Sexual pain can have various biological and medical causes, and psychological and sexual factors affect the experience of pain.
In addition to patient history, a gynaecological examination is important for differential diagnosis.
Sexual pain may be due to vulvodynia or vaginism, for example.
Treatment should focus on the underlying cause of the pain, and it should be multiprofessional.
Sexual pain differs from other chronic pain in that it must usually be shared with the partner or partners.
Provision of factual information on the disorder and its treatment is usually a great relief for the patient, who may already have seen several doctors.
Classification and causes of pain
Female sexual pain can be divided into:
pain associated with penetration in intercourse
genital or pelvic pain after touching the genital area
fear of genital or pelvic pain and associated anxiety
Based on anatomical structures, the pain can be divided into external genital pain, vaginal pain and dyspareunia occurring deep in the pelvic floor; see Dyspareunia in Women.
Diagnosis
As pain may be associated with many diseases or disorders, careful history taking is important.
Diseases, medication, infections, dermatological diseases and any childbirth or surgery
Female sexual arousal disorder also causes and increases sexual pain Female Sexual Disorders. In female sexual arousal disorder, response to sexual stimuli is absent, and increased blood flow to and lubrication of the genital area does not protect the woman from friction associated with penetration, for instance. Female sexual arousal disorder may be due not only to biological causes involving the genital area but also to relationship problems, mental factors or underlying trauma.
The most common cause of sexual pain in the external genitals is vulvodynia. To make the diagnosis, other causes of pain in the genital area must be excluded.
Vulvodynia can be classified further, with vestibulodynia occurring at the vestibule to the vagina being more common in younger age groups.
Its exact aetiology is unknown but some triggering factors have been suggested, such as starting to use low-dose combination-type contraceptive pills at a young age or prolonged candidiasis or UTI.
A typical clinical finding is cutting, smarting or burning pain reported by the patient at the vaginal orifice (at 5-7 and 11-1 o'clock) on even gentle examination with a moistened cotton-tipped swab.
The pain nearly invariably causes pelvic muscle dysfunction.
Vaginism is defined as continuous or recurring difficulty in allowing the insertion of a penis, a finger or an object the woman wants to insert into her vagina.
There is often an underlying psychosomatic fear associated with sexuality and intercourse.
There may sometimes be an aversion, i.e. actual disgust towards sexuality.
Treatment concentrates on the fear-induced avoidance reaction and any associated issues.
Treatment
Treatment should focus on the underlying cause.
It is essential to have a multiprofessional team cooperating at various stages of treatment; this may include, in addition to a physician, a sexual counsellor and therapist, dermatologist, physiotherapist and possibly a psychotherapist.
In the treatment of vulvodynia, pausing combination-type contraception, even prolonged prophylaxis of candidiasis, as necessary, and topical or systemic medication for the treatment of neuropathic pain may be helpful Vulvodynia.
Sexual counselling and sexual therapy, as necessary, will help the patient to relinquish the fear of pain, facilitating a connection between body and mind.
Trauma therapy is needed if underlying sexual or other violence is revealed.
Correctly timed pelvic floor physiotherapy is essentially important.
References
Parish SJ, Cottler-Casanova S, Clayton AH et al. The Evolution of the Female Sexual Disorder/Dysfunction Definitions, Nomenclature, and Classifications: A Review of DSM, ICSM, ISSWSH, and ICD. Sex Med Rev 2021;9(1):36-56. [PubMed]