Dyspareunia
Dyspareunia ( ) is painful sexual intercourse due to medical or psychological causes. The term "dyspareunia" covers both female dyspareunia and male dyspareunia, but many discussions that use the term without further specification concern the female type, which is more common than the male type. In females, the pain can primarily be on the external surface of the genitalia, or deeper in the pelvis upon deep pressure against the cervix. Medically, dyspareunia is a pelvic floor dysfunction and affects up to 53% of adult females at some point in their lives, although it is frequently underdiagnosed. It can affect a small  portion of the vulva or vagina or be felt all over the surface. Understanding the duration, location, and nature of the pain is important in identifying the causes of the pain. Numerous physical, psychological, and social or relationship causes can contribute to pain during sexual encounters. Commonly, multiple underlying causes contribute to the pain. The pain can be acquired or congenital. Symptoms of dyspareunia may also occur after menopause. Diagnosis is typically by physical examination and medical history. Underlying causes determine treatment. Many women experience relief when physical causes are identified and treated. Globally, dyspareunia has been estimated to affect  between 8–22% of women, at some point in their lives. Signs and symptoms. Women who experience pain with attempted intercourse describe their pain in many ways. This reflects how many different and overlapping causes there are for dyspareunia. The location, nature, and time course of the pain help to understand potential causes and treatments. Some women describe superficial pain at the opening of the vagina or surface of the genitalia when penetration is initiated. Other women feel deeper pain in the vault of the vagina or deep within the pelvis upon deeper penetration. Some women feel pain in more than  one of these places. Determining whether the pain is more superficial or deep is important in understanding what may be causing a woman's pain. Some women have always experienced pain with intercourse from their very first attempt. Other women begin to feel pain with intercourse after an injury or infection or cyclically with menstruation. Sometimes the pain increases over time. When pain occurs, the woman may be distracted from feeling pleasure and excitement. Both vaginal lubrication and vaginal dilation decrease. When the vagina is dry and undilated, penetration is more painful. Fear of being in pain can make the  discomfort worse. Even after the original source of pain has disappeared, a woman may feel pain simply because she expects pain. Fear, avoidance, and psychological distress around attempting intercourse can become large parts of a woman's experience of dyspareunia. Physical examination of the vulva (external genitalia) may reveal clear reasons for pain including lesions, thin skin, ulcerations or discharge associated with vulvovaginal infections or vaginal atrophy. An internal pelvic exam may also reveal physical reasons for pain including lesions on the cervix or anatomic variation. When there are no visible findings on vulvar exam that would suggest a cause  for superficial dyspareunia, a cotton-swab test may be performed. This is a test to assess for localized provoked vulvodynia. A cotton tip applicator is applied at several points around the opening of the vagina and a woman reports whether she experiences pain on a scale from 0–10. Causes. Women. The cause of the pain may be anatomic or physiologic, including but not limited to lesions of the vagina, retroversion of the uterus, urinary tract infection, lack of lubrication, scar tissue, abnormal growths, or tender pelvic sites. Some cases may be psychosomatic, which can include fear of pain or injury , feelings of guilt or shame, ignorance of sexual anatomy and physiology, and fear of pregnancy. In women, common causes for discomfort during sex include Men. In men, as in women, there are a number of physical factors that may cause sexual discomfort. 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 intense burning or itching sensations following ejaculation. Men suffering from interstitial cystitis may experience intense pain at the moment of ejaculation. Gonorrheal infections are sometimes associated with burning or sharp penile  pains during ejaculation. Urethritis or prostatitis can make genital stimulation painful or uncomfortable. Anatomic deformities of the penis, such as exist in Peyronie's disease, may also result in pain during coitus. One cause of painful intercourse is due to the painful retraction of a too-tight foreskin, occurring either during the first attempt at intercourse or subsequent to tightening or scarring following inflammation or local infection. Another cause of painful intercourse is due to tension in a short and slender frenulum, frenulum breve, as the foreskin retracts on entry to the vagina irrespective of lubrication. In one study frenulum  breve was found in 50% of patients who presented with dyspareunia. During vigorous or deep or tight intercourse or masturbation, small tears may occur in the frenum of the foreskin and can bleed and be very painful and induce anxiety, which can become chronic if left unresolved. If stretching fails to ease the condition, and uncomfortable levels of tension remain, a frenuloplasty procedure may be recommended. Frenuloplasty is an effective procedure, with a high chance of avoiding circumcision, giving good functional results and patient satisfaction. The psychological effects of these conditions, while little understood, are real, and are visible in  literature and art. Diagnosis. Differential diagnosis. Dyspareunia is a condition that has many causes and is not a diagnosis of itself. It is combined with vaginismus into genito-pelvic pain/penetration disorder in the DSM-5. Criteria for genito-pelvic pain/penetration disorder include multiple episodes of difficulty with vaginal penetration, pain associated with intercourse attempts, anticipation of pain due to attempted intercourse, and tensing of the pelvis in response to attempted penetration. To meet criteria for this disorder, a patient must experience the symptoms for at least six months and suffer "significant distress". The differential diagnosis for dyspareunia is long  because of its complicated and multifactorial nature. Often there are physiologic conditions underlying the pain, as well as psychosocial components that must be assessed to find appropriate treatment. A differential diagnosis of underlying physical causes can be guided by whether the pain is deep or superficial: Treatment. The treatment for pain with intercourse depends on what is causing the pain. After proper diagnosis one or more treatments for specific causes may be necessary. For example: In addition, the following may reduce discomfort with intercourse: History. The word "dyspareunia" comes from Greek δυσ-, "dys-" "bad" and πάρευνος, "pareunos" "bedfellow", meaning "badly  mated". The previous "Diagnostic and Statistical Manual of Mental Disorders", the "DSM-IV", stated that the diagnosis of dyspareunia is made when the patient complains of recurrent or persistent genital pain before, during, or after sexual intercourse that is not caused exclusively by lack of lubrication or by vaginal spasm (vaginismus). After the text revision of the fourth edition of the DSM, a debate arose, with arguments to recategorize dyspareunia as a pain disorder instead of a sex disorder, with Charles Allen Moser, a physician, arguing for the removal of dyspareunia from the manual altogether. The most recent version, the  DSM 5, has grouped dyspareunia under the diagnosis of Genito-Pelvic Pain/Penetration Disorder.