Dyspareunia

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vishnu Vardhan Serla M.B.B.S. [2]Roghayeh Marandi

Dyspareunia is painful sexual intercourse due to medical or psychological causes. The term is used almost exclusively in women, although the problem can also occur in men. Even when long-standing, the causes are often reversible, but self-perpetuating pain is a factor after the original cause has been removed. Dyspareunia is considered to be primarily a physical, rather than an emotional problem until proven otherwise. In most instances of dyspareunia, there is an original physical cause. Extreme forms, in which the woman’s pelvic floor musculature contracts involuntarily, is termed vaginismus.Based on Diagnosis Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013),dyspareunia and vaginismus were typically classified as distinct sexual pain disorders. This new classification unifies vaginismus and dyspareunia into one category called “genito-pelvic pain/penetration disorder” due to the clinical difficulties in distinguishing these conditions. GPPPD is an umbrella term for two sexual pain disorders:dyspareunia and vaginismus, because in practice, it is difficult to differentiate these two from each other. Sometimes the pain may cause pelvic muscle spasms or involuntary pelvic muscle spasms in vaginismus to cause pain. However, possible medical causes of dyspareunia should be ruled out or treated before considering a diagnosis of genito-pelvic pain/penetration disorder(GPPPD). If a medical cause is successfully treated, and pain has not been resolved yet, a diagnosis of vulvodynia or genito-pelvic/penetration disorder is appropriate to be considered.

There is limited information about the historical perspective of dyspareunia.

Dyspareunia may be classified into different types based on its location, onset, and frequency in women. Male dyspareunia is divided into broad categories of underlying causes ranging from anatomic anomalies to psychosocial problems.

pathophysiology of genito-pelvic pain/penetration disorder can be considered as multifactorial, multisystemic, or complex. If pain is due to a physical cause, the pathophysiology of the underlying cause should be considered.

Common causes of dyspareunia in premenopausal women include the most frequent biological etiologies of dyspareunia which are vulvar vestibulitis/provoked vestibulodynia, with recurrent candida infections and/or a hyperactive pelvic floor in the background, and painful outcomes of delivery (either because of episiotomy/rraphy, or traumatic deliveries). Endometriosis, chronic pelvic pain, and pelvic inflammatory disease are leading contributors of deep dyspareunia in premenopausal women. Common causes of dyspareunia in postmenopausal women include vaginal dryness and vulvovaginal dystrophy, which are the leading etiological factors of dyspareunia, and may concur to deep dyspareunia, with iatrogenic factors such as surgical shortening of the vagina and/or radiotherapy contributing to deep sexual pain. Possible medical causes of dyspareunia should be ruled out or treated before considering a diagnosis of Genito-Pelvic Pain/Penetration Disorder(GPPPD). If a medical cause is successfully treated and pain has not been resolved yet, a diagnosis of vulvodynia or genito-pelvic/penetration disorder is appropriate to be considered.

Genito-pelvic/penetration disorder(GPPPD) must be differentiated from other medical causes of dyspareunia in women. The medical causes of dyspareunia such as Endometriosis,Atrophic vaginitis,Vaginal dryness, Infections(Human papillomavirus, Herpes simplex virus, Pelvic inflammatory disease, Chronic salpingitis, uterine fibroids, pelvic adhesions, adnexal pathology, retroverted uterus, chronic cervicitis, pelvic congestion, genitourinary( urethritis, cystitis, Interstitial cystitis, psychological problems such as anxiety, depression, inadequate sexual stimuli,lichen sclerosis,pelvic inflammatory disease.

The World Health Organization reported a global prevalence of dyspareunia ranging between 8% and 21.1% in 2006, which varied by country.

Risk factors vary base on the underlying cause of dyspareunia. For example, the history of Physical abuse, Sexual abuse are risk factors of vaginismus.

The symptom of dyspareunia is pain during intercourse/penetration, which could be either introital (at the vaginal entrance), deep (in the vagina or pelvis), or both. Dyspareunia can have a negative impact on a patient’s mental and physical health, body image, relationships with partners, and efforts to conceive. It can affect the quality of life. It can lead to, or be associated with other female sexual dysfunction disorders, such as decreased libido, decreased arousal, and anorgasmia. Prognosis may vary based on the cause of dyspareunia.

