Sexual Pain – Causes and Prevention

Sexual Pain

Also called: Dyspareunia

Summary

Sexual pain is pain that occurs immediately before, during or after intercourse. Also known as dyspareunia, sexual pain may be felt in the pelvic area or genitals.

Sexual pain is more common in women but also affects men. Causes of sexual pain in women include inadequate lubrication, menopause, vaginal infection, muscle spasm and genital irritation. Causes of sexual pain in men include prostate disorders, urethritis (inflammation of the urethra), spinal cord disorders, trauma and sickle cell anemia. Pain related to intercourse may also result from mental health issues, including anxiety, guilt, hostility, aversion to sexuality and unresolved issues with past sexual abuse.

To determine the cause of sexual pain, a physician will take the patient’s medical history and perform a physical examination. Depending on these results, the physician may order additional tests such as cultures or imaging tests (e.g., ultrasound, CAT scan, MRI).

It is important for the physician to determine the cause of a patient’s sexual pain because relief options are often based on the cause. Relief options may include lubricants, antibiotics, pain relievers, counseling and psychotherapy.

People can reduce their risk of developing sexual pain by using lubricant and practicing safe sex. Those experiencing sexual pain are encouraged to contact their physician. This is especially important when the pain is accompanied by bleeding, genital lesions, irregular periods, discharge from penis or vagina or involuntary vaginal contractions.

About sexual pain

Sexual pain is a term used to describe pain associated with sexual intercourse. Also known as dyspareunia, the disorder can cause a patient to lose interest in sexual activity.

Pain related to intercourse may occur in the pelvic area or genitals. It may occur immediately before, during or after intercourse. Sexual pain can occur in men but is more common in women.

The majority of female patients complain of pain at the entrance of the vagina at the time of penetration. Deep pelvic pain, however, can also occur as the result of thrusting. In addition, some women experience pain at multiple sites. Men may complain of pain at the time of erection, penetration or ejaculation.

Sexual pain may be described as primary or secondary. Primary sexual pain is pain that is present at first intercourse and all other attempts at intercourse. Pain developing after previous acts of pain-free intercourse is referred to as secondary sexual pain. Sexual pain may also be described as complete or situational. Pain occurring with each act of intercourse is described as complete, whereas pain occurring with only some acts of intercourse is described as situational. Situational pain may occur exclusively with one partner or in certain situations.

In addition, intercourse-related pain may be further classified as superficial-entrance pain and deep thrust pain. Superficial-entrance pain is noticeable at the initial moment of penetration. Deep thrust pain, on the other hand, is noticeable during or after the moment of penetration.

Patients experiencing sexual pain are encouraged to discuss it with their physician. Sexual pain may be a sign of a number of physical, hormonal or psychological conditions. It is particularly important for patients to contact their physician when the pain is accompanied by additional symptoms including bleeding, genital lesions, irregular periods, discharge from the penis or vagina, or involuntary vaginal contractions.

Potential causes of sexual pain

A number of physical, hormonal and psychological conditions can cause sexual pain. Causes of sexual pain in women include:

  • Surgery or childbirth. Women who have intercourse too soon after surgery or childbirth may experience pain. Women who develop a laceration during childbirth, or undergo an episiotomy (a procedure in which some of the skin between the vagina and anus is cut) may also experience pain during intercourse for a period of time after delivery.

  • Inadequate lubrication. Vaginal dryness resulting from a lack of lubrication can cause sexual pain. Causes of inadequate lubrication include menopause and insufficient stimulation.

  • Vaginal infection. Bacterial and yeast infections are common causes of sexual pain. Vulvovaginitis, a condition in which the vagina or vulva is inflamed or infected, may also cause sexual pain.

  • Genital irritation. A variety of soaps, detergents, douches and other feminine hygiene products can irritate the genitals and trigger sexual pain.

  • Endometriosis. A condition in which cells that make up the lining of the uterus (endometrium) are found outside the uterine cavity.

  • Vaginismus. A condition in which the vaginal muscles involuntarily contract.  

  • Poorly fitting diaphragm. A diaphragm that does not fit properly can cause sexual pain.

  • Allergic reaction. Allergic reactions triggered by the latex in a condom or diaphragm can cause sexual pain. Seminal plasma hypersensitivity (semen allergy) can also cause sexual pain.

