Dyspareunia: Insertional

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Chapter 70 Dyspareunia: Insertional

INTRODUCTION

Description: Pain that occurs with sexual penetration is considered to be insertional dyspareunia. This may be in the form of mild discomfort that may be tolerated, pain that completely prevents intromission, or any level of pain in between. In severe cases, pain may lead to severe vaginal spasms that interfere with penetration (vaginismus).

Prevalence: Roughly 15% of women each year (severe—less than 2% of women).

Predominant Age: Reproductive and beyond.

Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Congenital factors (duplication of the vagina, hymenal stenosis, vaginal agenesis, vaginal septum), cystitis (acute or chronic), hemorrhoids, inadequate lubrication (abuse [current or past], arousal disorders, insufficient foreplay, medication, phobias), pelvic (levator) muscle spasm, pelvic scarring (episiotomy, surgical repairs [colporrhaphy]), proctitis, trauma (acute or chronic sequelae), urethral diverticula, urethral syndrome, urethritis (bacterial or chlamydial), vaginismus, vulvar (atrophic vulvitis, chancroid, chemical irritation [deodorants, adjuncts, lubricants]), herpes vulvitis, hypertrophic vulvar dystrophy, lichen sclerosus, lymphogranuloma venereum, vestibulitis, vulvitis (infectious), vulvodynia.

Risk Factors: Those associated with causal pathologic conditions.

CLINICAL CHARACTERISTICS

Signs and Symptoms

Sharp, burning, or pinching discomfort felt externally (vulva and perineum) during attempts at vaginal penetration (not limited to the penis). The discomfort is generally localized to the vulva, perineum, or outer portion of the vagina. The symptoms may help to localize the cause but are often generalized and nonspecific.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation, reassurance, and relaxation measures. Vaginal lubricants (water-soluble or long-acting agents such as Astroglide, Replens, Lubrin, K-Y Jelly, and others), local anesthetics (for vulvar lesions), or pelvic relaxation exercises may be appropriate while more specific therapy is under way. These may be especially useful during the early phase of therapy when arousal may be compromised by the experience of pain.

Specific Measures: Because dyspareunia is ultimately a symptom, the specific therapy for any form of sexual pain is focused on the underlying cause.

Diet: No specific dietary changes indicated.

Activity: No restriction.

Patient Education: Reassurance, relaxation training, progressive desensitization; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP020 (Pain During Intercourse), AP042 (You and Your Sexuality [Especially for Teens]).

Drug(s) of Choice

The judicious use of anxiolytics or antidepressant medications for selected patients may be appropriate but for short periods of time only.

Alternative Therapies

Modifying the sexual techniques used by the couple may reduce pain with intercourse. Delaying penetration until maximal arousal has been achieved improves vaginal lubrication, ensures vaginal apex expansion, and provides an element of control for the female partner. Sexual positions that allow the women to control the direction and depth of penetration (such as woman astride) may also be of help.

FOLLOW-UP

Patient Monitoring: Normal health maintenance. Watch for signs of abuse, anxiety, or depression.

Prevention/Avoidance: None.

Possible Complications: Marital discord, orgasmic or libidinal dysfunction.

Expected Outcome: With diagnosis and treatment of the underlying cause, response should be good.

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy.

ICD-9-CM Codes: 625.0.

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