Dyspareunia overview

# 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).