Many women who complain about low libidos actually experience pain during sex, according to Dr Elna Rudolph, head of the multi-disciplinary team at My Sexual Health in Pretoria.
“When it comes to sex, some medical practitioners feel out of their depth. They know that when sex is painful it can cause a massive divide in a relationship, but they don’t know how to address the issue and they often end up telling the patient there is nothing ‘wrong’ with her, because a clinical examination does not reveal any overt pathology like visible lesions, discharges or anatomical abnormalities. As a result, patients tend to move from one medical practitioner to the next hoping for a solution. In some instances, it takes years before she is diagnosed and treated.”
Dr Rudolph noted that every time a woman is told that there is nothing wrong with her or that it is ‘all in her head’, she interprets it as meaning there is in fact something seriously wrong with her, because nobody can figure it out.
She appealed to doctors to refrain from using the phrase ‘it is all in your head’ when consulting a patient who complains about painful sex. Rather say that you cannot find the cause for the pain and refer her to a centre that specialises in the management of painful intercourse.
An Approach to Dyspareunia:
The DSM V now reads Genito-Pelvic Pain/Penetration Disorders and throws all causes for dyspareunia under one psychiatric diagnosis. The fact that it is in the DSM V acknowledges that dyspareunia has a significant psychological impact on a patient, but it should not be interpreted as “sexual pain is all in the mind.” This umbrella-term certainly also does not aid in diagnosing and treating the cause of the pain. The next section aims to provide an approach to dyspareunia: Pain during sex can be either deep or superficial.
Deep pain usually signals a gynaecological problem like ovarian cysts, fibroids, endometriosis, occasionally a retroverted uterus (although this is a relatively common finding, it is seldom the cause of the pain), pelvic inflammatory disease and neoplastic disorders. If the patient has deep dyspareunia and the cause cannot be diagnosed and or treated by the GP, referral to a gynaecologist is very important.
Irritable or Inflammatory Bowel Disease as well as simple constipation can cause dyspareunia. If there is any occult faecal blood, weight loss or any other danger sign, the patient should be referred for colonoscopy.
A chronic, untreated urinary tract infection and other bladder pathology can cause painful intercourse. A condition that is often missed is painful bladder syndrome, formerly known as interstitial cystitis. This is now seen as a pain disorder involving central sensitization rather than being an organic disease. The patient experiences pain over the bladder and what feels like chronic or recurrent urinary tract infections, but with sterile urine with or without hematuria. If there is hematuria, urological referral is advised. If not, it should be treated like a pain disorder in the context if an experienced multi-disciplinary team. Medications that are used include anti-histamines, gabapentin, pregabalin, amitriptyline, duloxetine, anti-inflammatories, muscle relaxants, etc.
Repeated abdominal and pelvic surgeries contribute to a large portion of deep dyspareunia. It also sometimes seen in patients who over-train their core muscles like pilates instructors, triathletes and dancers. In these cases, referral for myofascial release by a specialist pelvic function physiotherapist can solve the problem.
Superficial pain is experienced around the vaginal opening and on attempted penetration. Patients usually describes a sharp stinging, burning or tearing sensation and that it feels like her partner is hitting a wall inside her vagina.
It is important to distinguish between localised and generalised pain.
Localised pain can be organic and nociceptive in nature with a clear cause like a visible herpes ulcers or fissures. In the cases where there is a lesion with an unknown cause, especially if it does not respond to empirical therapy in two weeks, a biopsy should be taken to make the correct diagnosis. Lichen Sclerosis, Erosive Lichen Planus, Spongiotic Dermatitis and undiagnosed Genital Herpes are common causes of localised genital pain. To take a biopsy of normal looking skin or mucosa is usually of no value – it will just show mild inflammatory changes and make no contribution to the diagnosis or the treatment plan.