  • Sexual assault. Sexual abuse or rape can cause vaginal injury or psychological trauma, either of which can trigger sexual pain.

  • Ovarian cyst. A fluid-filled structure located within or on an ovary.

  • Vulvodynia. Chronic discomfort or pain of the vulva (the external genitalia composed of the labia, clitoris and vaginal opening), especially burning, stinging, irritation, or rawness.

  • Uterine fibroids. A condition in which tumors grow within the wall of the uterus (womb).

  • Vulvar vestibulodynia. A condition in which a woman experiences pain in the vulvar vestibule (the folds of skin around the vagina) on contact.

  • Adenomyosis. A condition in which the cells that make up the lining of the uterus (endometrium) grow into the muscle wall of the uterus (myometrium).

  • Gynecologic cancers, such as vaginal or cervical cancer.

  • Retroversion of the uterus. A condition in which the uterus is tipped back instead of forward.

Causes of sexual pain in men include:

  • Urethritis. Inflammation of the urethra, the canal that carries urine and semen out of the body.

  • Benign prostatic hyperplasia (BPH, also called benign prostatic hypertrophy). Noncancerous enlargement of the prostate gland. The prostate, which surrounds the upper part of the urethra, grows as men age. This can constrict the urethra, causing pain during urination (dysuria) and during ejaculation (dyspermia). BPH affects more than half of men after age 50, according to the U.S. National Institutes of Health (NIH).

  • Prostatitis. A common acute or chronic condition in which the prostate gland becomes inflamed, usually because of bacterial infection. Prostatitis can lead to chronic pelvic pain syndrome.

  • Prostatodynia. A painful condition that resembles prostatitis except there is no evidence of inflammation or infection by microorganisms.

  • Prostate cancer. Malignant tumors in the prostate, one of the most common kinds of cancer, can impinge on the urethra, making urination and ejaculation painful.

  • Trauma, including testicular and scrotal pain.

  • Reiter’s syndrome. A condition involving urethritis, arthritis and conjunctivitis (an inflammation of the eyelids), seen mainly in young men and often caused by chlamydia.

  • Peyronie’s disease. A condition in which a hard lump forms on the penis and can cause the penis to bend painfully during an erection. One percent of men may have Peyronie’s disease, according to the NIH.

  • Penile cancer. Cancer of the penis is rare in the United States but more common in Africa and other developing regions.

  • Balanitis and balanoposthitis. Inflammations affecting the skin over the tip of the penis.

  • Phimosis and paraphimosis. Conditions involving the tightening of the foreskin.

In addition, men can experience priapism, a painful erection lasting four hours or more. Causes of priapism include sickle cell anemia, spinal cord disorders, neuritis, sexually transmitted diseases (STDs), leukemia (cancer of the blood), trauma, drug abuse, carbon monoxide poisoning and the bite of a black widow spider.

According to the NIH, about 10 to 40 percent of men with sickle cell anemia experience priapism, which can cause impotence. Certain medications, including treatments for erectile dysfunction, some antidepressants and some antipsychotic drugs, can also cause priapism.

Additional causes of sexual pain in women or men include:

  • Sexually transmitted diseases. Herpes sores, genital warts and other signs and symptoms of sexually transmitted disease can cause sexual pain. 

  • Urinary tract infections. An infection that develops along the urinary tract, which includes the kidneys, ureters (tubes from the kidneys to the bladder), bladder and urethra.

  • Psychological issues. Psychological and mental disorders are one of the most common triggers of sexual pain. Causes of psychogenic dyspareunia include anxiety, guilt, hostility, aversion to sexuality, anger toward the sexual partner and unresolved issues with past abuse.

  • Hemorrhoids. Sexual pain may result from the presence of swollen veins in the lower portion of the rectum or anus.

  • Interstitial cystis. A chronic inflammation of the bladder that can cause pain and the need to urinate frequently.

  • Urethral diverticulum. A condition in which an outpouching (or pocket) of tissue forms from the urethra.

  • Pelvic adhesions. Bands of fibrous tissue that form between two surfaces inside the body. They may result from inflammation, surgery or injury.

  • Pelvic floor tension myalgia. A spasm of the pelvic floor muscles.

