157 Dyspareunia (302.76)

DSM-IV-TR criteria

• A. Recurrent or persistent genital pain associated with sexual intercourse in either a male or female
• B. The disturbance causes marked distress or interpersonal difficulty.
• C. The disturbance is not caused exclusively by Vaginismus or lack of lubrication, is not better accounted for by another Axis I disorder (except another Sexual Dysfunction), and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
• Specify type:
  • Lifelong Type
  • Acquired Type
• Specify type:
  • Generalized Type
  • Situational Type
• Specify:
  • Due to Psychological Factors
  • Due to Combined Factors

Associated Features

• A person with dyspareunia experiences pain in the genital area before, during or after sexual intercourse. The nature, duration, and intensity of the pain may vary across individuals, but is most often experienced during sexual intercourse.
• The most reported type of pain is superficial pain which occurs upon penetration.

Child vs. adult presentation

This occurs in sexually active individuals and is not normally seen in children.

Gender and cultural differences in presentation

• Men can have this disorder, however, it is very rare. When men do have it, it is almost always due to a medical condition.
• Estimates of the prevalence of male dyspareunia are sparse but appear to affect 3% to 5% of men in Western countries and 10% to 12% of men in the Middle East and Southeast Asia.
• A study of 404 gay men reported a prevalence rate of approximately 14% anodyspareunia from receptive anal sex, with the majority experiencing it lifelong. A significant proportion of men found it highly distressing, and, as a result, it led to avoidance of sexual activity or restricting activity to insertive anal sex.

Epidemiology

• In a survey of 329 women in 1993 at a gynecological clinic it was found that 7.7% of women experienced painful intercourse on most or all occasions. There is very little data on the prevalence of this disorder in men. However, studies have shown that when this disorder exists in men, it is usually caused by a medical problem.
• 60% of women experience genital pain before, during, or after intercourse at some point. However, the location and frequency varies among women.

Etiology

There are several causes of dyspareunia. There are entry pain causes. These would include inadequate lubrication, injury, trauma, or irritation. This could be due to a pelvic surgery or a female circumcision. Another cause could be inflammation, infection, or skin disorder, such as eczema. Also, allergic reactions to birth control products, such as latex could be the cause. Also, an improper fit of a diaphragm can cause pain. Vaginismus can also be a cause, which is involuntary muscle spasms of the vagina. Finally, vestibulitis is unexplained stinging or burning around opening of vagina can cause entry pains associated with dyspareunia. There are also deep pains that are caused by illnesses, infections and surgeries or medical treatments. These could include pelvic inflammatory disease, uterine prolapse, infections in the uterus or Fallopian tubes, and complications from hysterectomies. There are also emotional causes that could include psychological factors, stress, and history of sexual abuse. Specifically, these could include fear of intimacy and depression. Also, pelvic floor muscles are very sensitive to stress, so this could be a factor. This being caused by a history of sexual abuse is not very common although it can be a factor.

Empirically supported treatments

• Carefully examining the pelvis to duplicate as closely as possible the discomfort and to identify a site or source of the pelvic pain.
• Clearly explaining to the patient what has happened, including identifying the sites and causes of pain. Making clear that the pain will, in almost all cases, disappear over the time or at least will be greatly reduced. If there is a partner, explaining him also the causes and treatment and encouraging him to be supportive.
• Encouraging the couple to add pleasant, sexually exciting experiences to their regular interactions, such as bathing together (in which the primary goal is not cleanliness), mutual caressing without intercourse, and using sexual books and pictures.
• Prescribing very large amounts of water-soluble sexual or surgical lubricant during intercourse.
• A manual physical therapy (Wurn Technique) which treats pelvic and vaginal adhesions and micro adhesions may decrease or eliminate intercourse pain.
• Reducing use of scented bath products can help, because they can irritate the genital area.
• Kegal exercises for relaxation of the vaginal muscles also can help.
• Instructing the receiving partner to take the phallus of the penetrating partner in their hand and control insertion themselves, so that they are in control.