Dr. Rebecca B. Singson, FPOGS, FACS, FPSCPC, LMT

Athough statistics show that one third of our youth are already engaging in pre-marital sex, there are still the two thirds who approach marriage keeping their virginity intact. There are still women who value their virginity as something they would reserve for their spouse.

Whether done premaritally or with the blessings of marriage, first time intercourse is approached with mixed reactions of anxiety, excitement, arousal and even fear. What can be done to make it as least traumatic as possible?

WHAT IS DYSPAREUNIA?

Dyspareunia (“dis-par-oon-ya”) is painful sex, due to medical or psychological reasons. It is used mostly to describe women, although men can also suffer pain during sexual contact. Most of the time, the cause can be reversed, even when long-standing, but for some, it may be a recurrent ordeal. When pain occurs, the woman experiencing dyspareunia may be distracted from feeling pleasure and excitement. Both vaginal lubrication and vaginal dilation decrease and she may begin to have a negative association with sex just anticipating the pain.

WHAT ARE THE CAUSES?

Pain during sex may happen in any part of the genitals. It is important to differentiate whether the pain happens upon penetration or on deep penetration or if it happens way after intercourse is over, because the causes may be entirely different.

Superficial dyspareunia is pain upon entry. The pain from these conditions is usually felt when a tampon or penis is inserted into the vagina. Sometimes, even sitting or wearing pants can cause discomfort. The most common cause of painful entry is lack of lubrication from lack of foreplay where the woman has not been “warmed up” by her partner and has, therefore, not been lubricated well enough. A man can reach his orgasm in 2 mins. but for a woman, it is prudent to spend at least 20 mins. on foreplay and insure the female genitals are well-flooded before entry begins. In pre-menopausal or menopausal women, this can be real concern because when estrogen wanes during this time of the woman’s life, the vulvar and vaginal skin thins out, dries out, and produces less lubrication which comes from transudation through the vaginal skin.

Dermatologic conditions can also cause pain upon entry. Sometimes it can be caused by something as simple as using soap to wash the external genitals or using the wrong vaginal wash. Frequent douching or washing especially with soaps or the wrong vaginal wash can kill the good bacteria or cause allergies from the chemicals used. Most soaps (even the mildest such as baby soap or Ivory or Dove) have a ph of 7 and above, meaning it has an alkaline ph. That is appropriate to cleanse the skin of the rest of the body but the female genitals need to maintain a ph of 3.5-5.5 to keep alive the protective bacteria, the lactobacilli, and doing their job of protecting you from fungal and bacterial infections. Tipping off the ph can make you prone to yeast infections or to bacterial vaginosis which can manifest with a discharge, a foul smell (more typical with bacterial vaginosis described as “fishy odor”) and skin irritation. This is the reason vaginal washes were produced to keep the vagina at the appropriate ph. However, not all vaginal washes are created alike. Some are more irritating than others because of the chemicals used to disinfect, color or perfume the solution. It is best to stick to lactic acid-based washes.

A viral infection such as Herpes can also produce painful sores on the genitals, both for males and females that can be transmitted to an uninfected partner, aside from increasing your predisposition to fungal infections. An infection of the Bartholin’s gland at the opening of the vaginal may produce a swelling or inflammation that may make entry during sex painful. A scar tissue from a previous episiotomy (cut on the perineum during a normal birth) can also cause pain during intercourse.

Vulvar Vestibulitis Syndrome (VVS) is the most common subtype of vulvodynia (medical term meaning chronic vulvar discomfort e.g. burning, stinging, irritation, rawness). affecting premenopausal women. It tends to be associated with a highly localized “burning” or “cutting” type of pain. The woman senses the irritation and burning which can be felt hours or days after sex, giving one a sense of hopelessness and depression (Bergeron et al. 1997; Marinoff and Turner 1991;[2] Peckham et al. 1986).

The prevalence of VVS is quite high: affecting 10%-15% of women seeking gynecological care (Bergeron et al. 1997). You can feel severe pain at the opening of the vagina with attempted penetration and after penetration you become sore and tender with pressure. Your doctor can apply the cotton-swab test, in which pressure is applied in a circular fashion around the vulvar vestibule to assess complaints of pain. The causes may include a subclinical human papillomavirus infection, chronic recurrent candidiasis, or chronic recurrent bacterial vaginosis (Marinoff and Turner 1991; Peckham et al. 1986) or it could result from chronic hypertonic perivaginal muscles, leading to vaginal tightening and subsequent pain. Some researchers even believe there is a neurological cause to it relating to thickened changes of the nerves. Finally, psychological factors may even worsen the problem, because the moment you think or desire sex upon arousal, it causes you to anticipate the pain, thus resulting in a conditioned spasmodic reflex . Problems with your spouse then emerge with chronic frustration, disappointment, and depression along with it.

