Dyspareunia Dr Felicia Molokoane

Introduction Sexual dysfunction manifested by genital pain experienced just before, during or after sexual intercourse. More common in women. It can affect the quality of life Associated symptoms CPP, dysmenorrhoea, tampon discomfort, urinary urgency, IBS

Epidemiology Incidence is unknown

Aetiology Causes are classified depending on onset, frequency, and anatomical site

Onset Primary SECONDARY Onset with the first sexual experience Causes are often psychosocial →sexual abuse in childhood →feeling of guilt or shame towards sex →fear of painful first intercourse SECONDARY The patient had a previous normal sexual function The causes are usually physical

Physical causes of dyspareunia Congenital disorders Imperforate hymen Vaginal septum Abdominopelvic disorders CPP Pelvic endometriosis Vaginal disorders Vaginitis Vaginismus Prolapse GIT Chronic constipation Diverticular disease IBS

Frequency Persistent Conditional Symptoms occur with all partners in all situations Possible causes include physical or psychosocial factors Symptoms occur with certain position, type of stimulation or a specific partner Causes include physical or psychosocial factors

Superficial or insertional Anatomical site Superficial or insertional Deep Sharp, stinging or burning pain at or near the vaginal introitus Commonly found in patients with vulvodynia, vaginismus, or vestibulodynia Pain felt within the pelvis with deep penetration, for example, penile thrusting within the vagina Causes include, pelvic tumours, infections, endometriosis

Conditions commonly associated with deep dyspareunia CPP Any pelvic pain that last for more than 6 months Endometriosis Common symptoms of endometriosis include pelvic pain, dysmenorrhoea, dyspareunia, abnormal bleeding and infertility Majority of women are asymptomatic Chronic PID Can present with pelvic pain or dyspareunia Pelvic adhesions may form as a result of inflammatory processes in the pelvis

Conditions commonly associated with superficial dyspareunia Vulvodynia Unpleasant burning sensation or painful response to stimulus that is not normally painful such as sexual intercourse or touch of cotton wool swab. Physical causes include of vulvodynia include lichen sclerosis, vulval infections and hypoestrogenic states. Vaginismus Physical response of involuntary spasm of the introital muscles to psychological stress. Insertion of the fingers, penis or tampoon are common triggers of the spasm Perineal trauma following childbirth

Examination

Investigation Vaginal swabs Pelvic ultrasound Diagnostic laparoscopy

Management Treatment depends on the cause Psychosexual factors, refer for psychosexual assessment

Medical treatment General measures Systemic or local estrogens Allow sufficient time for arousal and lubrication Avoid some sexual position Watery based or silicone based lubricants Systemic or local estrogens

Surgical treatment Rarely needed Endometriosis→ Excision of the lesion