Dyspareunia

Dyspareunia (painful sexual intercourse) often can be resolved, even when long-standing, self-perpetuating pain is a factor. This article is about dyspareunia in women.

Clinicians should consider dyspareunia to be primarily a physical, rather than an emotional, problem until proven otherwise. In most instances of dyspareunia, there is an original physical cause. Among many African women, dyspareunia results from the damage caused by female genital mutilation.

When pain occurs, the woman may be distracted from feeling pleasure and excitement. Both vaginal lubrication and vaginal dilation decrease. When the vagina is dry and undilated, penile thrusting is painful. Even after the original source of pain (a healing episiotomy, for example) has disappeared, a woman may feel pain simply because she expects pain. In brief, dyspareunia can be classified by the time elapsed since the woman first felt it:

• During the first 2 weeks or so, dyspareunia caused by penile insertion or movement of the penis in the vagina or by deep penetration is often due to disease or injury deep within the pelvis.
• After the first 2 weeks or so, the original cause of dyspareunia may still exist with the woman still experiencing the resultant pain. Or it may have disappeared, but the woman has anticipatory pain associated with a dry, tight vagina.

Dyspareunia is treated by the taking following steps:

• Carefully taking a history.
• 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.
• Removing the source of pain when possible.
• Prescribing very large amounts of water-soluble sexual or surgical lubricant during intercourse. Discourage petroleum jelly. Moisturizing skin lotion may be recommended as an alternative lubricant, unless the patient is using a condom or other latex product. Lubricant should be liberally applied (2 tablespoons full) to both the penis and vulva or introitus. A folded bath towel under the woman's hips helps prevent spillage on bedclothes.
• Instructing the woman to take the penis in her hand and control insertion herself rather than letting the man do it.
• 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. Such activities tend to increase both natural lubrication and vaginal dilation, both of which decrease friction and pain.
• Recommending a change in coital position to one admitting less penetration for women who have pain on deep penetration because of pelvic injury or disease:
  • Maximum penile penetration is achieved when the woman lies on her back with her pelvis rolled up off the bed, compressing her thighs tightly against her chest with her calves over the man's shoulders. Minimal penetration occurs when the woman lies on her back with her legs extended flat on the bed and close together while her partner's legs straddle hers.
  • If no vaginal penetration is tolerable, the couple may substitute interfemoral intercourse, in which the woman lies with her legs straight and her ankles locked (crossed). A triangular space between the upper thighs and vulva permits stimulation of both vulva and penis.

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The original text for this article is taken from the public domain CDC document at http://www.cdc.gov/nccdphp/drh/Africa_pdf/Chap_10.pdf