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.
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.
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.
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.
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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