Deep dyspareunia is pain on deep penetration or deep thrusting can be caused by a chronic pelvic inflammatory disease such as gonorrhea or Chlamydia or by endometriosis (condition where the lining of the uterus implants outside the uterus so everytime you menstruate, you bleed into the abdominal cavity). Pelvic masses such as myomas or ovarian cysts can also cause pain.

Vaginismus (“vag-in-is-mus”) is a spasm of the muscles around the vagina, sometimes so severe that penile penetration is impossible. Causes can be from past sexual abuse, painful 1st sexual intercourse or gynecologic examination, religious brainwashing to think that sex is “bad or dirty” or a misconception in the size of the vagina, an unopened hymen (yes, anatomic defect where there is no hole), chronic infection like gonorrhea or Chlamydia.

Interstitial Cystitis (IC). is now a recognized cause of dyspareunia. It is a condition where patients may struggle with bladder pain and discomfort during or after sex. For women with IC, pain usually occurs the following day, the result of painful, spasmodic contractions of the pelvic floor muscles. Men are not spared from this condition since pain occurs at the moment of ejaculation and is focused at the tip of the penis. Interstitial cystitis patients also struggle with urinary frequency and/or urinary urgency.

Dyspareunia in Men

In men, as in women, there are a number of physical factors that may cause sexual discomfort. Sometimes, immediatlely after ejacuation, pain is experienced in the testicular or glans area of the penis. This may be caused by infections of the prostate, bladder, or seminal vesicles can lead to post-ejaculatory intense burning or itching. Men suffering from interstitial cystitis and gonorrhea may also experience intense pain at the moment of ejaculation. Urethritis or prostatitis can likewise make genital stimulation painful or uncomfortable. Anatomic deformities of the penis such as Peyronie’s disease should also be ruled out since it may also result in pain during coitus. One not-so-obvious cause of painful intercourse may be 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 (Bancroft 1989). During vigorous intercourse or masturbation, small tears may occur in the frenulum of the foreskin and can be very painful.

A rare form of male dyspareunia – postejaculatory pain syndrome – manifests with persistent and recurring pain described as sharp, stabbing and/or burning, in the genital organs during ejaculation or immediately thereafter. Although the pain lasts only briefly, it can persist and be quite intense. Although the immediate cause of this psychogenic problem is the involuntary painful spasm or cramping of certain pain-sensitive muscles in the male genital and reproductive organs, the excruciatingly 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. Spasmodic, inflammed, overtoned or shortened pelvic muscles can result in the compression or sometimes the entrapment of the pudendal nerve, the nerve supplying the pelvic floor.

Guilt about sexual pleasure or about the paraphiliac nature(a sexual deviation where sexual fantasies revolve around a non-human object or a non-consenting partner like a child, or involving pain or humiliation of self or partner) of the erotic fantasies can lead to pain with orgasm. In other cases, men who want sexual freedom but is with a sexually inhibited partner may feel general resentment, or be angry at their current sexual partners for unconscious or conscious reasons.

WHAT CAN BE DONE

Seek counsel with your obstetrician who can differentiate the diagnosis based on your symptoms.Your Ob-gyn must elicit a complete history and perform a physical exam to determine where is the exact pain, what triggers it and timing of the pain. For dypareunia due to lack of lubrication, lubricants abound in the market (Felina, Astroglide and Replens are recommended brands). Bartholin Duct cysts can be excised. Laboratory tests to exclude fungal, bacterial or viral infection must be done. It atrophy of the skin seems to be the cause, hormone replacement therapy is available either orally, transdermally or even locally with vaginal tablets. For deep dyspareunia, an ultrasound or CT scan may clinch the diagnosis. Tumors may be removed surgically and endometriosis may be removed surgically or medically depending on size and extent. Management of psychiatric causes is the most challenging because sex therapists do not abound although the problem of sexual dysfunction does. However, whatever the cause is, professional help is necessary to alleviate the problem of painful intercourse. Admitting it and resolving to seek consult for it can be the first step to an improved sex life and a more wholesome relationship.