Pain during sex

**Painful sexual act** is a medical problem where a person feels pain in their genitals before, during, or after a sexual act. Doctors call this problem **dyspareunia**. It can have physical or emotional causes. Both men and women can have dyspareunia. Up to one-fifth of women (one in every five) may have dyspareunia at some point in their lives.

## Symptoms in women

When a woman experiences a painful sexual act, the pain may prevent her from feeling pleasure and excitement. Her vagina will be less wet and will not expand as much as usual. When the vagina is dry and undilated, thrusting of the penis is painful. Even after the original cause of her pain has disappeared, a woman may feel pain simply because she expects pain.

## Causes in women

In most cases, painful sexual acts have a physical cause at first. There are many physical problems that can cause or worsen painful sexual act. A doctor may be able to identify the cause by doing a careful physical examination and medical history. Some of the most common physical causes are infections of the vagina, urinary tract, cervix, or fallopian tubes; endometriosis; scar tissue left by surgery (like an episiotomy); and ovarian cysts and tumors. Common infections are mycoses (infections caused by a fungus), candidiasis, chlamydia, trichomoniasis, urinary tract infections, coliform bacteria, monilial organisms and herpes). Painful sexual acts can also be caused by problems with a woman's anatomy, like hymenal remnants (pieces of the hymen that stay in the vagina) or female genital mutilation, or when the entrance to the vagina has become too small for normal penetration (Sarrell and Sarrell 1989).

In women who are past menopause, a common cause of painful sexual act is having too little estrogen. In women who are breastfeeding, a common cause is dryness of the vagina. Women who are getting radiation therapy for cancer in the pelvic area may have pain during sex because the walls of the vagina have atrophied (wasted away) and are more sensitive to injury.  Dryness in the vagina can also be a cause of painful sexual act for women with Sjögren's syndrome, which attacks the glands that create saliva and tears.

Painful sexual acts may be one of the first symptoms of cystitis (a bladder infection). People with cystitis may have bladder pain during or after sex.  Women with cystitis usually have pain the day after sex, because the muscles around her bladder are spasming (tightening up painfully). Women with cystitis usually also have urinary frequency (needing to urinate a lot) and/or urinary urgency (needing to urinate suddenly).

## In men

Pain is sometimes experienced in the testicular or glans area of the penis immediately after ejaculation. Infections of the prostate, bladder, or seminal vesicles can lead to burning or itching sensations following ejaculation. Men suffering from cystitis may experience intense pain at the moment of ejaculation, focused at the tip of the penis. Gonorrheal infections are associated with burning or sharp penis pains during ejaculation. Urethritis or prostatitis can make genital stimulation painful or uncomfortable. Anatomic deformities of the penis (retraction of a too-tight foreskin) may also result in pain during sexual act.

In men pain in the genital organs during ejaculation or immediately after is experienced as sharp, stabbing, and/or burning, it may be persistent and returning. The duration of pain is usually brief. The immediate cause of psychogenic post ejaculatory pain is the involuntary painful spasm or cramping of certain pain-sensitive muscles in the male genital and reproductive organs. The painful muscle cramps may be attributable to a man’s conflict about ejaculating.

A pelvic floor disorder can also be the cause of pain during and after sex.

## Diagnosis

Sufferers will see several doctors before a correct diagnosis is made. Women are also often hesitant to seek treatment for chronic vulvar pain, especially since many women begin experiencing symptoms around the time they become sexually active. Before being successfully diagnosed patients sometimes are told that the pain is "in their head". For the diagnosis doctor carefully takes a history and carefully examines the pelvis to duplicate the discomfort and to identify a site or source of the pelvic pain. The diagnosis of painful sexual act has to be differentiated from conditions known as ‘’’chronic vulvar pain’’’ and vaginismus. The pain may be acquired or lifelong. It may be generalized (complete) or situational. During the first two weeks, painful sexual acts caused by penis insertion or movement of the penis in the vagina or by deep penetration is often due to disease or injury deep within the pelvis. Inquiry should determine whether the pain is superficial or deep - whether it occurs primarily at the vaginal outlet or vaginal barrel or upon deep thrusting against the cervix. The possible role of psychological factors in either causing or maintaining the pain must be considered.

Atrophy of vagina as a source of painful sexual act is most frequently seen in women after menopause and is generally associated with estrogen deficiency. That  is associated with inadequacy of lubrication of vagina, which can lead to painful friction during sexual act.

## Treatment

- Doctor explains to the patient what has happened; identifying the sites and causes of pain. He makes clear that the pain will, in almost all cases, disappear over  time or at least will be greatly reduced. If there is a partner, doctor explains him also the causes and treatment and encourages him to be supportive. Doctor removes the source of pain when needed. He encourages the patient to learn about her body, to explore her own anatomy and learn how she likes to be caressed and touched. Doctor  encourages the couple to add pleasant, sexually exciting experiences to their regular interactions, such as bathing together (in which the primary goal is not cleanliness), mutual caressing without sexual act, and using sexual books, pictures, and videos. Such activities tend to increase both lubrication of vagina and its dilation, both of which decrease friction and pain. Prior to sexual act, oral sex may also prove very useful to relax and lubricate the vagina (providing both partners are comfortable with it). Doctor prescribes very large amounts of water-soluble lubricant during sexual act. He discourages petroleum jelly. Moisturizing skin lotion may be recommended as an alternative lubricant, unless the patient is using a condom or other latex product. Lubricant should be liberally applied (two tablespoons full) to both the penis and the orifice of the vagina. A folded bath towel under the receiving partner's hips helps prevent spillage on bedclothes. Doctor instructs the receiving partner to take the penis of the penetrating partner in their hand and control insertion themselves, rather than letting the penetrating partner do it.
- For those who have pain on deep penetration because of pelvic injury or disease, doctor recommends a change in sex positions to one admitting less penetration. Maximum vaginal penetration is achieved when the receiving woman lies on her back with her pelvis rolled up off the bed, compressing her thighs tightly against her chest with her calves over the penetrating partner's shoulders. Minimal penetration occurs when a receiving woman lies on her back with her legs extended flat on the bed and close together while her partner's legs straddle hers.
- A manual physical therapy  treating pelvis and vagina sticking together may decrease or eliminate pain during sexual act.

## Related conditions

- Vaginismus
- Endometriosis

## Other websites

- Sandra Risa Leiblum, Ph.D. sexual act/ Sexual Pain Disorders - Painful sexual act
- WhenSexHurts - a support community for couples struggling with intimacy due to disability