Dyspareunia overview: Difference between revisions
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{{CMG}} {{AE}} {{VVS}}[[Roghayeh Marandi]] | {{CMG}} {{AE}} {{VVS}}[[Roghayeh Marandi]] | ||
==Overview== | ==Overview== | ||
Dyspareunia is painful [[sexual intercourse]] | |||
Dyspareunia is painful [[sexual intercourse]] due to [[medical]] or [[psychological]] causes. The term is used almost exclusively in women, although the problem can also occur in men. Even when long-standing, the causes are often reversible, but self-perpetuating pain is a factor after the original cause has been removed. [[Dyspareunia]] is considered to be primarily a physical, rather than an emotional problem until proven otherwise. In most instances of [[dyspareunia]], there is an original physical cause. Extreme forms, in which the woman's [[pelvic floor]] [[musculature]] contracts involuntarily, is termed [[vaginismus]].Based on [[DSM|Diagnosis Statistical Manual of Mental Disorders]] (DSM-5; American Psychiatric Association, 2013),[[dyspareunia]] and [[vaginismus]] were typically classified as distinct [[sexual pain disorders]]. This new classification unifies [[vaginismus]] and [[dyspareunia]] into one category called "genito-pelvic pain/penetration disorder" due to the clinical difficulties in distinguishing these conditions. GPPPD is an umbrella term for two sexual pain disorders:[[dyspareunia]] and [[vaginismus]], because in practice, it is difficult to differentiate these two from each other. Sometimes the pain may cause pelvic muscle spasms or involuntary [[pelvic]] muscle spasms in [[vaginismus]] to cause pain. However, possible medical causes of [[dyspareunia]] should be ruled out or treated before considering a diagnosis of genito-pelvic pain/penetration disorder(GPPPD). If a medical cause is successfully treated, and pain has not been resolved yet, a diagnosis of [[vulvodynia]] or genito-pelvic/penetration disorder is appropriate to be considered. | |||
==Historical Perspective== | ==Historical Perspective== | ||
There is limited information about the historical perspective of [[dyspareunia]]. | There is limited information about the historical perspective of [[dyspareunia]]. | ||
==Classification== | ==Classification== | ||
[[Dyspareunia]] may be classified into different types based on its location, onset, and frequency in women. Male [[dyspareunia]] is divided into broad categories of underlying causes ranging from [[anatomic]] anomalies to [[psychosocial]] problems. | |||
==Pathophysiology== | ==Pathophysiology== | ||
[[pathophysiology]] can be considered as multifactorial, [[multisystemic]], or [[complex]]. | [[pathophysiology]] of genito-pelvic pain/penetration disorder can be considered as multifactorial, [[multisystemic]], or [[complex]]. If pain is due to a physical cause, the [[pathophysiology]] of the underlying cause should be considered. | ||
==Causes== | ==Causes== | ||
Common causes of [[dyspareunia]] in [[premenopausal]] women include the most frequent [[biological]] [[etiologies]] of [[dyspareunia]] which are [[vulvar vestibulitis]]/provoked vestibulodynia, with recurrent [[Candida|candida]] infections and/or a hyperactive [[pelvic floor]] in the background, and painful outcomes of [[delivery]] (either because of [[episiotomy]]/rraphy, or traumatic deliveries). [[Endometriosis]], [[chronic pelvic pain]], and [[pelvic inflammatory disease]] are leading contributors of deep [[dyspareunia]] in [[premenopausal]] women. Common causes of [[dyspareunia]] in [[postmenopausal]] women include [[vaginal dryness]] and vulvovaginal [[dystrophy]], which are the leading etiological factors of [[dyspareunia]], and may concur to deep [[dyspareunia]], with [[iatrogenic]] factors such as surgical shortening of the [[vagina]] and/or [[radiotherapy]] contributing to deep sexual pain. Possible medical causes of [[dyspareunia]] should be ruled out or treated before considering a [[diagnosis]] of [[Genito-Pelvic |Genito-Pelvic Pain/Penetration Disorder]](GPPPD). If a medical cause is successfully treated and pain has not been resolved yet, a diagnosis of [[vulvodynia]] or [[genito-pelvic/penetration disorder]] is appropriate to be considered. | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
