Pain during sex (Dyspareunia)

Dyspareunia is persistent or recurrent pain in intimate areas during sexual intercourse or any sexual activity that involves penetration. This is commonly seen in women, though rarely, symptoms have also been reported in males.

Sexual life is an important aspect of a person’s life, which is influenced by the physical, social, and psychological well being of an individual, as well as that of their partner. Sometimes, it is difficult to identify the exact cause, which makes it even harder to treat. These causes are not properly understood and are often complex in nature. To date, all studies related to painful sex have been conducted on small groups, which do not include the vast majority of unreported cases of women. Hence, such studies do not represent the entire population. It has been reported that female sexual disorders are more prevalent in well-educated women between 26- 30 years of age.

The types of dyspareunia are:

• Primary dyspareunia
  This occurs due to anatomical defects or problems of the reproductive organs and is experienced during penetration. It may occur due to conditions like genital herpes simplex infection, birth defects, narrowing of the opening of the vagina, vaginal tissue breakdown.
• Secondary dyspareunia
  This type is associated with diseases of the pelvis and is accompanied by pain during the act of deep thrusting. This is usually seen in certain conditions of the uterus like fibroids, endometriosis or disorders of the ovaries. 
• Superficial dyspareunia
  In superficial dyspareunia, there is a pain in and around the vaginal opening while having sex. (Read more: Vaginal pain causes and treatment)
• Deep dyspareunia
  Deep dyspareunia is when the pain is experienced deep in the pelvic region while having sex. It is usually felt in the uterus or cervix. It may even linger for hours after sexual intercourse.

Pain during sexual intercourse is the primary symptom. It may be accompanied by:

• Burning, tearing, and ripping sensations during sex.
• Pain in the vagina or any region of the pelvis. (Read more: Pelvic pain causes)
• Pain during the time of penetration or thrusting.

Such sensations may reduce sexual arousal and pleasure during intimacy.

Causes

The cause of dyspareunia depends on the type of pain, whether it is superficial or deep.

Dyspareunia in women

• Superficial pain
  • Insufficient lubrication
    One of the reasons for painful sexual intercourse is that the vagina secretes an inadequate amount of fluids needed for lubrication. Due to insufficient lubrication, the vagina feels dry and hence, penetration is painful. This occurs due to inadequate foreplay. With advancing age, the oestrogen levels in women begin to fall, which may cause the lining of the vagina to become dry and thin. Even during breastfeeding, the vagina feels dry due to a fall in oestrogen levels.
  • Medications
    Use of medicines for allergies, high blood pressure, sedatives, and birth control pills can produce side effects, making the vagina dry that can make sexual intercourse a painful experience.
  • Increased sensitivity
    Heightened sensitivity of the genitals to pain. Vaginismus, an involuntary contraction of the muscles of the vagina may also lead to painful penetration.
  • Infection and trauma
    Genital herpes or an infection of the Bartholin glands (small glands situated on either side of the vaginal opening), and inflammation (swelling) and infection of the urinary tract may cause painful intercourse. Even skin conditions like eczema (contact dermatitis) around the genitals may lead to dyspareunia. Use of vaginal washes, douches, and perfumed soaps can also lead to irritation, burning, and pain in the genital area. Injuries to genital organs from accidents and surgery, like the incision made during delivery (known as episiotomy) can also cause pain during sex. Conditions like vulvodynia (pain around the vulva) is a common cause of painful sex. (Read more: Tips on keeping your vagina healthy)
  • Allergies
    Allergies to jellies or other types of contraceptive foams and creams or latex condoms can make intercourse painful.
  • Birth defects
    Birth defects, also known as congenital anomalies, such as a partition within the vagina, an incomplete formation of the vagina or a membrane blocking the opening of the vagina (imperforate hymen) may result in painful sex.
• Deep pain
  Deep pain is experienced during deep penetration. Pain may be aggravated in certain conditions like:
  • Illnesses
    Conditions like sexually transmitted diseases, fibroids, cysts, tumours, prolapse of the uterus (when a part of the uterus sags into the vagina leading to pain), endometriosis (growth of the lining of the uterus in other organs such as fallopian tubes and ovaries), pelvic inflammatory disease (infections of the cervix, fallopian tubes cause pain while intercourse), irritable bowel syndrome (increased sensitivity and swelling of the bowel), piles, and retroverted uterus (backward bend of the uterus) can lead to extreme pain during and/or after sexual intercourse.
  • Treatment or surgical procedures
    Scars that form as a result of surgical procedures can result in adhesions, or after radiation treatment for cancers of the pelvic region like those of the uterus, bladder, and kidney can also lead to painful intercourse.
  • Psychological causes
    Factors like depression, anxiety, guilt, shame, awkwardness, worries about one’s physical appearance, intimacy and relationship or marital problems can lead to low libido causing pain during sex. Sexual problems of the partner too can make you anxious during sex, leading to pain. A simple mismatch between the desired level of sex can lead to altered sexual responses in women, making intercourse painful. Women who have undergone surgery might have an altered body image which reduces their desire for sex. Some medical conditions like cancer, arthritis, diabetes and thyroid diseases alter sexual responses, making sex painful. (Read more: How to increase libido)
  • Stress and emotional problems
    During stressful states, the muscles on the floor of the pelvis respond and get tightened. This leads to pain during intercourse. (Read more: Ways to reduce stress)
  • History of sexual abuse
    Emotions play a big role in intimacy. Pain while having sexual intercourse is influenced by negative emotional memories. A history of sexual abuse such as rape, other traumatic sexual experiences, anger towards partner may trigger pain. Sexual intercourse without consent is also known to cause pain.