In addition, a number of medications have been linked to sexual pain, including antibiotics, antidepressants, antihistamines and low-estrogen oral contraceptives (birth control pills).

Common tests performed for sexual pain

Physicians will typically begin an evaluation by taking the patient’s medical history. Patients may be asked to complete a pain assessment. They should be prepared to answer a number of questions about pain, including:

  • Has intercourse always been painful? If not, when did the pain begin?

  • Is intercourse painful every time?

  • At what point before, during or after intercourse does the pain begin (e.g., upon entry/penetration, during ejaculation)?

  • Where does the pain occur?

  • How long does the pain last?

  • How strong is the pain?

  • How does the pain feel (e.g., dull, sharp, steady)?

  • Does anything relieve the pain (e.g., changing positions, using lubricant)?

  • Is the pain accompanied by any other symptoms (e.g., genital discharge, itching, odor, burning or bleeding)?

  • What medications are being taken?

  • Are any other illnesses, diseases and disorders currently being treated?

  • Have there been genital or pelvic infections in the past (e.g., sexually transmitted disease)?

  • Has there been surgery or another procedure that could have affected the sexual organs (e.g., episiotomy, chemotherapy)?

  • What forms of contraception are used?

  • Does the pain occur in special situations?

Physicians may also ask a number of psychological questions, such as:

  • Are there any psychological conditions?
  • Was there a traumatic event (e.g., rape, child abuse) in the past?
  • Has there been a significant emotional event recently?
  • What is the general attitude about intercourse?
  • How is the relationship with the sexual partner?

These psychological questions are necessary because sexual pain can result from mental health issues. This possibility is often considered when there is no apparent physical cause for the pain.

A physical examination will be performed. Physicians will attempt to pinpoint and re-create the pain. The exam will include palpation (feeling) of the abdomen and pelvis. This allows physicians to locate possible trigger points or areas of tenderness. The external genitalia will also be inspected for signs of lesions and other abnormalities.

For women, a cotton swab may be used probe the vagina for areas of tenderness. A pelvic examination (examination of the uterus, cervix and other pelvic organs) may also be performed. This enables physicians to look for abnormalities including fissures, erosion, ulcers and atrophy. At the end of the exam, physicians may place one hand on the abdomen and place a finger in vagina to feel the uterus and ovaries.

A rectovaginal examination, in which one finger is placed in the vagina while another is placed in the rectum, may also be performed. In some cases, the pelvic exam may be delayed until the pain is under control. Samples of vaginal discharge may be collected for pH measurements (measurements of acidity) and a wet mount (a test for vaginitis).

Men may undergo a rectal examination as well. During a prostate exam, the physician briefly inserts a lubricated, gloved finger into the rectum to feel the prostate for abnormalities, such as enlargement of the gland (benign prostatic hyperplasia) or nodules that may indicate cancer.

The physical examination enables physicians to eliminate possible causes and focus on the most likely causes of sexual pain. Depending on the type of conditions suspected, a number of additional tests may be performed, including:

  • Cultures. Cervical, vaginal or prostate cultures may be taken and analyzed to look for signs of infection.

  • Blood tests. Analysis of blood samples can reveal many conditions including herpes, other infections and sickle cell anemia. Regular prostate-specific antigen (PSA) tests can help in diagnosing prostate disorders.

  • Urine tests. Urinalysis can reveal disorders including urinary tract infections, prostatitis and orchitis (inflammation of a testicle).

  • Urethroscopy or cystoscopy. After applying local anesthetic, the physician inserts a specialized endoscope (a small tube with camera attached) through the urethra to look for blockage or other abnormalities.

  • Colposcopy. A colposcope (instrument with magnifying lenses) is used to to view the cervix and vagina.

  • Imaging studies. Pelvic, bladder, transrectal or transvaginal ultrasound may be performed. The physician may also order tests such as a CAT scan or MRI.
  • Allergy tests.

  • Biopsy. A sample of tissue may be taken if a condition such as cancer is suspected.

  • Laparoscopy. Insertion of a small lighted viewing device (laparoscope) through an incision. It may be performed to examine the pelvis for evidence of abnormalities.

Relief options for sexual pain

Relief options for sexual pain vary based on the cause of the pain. Common relief options include:

  • Water-based lubricants. Lubricants may be recommended to relieve pain related to vaginal dryness.

