginal tube. Various plastic surgery operations can fashion a new vagina, (called a “neovagina”).
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