Dyspareunia, pain during sexual intercourse, may have many causes and lead to physical and psychological sexual problems. Treatment targets the cause.
Symptoms
Intercourse may cause superficial pain in the vulval area or deep pain in the vagina and the pelvic floor.
Pain may be experienced throughout intercourse, or pain and a burning sensation may occur after intercourse. Pain may be sufficient to prevent intercourse altogether.
A careful examination of the external genitalia, and a gynaecological examination, should be performed to identify the site of pain.
If infection is suspected, samples and laboratory tests are indicated as well as a cervical smear test.
Sexual violence and non-gynaecological causes should be eliminated through a careful history.
Treatment
According to cause
Infections and skin conditions are treated according to the causative organism. Lichen sclerosus and lichen planus are treated with a strong corticosteroid cream.
The management of vulvodynia consists of prophylactic treatment against yeast infection, temporarily stopping oral contraceptives, medication to increase the pain threshold and surgery if necessary.
The muscular tightness of the pelvic floor associated with vaginismus can be improved with physiotherapy.
An attempt should be made to remove any keloid scarring of the vagina and vulva.
Dryness and atrophy of the mucous membranes are associated with either the use of oral contraceptives or menopause.
A different contraceptive pill may be tried or the medication stopped for a while, lubricating creams may also be tried and, if necessary, topical oestrogen products.
In menopause, topical oestriol vaginal cream or vaginal suppositories (over the counter products) or oestradiol vaginal tablets or ring (either over the counter or with prescription). Lubricants may be used to facilitate penetration.
Some condoms may irritate the mucous membranes, and a different make should be tried. Latex allergy may become manifest for the first time in association with condom use.
The treatment in endometriosis or adenomyosis is hormonal or surgical. Deep endometriosis lesions, either behind the uterus or in the rectovaginal space, often cause deep vaginal pain during intercourse; surgical removal of the lesions will improve the condition.