There are no established criteria for the diagnosis of dyspareunia. Based on Diagnosis Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013),dyspareunia and vaginismus were typically classified as distinct sexual pain disorders. This new classification unifies vaginismus and dyspareunia into one category called “genito-pelvic pain/penetration disorder” due to the clinical difficulties in distinguishing these conditions. GPPPD is an umbrella term for two sexual pain disorders:dyspareunia and vaginismus, because in practice, it is difficult to differentiate these two from each other. Sometimes the pain may cause pelvic muscle spasms or involuntary pelvic muscle spasms in vaginismus to cause pain. However, possible medical causes of dyspareunia should be ruled out or treated before considering a diagnosis of Genito-Pelvic Pain/Penetration Disorder(GPPPD). If a medical cause is successfully treated and pain has not been resolved yet, a diagnosis of vulvodynia or genito-pelvic/penetration disorder is appropriate

The hallmark of dyspareunia is pain before, during, or after sexual activity. Symptoms such as :itching, burning, irritation, abnormal discharge can be associated with it.

The presence of erythema, discharge, atrophy or ulceration, growth, deformity, or warts on external genitalia or lesions on the cervix and internal genitalia can be suggestive of dyspareunia. The presence of pain on the cotton-swab test is diagnostic of localized provoked vulvodynia.

Different laboratory findings can be seen in patient with dyspareunia based on the underlying cause.Laboratory tests that help to the diagnosis of the underlying cause of dyspareunia include:Vaginal secretions analysis for infections, NAAT test for gonorrhea, chlamydia, trichomonas, Herpes simplex virus (HSV) culture, HSV-1 and HSV-2 type-specific IgG antibodies, Rapid plasma reagent (RPR), Vulvar or vaginal biopsy for dermatological problems, malignancy, Urine analysis, culture for urological problems, Blood count, Glucose, Hormones: prolactin, TSH, FSH,LH, Testosterone

There are no x-ray findings associated with dyspareunia.

There are no echocardiography findings associated with dyspareunia. Ultrasound may be helpful in the diagnosis of the underlying cause of dyspareunia.

Ct-Scan may be helpful in the diagnosis of the underlying cause of dyspareunia such as pelvic tumors.

There are no MRI findings associated with dyspareunia.

There are no other imaging findings associated with dyspareunia.

Laparoscopy may be helpful in the diagnosis of the underlying cause of dyspareunia.

The mainstay of treatment for dyspareunia is the treatment of the underlying cause. Non-Medical treatment also should be considered.Educate patients about pelvic anatomy, physiology, and lifestyle modification. Psychological intervention, often in the form of CBT can be helpful.

Surgery is performed as a last resort when all conservative and medical management options have failed or when surgery is indicated in situations such as endometriosis to remove the topic uterine tissue.

There are no established measures for the primary prevention of dyspareunia, but can prevent of some of the causes of dyspareunia, for example: prevent sexually transmitted diseases (STDs) by using condoms or other barriers, get proper routine medical care, use proper hygiene, wait at least six weeks before resuming sexual intercourse after childbirth.

Effective measures for the secondary prevention of dyspareunia depends on the underlying cause of it, for example: using a water-soluble lubricant when vaginal dryness is an issue, encouraging natural vaginal lubrication with enough time for foreplay and stimulation, doing exercise to relieve muscular tightness in vaginismus.

More research must be done to suggest a strong genetic link with Genito-Pelvic Pain/Penetration Disorder (GPPPD).

There is limited information about the historical perspective of dyspareunia.

There is limited information about the historical perspective of dyspareunia.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:

Dyspareunia may be classified into different types based on its location, onset, and frequency in women. Male dyspareunia is divided into broad categories of underlying causes ranging from anatomic anomalies to psychosocial problems.

• Based on Diagnosis Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013),dyspareunia and vaginismus were typically classified as distinct sexual pain disorders. This new classification unifies vaginismus and dyspareunia into one category called “genito-pelvic pain/penetration disorder” due to the clinical difficulties in distinguishing these conditions because, in practice, it is difficult to differentiate these two from each other. Sometimes the pain may cause pelvic muscle spasms or involuntary pelvic muscle spasms in vaginismus to cause pain. GPPPD is an umbrella term for two sexual pain disorders:dyspareunia and vaginismus. However, possible medical causes of dyspareunia should be ruled out or treated before considering a diagnosis of Genito-Pelvic Pain/Penetration Disorder (GPPPD). If a medical cause is successfully treated and pain has not been resolved yet, a diagnosis of vulvodynia or genito-pelvic/penetration disorder is appropriate.^[1]

Dyspareunia may be classified into 2 type: superficial and deep based on its location:

• Superficial, which occurs in or around the vaginal entrance, and is characterized by initial discomfort in initial or attempted penetration of the vaginal introitus. Commonly found in:
• Deep dyspareunia is a pain that occurs with deep vaginal penetration, which results from pelvic thrusting during intercourse. Conditions are associated with deep dyspareunia are:
  • Chronic pelvic pain
  • Endometriosis
  • Chronic PID

It may be classified into 2 type: primary and secondary based on its onset:

• Primary (onset with first sexual experience) Often has psychological causes, such as sexual abuse in childhood, feeling of guilt or shame toward sex or fear of intercourse or painful first intercourse.
• Secondary dyspareunia that its beginning is after a previous sexual activity that was not painful.
  

