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Chapter: Essentials of Psychiatry: Sexual Disorders

Sexual Disorders: Dyspareunia

Recurrent uncomfortable or painful intercourse in either gender is known as dyspareunia.





Recurrent uncomfortable or painful intercourse in either gender is known as dyspareunia. Women’s dyspareunia varies from dis-comfort at intromission, to severe unsparing pain during penile thrusting, to vaginal irritation following intercourse. In both sexes, recurring coital pain leads to inhibited arousal and sexual avoidance. “Dyspareunia” is used as both a symptom and a di-agnosis. When coital pain is caused solely by defined physical pathology, dyspareunia due to a medical condition is diagnosed. When coital pain is due to vaginismus, insufficient lubrication, or other presumably psychogenic factors, dyspareunia not due to a medical condition diagnosis is made. Psychogenic etiologies may include a CNS pain perception problem raising the question, “What do we mean by psychogenic?” This arena’s nomenclature will undoubtably change when a breakthrough in understanding the causes of coital pain occurs.


Psychogenic Sources of Dyspareunia


Pain associated with intercourse may have purely subjective or psychologic origin. Couple dynamics are often relevant, but the pain may be seen as a means of not allowing painful memories of childhood sexual abuse into clear focus. Fear of or helplessness about negotiating interpersonal conflicts may eventually lead to pain becoming a solution for avoiding unwanted sexual behav-iors. While physicians tend to assume that pain has unconscious origins, sometimes it is merely faked; more often the patient is quite aware of its developmental origins but is too embarrassed quickly to communicate it to the doctor.


Personal psychological origins of painful intercourse pass through the common denominator of anxiety. Such anxiety may take the forms of dread of physical damage, worry about the psy-chological dependence that might result from physical union, fear of a first or another pregnancy, or a sexually transmitted disease. Intense anxiety, the psychological source of her pain, may lead to involuntary contraction of vaginal muscles which is the me-chanical source of her pain. Thus, dyspareunia and vaginismus reinforce each other. Both situational and acquired dyspareunia may reflect a woman’s conscious or unconscious motivation to avoid sex with a particular partner; it may be her only means to express her despair about their nonsexual relationship. Life-long dyspareunia draws the clinicians attention to developmental experiences.


Differential Diagnosis


Because the symptom dyspareunia is produced by numerous organic conditions, the psychiatrist should be certain that the patient has had a pelvic examination by a person equipped to assess a broad range of regional pathology. Vulvovestibulitis is diagnosed by pain in response to cotton swab touching in a normal appearing vulvar vestibule. A fundamental question remains unanswered about this often devastating problem: “Is the disorder of local or central origin?” In these patients and some others, the pain can not be classified with certainty as a symptom or a disorder. Pain upon penile or digital insertion may be due to an intact hymen or remnants of the hymenal ring, vaginitis, cervicitis, episiotomy scars, endometriosis, fibroids, ovarian cysts, and so on. Postcoital dyspareunia often begins at orgasm when uterine contractions occur. Fibroids, endome-triosis and pelvic inflammatory disease should be considered. Postmenopausal pain, particularly if the woman has had many years without intercourse, is often a result of thinning of the vaginal mucosa, loss of elasticity of the labia and vaginal out-let, and decreased lubrication. Normal menopause, however, is often associated with mild pain due to inadequate lubrication (in both partners).


Dyspareunia in men is usually due to a medical condition. Herpes, gonorrhea, prostatitis and Peyronie’s disease cause pain during intercourse. Remote trauma to the penis may cause penile chordee or bowing which makes intercourse mechanically dif-ficult and sometimes painful. Pain experienced upon ejaculation can be a side effect of trazodone.




Vaginismus is an involuntary spasm of the musculature of the outer third layer of the vagina which makes penile penetration difficult or impossible. The diagnosis is not made if an organic cause is known. Although a woman with vaginismus may wish to have intercourse, her symptom prevents the penis from en-tering her body. It is as though her vagina says, “No!” In life-long vaginismus, the anticipation of pain at the first intercourse causes muscle spasm. Pain reinforces the fear and, on occasion, the partner’s response gives her good reason to dread a second opportunity to have intercourse. Early episodic vaginismus may be common among women, but most of the cases that are brought to medical attention are chronic. Lifelong vaginismus is relatively rare. The clinician needs to focus attention on what may have made the idea of intercourse so overwhelming to her: parental intrusiveness, sexual trauma, childhood genital injury, illnesses whose therapy involved orifice penetration and surgery?


The woman with lifelong vaginismus not only has a his-tory of unsuccessful attempts at penetration but displays an avoidance of finger and tampon penetration. The most dramatic aspect of her history, however, is her inability to endure a specu-lum examination of her vagina. Vaginismus is a phobia of vaginal entrance.


Treatment of Dyspareunia and Vaginismus


While vaginismus has the reputation of being readily treatable by gynecologists by pairing relaxation techniques with progressively larger vaginal dilators, the mental health professional typically approaches the problem differently. The psychiatric approach to both vaginismus and dyspareunia is attuned to the role that her symptom plays in her life. The therapy, therefore, does not begin with a cavalier, optimistic attempt to remove the symptom, which only frightens some patients. Rather, it begins with a patient ex-ploration of the developmental and interpersonal meanings of the need for the symptom. “I wonder how this problem originally got started? Can you tell me a bit more about your life?” In the course of assisting women with these problems a variety of techniques may be utilized including relaxation techniques, sensate focus, dilatation, marital therapy and medication. Short-term therapies should not be expected to have lasting good results because once the symptom is relieved, other problematic aspects of the pa-tient’s sexual equilibrium and nonsexual relationship often come into focus. Clinicians have developed an impression that women with a diagnosis of dyspareunia are particularly difficult to help permanently. However, this is a largely unstudied topic.


Sexual Dysfunction Not Otherwise Specified


This diagnosis is reserved for circumstances that leave the doc-tor uncertain as to how to diagnose the patient. This may occur when the patient has too many fluctuating dysfunctional symp-toms without a clear pattern of prominence of anyone of them. Sometimes the psychiatrist is unable to determine whether the dysfunction is the basic complaint or when the sexual complaints are secondary to marital dysfunction. At other times the etiology is the uncertain: psychogenic, due to a general medical condition, or substance-induced. When the patient does not emphasize the dysfunction as the problem but emphasizes instead the lack of emotional satisfaction from sex, the psychiatrist may temporarily provide this NOS diagnosis. It is usually possible to find a better dysfunction diagnosis after therapy begins.


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