Fissuring or splitting of the posterior fourchette – which can occur at the first attempt at sex or years later – can cause pain that is described as: ‘like a paper-cut’, ‘knife-like’ or as a tearing sensation. They have mild to severe pain with penetration and might tear when inserting tampons or during gynaecological examination. They often see bleeding or spotting after sex and will complain of itching, burning or stinging when the area comes into contact with semen, water or urine. An examination will reveal a tiny split or linear erosion at the midline of the base of the vagina on the perineal skin. In addition, the posterior fourchette may form a tight band or tent (membranous hypertrophy). Splitting occurs when the posterior fourchette is pulled into the vagina and experiences friction from thrusting, especially if there is not enough lubrication or if the mucosa is atrophic due to hormonal changes. Correcting the hormonal imbalance, using a non-irritating protective substance like Aquaphor, using a silicone lubricant and making sure the fragile part does not get pushed into the vagina during penetration by manually pulling down on it with a thumb when inserting the penis, works very well. If this does not help, it is usually due to an undiagnosed chronic infection or other skin condition and a biopsy is warranted.
Genito-Urinary Syndrome of Menopause:
Previously known as atrophic vaginitis, this condition causes significant discomfort and impairment of quality of life for older women. If peri- or post-menopausal woman experiences pain during sex, it is probably due to a local oestrogen deficiency. They also experience significant urinary symptoms: they feel as though they have recurrent infections, when in fact they don’t and they often have trouble with incontinence as well. Post- menopausal women who are on topical oestrogen are twice as like as their oestrogen-deficient peers to be sexually active.
A common form of localised pain where there is no visible pathology is Provoked Vestibulodynia. This condition is easily diagnosed by touching the vestibule with a wet ear bud. If the patient experiences a burning or stinging sensation, it is called allodynia and it is diagnostic. The patient should be asked to rate the pain out of 10 at the following positions: above the urethra, under the urethra, as well as at the the 4’O clock 6’O clock and 8’O clock positions. This condition is due to neuroproliferation and can be genetic, due to recurrent infections or due to hormonal abnormalities caused by hormonal contraception or menopause. If only the posterior aspect of the vestibule is affected, it is due to a hypertonic pelvic floor with irritation of the pudendal nerve.
Oral contraceptives, especially the low-dose anti-androgenic ones cause a relative oestrogen and testosterone deficiency in the vestibillum, which induces neuroproliferation, in some women. It is more likely to happen in those who start off with congenital neuroproliferation around the vaginal opening. You will find that those patients also have a sensitive umbilicus. Look out for vestibulodynia in the patients with the sensitive umbilicus, those who can’t use tampons and first-time pill users.
Recurrent infections can also cause neuroproliferation, but one of the biggest contributors in those with recurrent infections is the repeated use of topical anti-fungals. In a sensitive vestibule, it causes a chemical dermatitis that feels like and infection, but is only worsened by continuous use of topical agents. Do a vaginal swab and ask for sensitivity to be done on the candida if there is any. We see many cases of candida glabrata and ducreii in clinical practice and it is most likely do to over-use of conventional anti-fungal treatments that selects for the resistant strains. Only treat what you find on the swab and aim for oral treatment rather than topical treatment in these cases.
In our experience, women with very small labia minora and an exposed introitus are more likely to suffer from provoked vestibulodynia. It is most likely due to higher exposure of the vestibule with irritation of the nerve-endings.
Provoked Vestibulodynia is treated by taking away the cause of the neuroproliferation, restoring the hormonal balance of the vestibule, treating the associated neuropathic pain and correcting the pelvic floor hypertonicity if it is present.
Hypertonic Pelvic Floor:
Almost all cases of superficial pain will have some degree of pelvic floor hypertonicity. It is often a chicken-and-egg situation where one is not sure if the muscle spasm caused the nerve irritation or if it was the other way around. The most important aspect of the treatment of superficial dyspareunia is making sure that the pelvic floor has normal tone. In the presence of hypertonicitiy, the pain is maintained, and cure is very difficult.
Injury such as traumatic vaginal delivery, pelvic surgery, positional insults such as prolonged driving or occupations that require prolonged sitting, gait disturbances, traumatic injury to the back or pelvis, and sexual abuse can cause the muscles in the pelvic floor to go into spasm.
According to the DSM V the more up-to-date term to use would be a “penetration disorder” but with vaginismus there is a distinct phobic reaction and avoidance behaviour associated with attempts at penetration. A hypertonic pelvic floor certainly contributes to vaginismus. In our clinic, most women with vaginismus also have another superficial pain disorder and the vaginismus is merely a response to repeated attempts at penetration that was extremely painful. Most of our vaginismus patients have also never been able to use a tampon. Some do have a history of sexual abuse and dysfunctional families, but that is actually a small percentage. Almost all patients have a history of a strict religious upbringing, very little sex education as well as negative ideas and messages about sex from early childhood.
