Dr. Rajiv Anand

Dyspareunia is pain prior to, during, or after, sexual intercourse. Dyspareunia is more common in women but can affect either sex. Dyspareunia can have several different causes. For instance, vaginismus is a ‘spasm’or contractions of the muscles surrounding the vagina.

• Dyspareunia is pain prior to, during, or after, sexual intercourse. Dyspareunia is more common in women but can affect either sex. Many women will experience dyspareunia at some time in their life. Sometimes a medial or physical etiology may not be obvious and psychosocial factors also can play an important role. In men, dyspareunia can be related to an allergic reaction to a condom or spermicidal. An infection of the prostate or prostatitis may also cause pain. If a female partner has a vaginal infection or dryness, the male can experience discomfort during intercourse.
• Dyspareunia can have several different causes. For instance, vaginismus is a “spasm” or contractions of the muscles surrounding the vagina. Women with vaginismus have pain with insertion of tampons as well as with penile penetration.
• Vulvodynia and vulvar vestibullitis are both conditions that are characterized by painful intercourses. They are also characterized by vulvar burning and itching. The discomfort may not necessarily be associated with intercourse.
• In older women vaginal dryness is a common cause of dyspareunia. This is a common problem for women that are not on hormone replacement. Dyspareunia can also be caused by abnormalities of the uterus or pelvic organs. Woman may describe the pain as feeling that something is being “pushed” or “bumped” during intercourse. An enlarged uterus or ovary can cause painful intercourse especially during deep penetration. A prolapsed or “dropped” uterus or bladder may also cause discomfort. Dyspareunia can also result from previous pelvic surgery or infection. These conditions can reduce movement of the pelvic organs resulting in pain with deep penetration.
• Women who experience trauma such as rape or sexual assault may also experience dyspareunia. Unfortunately, many women may have difficulty sharing this information with their health care providers.
• In order to treat dyspareunia appropriately the cause must be identified. The time at which the pain occurs during intercourse and other associated symptoms can help determine the potential etiology. For instance, pain during entry may have a different etiology than pain with deep penetration.

It is also important for a health care provider to know when in a woman’s life symptoms began. For example, if a woman’s symptoms began around or shortly after menopause; her symptoms could result from atrophic vaginal tissue. She may describe her symptoms as burning or “friction” with intercourse. Vaginal lubricants or estrogen can improve dryness and decrease pain. For women with a history of endometriosis, pelvic surgery, or infection, treatment of dyspareunia is aimed at restoring pelvic organs to their normal positions and reducing scar tissue. Surgical management may also be recommended for women with symptomatic prolapsed of the uterus, rectum, or bladder.

Women with a history of sexual abuse or treatment may benefit from psychological evaluation and treating any depressive symptoms that are present.

Types of dyspareunia:

It is useful to differentiate between the different types of dyspareunia to arrive at the appropriate diagnosis, treatment, and eventual prognosis.

1. Superficial dyspareunia. Vaginismus is a specific type of dyspareunia that refers to spasms of the levator ani and perineal muscles, making intercourse difficult, painful. Undesirable, and often impossible. May clinicians have defined vaginismus as an almost certain psychogenic illness. However, organic disorders of the external genitalia and introital areas can cause such severe discomfort that any attempts at penetration can leas to spasm. This particular cycle, primarily caused by situational and anticipatory anxiety, can become self perpetuating often both organic and functional and can be solely a result of recognized disease entities.
2. Deep dyspareunia refers to a deeper pelvic pain that is experienced at any time during intercourse. Again, this may be secondary to pelvic abnormality, or it may be functional in origin. It also tends to overlap more with chronic pelvic pain syndrome.
Etiology of dyspareunia:

The presence of organic disease is often the cause of dyspareunia. Virtually all gynecologic disease entities list dyspareunia as a possible symptom.

Prominent in the list of diseases associated with dyspareunia are the following:

• Chronic pelvic infection.
• Endometriosis
• Pelvic carcinoma
• Extensive prolapsed or organ displacement
• Episiotomy.
• Acute vulvovaginitis
• Cystitis
• Urethral syndrome or other urinary tract disorders.
• Introital, vaginal, and cervical scarring.
• All space occupying lesions.
• Levator ani myalgia.
• Vulvar vestibulitis.

1. As with chronic pelvic pain syndromes, gastrointestinal (gi) diseases (e. G, bowel motility disorders) must be excluded.