Dyspareunia can be classified into 2 types: persistent or conditional, based on its frequency:

• Persistent which occurs in all situations, possibly due to physical or psychological factors.
• Conditional dyspareunia that occurs in certain situations.Abdomino-pelvic disorders such as endometriosis, imperforate hymen, vaginal septum, or organic vulvodynia due to infection, lichen sclerosis, or vestibulitis, vaginal infections, prolapse, trauma, or vaginal dryness can cause dyspareunia. It can also be due to gastrointestinal disorders such as chronic constipation, diverticular diseases, inflammatory bowel disease/proctitis. Scarring due to previous pelvic surgery, episiotomy, and perineorraphy, or urological causes such as cystitis, interstitial cystitis, or urethritis can cause dyspareunia as well. Male dyspareunia is divided into broad categories of underlying causes ranging from anatomic anomalies to psychosocial problems. Male dyspareunia is related to the following anatomical structures: 1) prepuce, 2) glans penis, 3) penile shaft, 4) testicles, and 5) urethra and prostate gland. Another classification system defines four broad categories: Isolated painful ejaculation, Chronic prostatitis/chronic pelvic pain, Medical causes, psychological causes.

Male dyspareunia may be classified into broad categories. It may be classified into 5 subtypes based on anatomic anomalies:
(1) prepuce
(2) glans penis
(3) penile shaft
(4) testicles
(5) urethra and prostate gland
Another classification system defines four broad categories for male dyspareunia:

• Isolated painful ejaculation
• Chronic prostatitis/chronic pelvic pain
• Medical causes
• psychological causes.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:

pathophysiology of genito-pelvic pain/ penetration disorder(GPPPD) can be considered as multifactorial, multisystemic, or complex.

Pathophysiology of sexual pain disorders in female can be considered as:^[1][2]

• Multifactorial
• Multisystemic
• Complex

Multifactorial:

• Biological, psychosexual, relational factors can coexist and interact to perpetuate and maintain a woman’s pain response in a woman complaining of coital pain. Over time, these different factors may act as predisposing, precipitating, or perpetuating sexual pain disorders.
  

Multisystemic: sexual function involves:

• Nervous system
• Endocrine system
• Vascular system
• Immunological systems
• Vaginal ecosystem: Vaginal receptiveness may be further modulated by; psychosexual, mental, interpersonal factors that may result in poor arousal with vaginal dryness. Fear of penetration, general muscular arousal secondary to anxiety, defensive contraction of the peri-vaginal muscles, leading to lifelong vaginismus.
  

Complex:Coital pain is greater than the simple peripheral tissue damage that may initially trigger the nociceptive component. When It becomes chronic, the pathophysiology of pain may gradually shift from nociceptive, a friend signal that should induce self-protection and defense, to neuropathic, with progressive involvement of the CNS.^[3]

• If pain is due to a physical cause, the pathophysiology of the underlying cause should be considered.

The pathophysiology of dyspareunia in males depends on the underlying cause, psychosexual and relational factors.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vishnu Vardhan Serla M.B.B.S. [2] Luke Rusowicz-Orazem, B.S. Roghayeh Marandi

Common causes of dyspareunia in premenopausal women include the most frequent biological etiologies of dyspareunia which are vulvar vestibulitis/provoked vestibulodynia, with recurrent candida infections and/or a hyperactive pelvic floor in the background, and painful outcomes of delivery (either because of episiotomy/rraphy, or traumatic deliveries). Endometriosis, chronic pelvic pain, and pelvic inflammatory disease are leading contributors of deep dyspareunia in premenopausal women. Common causes of dyspareunia in postmenopausal women include vaginal dryness and vulvovaginal dystrophy, which are the leading etiological factors of dyspareunia, and may concur to deep dyspareunia, with iatrogenic factors such as surgical shortening of the vagina and/or radiotherapy contributing to deep sexual pain. Possible medical causes of dyspareunia should be ruled out or treated before considering a diagnosis of Genito-Pelvic Pain/Penetration Disorder(GPPPD). If a medical cause is successfully treated, and pain has not been resolved yet, a diagnosis of vulvodynia or genito-pelvic/penetration disorder is appropriate to be considered.

In premenopausal women:

• The most frequent biological etiologies of dyspareunia are vulvar vestibulitis/provoked vestibulodynia, with recurrent candida infections and/or a hyperactive pelvic floor in the background, and painful outcomes of delivery (either because of episiotomy/rraphy, or traumatic deliveries). Endometriosis, chronic pelvic pain, and pelvic inflammatory disease are leading contributors of deep dyspareunia in premenopausal women.