Dyspareunia in men

In males, painful sex can be triggered by:

• Allergies causing irritation of the penis.
• Tight foreskin.
• Structural abnormalities of the penis.
• Diseases of the prostate gland or testes.
• Sexual abuse.

Risk factors

Factors that can increase the chances of painful sex include:

• Age
  Painful sex is common in younger women, where almost half of the young females have known to have experienced painful first intercourse. Severe painful sex is more common in menopausal and postmenopausal women. (Read more: Tips for the first time you have sex)
• Illnesses
  In some individuals, the presence of a certain disease may lead to difficulties with arousal, leading to painful sex. Illnesses like erectile dysfunction, diabetes, and heart diseases in men also increase the risk of painful sex. (Read more: Low libido in men causes)

Dyspareunia can be prevented by:

• Maintaining proper hygiene before sexual intercourse. (Read more: Things to do before and after sex)
• Practising safe sex to prevent sexually transmitted infections.
• Using water-based lubrication jellies. Avoid the use of petroleum jelly, as it is not water-soluble and can lead to vaginal infections.
• Resuming sexual intercourse at least six weeks after delivery. Use of lubricants is recommended as hormonal changes may lead to dryness of the vagina. (Read more: Sex after pregnancy)
• Good communication with the partner in general and about each other’s thoughts on sex.
• An adequate foreplay that helps in a sufficient lubrication of the vagina before penetration.

Diagnosis of dyspareunia is made by:

• Medical history
  The doctor will ask for a detailed medical history of the individual where he/she will inquire about the onset of pain, location, intensity, and sexual position. In the case of multiple sexual partners, the doctor will ask if the pain occurs with every partner. The doctor will also ask about the history of surgical procedures, illnesses, previous sexual history, drug allergies, contraceptive use, and obstetric history. It is best not to be embarrassed while answering these questions and answer honestly without hiding details, as the answers will give clues to the cause of pain.
• Pelvic examination
  The doctor will examine the genital area of the patient to check for signs of inflammation, infection or any anatomical defects. He/she may also apply pressure to the genital area to locate the area of pain. An instrument called a speculum may be used to examine the vagina. Women who complain of painful sex may often not be able to bear even light pressure during a pelvic exam. If such is the case, you should request the doctor to stop the examination at this point. A rectal examination may also be performed.
• Investigations
  If the doctor finds an abnormality or an infection near the genital area, they may obtain a small tissue sample for further evaluation. A pelvic ultrasound may also be advised to look for other causes of painful sexual intercourse. Other special tests like a hysteroscopy or a laparoscopy may be recommended at the doctor’s discretion to confirm any deeper medical conditions like endometriosis. A laparoscopy is a test where a lighted camera fitted on a thin tube is inserted through a small cut made on the skin of the abdomen to look for internal medical conditions that are not diagnosable through an external test or examination. In a hysteroscopy, a lighted camera is passed into the uterus to look for abnormalities. 

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Treatment of dyspareunia depends on the cause and may include:

Medications

• Antibiotics, antifungals or specific medications may be advised for infections that may be causing painful sex. Specific treatment may be advised depending upon the cause.
• If the cause is vaginal dryness after menopause, topical vaginal creams containing oestrogen in the form of a tablet or a ring may be given. Hormonal replacement therapy may also be advised. Drugs that might be causing the dryness or reduced sexual responses leading to pain will be either replaced, stopped or their dosage will be lowered.

Surgery

Surgical correction is recommended for cysts, abscesses, and physical defects that are correctable.

Non-medical treatment

• Vaginal relaxation exercises like Kegels help to relieve pain.
• To improve intimacy issues, visiting a sexual health counsellor can be beneficial. It can help couples communicate better with each other.
• Sexual counselling helps to relieve negative emotions from the past that might be causing the pain.
• Cognitive behavioural therapy can also help to change one’s thought patterns regarding sexual intercourse.

Lifestyle management

• Couples should find ways to achieve sexual pleasure mutually. This can be achieved in ways like oral stimulation, stimulation involving hands or the use of a vibrator.
• To reduce superficial pain, use of an anaesthetic ointment or sitz baths can be of great help.
• Use sufficient amounts of lubricating jelly before having intercourse. It is better to use water-based lubricants instead of petroleum jelly as the latter can make the vagina dry and may damage condoms, diaphragms, and other contraceptive devices. Petroleum jelly is also known to increase the growth of yeast infections. Remember to read the labels on the products before purchasing. (Read more: Vaginal yeast infection symptoms)
• Increase the duration of foreplay. Prolonged foreplay helps to stimulate the release of oestrogen in the body, thus resulting in proper lubrication, good arousal, and reduced pain during penetration. Indulge in different positions during intercourse for better control of penetration and thrust. (Read more: Tips to make sex life better and fun)

Prognosis

Outcomes of dyspareunia depend on the cause. Each case needs to be investigated thoroughly before beginning the course of treatment. In general, medical treatment helps in most cases. Although treatment can extend for several months, as seen in persons with previous sexual trauma, such people learn to enjoy their sexual life after a complete cure. If there is a physical cause leading to painful sex, it can be treated with proper medical attention.

Complications

Dyspareunia does not lead to major complications. More often, the sex life of the individual, as well as of their partner, gets disturbed and they are unable to speak to a specialist or a therapist due to embarrassment or social stigma. Lowered quality of life is the most important complication of painful sex and can strain the relationship with the partner significantly.