  • Analgesics such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. These medications may be used to relieve pain caused by a number of conditions.

  • Antibiotics. These drugs may be prescribed to treat a number of bacterial infections that cause sexual pain, including urinary tract infections, sexually transmitted diseases, prostatitis and bacterial vaginitis.

  • Antifungals. Yeast infections are treated with over-the-counter or prescription fungus-fighting drugs.

  • Hormones. Women experiencing vaginal dryness as the result of menopause may benefit from using prescription estrogen replacement creams.

  • Alpha blockers or DHT (dihydrotestosterone) inhibitors. These medications are common treatments for benign prostatic hyperplasia (BPH).

  • Stool softeners. This drug may be used to relieve sexual pain caused by hemorrhoids.

  • Psychological counseling. Counseling may be recommended to treat patients whose sexual pain is related to mental health issues including guilt and unresolved issues with past sexual abuse.

  • Relaxation exercises. Women may benefit from using relaxation techniques to regain control over their vaginal muscles and reduce intercourse-related pain.

  • Transurethral procedures. A number of nonsurgical techniques are available to treat BPH. These procedures involve insertion of narrow heating devices through the urethra to shrink excess prostate tissue.

  • Surgery. Surgery may be recommended for a number of painful conditions, including BPH, endometriosis and retroversion of the uterus.

Scientists have found that a selective estrogen receptor modulator being developed to prevent and treat the bone disease osteoporosis in postmenopausal women may also relieve their sexual pain. Additional clinical trials of this orally administered drug are under way. 

Prevention methods for sexual pain

Many causes of pelvic pain cannot be prevented. However, there are a few steps people can take to reduce their risk. These include:

  • Adequate foreplay and stimulation. This ensures proper lubrication of the vagina before penetration.

  • Using water-soluble lubricant. The use of commercial lubricants can prevent pain related to vaginal dryness. Lubricants that are not water-soluble, however, should be avoided because they can cause vaginal irritation.

  • Practicing monogamy with an uninfected parter. Having multiple sexual partners increases the risk of infection and can cause sexual pain.

  • Consistently and correctly using a condom during sexual intercourse. This lowers a patient’s risk of developing sexual pain because it prevents the transmission of sexually transmitted diseases.

  • Not having an episiotomy unless medically necessary. The American College of Obstetricians and Gynecologists issued new guidelines in 2006 against the routine use of incisions to widen the vaginal opening during childbirth. Though episiotomies are sometimes needed, risks include lacerations, incontinence and sexual pain.

  • Avoiding intercourse immediately following childbirth. Women are advised to wait at least six weeks after childbirth before resuming intercourse.

  • Healthy diet and weight. Research has linked obesity to increased risk of benign prostatic hyperplasia, prostate cancer, endometrial cancer and other cancers. Research has linked a diet rich in plant foods and low in animal fats to reduced risk of prostate cancer, ovarian cancer and other cancers.

Women are advised to see a gynecologist regularly and have routine tests such as the Pap smear according to the recommended schedule. Though many men do not have a urologist or andrologist (physician specializing in men’s health), they may benefit from regular visits to one. Men are advised to try to have their prostate exam performed by the same physician each time so it is easier to note changes.

Questions for your doctor about sexual pain

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about sexual pain:

  1. What may be causing me to experience pain during intercourse?
  2. What tests may be used to determine the cause of my sexual pain?
  3. What do these tests involve? Will they cause me any pain?
  4. What do my test results show?
     
  5. How can I relieve my sexual pain?
  6. Will I require surgery if conservative options don’t work?
  7. How can I prevent sexual pain?
  8. At what point should I call you or seek emergency treatment for sexual pain?

Additional questions for women:

  1. How often should I see my gynecologist?
  2. What should my gynecological care include?
  3. How can I relieve vaginal dryness?
  4. Are routine episiotomies OK during childbirth, or should I not have one unless medically necessary?
  5. How long should I wait before resuming intercourse after childbirth?

Additional questions for men:

  1. How often should I have a prostate exam and testicular exam?
  2. Should I see a urologist or andrologist regularly for monitoring and preventive care, or only if I have a problem?
  3. Should I perform testicular/genital self-exams?
  4. How can I reduce my risk of groin injuries?
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