Sexual Pain

Sexual pain is a discomfort during or after sexual intercourse. It is reported that sexual pain is very common and three out of every four women experience it in lifetime. Worldwide 8-21% women are affected with this problem. This condition can either be a temporary problem or a long term one.

Medically, pain during sexual intercourse is called as ‘dyspareunia’. The reasons behind dyspareunia range from structural problems to psychological issues. Let us see in detail where exactly the pain exists, what are the causes and signs of sexual pain and remedies for it.

What is dyspareunia?

Painful sexual intercourse is clinically known as dyspareunia. In dyspareunia, genital pain is experienced before, during or after sexual intercourse. It can exist anywhere in the genital area‑vagina, vulva (the area surrounding the opening of vagina), clitoris (a small sensitive organ located at the top of the vulva), labia (a lip shaped structure serving as an opening of vulva, surrounding and protecting the clitoris) or lower back region. The patients describe this pain as sharp, pricking, cramping, gnawing or burning. There are many physiological, psychological and social problems that lead to sexual pain.

What are the types of sexual pain?

Pain during sexual intercourse can be categorized as a primary or secondary, as a complete or situational, and as a superficial or deep thrust pain. Let us see what we mean by these types.

Primary or secondary: Primary pain is a pain that is incurable and exists for the woman's entire sexual lifetime. Secondary pain develops after a symptom-free period of time.
Complete or situational: Complete pain means the woman experiences pain in all situations of intercourse. As the name suggests, situational pain occurs in a certain type of stimulation.
Superficial or deep thrust: Superficial pain occurs while penetration. Whereas, deep thrust pain is experienced at the cervix or in the lower abdominal area and experienced during or after penetration.

What are the causes of dyspareunia?

Following are the most common gynecologic conditions that cause pain during sex.

Vaginismus: This is a very common cause of dyspareunia. Vaginismus is a physical or psychological condition in which there are involuntary spasms and tightening of vaginal muscles. It is mainly caused due to feeling of getting hurt. During sexual intercourse, vaginal tightness may cause sexual discomfort, sensations of burning, tightness, pain or inability to penetrate. Identifying the cause of vaginismus is important to decide the mode of treatment.
Insufficient vaginal lubrication or vaginal dryness: This is often reported by breast‑feeding mothers. Insufficient vaginal lubrication or vaginal dryness leads to difficulty in penetration and pain during intercourse.
Vulvodynia: Vulvodynia is a chronic burning pain near vulvar area without any identifiable cause. The exact location and severity of the pain vary highly among patients. Some women experience pain only near area of the vulva (only in the left labia or near the clitoris), while others experience pain in multiple areas (such as labia, vestibule, clitoris, perineum and inner thighs).
Vaginal infections: These include yeast, fungal or bacterial infections in vagina or lower urinary tract infections. In most of the cases they cause superficial pain. Whilst, infections of cervix or pelvic inflammatory diseases cause deeper pain at the time of penetration, as the tissues deep inside become badly inflamed.
Allergic reactions or skin disorders: Certain skin disorders or allergies like contact dermatitis can result in ulcers, rash or cracks in the skin of valve and vagina. Skin allergies near genital area may be due to perfumed soaps, douche product, synthetic undergarments, condoms or lubricants.
Sexually transmitted diseases: These can include genital warts, genital herpes, syphilis or gonorrhea. As a result, the patient experiences striking burning pain during sexual intercourse.
Obstructions: Some of the obstructive disorders such as hemorrhoids, fibroids, endometriosis, ovarian cysts, uterine retroversion (uterus is tilted backward instead of forward) and genital or pelvic tumors can also cause pain during sexual penetration.
Interstitial cystitis: This is a chronic inflammatory bladder condition that causes recurrent pelvic pain, bladder pressure, or mild discomfort in the bladder and pelvic region. In turn leading to dyspareunia.
Injuries: Tissue injuries after trauma to pelvis from injury, surgery or tear from childbirth may cause extreme pain during sexual intercourse.
Hormonal changes: Age related changes associated with menopause are one of the causes of dyspareunia. With menopause, the estrogen levels drop down and vaginal lining loses its normal moisture. As, estrogen deficiency is associated with lubrication inadequacy, it can lead to painful friction during intercourse.
Congenital abnormality: Problems present right from birth such as absence of fully formed vagina or immature hymen can lead to dyspareunia in future.