2. Estrogen deprivation, irritating vaginal medications, sympathomimetic drugs, amphetamines, and cocaine are also causes, primarily in superficial dyspareunia and vaginismus.

3. The most common causes of superficial dyspareunia include vaginitis (atrophic or infectious) or lack of lubrication (either caused by physiologic conditions or suboptimal sexual technique.

4. Lesions in the cul-de-sac are said to correlate most often with deep penetration dyspareunia.

5. Women who have deep penetration dyspareunia and who do not have superficial pain on penetration or vaginismus usually do not have a causative external inflammatory syndrome.

6. Some individual with external dyspareunia or vaginismus have small, almost imperceptible scar tissue secondary to surgery or childbirth.

7. Two clinical syndromes not usually recognized involve broad ligament varicosities and the broad ligament tear syndrome.
8. Frequently unrecognized etiology, particularly on first, interview, is a history or sexual assault or abuse.

Diagnostic workgroup

It is extremely important to look for evidence of sexual abuse both on history and physical examination before undertaking an expensive workup. Routine studies include a cbc, sedimentation rate, urinalysis, urine culture and sensitivity, and vaginal smear and culture. A pap smear should also be done. If pregnancy is suspected, a pregnancy test should be done. If there is a pelvic mass, pelvic ultrasound may be helpful. A referral to gynecologist is usually made before ordering this study, however. If vulval dystrophy is suspected, a vaginal biopsy may be useful. If the vaginal examination is normal, perhaps a psychiatrist should be consulted.

• Normal pelvic examination
• Abnormal pelvic examination
• Difficult penetration
• Difficult during intercourse
• With abnormal rectal examination
• Inflamed
• Hymeneal
• Orifice
• Bartholinitis
• Vulvitis
• Vulval
• Dystrophy
• Cystitis
• Urethritis
• Difficult during intercourse
• Salpingooophoritis
• Retroverted
• Uterus
• Endometriosis
• Ovarian cyst.
• With abnormal rectal examination
• Hemorrhoids
• Anal fissure
• Impacted
• Feces
• B-normal pelvic examination

With sexual desire 2. Without sexual desire
Functional dyspareunia not true dyspareunia

Differential diagnosis

Sexual pain disorder: persistent recurrent genital pain or nonorganic cause associated with sexual stimulation.

Vaginismus: painful, involuntary spasm of the vagina, preventing intercourse

Vulvar vestibulitis: a chronic and persistent clinical syndrome characterized by severe pain with vestibular touch or attempted vaginal entry, tenderness in response to pressure within the vulvar vestibule, and physical findings confined to various degrees of vestibular erythema.

Vulvodynia: chronic vulvar discomfort (e. G. Burning, stinging, irritation, rawness).

Female sexual dysfunction (disorders of desire, arousal, or orgasm)

Homeopathic remedies.

1. Bellis perennis
Bruised sensation in the vagina, if intercourse is interrupted.

2. Cactus grandiflora
Vagina squeezes shut when intercourse is attempted. Intercourse may be easier just before menses.

3. Coffea
Over sensitivity of the vulva and vagina. Heat and itchiness. Vaginismus with pain.

4. Cuprum
Cramping in the vagina and sometimes also in the legs, during intercourse.

5. Ferrum
Vagina feels dry, painful and raw. No feelings of arousal.

6. Gelsemium
Anxiety before intercourse. Tendency to vaginismus.

7. Lycopodium
Dry, burning vagina during and after intercourse. May have varicose veins in vulva.

8. Natrum mur
Dryness, with smarting and burning pains. Acrid discharge.

9. Platina
Strong sexual desire. May have erotic dreams. Difficult to have intercourse as vulva is extremely over-sensitive. Intercourse is painful and causes bruised sensation.

10. Rhus tox
Soreness during and after intercourse, often accompanied by physical restlessness.

11. Sepia
Dryness with bleeding after intercourse. (if you have this symptom seek medical advice.) feeling that everything will prolapse. Suits women who are exhausted and want to escape from their situation.

12. Staphisagria
Extremely useful remedy for pain after loss of virginity or in instances of rape or sexual assault.

13. Thuja
Vagina is over-sensitive making intercourse painful and difficult. Pains: burning, sore, bruised. May be helpful where there is a history of sti’s or if there are feelings of shame and self-disgust in relation to intercourse.

But before taking these medicine please consult your homoeopathic doctor.