Dyspareunia resident survival guide
|Dyspareunia Resident Survival Guide Microchapters|
Dyspareunia is recurrent or persistent pain with sexual activity that causes marked distress or interpersonal conflict. It can affect men but more common among women. It can be due to psychological factors, physical factors, or combined factors among both males and females. Dyspareunia and vaginismus have been grouped as genito-pelvic pain/penetration disorder in DSM-5. This is defined as persistent or recurrent difficulty in vaginal penetration, marked pelvic or vulvovaginal pain during or while attempting penetration, fear or anxiety about pain before, during, or after penetration, and tightening or tensing of the pelvic floor muscles when penetration is attempted.. It may be classified into two types among women that include superficial and deep dyspareunia. Causes are divided into three groups according to onset and frequency. Onset can be divided primary or secondary. Primary causes often include psychological issues. Based on the frequency, dyspareunia can be persistent, and possibly due to physical or psychological factors, or conditional dyspareunia. Abdomino-pelvic disorders such as endometriosis, imperforate hymen, vaginal septum, vulvar and vaginal infections, lichen sclerosis, prolapse, trauma, or vaginal dryness can cause dyspareunia. It may also be caused by gastrointestinal disorders and scarring from previous pelvic surgery. Male dyspareunia is divided into broad categories based on the underlying causes, and ranges from anatomic anomalies to psychosocial problems. Male dyspareunia can be divided into four broad categories: Isolated painful ejaculation, Chronic prostatitis/chronic pelvic pain, medical causes, and psychological causes. The management is based on identifying the underlying cause. Treatment ranges from psychosexual therapy, medications or surgery. Multimodal sex therapy, consisting of individual and couples therapy and other interventions such as cognitive–behavior techniques, is an important part of the multidisciplinary approach to these disorders.
- Superficial dyspareunia: Occurs in or around the vaginal entrance, and is characterized by initial discomfort in initial or attempted penetration of the vaginal introitus. Causes include:
- Vaginismus, infections (such as HSV and candidiasis), trauma, vaginal septum, or organic vulvodynia due to infection, or vestibulitis, prolapse, lichen sclerosis, vaginal infections, and imperforate hymen.
- Scarring due to previous pelvic surgery, episiotomy, and perineorraphy, or urological causes such as cystitis, interstitial cystitis, or urethritis can cause dyspareunia as well.
- Deep dyspareunia is caused by pelvic thrusting during intercourse. The causes are divided into three groups according to the onset and frequency.
- Based on the onset:
- Primary (onset with the first sexual experience): Psychological, such as sexual abuse during childhood, feeling of guilt or shame toward sex, fear of intercourse, or painful first intercourse.
- Secondary: Begins after a painless previous sexual activity. Causes include pelvic inflammatory disease, vaginal dryness in perimenopause and menopause.
- Based on the frequency:
Causes of dyspareunia in males
- The causes of male dyspareunia can be classified into four broad categories:
Dyspareunia in Female
|Assessment of dyspareunia in female|
History and physical exam
❑ Ask about the pain characteristics:
❑ Ask about associated vulvovaginal symptoms:
❑ Take musculoskeletal history:
❑Obtain sexual hsitory:
❑ Obtain psychological history:
❑ Inquire about any history of abuse:
❑ Physical exam:
❑ Evaluation of external musculoskeletal:
❑ external visual and sensory examination
❑ Work up:
❑ If history is suggestive, perform:
❑ Vulvar or vaginal biopsy for dermatological problems, malignancy
❑ Endometrial conditions:
❑ Gynaecological conditions:
❑ Pelvic disorders::
❑ Dermatological problems:
Systemic disorders/Comorbid conditions/Medications
❑ Sjögren's syndrome
❑ Systemic sclerosis
❑ Vulvar Crohn's disease
❑ Inflammatory bowel disease
❑ Irritable bowel syndrome
❑ Parkinson's disease
❑ Peripheral neurpathies
❑ Behçet's syndrome
Dyspareunia in Male
|Assessment of dyspareunia in male|
History and physical exam
Ask about Pain Characteristics:
❑ Tight foreskin (Phimosis)
❑ Growths, cysts, warts, and lumps in the penis
❑ little tears in the foreskin
❑ Peyronie's disease
❑ Thrush or male []candidiasis
❑ Sexually transmitted infections ( STIs) including herpes
❑ Skin irritation caused by an allergic reaction to a particular brand of condom or spermicide
❑ Sharp pain during penetration can be caused by threads of an intrauterine contraceptive device (for birth control) that protrude from the woman’s cervix
❑Isolated painful ejaculation due to:
❑ Several dermatologic conditions of the penis such as:
|Treatment of dyspareunia:|
❑ Surgery is performed as a last resort when all conservative and medical management options have failed or when surgery is indicated in situations such as:
- Use of a water-based lubricant with intercourse.
- Women with chronic dyspareunia who feel that the pain is having a significant impact on libido or psychosexual self-image should be referred for counseling.
- Multimodal sex therapy, consisting of individual and couples therapy and other interventions such as cognitive–behavior techniques, is an important part of the multidisciplinary approach to these disorders.
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