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DYSPAREUNIA

Group members:
Neerupa Kissoon
Priya Kissoon Navita Mahabir Ravidya Shripat Janelle Seecharan

dyspareunia
CASE Mrs.M is a 21 year old female who was married 6 months ago
Mrs.M has been experiencing superficial dyspareunia for a period of 6 months on a frequent basis. Her first sexual encounter was with her husband on their wedding night. Mrs.M grew up in a sheltered home with parents who were extremely conservative and did not embrace physical affection. Over the past 2 months she has had a strained relationship with her husband as he has accused her of not spending time with him. She is a 2nd year psychology student at U.W.I. and complains about being very stresses out trying to balance her marratial duties with her school work Mrs.M has come to you who has been her GP for a number of years for advice before proceeding further.

SOCIAL ISSUES TO ADDRESS

Mrs.M is 21 years old. She grew up in a conservative environment where physical

affection was frowned upon.

Newly married
She was a virgin prior to marriage

She finds it difficult to balance school & home life

She now has a strained relationship with husband.

DEFINITION
Dyspareunia is abnormal pain during or after sexual

intercourse.
It may occur in men, but is far more common in women. Women with dyspareunia may experience pain in the

vagina, clitoris or labia

Prevalence: >39% women complain Risk factors: -sexual inexperience -menopause Causes: -abnormal conditions of the genitalia, -dysfunctional psychophysiologic reaction to sexual union -forcible coition -incomplete sexual arousal

AETIOLOGY: SUPERFICIAL dyspareunia

1.Insufficient lubrication Inadequate foreplay Drop in oestrogen levels after menopause After childbirth Drugs eg antihypertensives, antidepressants Injury or irritation from an accident Pelvic surgery, Episiotomy Congenital abnormality. Genital tract infections Urinary tract infections Eczema Allergic reactions Improperly fitted diaphragm Involuntary spasms of the muscles of the vaginal wall

2.Injury, trauma or irritation

3.Inflammation, infection or skin disorders

4.Reactions to birth control products 5.Vaginismus

AETIOLOGY: DEEP dyspareunia

Certain illnesses and conditions: endometriosis, pelvic

inflammatory disease, uterine prolapse, retroverted uterus, uterine fibroids, cystitis, irritable bowel syndrome, hemorrhoids and ovarian cysts.

Infections. An infection of the cervix, uterus or fallopian tubes can

cause deep pain.

Surgeries Treatment: Scarring from surgeries involving the pelvic

area such as a hysterectomy painful intercourse.

Medical Treatments: cancer treatment, such as radiation and

chemotherapy, can cause changes that make sex painful.

AETIOLOGY:EMOTIONAL FACTORS
Psychological problems: Anxiety, depression, concerns about ones physical appearance, fear of intimacy or relationship

problems all low level of arousal resulting in discomfort or pain.

Stress: The pelvic floor muscles are very sensitive to stress. Stress can painful intercourse.

The Consultation : History

Questions to ask:
1. When did it start (recent or recurrent problem)? 2. Have you tried artificial lubricants? 3. Sexual history : to help assess the risk of stds 4. Any sexual abuse / trauma to the genitals, including childbirth? 5. Symptoms of the menopause? 6. Symptomatic uteral prolapse? 7. Symptoms of a UTI? 8. Breast-feeding (can lead to vaginal dryness and dyspareunia) 9. Note comorbid medical history

The Consultation: Examination

1)

Abdominal Examination a. Masses b. Suprapubic tenderness

2. Skin disease 3. Vaginal Examination Any obvious reflex tightening psychological problems may be the result rather than the cause of pain 4. Vaginal secretions Normal or sparse?

EXAMINATION CONTD
6)

Scarring, inflammation or infection

Candida, herpes simplex or genital warts

7. Gently palpate for pelvic masses, tenderness or lack of mobility of the pelvic organs. This suggests endometriosis. 7) Cervical excitation pain suggests pelvic inflammatory disease (PID). Take swabs at this point. 8) Tenderness on posterior palpation of the rectum is common in irritable bowel syndrome (IBS).

Differentials
Pain with arousal
Sensitive external genitalia Pain at introitus with entry of penis Midvaginal pain Pain with orgasm Pain with deep penetration

MANAGEMENT
1. Use of a water based lubricant * Use silicone based lubricant if water based lubricant causes irritation * It is not advised to use petroleum jelly, baby oil, mineral oil with condoms
2. Try different sexual positions to minimize pain

MANAGEMENT
3. Time for sex should be set aside when the patient or her partner is not tired or anxious 4. The patient needs to talk to her partner concerning where she feels pain as well as what activities she finds pleasurable
5. Try sexual activities that do not cause pain eg. Oral sex or mutual masturbation

MANAGEMENT
6. Take pain relieving steps before sex a. Emptying her bladder b. Taking a warm bath c. Over the counter pain relievers before intercourse 7.To relieve burning after intercourse, the patient can apply ice or a frozen gel pack wrapped in a small towel to the vulva.

MANGAGEMENT
8. Pelvic muscle relaxation exercises 9. Anaesthetic ointments 10. Sitz baths
More specific treatment depends on the cause 11. Topical steroids:dermatolgical problems 12. Topical estrogens:improve atrophic changes 13. Infections: Antibiotics, antifungal drugs etc. 14. Cysts, abscesses : surgical correction 15. Uterine prolapse : pessary insertion, surgery

THE END IS HERE :-)