Dyspareunia

Dyspareunia is broadly defined as painful intercourse - a neglected female health problem that is very common. The prevalence of this condition depends on the which underlying cause is associated with it as most studies pertain to the condition causing the Dyspareunia versus just Dyspareunia itself. In a study among primary care practices where the condition was defined as ‘pain during or after intercourse’ the percentage of women suffering was 46%; but as many as 60% experience dyspareunia at some point in their life.

The signs and symptoms associated with Dyspareunia are often difficult to diagnose and treat. Complex etiological factors lead to poor diagnosis and patients' adherence to the treatment plans. (Mitchell et al., 2017)

It can further be characterized as deep or superficial, primary or secondary. Superficial Dyspareunia is associated with the vaginal entrance or Vulva, while deep means the pain extends to the lower pelvis or vagina. The Pain of the Secondary Dyspareunia initiates after the painless Intercourse activity, while the Primary Dyspareunia pain starts right at the time of Sexual activity.

Dyspareunia vs Vulvodynia

Dyspareunia It is often confused with the Vulvodynia, the pain of the genital area lasting longer than 3 months, including or excluding the association with sexual intercourse. Dyspareunia can also be caused as a result of skin conditions associated with vulvas infection like Lichen Sclerosis, Urinary Tract Infections UTIs, Vulvovaginal, Sexually transmitted infections STI's and Endometriosis. Both Dyspareunia and Vulvodynia also leads to sexual abnormalities including deficiency of arousal and sexual desire, creating multiple ambiguities in sexual relationships. However, the difference between these conditions is that Dyspareunia encompasses conditions outside of the Vulva such as pelvic pain or pain caused due to psychological factors.

Symptoms of Dyspareunia

Symptoms associated with Dyspareunia often get intermixed with other health conditions. The pain duration, location, intensity, and psychological factors play a vital role in confirming the diagnosis. Pain can occur under the following circumstances or in the follow areas:

Bladder, Urethra, Or Vagina
During or after intercourse
Upon initial penetration (e.g. tampon or penis)
Deep In Pelvis for example during thrusting
After intercourse (even if the pain was not apparent during sex)
Additional itching, burning, or aching
Cramping that mimics a menstrual cramp

The Burning pain links to Vulvodynia, Vaginitis, inadequate lubrication, or Vaginal Atrophy for example, while the deep aches can be caused by conditions such as Pelvic Congestion-Syndrome, Endometriosis, Pelvic Inflammatory Diseases and more.

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Causes of Dyspareunia

The causes of Dyspareunia include a wide variety of conditions including inflammatory, infectious, traumatic, structural deformities, hormonal, and psychological experiences.

Causes of Pain Upon Vaginal Entry

The most common physical causes associated with Dyspareunia are often experienced upon entry and include the following;

Hormonal changes or medications which can cause vaginal dryness such as post-menopause, postpartum, breastfeeding, birth control pills and other medications or NSAIDs
Infections including Yeast Infection or Urinary Tract Infections (UTIs)
Trauma from childbirth including Episiotomy or perineal tears or scarring from forceps delivery
Pelvic Organ Prolapse – Bladder, Rectum, or Uterus prolapsing into the vagina
Vaginal Atrophy - thinning, drying, and inflammation of vaginal walls caused by a lack of estrogen (often caused after menopause and labelled “genitourinary syndrome of menopause (GSM)”)
Vulvodynia (Vulvar vestibulitis) – chronic pain or discomfort at the vula (vaginal opening)
Vaginitis - the inflammation of the vagina
Vaginismus - a spontaneous rigidity/ tightening of the vaginal wall muscles
Congenital abnormalities – absence of a fully formed vagina (vaginal agenesis) or a blockage of the vaginal opening (imperforate hymen)
Lack of arousal
Skin and Dermatological disorders like eczema, lichen sclerosis, lichen planus, and psoriasis cause inflammation of the vaginal mucosa
Hymeneal remnants – a remnant tissue outside of the vagina left after embryonic developmen.

Some causes of deeper pain during penetration:

Surgeries or scarring caused by hysterectomy (removal of the uterus) or pelvic surgeries
Uterine Prolapse
Retroverted Uterus – Uterus is tipped backwards towards rectum
Uterine Fibroids
Pudendal Neuralgia
Pelvic inflammatory disease (PID)
Cystitis – inflammation of the bladder
Endometriosis – tissues that lines the uterus grows outside of it
Ovarian Cysts
Irritable bowel syndrome (IBS)
Radiation or chemotherapy

Emotional or psychological factors that can cause Dyspareunia:

The Factors which reduce sexual desires or do affect any person’s capacity of becoming aroused can also be caused by dyspareunia. These factors are following:

Vaginismus – fear of penetration that causes the vaginal opening to close as the muscles tighten ·
Anxiety & stress, which can result in pelvic floor muscle tightening
Regret, fear, guilt, shame related to sexual activity
Negative self-image or other body issues
Medications like birth control pills or NSAIDs which may decrease sex drive
Sexual or relationship issues
Health conditions such as cancer, diabetes, arthritis, and the thyroid disease
History of any sexual abuse

How Pelvic Physiotherapy can help manage the symptoms of dyspareunia

Pelvic Physiotherapy Assessment

Pelvic Physiotherapists assess pelvic floor muscle strength and condition, positioning of the the pelvic organs, evaluate scar tissues, measure prolapse, and assess other functional damages associated with the vagina, rectum, bladder, uterus, and for men, the prostate. Remember it is important to also get a full medical assessment by a doctor as well in case there are other underlying causes of your painful intercourse. Physiotherapy focuses on the muscles of the pelvic floor whereas a medical assessment can also look at ovaries, uterus, family history, and other organs outside Pelvic Floor Muslces.

**Birth trauma and postpartum**

A Pelvic Physiotherapist can help you heal scar tissue from tears or episiotomy and reduce symptoms such as prolapse.

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Follow-Up Physiotherapy Appointments

Pelvic Floor Physiotherapy serves as a perfect treatment option for Dyspareunia as it can be used to treat many of the underlying causes of pain including Pelvic Organ Prolapse, tight pelvic muscles, Vulvodynia, Vaginismus, persistent pelvic pain, episiotomy or childbirth scarring, vagina, and more. Physiotherapy can train the Pelvic Floor Muscles to relax helping to re-train the pain receptors.

Pelvic Floor Physiotherapists can help (or teach you how to) perform Perineal Massage as a way to relax muscles, or break down vaginal scar tissue to reduce the tenderness and pain caused by dyspareunia. One of the perineal massages is termed as ‘’Thiele massage’’ . Pelvic Floor Physiotherapy is also accessible as it does not require a referral from your physician, wait times are short, and there are limited to no risks. Pelvic floor physiotherapy is often accessible under corporate benefits plans as it is a registered service in Canada.

Counselling and Mental Health Support

In the cause of emotional or psychological causes, Cognitive Behavioral Therapy helps to reduce depression, anxiety, and fear related to dyspareunia. Trauma or body image centered counselling depending on the cause of the anxiety. Sexual Desensitization Therapy can also help fear centric dyspareunia as an individual is gradually introduced to intercourse.

For more mild cases of anxiety, working on your relationship with your sexual partner including communication with your partner or other mental health relaxation techniques from meditation to warm bathing before intercourse. Sexual Therapy or Couples Therapy is also a treatment option.

Lubrication

A natural way to increase lubrication is through gentle vulva stimulation (fourplay) to increase blood flow to the vaginal in advance of penetration. Or, you can purchase over-the-counter natural lubricants to improve pleasure during sexual activities.

If your lubrication issue is caused by lack of estrogen then hormone replacement therapy can be explored. If it is caused from a medication you are on (e.g. birth control or antidepressants, you might want to seek an alternative).

Natural Remedies and Alternative Therapies

Applying ice to the vulvar region to calm burning or inflammation can help. Taking a bath before intercourse to relax the pelvic muscles. Emptying your bladder before intercourse to reduce pressure on the pelvis. Kegel Exercises can help if prolapse is causing the discomfort.

A glimpse into what working with a doctor looks like

Pelvic Examination

This involves examination by your doctor (not a physiotherapist). They look at your vulva and internal reproductive organs including your ovaries, cervix, vagina, fallopian tubes, and uterus. In the external portion of the examination the doctor looks at your vulva and vaginal opening for skin irritations, infections, abnormal discharge, vaginal warts, and cysts. For the internal portion of the examination, a speculum might be used to separate the vaginal walls (which can be uncomfortable). The bimanual portion of the exam is where the doctor will place their finger into your vagina while pressing on your lower abdomen to check for abnormalities within the uterus, ovaries, and fallopian tubes. Lastly, the rectovaginal examination is done by putting a finger in your rectum to check the muscles between your vagina and rectum.

Ultrasounds

At times a doctor will want to investigate structural abnormalities such as fibroids, cysts, or endometrial hyperplasia by performing a transvaginal examination.

The treatment of Dyspareunia requires a multimodal approach of treatment ranging in emotional, physical, and behavioral domains. This treatment approach should consist of a Gnecologist, Physical Therapist, Mental Health Counsellors, and your family physician. (Tayyeb & Gupta, 2021)

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Dyspareunia (Painful Intercourse) - Symptoms, Causes, and Treatment