Dyspareunia can be defined as persistent or recurrent pain that occurs with sexual activity, and results in notable distress or even interpersonal altercation. The condition affects up to 40% of women at a certain point during their lifetimes, making it a common problem in quotidian gynecologic practice.
The condition presents with a combination of anatomic, pathologic and emotional factors, thus establishing an adequate diagnosis and choosing the appropriate treatment can be quite challenging.
In the medical literature, dyspareunia is usually classified as superficial or deep. Superficial dyspareunia (also known as entry dyspareunia) is characterized by the occurrence of pain with incipient (or even attempted) penetration of the vaginal introitus, while deep dyspareunia is the occurrence of pain together with deep penetration of the vagina.
Pain in dyspareunia may be observed before entry, during the entry, or after the penis enters the vagina. This is important, as the exact timing of the pain may provide significant clues to the underlying cause of the condition. Studies reveal that the majority of women experience pain during vaginal entry, which may arise due to a plethora of conditions affecting the vestibule or labia.
A history of pain during entry is usually linked to vaginismus (i.e. involuntary muscle contraction around the vaginal opening) and deficient lubrication (often stemming from incomplete arousal). Such pain may also suggest the presence of vulvodynia, atrophy, or some transient entities such as vulvar dystrophy or bacterial/fungal vaginitis.
Careful inspection may reveal fissures and ulcerations that are commonly responsible for sharp pains. Furthermore, herpes simplex virus (HSV) is often seen as a culprit for superficial dyspareunia. On the other hand, tenderness found along the urethra or urinary bladder point to urethritis or urethral syndrome.
In deep dyspareunia, the observed pain is commonly associated with deep thrusts, and often described in lay terms as “being bumped into.” As the vaginal barrel does not elongate and distend during the arousal phase, this may result in substantial discomfort – most notably in certain sexual positions or when the penis comes into contact with the uterine cervix.
The urinary system can also be a source of dyspareunia – not only as tenderness that is characteristic for superficial type of the condition, but also as deep dyspareunia. For example, interstitial cystitis manifests with pain during the filling phase of the bladder. Dyspareunia may be one of the initial symptoms (together with nocturia, urgency, frequency and suprapubic pressure), and then proceed to chronic pain.
Despite the condition being well characterized, there are no consistent features of patients with dyspareunia. One study has shown that higher age and university education can be linked to a lower probability of dyspareunia. Another study has found no association between dyspareunia and age, marital status, parity, race, level of education or income.
In any case, most patients report pain during sexual intercourse, although some women experience pain after coitus. If pain is present before sexual intercourse, it may stem from the vasocongestion occurring during the phase of excitement, or from the irritation of external genitals. In addition, patients presenting with dyspareunia more often report pain during gynecological exam, or when inserting just a digit or a tampon.
- Dor K. Dyspareunia. In: O’Connell TX, Dor K. Instant Work-Ups: A Clinical Guide to Obstetric and Gynecologic Care. Elsevier Health Sciences, 2009; pp. 66-70.
- Graziottin A, Murina F. Clinical Management of Vulvodynia: Tips and Tricks. Springer Science & Business Media, 2011; pp. 15-28.