[[Genito-pelvic/penetration disorder]](GPPPD) must be differentiated from other medical causes of [[dyspareunia]] in women. The medical causes of [[dyspareunia]] such as [[Endometriosis]],[[Atrophic vaginitis]],[[Vaginal dryness]], Infections([[Human papillomavirus]], [[Herpes simplex virus]], [[Pelvic inflammatory disease]], Chronic [[salpingitis]], [[uterine fibroids]], pelvic [[adhesions]], [[adnexal]] pathology, retroverted [[uterus]], chronic [[cervicitis]], [[pelvic]] congestion, [[genitourinary]]( [[urethritis]], [[cystitis]], [[Interstitial cystitis]], [[psychological]] problems such as [[anxiety]], [[depression]], inadequate sexual stimuli,[[lichen sclerosis]],[[pelvic inflammatory disease]]. | |||
==Epidemiology and Dermographics== | ==Epidemiology and Dermographics== | ||
The prevalence of dyspareunia | The [[World Health Organization]] reported a global [[prevalence]] of [[dyspareunia]] ranging between 8% and 21.1% in 2006, which varied by country. | ||
==Risk factors== | ==Risk factors== | ||
Risk factors vary base on the underlying cause of dyspareunia. | Risk factors vary base on the underlying cause of [[dyspareunia]]. For example, the history of [[Physical abuse]], [[Sexual abuse]] are risk factors of [[vaginismus]]. | ||
==Natural history, Complications, and Prognosis== | ==Natural history, Complications, and Prognosis== | ||
The symptom of [[dyspareunia]] is pain during intercourse/penetration, which could be either introital (at the vaginal entrance), deep (in the [[vagina]] or [[pelvis]]), or both. [[Dyspareunia]] can have a negative impact on a patient's mental and [[physical]] health, body image, relationships with partners, and efforts to conceive. It can affect the quality of life. It can lead to, or be associated with other female sexual dysfunction disorders, such as [[decreased libido]], [[arousal|decreased arousal]], and [[anorgasmia]]. Prognosis may vary based on the cause of [[dyspareunia]]. | The symptom of [[dyspareunia]] is pain during intercourse/penetration, which could be either introital (at the [[vaginal]] entrance), deep (in the [[vagina]] or [[pelvis]]), or both. [[Dyspareunia]] can have a negative impact on a patient's mental and [[physical]] health, body image, relationships with partners, and efforts to [[Conceive a child|conceive]]. It can affect the quality of life. It can lead to, or be associated with other female sexual dysfunction disorders, such as [[decreased libido]], [[arousal|decreased arousal]], and [[anorgasmia]]. [[Prognosis]] may vary based on the cause of [[dyspareunia]]. | ||
==Diagnosis== | ==Diagnosis== | ||
===Diagnostic criteria=== | ===Diagnostic criteria=== | ||
There are no established [[criteria]] for the diagnosis of [[dyspareunia]]. Based on [[DSM|Diagnosis Statistical Manual of Mental Disorders]] (DSM-5; American Psychiatric Association, 2013),[[dyspareunia]] and [[vaginismus]] were typically classified as distinct [[sexual pain disorders]]. This new classification unifies [[vaginismus]] and [[dyspareunia]] into one category called “genito-pelvic pain/penetration disorder” due to the clinical difficulties in distinguishing these conditions. | There are no established [[criteria]] for the diagnosis of [[dyspareunia]]. Based on [[DSM|Diagnosis Statistical Manual of Mental Disorders]] (DSM-5; American Psychiatric Association, 2013),[[dyspareunia]] and [[vaginismus]] were typically classified as distinct [[sexual pain disorders]]. This new classification unifies [[vaginismus]] and [[dyspareunia]] into one category called “genito-pelvic pain/penetration disorder” due to the clinical difficulties in distinguishing these conditions. GPPPD is an umbrella term for two sexual pain disorders:[[dyspareunia]] and [[vaginismus]], because in practice, it is difficult to differentiate these two from each other. Sometimes the pain may cause pelvic [[muscle spasms]] or involuntary pelvic [[muscle spasms]] in vaginismus to cause pain. However, possible medical causes of [[dyspareunia]] should be ruled out or treated before considering a diagnosis of Genito-Pelvic Pain/Penetration Disorder(GPPPD). If a medical cause is successfully treated and [[pain]] has not been resolved yet, a diagnosis of vulvodynia or genito-pelvic/penetration disorder is appropriate | ||
===History and Symptoms=== | ===History and Symptoms=== | ||
The hallmark of [[dyspareunia]] is [[pain]] before, during, or after [[sexual activity]]. Symptoms such as :[[itching]], burning, [[irritation]], abnormal [[discharge]] can be associated with it. | |||
==='''Physical Examination'''=== | ==='''Physical Examination'''=== | ||
