PAINFUL INTERCOURSE
(DYSPAREUNIA)

Dyspareunia is painful sexual intercourse due to medical or psychological causes. 

The pain can primarily be on the external surface of the genitalia, or deeper in the pelvis upon deep pressure against the cervix. It can affect a small portion of the vulva or vagina or be felt all over the surface.

 Understanding the duration, location, and nature of the pain is important in identifying the causes of the pain.

Some women describe superficial pain at the opening of the vagina or surface of the genitalia when penetration is initiated. Other women feel deeper pain in the vault of the vagina or deep within the pelvis upon deeper penetration. 

Some women feel pain in more than one of these places. Determining whether the pain is more superficial or deep is important in understanding what may be causing a woman's pain.

Some women have always experienced pain with intercourse from their very first attempt. 

Other women begin to feel pain with intercourse after an injury or infection or cyclically with menstruation. Sometimes the pain increases over time.

When pain occurs, the woman may be distracted from feeling pleasure and excitement. 

Both vaginal lubrication and vaginal dilation decrease. 

When the vagina is dry and undilated, penetration is more painful. 

Fear of being in pain can make the discomfort worse. 

"Even after the original source of pain has disappeared, a woman may feel pain simply because she expects pain."

 Fear, avoidance, and psychologic distress around attempting intercourse can become large parts of a woman's experience of dyspareunia.

CAUSES:;

Infections
Tissue injury
Hymen remnants
Pelvic masses
Menopause

TREATMENT ::

The treatment for pain with intercourse depends on what is causing the pain. After proper diagnosis one or more treatments for specific causes may be necessary.

For example:

For pain due to yeast or fungal infections, a clinician may prescribe mycogen cream (nystatin and triamcinolone acetonide), which treats both a yeast infection and associated painful inflammation and itching because it contains both an antifungal and a steroid.

For pain that is likely due to post-menopausal vaginal dryness, estrogen treatment can be used.

In addition, the following may reduce discomfort with intercourse:

Clearly explain to the patient what has happened, including identifying sites and causes of pain. Make clear that the pain, in almost all cases, disappears over time, or at least greatly lessens.

 If there is a partner, explain the causes and treatment and encourage them to be supportive.
Encourage the patient to learn about her body, explore her own anatomy and learn how she likes to be caressed and touched.

Encourage the couple to add pleasant, sexually exciting experiences to their regular interactions, such as bathing together (in which the primary goal is not cleanliness), or mutual caressing without intercourse.

 In couples where a woman is preparing to receive vaginal intercourse, such activities tend to increase both natural lubrication and vaginal dilation, both of which decrease friction and pain. 

Prior to intercourse, oral sex may relax and lubricate the vagina (providing both partners are comfortable with it).

For those who have pain on deep penetration because of pelvic injury or disease, recommend a change in coital position to one with less penetration. 

For vaginal penetration in women, the maximum vaginal penetration can be achieved when the receiving woman lies on her back with her pelvis rolled up off the bed, her thighs compressed tightly against her chest, and her calves placed over the shoulders of the penetrating partner. 

Minimal penetration occurs when a receiving woman lies on her back with her legs extended flat on the bed and close together while her partner's legs straddle hers. 

Recommend water-soluble sexual or surgical lubricant during intercourse. Discourage petroleum jelly. Lubricant should be liberally applied (two tablespoons full) to both the penis and the orifice. A folded bath towel under the receiving partner's hips helps prevent spillage on bedclothes.

Instruct the receiving partner to take the penis of the penetrating partner in their hand and control insertion themselves, rather than let the penetrating partner do it.