Painful sex: Find out what causes dyspareunia and how to treat it.

Sexual intercourse can be a positive and pleasurable experience for a couple. But if one of the partners feels pain, the desire for sex can decrease. Whether you experience discomfort during insertion, the act or afterwards, you should get to the bottom of unpleasant sensations during sex.

In this article you will learn everything about dyspareunia, what the causes of the pain can be and what treatment options are available.

What is dyspareunia?

The understanding and diagnosis of dyspareunia has changed over the years. Dyspareunia is a medical term used to describe recurring or persistent pain in the genital or pelvic area during or after sexual intercourse. This can apply to female, male and intersex people.

While the term is commonly used to refer to pain during vaginal intercourse, dyspareunia is also defined as a medical condition and sexual dysfunction.

According to the fifth edition of the American Diagnostic and Statistical Guide to Mental Disorders’ (DSM 5), dyspareunia and vaginismus (pain during penetration caused by involuntary spasms of the pelvic floor muscles) belong together and are collectively defined as genito-pelvic pain penetration disorder. In this case, the dysfunction relates exclusively to the female sex.

The ‘International Statistical Classification of Diseases and Related Health Problems’ (ICD), on the other hand, makes a distinction in ICD-11 between dyspareunia and sexual–pain penetration disorder. In this case, dyspareunia is considered considered a symptom of a purely physical cause. It is also defined as a disease of the female sex.

In this article, we take a holistic approach to dyspareunia and recognise that it can impact anyone.

Who can dyspareunia affect?

Although women, men, and intersex people can be affected by the condition, women are more likely to suffer from it. There are currently hardly any studies on the frequency in men. It is estimated that 10 to 28% of women worldwide will be affected by dyspareunia at some point in their lives. The symptoms and the intensity of the pain can vary depending on the cause and the individual case.

Women can experience pain in the vulva, vagina, or pelvic area during sex, which can take various forms, such as stinging or burning, and can range from mild discomfort to severe pain. Dyspareunia in females can be divided into superficial and deep, primary and secondary dyspareunia.

  • Superficial dyspareunia: This is limited to the vulva or the vaginal entrance (introitus vaginae).
  • Deep dyspareunia: This means pain deeper in the vagina or lower pelvis.
  • Primary dyspareunia: Here the pain starts at the beginning of sexual intercourse.
  • Secondary dyspareunia: The pain only occurs after a period of pain-free sexual activity.

In men, pain in the penis, testicles, or pelvic area can occur before, during, or after intercourse.

Why can sex cause pain?

The causes of dyspareunia in both women and men can be related to physical aspects and functioning or psychological factors.

Possible physical or physiological causes in women

  • Vaginal dryness: A common cause of dyspareunia in women is vaginal dryness, which is caused by a lack of natural lubrication of the vagina during sexual arousal. This can be due to hormonal changes, for example during menopause. The reduced production of estrogen can lead to a reduction in vaginal moisture, leading to friction and pain during intercourse.
  • Endometriosis: Endometriosis is a disease in which tissue grows outside the uterine cavity. This abnormal tissue can cause pain during intercourse. In a 2020 study, over 42 % of women with endometriosis surveyed said that they felt pain during during intercourse or within 24 hours after.
  • Inflammation: Inflammation can cause both superficial pain during sexual intercourse, such as inflammation at the vaginal entrance, and deeper pain, such as inflammation of the fallopian tubes or ovaries (adnexitis). This may be a sign of infection, a medical condition, or irritation from foreign objects, such as a condom or sex toys. When choosing a condom to reduce the risk of pregnancy and protect against sexually transmitted infections (STIs), individuals with a latex sensitivity may want to consider a polyurethane condom.
  • Infections: Infections in the vaginal area, such as pelvic inflammatory disease or fungal or urinary tract infections, can also cause dyspareunia. These infections can cause inflammation, itching, and pain, especially due to penetration.
  • Cysts or tumours: Cysts or tumour-like growths can form in the uterus, ovaries or pelvis and cause pain.
  • Consequence of surgery: Surgery can result in scarring or adhesions that can be painful during sex. For example, an episiotomy after childbirth can later cause pain during intercourse.
  • Vaginismus. Vaginismus is a medical condition where the female pelvic floor muscles involuntarily spasm, making penetration difficult and painful.

