Dyspareunia (Painful Intercourse)

Dyspareunia is persistent or recurrent genital pain associated with sexual intercourse, defined in DSM-5 within Genito-Pelvic Pain/Penetration Disorder, and ICD-11 separately. Classification by location: superficial (introital/entrance — pain at vaginal opening, often vulvar vestibulodynia), deep (pelvic — pain with deep penetration, often related to internal pelvic structures); by onset: primary (present from first sexual experience), secondary (developed after period of pain-free intercourse); by setting: situational (specific contexts/partners) or generalized; by relation to penetration: provoked (only with specific stimulation) or spontaneous. Estimated prevalence 10-20% of women in general populations, higher in postmenopausal women (40-50%), 1-5% of men.

Etiology is multifactorial. Vulvar/superficial causes: provoked vestibulodynia (pain at vestibule with touch — most common cause in young women, formerly vulvar vestibulitis), generalized vulvodynia, vulvovaginal atrophy from estrogen deficiency (postmenopause, lactation, oral contraceptives), lichen sclerosus, lichen planus, vulvar dermatoses, vulvar contact dermatitis, recurrent vulvovaginal candidiasis, herpes, bartholin gland abnormalities, episiotomy scarring, female genital cutting, hymenal abnormalities, vaginismus (involuntary muscle spasm). Deep dyspareunia causes: endometriosis (most common), pelvic inflammatory disease, adenomyosis, uterine fibroids, ovarian cysts, pelvic adhesions, retroverted uterus, pelvic congestion syndrome, levator ani myofascial pain, interstitial cystitis/painful bladder syndrome, irritable bowel syndrome, pudendal neuralgia. Male dyspareunia: phimosis, paraphimosis, balanitis, prostatitis, Peyronie's disease, urethritis, testicular pain. Psychological factors: anxiety, depression, sexual abuse history, relationship problems, body image concerns, sexual misinformation.

Diagnosis requires comprehensive biopsychosocial evaluation: detailed sexual and medical history (timing, location, quality, exacerbating/relieving factors, partner relationships), psychosocial assessment, physical examination including external genital inspection (lichen, atrophy, lesions), Q-tip test for vestibulodynia (mapping painful points on vulvar vestibule), bimanual pelvic examination evaluating tenderness, masses, organ position, levator ani assessment, transvaginal ultrasound for deep dyspareunia, MRI pelvis if endometriosis or deep infiltrating lesions suspected, hysterosalpingography, laparoscopy as gold standard for endometriosis, vaginal cultures for infections. Treatment is etiology-specific and multimodal: vulvovaginal atrophy — local estrogen, moisturizers, lubricants, ospemifene; vestibulodynia — topical lidocaine, gabapentin/pregabalin, tricyclic antidepressants, pelvic floor physiotherapy, cognitive-behavioral therapy, capsaicin, surgical vestibulectomy as last resort; vaginismus — pelvic floor PT with dilator therapy, sex therapy; endometriosis — hormonal suppression (continuous OCPs, GnRH agonists/antagonists, dienogest), surgical excision; pelvic floor dysfunction — physiotherapy with biofeedback, trigger point injections, botulinum toxin; psychosocial — couples counseling, cognitive-behavioral therapy, mindfulness-based therapy, treating underlying anxiety/depression. Multidisciplinary team essential.