Dyspareunia is a condition that can be defined as a recurrent and (often) unremitting urogenital pain that is observed before, during, or even after penetration (sexual intercourse). It is mostly observed in women and may result in a significant decrease of perceived quality of life.
A multidisciplinary treatment approach that addresses the biological, nutritional and psychological causes is often the only way towards symptom resolution. Using a coordinated group of specialists the patient needs are directly addressed, and improvement is seen in more than three-quarters of affected women.
Since the underlying cause of dyspareunia is often elusive, the clinician should first act to ease the pain for the affected patient. Non-steroidal anti-inflammatory drugs (NSAIDs) usually suffice, as do showers, baths, massages, sleeping or exercise. Topical anesthetics are also sometimes used to alleviate genital pain.
Moreover, the physician should create a “pain prescription” together with the patient, which means they should jointly decide what the woman should do first when the pain kicks in, and when she should consult with her doctor. This is also helpful in making a diary of symptoms, as it brings clues what exactly causes dyspareunia.
If relationship difficulties are considered a fundamental factor in the development of dyspareunia, couples should be encouraged to talk. The lack of improvement in this step usually means that the couple should seek professional help from a couple’s counsellor. In any case, treatment should be individualized to the specific couple and their desires.
A combination of behavioral and penetration desensitization exercises, where the affected woman is encouraged to insert one finger into her vagina, followed by two and three fingers (while at the same time relaxing the lower muscles) has been shown to be quite effective for dyspareunia. Graded vaginal trainers may also be used, but clear instructions are vital for the success of this approach.
If psychosexual problems persevere, the patient should be referred to a psychosexual therapist. Often the basis of the treatment is enabling the women to become more comfortable with her genitals in order to overcome the fear of penetration. Education is also central, and sometimes there is a need for exploration of fantasies.
Specific Treatment Approaches
Couples that present with penetration difficulties due to inadequate lubrication usually try different agents; however, their suitability in achieving satisfactory intercourse can be varied and highly individualized. In general, simple water-based products have been the treatment of choice in such cases.
Antibiotics are prescribed for sexually transmitted infections or infections of the urinary tract, whereas antifungal drugs are given for vaginal yeast infections. If endometriosis is the main culprit, surgical procedure is often the only way to remove anomalous growths of uterine tissue.
Variants of vaginal estrogen creams and different modes of delivery are available for the treatment of moderate and severe dyspareunia caused by vulvovaginal atrophy. However, the question of whether local estrogen usage is safe in cancer survivors must always be taken into account.
Electromyographic biofeedback has also been tried on women with dyspareunia. Evidence from current studies suggests that this technique (together with the pelvic floor training) may significantly reduce pain and sometimes even eliminate the condition altogether. However, success rate have varied significantly, calling for further research.
In conclusion, both the patient and the physician should agree to accept partial improvement and partial gains, as this condition is often a combination of different pathophysiological factors. Those physicians who have all the necessary information about the causes and potential therapies are in the position to effectively and comfortably start a conversation about this frequently neglected issue.