The research show that this condition is best managed in the context of a multi-disciplinary team. These patients need to have the contributing medical conditions like provoked vestibulodynia diagnosed and treated, but they also need sex therapy, relationship therapy, cognitive behavioural therapy (where she learns to take control of her own vagina and what happens in her genital area), dilator therapy and physiotherapy by a women’s health physiotherapist who specialises in the treatment of sexual dysfunction (there is only a handful around!) During the treatment process sex is forbidden but the couple is given sensate focus exercises to re-establish intimacy if it has dwindled and to rewire the women’s mind – she has to learn that sensual experiences are not always threatening can be pleasurable. She also needs to get in touch with her sexual self – something that most patients suffering from vaginismus though would never be possible.
The patient will see each of the multi-disciplinary team members alone or with her partner a few times during the treatment period. When we are satisfied that she is physically and emotionally ready to attempt penetration, it is done in a gradual manner where the partner first helps with dilators and then gently attempts penetration when they are both ready.
The process does consume a lot of resources: time, money, emotional energy, but it is all worth it in the end. The treatment success of a program like this is very high, all over the world.
Generalised superficial pain:
Generalised superficial pain is often unprovoked and not only associated with intercourse, although an attempt at penetration can worsen the pain. This is referred to Vulvodynia can be seen as a chronic pain syndrome. The pain usually comes and goes with some patients experiencing long pain-free intervals and some have constant pain that gets better and worse depending on a whole range of factors.
A specific form of superficial pain is called pudendal neuralgia where patients experience a burning pain in the distribution of the pudendal nerve. The pain can be in the whole area from the clitoris to the anus or only one specific branch. It can also be unilateral or bilateral. This pain usually gets worse when the patient is sitting and better if they are lying on their sides. The treatment involves physiotherapy, pharmacotherapy with drugs like pregabalin or gabapentin, often pudendal nerve blocks (which is also diagnostic) and only occasionally surgery where a narrowing of Alcock’s canal can be demonstrated.
Chronic Pelvic Pain:
An estimated 40% of diagnostic laparoscopies and 12% of hysterectomies are performed for pelvic pain, according to Weiss et al. Although diagnositic laparoscopy is necessary to diagnose some important causes of chronic pelvic pain like endometriosis, repeated exploratory laparoscopies and especially laparotomies is not advised. In fact, it worsens the condition due to scar tissue formation and with worsening of myofascial pain. This is a complicated condition with often no clear cause or multiple contributing factors. In many cases, conventional treatment is ineffective and management by a multi-disciplinary team is required.
Other Chronic Pain Disorders:
Patients with disorders like fibromyalgia and rheumatoid arthritis have a higher incidence of dyspareunia – deep or superficial as well as chronic pelvic pain. In these situations the underlying painful condition should be treated optimally, but it is often necessary to address the painful intercourse separate as well.
Persistent genital arousal disorder:
This condition is marked by constant or intermitted feeling of genital arousal with or without spontaneous orgasms. Its unwanted and not due to sexual stimulation or thoughts and causes significant distress for the patient. Of late, this condition is seen as a type of genital pain disorder and is treated much like vulvodynia in specialised sexual pain centres. Referral is advised.
Some useful tips
If a women complains about dyspareunia, ask her to tell you about the pain. Let her talk for a minute or two – the diagnosis is usually already clear if you just allow her to describe her symptoms.
Then get a good history and ask about her overall physical health and medication use.
If a woman is tense or scared, take the time to reassure her by giving her a step-by-step account of what you are going to do next. Start the examination with a general exam and then by touching her thighs – after informing her of your intension – then move to the vulva.
In addition, if the patient is scared, do not use a speculum at the first examination – a finger and an ear bud are all you need to diagnose the cause of superficial pain.
Always ask a patient to rate her pain on a scale of 1-10 and to describe the sensation. Make a note of this and compare it at the follow-up consultation. If there is no improvement, refer the patient.