The presence of [[erythema]], [[discharge]], [[atrophy]] or [[ulceration]], [[growth]], [[deformity]], or [[warts]] on external genitalia or lesions on the [[cervix]] and [[internal genitalia]] can be suggestive of [[dyspareunia]]. The presence of pain on the [[cotton-swab test]] is diagnostic of localized provoked [[vulvodynia]]. | |||
===Laboratory Findings=== | ===Laboratory Findings=== | ||
Different laboratory findings can be seen in patient with dyspareunia based on the underlying cause. | Different laboratory findings can be seen in patient with [[dyspareunia]] based on the underlying cause.Laboratory tests that help to the diagnosis of the underlying cause of [[dyspareunia]] include:[[Vaginal Discharge|Vaginal secretions]] analysis for [[infections]], [[NAAT |NAAT test]] for [[gonorrhea]], [[chlamydia]], [[trichomonas]], [[Herpes simplex virus]] (HSV) culture, [[HSV-1]] and [[HSV-2]] type-specific [[IgG|IgG antibodies]], [[Rapid plasma reagent]] (RPR), Vulvar or vaginal [[biopsy]] for [[dermatological]] problems, [[malignancy]], [[Urine analysis]], [[culture]] for [[urological]] problems, [[Blood count]], [[Glucose]], [[Hormones]]: [[prolactin]], [[TSH]], [[FSH]],[[LH]], [[Testosterone]] | ||
===X-Ray=== | ===X-Ray=== | ||
There are no x-ray findings associated with dyspareunia. | There are no x-ray findings associated with [[dyspareunia]]. | ||
===Echocardiography and Ultrasound=== | ===Echocardiography and Ultrasound=== | ||
There are no echocardiography findings associated with dyspareunia. Ultrasound may be helpful in the diagnosis of the underlying cause of dyspareunia. | There are no echocardiography findings associated with [[dyspareunia]]. Ultrasound may be helpful in the diagnosis of the underlying cause of [[dyspareunia]]. | ||
===CT Scan === | ===CT Scan === | ||
Ct-Scan may be helpful in the diagnosis of the underlying cause of dyspareunia such as pelvic tumors. | Ct-Scan may be helpful in the diagnosis of the underlying cause of [[dyspareunia]] such as [[pelvic tumor|pelvic tumors]]. | ||
===MRI=== | ===MRI=== | ||
There are no MRI findings associated with [[dyspareunia]]. | There are no MRI findings associated with [[dyspareunia]]. | ||
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===Other Diagnostic Studies=== | ===Other Diagnostic Studies=== | ||
Laparoscopy may be helpful in the diagnosis of [[dyspareunia]]. | Laparoscopy may be helpful in the diagnosis of the underlying cause of [[dyspareunia]]. | ||
==Treatment== | ==Treatment== | ||
===Medical Therapy=== | ===Medical Therapy=== | ||
The mainstay of treatment for [[dyspareunia]] is the treatment of the underlying cause. Non-Medical treatment also should be considered.Educate patients about [[pelvic]] [[anatomy]], [[physiology]], and [[Lifestyle|lifestyle modification]]. [[Psychological]] intervention, often in the form of [[CBT]] can be helpful. | |||
===Surgery=== | ===Surgery=== | ||
[[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 | [[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 [[endometriosis]] to remove the topic [[uterine]] tissue. | ||
===Primary prevention=== | ===Primary prevention=== | ||
There are no established measures for the primary prevention of [[dyspareunia]], but can prevent of some of the causes of dyspareunia, for example: prevent sexually transmitted diseases (STDs) by using condoms or other barriers, get proper routine medical care, use proper hygiene, wait at least six weeks before resuming sexual intercourse after childbirth. | There are no established measures for the [[primary prevention]] of [[dyspareunia]], but can prevent of some of the causes of [[dyspareunia]], for example: prevent [[sexually transmitted diseases]] ([[STDs]]) by using [[condoms]] or other barriers, get proper routine medical care, use proper [[hygiene]], wait at least six weeks before resuming sexual [[intercourse]] after [[childbirth]]. | ||
===Secondary prevention=== | ===Secondary prevention=== | ||
Effective measures for the secondary prevention of [[dyspareunia]] depends on the underlying cause of it, for example: using a water-soluble lubricant when vaginal dryness is an issue, encouraging natural vaginal lubrication with enough time for foreplay and stimulation, doing exercise to relieve muscular tightness in [[vaginismus]]. | Effective measures for the [[secondary prevention]] of [[dyspareunia]] depends on the underlying cause of it, for example: using a water-soluble [[lubricant]] when [[vaginal dryness]] is an issue, encouraging natural [[vaginal]] lubrication with enough time for foreplay and stimulation, doing exercise to relieve [[muscular]] tightness in [[vaginismus]]. | ||
