“Will I ever enjoy sex again?”

“Is there something wrong with me?”

“Is the pain all in my head?”

“I am afraid of the pain.”

“Can my relationship survive this pain?”

“I don’t care if I never have sex again.”

These are common statements we hear from sex therapy clients who endure pain during sex.

There is an estimated 6.5-45% of older women and 14-34% of younger women who experience pain from vaginal touch or penetration during sexual activity. The medical term for this pain is dyspareunia.

Several causes of genital pain and dyspareunia in women are:

• Underlying physical pathologies

  • Endometriosis

  • Interstitial cystitis

  • Lichen sclerosis

  • Genital infections such as Candidiasis, Herpes, or Bacterial vaginosis

• Events like childbirth and menopause

• Vulvodynia

What is Vulvodynia?

Vulvodynia is characterized by burning pain for which there are no relevant physical findings. The International Society for the Study of Vulvovaginal Disease (ISSVD) classifies vulvodynia into two symptom presentations of localized (involves a portion of the vulva) and generalized (involves the entire vulva).

The most common type of vulvodynia is provoked vestibulodynia (PVD), which is characterized by burning pain triggered by pressure to the vulvar vestibule or attempted vaginal penetration in sexual or non-sexual contexts. Some women report pain deeper in the vaginal canal, which is referred to as deep dyspareunia or pelvic pain. There is limited research conducted on deep dyspareunia.

Vulvodynia falls into one of three categories:

• Muscular, which is usually treated with the help of a pelvic floor physical therapist.

• Hormonally mediated, which is often due to continuous birth control pill usage and can be treated by going off the birth control pill and using an appropriate topical medication.

• Primary or neuroproliferative, which is due to too many nerve endings in the affected area. This is usually treated through a surgery called vulvectomy.

Diagnosis of Genital Pain

The DSM 5, the Diagnostic and Statistical Manual of Mental Disorders (5th Edition), utilizes the diagnostic term dyspareunia in the category of sexual dysfunction. In addition, the diagnosis of dyspareunia and vaginismus have been collapsed into a single diagnostic entity titled genitopelvic pain/penetration disorder.

To receive a diagnosis of genitopelvic pain/penetration disorder, a woman must be dealing with at least one of the following:

• Difficulty experiencing vaginal penetration

• Pain from vaginal penetration

• Fear of vaginal penetration or of pain during vaginal penetration

• Pelvic floor muscle dysfunction

Genital Pain Assessment

It has been found that only 60% of women who reported chronic genital pain sought treatment, and 40% of those women never received a diagnosis. Unlike many areas of medicine, a sex therapy practice utilizes direct questions via a psychosexual assessment to gain information about sexual problems.  

The psychosexual assessment gathers information about:

• Properties of the pain; onset, pattern, duration, location (deep or superficial), quality and severity

• Personal explanations for the pain

• Factors that make it worse and better

• Previous treatment attempts and the outcome

• Determine if the pain occurs during non-sexual activities

• Interference of the pain and other issues such as other sexual problems, relationship, or psychological distress

• Determine how the pain impacts relationship dynamics and how relationship factors may affect the pain

• Obtain a full sexual history

• Assess the cognitive, affective, behavioral and interpersonal dimensions of the pain in both the woman and her partner

  • Cognitive distortions usually play a significant role in genital pain and treatment outcomes, including catastrophizing, hypervigilance and pain self-efficacy (the belief in one’s ability to control the pain)

  • Fear of pain and heightened anxiety and depression are common

  • Experiencing pain leads to avoidance of sexual activities

Direct questions are necessary, as many women will not volunteer information about sexual issues.

Etiology: Causes of Genital Pain

Genital Pain in Women

There are a number of biomedical risk factors found in women with genital pain:

• Early puberty

• Pain with first tampon use

• Vulvovaginal and urinary tract infections

• Early and prolonged use of contraceptives

• Nociceptor proliferation and sensitization

• Lower touch and pain thresholds

• Peripheral and central mechanisms such as recurrent yeast infections

• Muscle abnormalities like hypertonicity, poor muscle control, hypersensitivity, and increased mucosal sensitivity

In addition to biomedical risk factors, there are cognitive, affective and behavioral factors that can lead to genital pain. Some examples include childhood sexual abuse, catastrophizing, fear of pain, hypervigilance to pain, lower self-efficacy, negative attributions about the pain, and anxiety (fear-avoidance model).

Genital Pain in Men

Up until now, we have focused on genital pain in women, but genital pain can also occur in men. There is very little literature on male genital pain, and the literature that does exist focuses on pain with erection or ejaculation. Prevalence rates of genital pain in men range from 5-15%.

Male dyspareunia was excluded from the DSM 5 due to lack of sufficient data. Male genital pain can be diagnosed as urological chronic pelvic pain syndrome (UCPPS), which describes a variety of urogenital pain symptoms due to different conditions such as chronic pelvic pain syndrome (CPPS) and interstitial cystitis.

In addition, anodyspareunia is recurrent or persistent anal pain experienced by the receptive partner in anal intercourse. Prevalence rates for this range from 12-14% of men who have sex with men. It has been found that patterns of sensitivity, pelvic floor muscle function, neural activation and structures in males with UCCPS closely mirror findings in women with PVD.

In our next blog post, we’ll cover the treatment for genital pain. If you suffer from any pain during sex, reach out to schedule an appointment to meet with our Sioux Falls therapists.