Possible physical or physiological causes in men

  • Foreskin injuries: Damage to the foreskin (skin covering the glans of the penis) caused by rubbing or tearing can cause pain.
  • Infections: Infections in the genital area, such as an infection under the foreskin, as well as sexually transmitted diseases such as genital herpes or gonorrhea can make sex painful.
  • Tightening of the foreskin: Congenital tightening of the foreskin (phimosis) occurs when the foreskin is so tight that it often cannot be pulled back over the glans. Already when an erection occurs and even before the actual sexual intercourse has started, this can be felt as painful.
  • Inflammation: Urethral infections, an inflamed glans penis or inflamed testicles can have a painful effect on sex. Inflammation of the prostate (prostatitis) can lead to pain during or after ejaculation, but also during intercourse.
  • Curvature of the penis: Peyronie's disease (curvature of the erect penis caused by tissue thickening) or other abnormalities of the penis can make sexual intercourse painful.
  • Lack of moisture: Like women, men can experience pain if the vagina is not adequately lubricated during sex.

Psychological causes

The reasons for pain during sex do not necessarily have to be physical.

According to a study from the UK, in which 6,669 sexually active women participated and 7.2% reported experiencing pain during intercourse, dyspareunia was often linked to psychological factors and sexual functional problems (such as vaginal dryness).

These included, for example, fear of sexual intercourse and lack of pleasure in sex. Other important factors were problems in the sexual relationship with the partner, such as different sexual interests, listlessness or lack of excitement. Past trauma or negative experiences, such as non-consensual sex, were also associated with the pain felt.

Dyspareunia may also be linked to both psychological and physical factors. Psychological aspects affecting pain also included negative body image, hypersensitivity to pain, anxiety, and low self-esteem.

Psychological problems can be both the cause and the consequence of the perceived pain.

How does pain during sex affect fertility?

Dyspareunia may indicate an underlying condition that affects fertility. For example, ovarian cysts can indicate such a disease. The presence of a cyst alone does not necessarily pose a fertility problem; however, certain medical conditions, such as polycystic ovary syndrome (PCOS) and endometriosis, which can lead to cysts, can affect fertility.

Furthermore, a lack of lubrication in the vagina can indicate a hormonal imbalance, which can also indicate a conditions that affect fertility. Scar tissue in the pelvic area caused by infections or previous operations can also be the reason for a pregnancy that does not want to occur.

In addition to physical illnesses that can be related to fertility problems, the psychological component can play.a significant role. If intercourse is painful for one of the partners, intimate moments may be avoided for fear of the pain. The consequences of dyspareunia can also be emotional stress such as anxiety, negative body image and reduced self-esteem, which can also reduce the desire for sex. If the frequency of sexual intercourse decreases, the likelihood of becoming pregnant decreases as a result.

Dyspareunia also impact relationships. A study on dyspareunia in men found that recurrent genital discomfort during intercourse can result in avoidance of sexual experiences, breaking off of existing sexual relationships, or new sexual relationships be prevented.

How can I get support for dyspareunia?

If you experience pain before, during or after intercourse, it is advisable to see your doctor. Even if it is often not easy to talk about the situation, it can be helpful to consult a specialist, because in most cases the cause can be found and something can be done about the pain. A multidisciplinary approach involving both medical and psychological professionals is often used. Holistic care allows for comprehensive treatment that takes physical and psychological health into account.

Medical examination

During the medical visit, your medical history will be recorded in a thorough anamnesis. You will have a detailed discussion with the specialist about your experiences and your medical history. Depending on your personal situation, a physical examination can then be recommended.

If you are uncomfortable with a physical exam, you should bring this to the attention of the healthcare professional. In this way, a solution can be found together to deal with your concerns.

After speaking to your doctor, you may be recommended various tests. In gynecology, this includes an inspection of the vulva, the insertion of a speculum (a tool used to examine the vagina) and possibly a gynecological examination of the abdomen using ultrasound. The internal sex organs, such as the ovaries, uterus and fallopian tubes are examined. Pain points can also be identified with a cotton swab.