==Future or investigational treatment== | |||
More research must be done to suggest a strong [[Genetic linkage|genetic link]] with [[Genito-Pelvic Pain/Penetration Disorder]] (GPPPD). | |||
[[Category:Gynecology]] | [[Category:Gynecology]] | ||
[[Category:Psychiatry]] | [[Category:Psychiatry]] | ||
[[Category:Sexual and gender identity disorders]] | [[Category:Sexual and gender identity disorders]] | ||
Latest revision as of 19:27, 28 September 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vishnu Vardhan Serla M.B.B.S. [2]Roghayeh Marandi
Overview
Dyspareunia is painful sexual intercourse due to medical or psychological causes. The term is used almost exclusively in women, although the problem can also occur in men. Even when long-standing, the causes are often reversible, but self-perpetuating pain is a factor after the original cause has been removed. Dyspareunia is considered to be primarily a physical, rather than an emotional problem until proven otherwise. In most instances of dyspareunia, there is an original physical cause. Extreme forms, in which the woman's pelvic floor musculature contracts involuntarily, is termed vaginismus.Based on Diagnosis Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013),dyspareunia and vaginismus were typically classified as distinct sexual pain disorders. This new classification unifies vaginismus and dyspareunia into one category called "genito-pelvic pain/penetration disorder" due to the clinical difficulties in distinguishing these conditions. GPPPD is an umbrella term for two sexual pain disorders:dyspareunia and vaginismus, because in practice, it is difficult to differentiate these two from each other. Sometimes the pain may cause pelvic muscle spasms or involuntary pelvic muscle spasms in vaginismus to cause pain. However, possible medical causes of dyspareunia should be ruled out or treated before considering a diagnosis of genito-pelvic pain/penetration disorder(GPPPD). If a medical cause is successfully treated, and pain has not been resolved yet, a diagnosis of vulvodynia or genito-pelvic/penetration disorder is appropriate to be considered.
Historical Perspective
There is limited information about the historical perspective of dyspareunia.
Classification
Dyspareunia may be classified into different types based on its location, onset, and frequency in women. Male dyspareunia is divided into broad categories of underlying causes ranging from anatomic anomalies to psychosocial problems.
Pathophysiology
pathophysiology of genito-pelvic pain/penetration disorder can be considered as multifactorial, multisystemic, or complex. If pain is due to a physical cause, the pathophysiology of the underlying cause should be considered.
Causes
Common causes of dyspareunia in premenopausal women include the most frequent biological etiologies of dyspareunia which are vulvar vestibulitis/provoked vestibulodynia, with recurrent candida infections and/or a hyperactive pelvic floor in the background, and painful outcomes of delivery (either because of episiotomy/rraphy, or traumatic deliveries). Endometriosis, chronic pelvic pain, and pelvic inflammatory disease are leading contributors of deep dyspareunia in premenopausal women. Common causes of dyspareunia in postmenopausal women include vaginal dryness and vulvovaginal dystrophy, which are the leading etiological factors of dyspareunia, and may concur to deep dyspareunia, with iatrogenic factors such as surgical shortening of the vagina and/or radiotherapy contributing to deep sexual pain. Possible medical causes of dyspareunia should be ruled out or treated before considering a diagnosis of Genito-Pelvic Pain/Penetration Disorder(GPPPD). If a medical cause is successfully treated and pain has not been resolved yet, a diagnosis of vulvodynia or genito-pelvic/penetration disorder is appropriate to be considered.
Differential Diagnosis
Genito-pelvic/penetration disorder(GPPPD) must be differentiated from other medical causes of dyspareunia in women. The medical causes of dyspareunia such as Endometriosis,Atrophic vaginitis,Vaginal dryness, Infections(Human papillomavirus, Herpes simplex virus, Pelvic inflammatory disease, Chronic salpingitis, uterine fibroids, pelvic adhesions, adnexal pathology, retroverted uterus, chronic cervicitis, pelvic congestion, genitourinary( urethritis, cystitis, Interstitial cystitis, psychological problems such as anxiety, depression, inadequate sexual stimuli,lichen sclerosis,pelvic inflammatory disease.