Other than these gynecologic causes, there are some psychological factors that can adversely affect sexuality and lead to dyspareunia. These factors may include trauma due to sexual assault, emotions such as fear, guilt and awkwardness about having sex, anxiety and depression. Additionally, there are some sexual response problems which can cause sexual pain. These may include relationship problems with partner that lead to stress and fatigue and in turn affect desire to have sex. Many medications like birth control methods, painkillers also reduce sexual desire.

What are the symptoms of dyspareunia?

The patients with dyspareunia describe the pain in many different ways. Hence it is difficult for doctors to diagnose the exact cause of pain. Let us see what are the common signs and symptoms shown by women with dyspareunia.

Pain only during sexual penetration i.e. at the time of entry
Continuous pain while penetration
Deep pain during thrusting
Burning pain or itching
Throbbing pain and cramps for long hours after intercourse

How dyspareunia is diagnosed?

The root cause of dyspareunia is relatively difficult to diagnose as there are varied causes. Also, many a times, patients are unable to describe intensity and exact location of pain. If you have frequent or severe pain during sex, you should see a gynecologist. It is very important to determine if it is a gynecologic problem or psychological cause behind dyspareunia.

The various diagnostic approaches are as follows.

A detailed history of patient is taken to understand the symptoms, severity and cause of pain.
Doctors may perform an extensive physical examination of patient’s pelvic region, abdomen and lower back to understand the anatomy and locate the pain area.
Cotton swab test: If there are no visible findings upon physical examination, a cotton swab test may be performed to assess vulvodynia. During the test, gentle pressure is applied to various vulvar sites with cotton swab and the patient is asked to rate the severity of the pain on a scale of 1 to 10.
Urinalysis: This can be performed to check if urinary tract infection is the cause of dyspareunia.
Pap test: A sample of cells is taken from a woman's cervix or vagina. This test is performed to rule out cancerous cells.
Laparoscopy: This test is useful if endometriosis or adhesions are suspected as the source of pain.
Pelvic ultrasound/ CT scan/ MRI scan: This test gives a clear picture of structure of pelvis.
Urethrogram/ cystogram: These x-ray exams give an image of urinary tract to rule out the infection.
Blood tests: These can be performed to assess levels of estrogen, progesterone and testosterone.

What are the treatment modalities for dyspareunia?

The treatment is based upon underlying root cause. A correct treatment can help eliminate or reduce this problem. The lack of a single etiology for the pain many a times contributes to the diagnostic difficulty. Very few women require medical attention in cases of severe pain. Otherwise the pain subsides on its own.

Following are some self-help measures you can try to relieve pain during sexual intercourse.

In cases of vaginal dryness or lack of lubrication, try water based lubricants or vaginal moisturizers. Do not use petroleum jelly, baby oil, or mineral oil with condoms. They can dissolve the fluid and lead to tearing up of condom.
Talk to your partner. Tell your partner where and when you feel pain and what feels good. Try sexual activities that do not cause pain.
Take pain-relieving steps before sex. These may include emptying your bladder, taking a warm bath, or taking an over-the-counter pain reliever before intercourse.
To relieve burning after intercourse, apply ice or a frozen gel pack wrapped in a small towel on the vulvar area.
Switch to unscented products with fewer ingredients if you suspect allergies
Some individuals may need to resolve issues such as guilt, inner conflicts regarding sex, or feelings regarding past abuse with the help of counselors.
Vaginal relaxation exercises can decrease pain. Your doctor may recommend pelvic floor exercises (Kegel exercises) to decrease pain during intercourse.

Consult your gynecologist if the pain lasts longer and there are symptoms such as bleeding, irregular menstruation or vaginal discharge. Doctors may start with one of the following treatment modes.

If infection is the root cause of dyspareunia, doctors would prescribe antibiotics to eradicate the infection.
In case of vaginal dryness due to menopause, hormone therapy is one of the treatment options. Gynecologists may prescribe estrogen creams which are to be applied directly to the vagina.
Antidepressants and psychotherapy can be of help.
Cognitive behavioral therapy also can be helpful in changing negative thought patterns and behaviors. A sex therapist or counselor can help you address these root psychological causes and work with you to cultivate a healthy and positive sexuality.