A pap smear, blood tests and a urine test can also be carried out. Depending on the individual case, further examinations, such as imaging of the uterine cavity (hysteroscopy) or a laparoscopy, may be necessary.

In men, a urological examination can be performed. This can include inspection and palpation of the external genitals, an ultrasound scan of the prostate and, if necessary, the testicles, penis or ureters. A blood draw and urine test may also be done.

Psychological support

If the pain isn't caused by a physical cause, your doctor may refer you to a therapist to help manage any psychological issues you may have. Mental health professionals can conduct a comprehensive assessment to identify possible psychological factors, such as anxiety disorders, depression, sexual trauma or relationship problems that may be contributing to dyspareunia. A detailed sexual history can help uncover possible sexual dysfunction or anticipatory anxiety related to sexual intimacy.

How can dyspareunia be treated?

In most cases, organic pain can be treated once the cause has been identified. Often, such as with vaginal dryness, creams or medication prescribed by a doctor can help. Most infections and inflammations can also be treated with medication. In some cases, surgery may be needed, such as removing a cyst in women or surgery to correct a tight foreskin in men.

Some treatments for painful intercourse do not require medical attention. Especially if the pain is psychological, it is advisable to seek psychological help. Individual or partnership counseling can help manage emotional distress and psychological factors associated with dyspareunia and improve sexual well-being.

Sex therapy can be helpful if, for example, internal conflicts related to sexual intercourse or traumatic experiences are causing the pain. It is important to be patient with yourself and take gentle steps as it often takes time for the pain to subside.

Physical therapists can also help with pelvic floor tightness or involuntary muscle spasms (e.g., vaginismus) if it's a cause of painful sex.

What can I do if I have painful intercourse?

The following tips may be helpful for dyspareunia:

  • Use lubricant: If a lack of lubrication in the vagina causes pain during sexual intercourse, it can be useful to use a lubricant. Lubricant can also be useful for outercourse (sexual contact that does not involve penetration) to reduce friction.
  • Have open communication: If both partners are open about their feelings, worries and fears, they can develop a better understanding of the other's situation. Open conversations help reduce emotional pressure and create a supportive environment in which both partners can engage with each other; this is an important step in restoring sexual intimacy and finding ways to manage the pain together.
  • Try new things: Some physical pain may be unique to certain sex positions, such as endometriosis or uterine prolapse. Changing position can reduce discomfort. In addition, non-penetrative sexual acts that do not cause pain, such as oral sex or mutual masturbation, may boost sexual pleasure.
  • Use relaxation techniques: Stress-relieving activities, such as yoga or qigong, can also have relaxing effects on the abdomen and pelvic floor and help relieve cramps. Massaging each other, which can also very relaxing, may be something to introduce as foreplay.
  • Take precautions against infection: In order to avoid infections, it is advisable to pay attention to hygiene, dry the genital area well and wear air-permeable underwear. Using condoms is also a way to have safer sex by enhancing protection against STIs.
  • Less is more: Sometimes harsh shower gels, vaginal perfumes, chemical contraceptives or scented toilet paper can trigger skin irritations and allergies. If you're prone to irritation, it's a good idea to limit your use of such products.

Conclusion

Dyspareunia is a condition in which genital or pelvic pain occurs during or after sexual intercourse. Women are affected more often than men.

Dyspareunia in women may be due to vaginal dryness, endometriosis, inflammation, infections, cysts or tumours and surgery. In men, pain can occur from foreskin injuries, infection, foreskin tightness, inflammation, penile curvature and lack of moisture. Psychological factors such as fear, sexual problems, trauma and negative experiences can also play a role. There may also be a link between pain during sex and fertility.

By finding the cause of dyspareunia and treating it, it is possible to restore and/or improve one’s sex life; in addition to empowering one’s sexuality and improving sexual health, this is important for couples who want to conceive. Treatment of the pain is possible in most cases, and a medical examination is recommended. If the cause is not physical, psychological support can help address dyspareunia.

Do you have questions about dyspareunia or fertility? Then don't hesitate to contact the Cada team! Our specialists will be happy to advise you. Reserve your spot for a free consultation today.