Pain After Intercourse...

Dyspareunia (painful intercourse) is a common complaint among women. Although this condition may occasionally happen, some women have pain with every episode of sexual relations. The cause of dyspareunia can usually be identified and treated.

There are three main types of painful intercourse. The least common is usually due to uterine contractions occurring only after intercourse or orgasm. This pain is often relived by taking medications such as non-steroidal anti-inflammatory drugs eg ibrufen, which can block pain from uterine contractions. Another source of this type of pain is an allergy to semen, which is actually quite uncommon. After her partner ejaculates there can be an intense burning sensation and redness around the vagina and vulva ('the outer lips' of the vagina). There have actually been a few reported cases of women going into shock after sexual intercourse due to an allergy to semen. A third cause of pain after intercourse is a vaginal infection, such as a yeast infection, which can cause a burning sensation within the vagina due to irritation.

Pain immediately upon penetration or touching the outer lips of the vagina can be caused by a variety of medical problems. For example, herpes infections cause blisters which are very tender to the touch. A scrape or small cut at the entrance to the vagina can create pain. Some women have a hymen that does not completely resolve after their first few attempts at intercourse, which can cause an intensely painful sensation upon penetration. Some infections, such as yeast infections or bacterial vaginosis, create irritation of the vulvar or vaginal tissue, leading to immediate pain with sex. And dermatological conditions such as squamous hyperplasia or lichen sclerosus may cause damage to the vulvar skin, making it tender to the touch. Inadequate lubrication may also cause pain. The diagnosis of these conditions requires a thorough gynecologic exam, and, in a few cases, a small biopsy of the skin using local anesthesia in the office. Another problem that can cause entry pain is vaginismus, where the vaginal muscles contract involuntarily, making penetration extremely painful or impossible. This may be due to a subconscious response to prior pain, where the body tries to protect itself from pain by 'closing off' the vagina, or may be due to psychological pain, in women who have an abuse history or who are fearful of sexual activity. As with any condition with a potential psychological component, there is controversy about this disorder. I have found it uncommon in my practice, but it must be considered in the differential diagnosis of conditions that can cause painful intercourse. Treatment for these conditions is antibiotics for infection, steroid creams for the dermatologic problems, a vaginal dilator or minor surgery for a partially intact hymen, and counseling and vaginal dilators for vaginismus. Lack of lubrication can be treated with water-based lubricants (NOT vaseline which may be harmful to vaginal tissues).

Probably the most common type of pain with intercourse is 'deep thrust' dyspareunia, where deep penile penetration causes pain. This is common during passionate sexual relations, and can come and go depending on the position used during intercourse. Many conditions can cause this type of pain, including a prolapsed uterus (where the cervix and uterus are 'falling out' of the vagina due to relaxation of the tissues that hold them up within the vagina), a 'fallen bladder' due to childbirth, scar tissue around the uterus or ovaries (called adhesions), an ovarian cyst (although this is an uncommon cause of such pain), large uterine fibroids (non-cancerous tumors of the uterus), and endometriosis, a condition where tiny implants of blood from the uterus stick to the female organs and cause pain. Many women suffer from irritable bowel syndrome, and intercourse can cause the uterus to hit the intestines causing pain. Medical studies have shown that many women with this condition are reluctant to engage in sexual relations due to fear of pain or accidental release of gas or feces during intercourse. Some of these causes of deep-thrust dyspareunia are difficult to diagnose, and may require multiple exams and even outpatient laparoscopic surgery. Laparoscopy, sometimes called 'belly button surgery' is an outpatient surgery where a lighted tube is inserted into the belly button to directly view the internal pelvic (female) organs to diagnose and treat problems. Treatment of these conditions may require various medications or even surgery, and requires the input of a health care professional experienced with these types of problems.

In summary, a number of conditions can cause painful intercourse. Contrary to popular belief psychological causes are very unusual, and medical causes are usually the culprit. Therefore women experiencing painful intercourse on a regular basis should seek the care of a gynecologist or other women's health care provider with experience in painful intercourse. With a little detective work and cooperation between the patient and her doctor, treatment can be provided that will lead to a more healthy and enjoyable sex life.

David Ashley Hill, M.D.
Associate Director
Department of Obstetrics and Gynecology
Florida Hospital Family Practice Residency
Orlando, Florida

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