Epidemiology and Dermographics
The World Health Organization reported a global prevalence of dyspareunia ranging between 8% and 21.1% in 2006, which varied by country.
Risk factors
Risk factors vary base on the underlying cause of dyspareunia. For example, the history of Physical abuse, Sexual abuse are risk factors of vaginismus.
Natural history, Complications, and Prognosis
The symptom of dyspareunia is pain during intercourse/penetration, which could be either introital (at the vaginal entrance), deep (in the vagina or pelvis), or both. Dyspareunia can have a negative impact on a patient's mental and physical health, body image, relationships with partners, and efforts to conceive. It can affect the quality of life. It can lead to, or be associated with other female sexual dysfunction disorders, such as decreased libido, decreased arousal, and anorgasmia. Prognosis may vary based on the cause of dyspareunia.
Diagnosis
Diagnostic criteria
There are no established criteria for the diagnosis of dyspareunia. Based on Diagnosis Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013),dyspareunia and vaginismus were typically classified as distinct sexual pain disorders. This new classification unifies vaginismus and dyspareunia into one category called “genito-pelvic pain/penetration disorder” due to the clinical difficulties in distinguishing these conditions. GPPPD is an umbrella term for two sexual pain disorders:dyspareunia and vaginismus, because in practice, it is difficult to differentiate these two from each other. Sometimes the pain may cause pelvic muscle spasms or involuntary pelvic muscle spasms in vaginismus to cause pain. However, possible medical causes of dyspareunia should be ruled out or treated before considering a diagnosis of Genito-Pelvic Pain/Penetration Disorder(GPPPD). If a medical cause is successfully treated and pain has not been resolved yet, a diagnosis of vulvodynia or genito-pelvic/penetration disorder is appropriate
History and Symptoms
The hallmark of dyspareunia is pain before, during, or after sexual activity. Symptoms such as :itching, burning, irritation, abnormal discharge can be associated with it.
Physical Examination
The presence of erythema, discharge, atrophy or ulceration, growth, deformity, or warts on external genitalia or lesions on the cervix and internal genitalia can be suggestive of dyspareunia. The presence of pain on the cotton-swab test is diagnostic of localized provoked vulvodynia.
Laboratory Findings
Different laboratory findings can be seen in patient with dyspareunia based on the underlying cause.Laboratory tests that help to the diagnosis of the underlying cause of dyspareunia include:Vaginal secretions analysis for infections, NAAT test for gonorrhea, chlamydia, trichomonas, Herpes simplex virus (HSV) culture, HSV-1 and HSV-2 type-specific IgG antibodies, Rapid plasma reagent (RPR), Vulvar or vaginal biopsy for dermatological problems, malignancy, Urine analysis, culture for urological problems, Blood count, Glucose, Hormones: prolactin, TSH, FSH,LH, Testosterone
X-Ray
There are no x-ray findings associated with dyspareunia.
Echocardiography and Ultrasound
There are no echocardiography findings associated with dyspareunia. Ultrasound may be helpful in the diagnosis of the underlying cause of dyspareunia.
CT Scan
Ct-Scan may be helpful in the diagnosis of the underlying cause of dyspareunia such as pelvic tumors.
MRI
There are no MRI findings associated with dyspareunia.
Other Imaging Findings
There are no other imaging findings associated with dyspareunia.
Other Diagnostic Studies
Laparoscopy may be helpful in the diagnosis of the underlying cause of dyspareunia.
Treatment
Medical Therapy
The mainstay of treatment for dyspareunia is the treatment of the underlying cause. Non-Medical treatment also should be considered.Educate patients about pelvic anatomy, physiology, and lifestyle modification. Psychological intervention, often in the form of CBT can be helpful.
Surgery
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 endometriosis to remove the topic uterine tissue.
Primary prevention
There are no established measures for the primary prevention of dyspareunia, but can prevent of some of the causes of dyspareunia, for example: prevent sexually transmitted diseases (STDs) by using condoms or other barriers, get proper routine medical care, use proper hygiene, wait at least six weeks before resuming sexual intercourse after childbirth.
Secondary prevention
Effective measures for the secondary prevention of dyspareunia depends on the underlying cause of it, for example: using a water-soluble lubricant when vaginal dryness is an issue, encouraging natural vaginal lubrication with enough time for foreplay and stimulation, doing exercise to relieve muscular tightness in vaginismus.
Future or investigational treatment
More research must be done to suggest a strong genetic link with Genito-Pelvic Pain/Penetration Disorder (GPPPD).