In postmenopausal women:

• vaginal dryness and vulvovaginal dystrophy are leading etiological factors of dyspareunia, and may concur to deep dyspareunia, with iatrogenic factors such as surgical shortening of the vagina and/or radiotherapy contributing to deep sexual pain.

• possible medical causes of dyspareunia should be ruled out or treated before considering a diagnosis of Genito-Pelvic Pain/Penetration Disorder(GPPPD). If a medical cause is successfully treated, and pain has not been resolved yet, a diagnosis of vulvodynia or genito-pelvic/penetration disorder is appropriate to be considered.

Cardiovascular	Hemorrhoids,Anal fissure, Renal nutcracker syndrome , Thrombosed piles
Dermatologic	Allergic contact dermatitis, Healed perineal lacerations, Irritant contact dermatitis, Kraurosis vulvae, Lichen planus, Lichen sclerosus, Obstetric perineal injury
Ear Nose Throat	Sjögren’s syndrome
Endocrine	Menopause, Perimenopause, Prolactin secreting pituitary tumour, Prolactinoma, Reduced estrogen, Reduced libido
Gastroenterologic	Inflammatory bowel disease , Irritable bowel syndrome
Genetic	Congenital absence of lower part of vagina, Müllerian anomalies
Iatrogenic	Episiotomy, Gynecologic surgery, Obstetric surgery, Vaginal surgery
Infectious Disease	Atrophic vaginitis, Atrophic vulvitis, Atrophic vulvovaginitis, Autoimmune interstitial cystitis , Bartholin gland cyst, Bartholinitis, Candida albicans, Candidiasis, Chlamydia, Cystitis, Herpes simplex virus, Herpes virus 2, Pelvic infection, Trichomonas vaginalis, Trichomonas, Trichomoniasis , Urethritis, Urinary tract infection, Vaginitis, Vulva infection, Vulvovaginitis
Musculoskeletal/Orthopedic	Parkinson’s disease, Vaginismus, Vulval dystrophy
Neurologic	Parkinson’s disease, Peripheral neuropathies
Obstetric/Gynecologic	Atrophic vaginitis, Atrophic vulvitis, Atrophic vulvovaginitis, Autoimmune endometriosis , Autoimmune interstitial cystitis , Bartholin gland cyst, Bartholinitis, Chronic pain syndromes, Congenital absence of lower part of vagina, Endometrial conditions, Endometriosis, Episiotomy, Estrogen deficiency, Estrogen-based contraceptives, Female genital mutilation, Genital system cancer , Genital tract tumor, Genital ulcers, Gonorrhea, Gynaecological conditions , Gynecologic surgery, Healed perineal lacerations, Hemorrhoids, Imperforate hymen, Inflamed hymeneal orifice, Lactation, Myofascial pelvic pain syndrome, Narrow vagina, Obstetric perineal injury, Obstetric surgery, Ovarian tumour, Pelvic adhesions, Pelvic disorders, Pelvic infection, Pelvic inflammatory disease, Pelvic malignancy, Pelvic organ prolapse, Pelvic tumor, Perimenopause, Poor vaginal lubrication, Post-childbirth, Prolapsed tender ovaries with retroverted uterus, Remnants of the hymen, Salpingo-oophoritis, Unruptured hymen, Vagina cancer, Vaginal abnormality, Vaginal dryness, Vaginal surgery, Virilising ovarian tumour , Vulva infection, Vulval dystrophy, Vulval neoplasia, Vulvar vestibulitis syndrome , Vulvitis, Vulvovaginitis, Vulvodynia, Vaginismus or Genito-Pelvic Pain/Penetration Disorder(GPPPD) , Provoked vestibulodynia,
Oncologic	Genital system cancer , Genital tract tumor, Ovarian tumour, Pelvic malignancy, Pelvic organ prolapse, Pelvic tumor, Prolactin secreting pituitary tumour, Prolactinoma, Uterine sarcoma , Uterine tumour, Vagina cancer, Virilising ovarian tumour , Vulval neoplasia, Yolk sack tumour
Psychiatric	Anxiety, Depression, Psychological disorders, Reduced libido, Relationship dysfunction
Renal/Electrolyte	Interstitial cystitis, Renal nutcracker syndrome
Rheumatology/Immunology/Allergy	Arthritis of the hips, Fibromyalgia, Kraurosis vulvae, Lichen planus, Menopause, Scleroderma, Sicca syndrome, Sjögren’s syndrome
Sexual	Chlamydia, Estrogen-based contraceptives, Female genital mutilation, Genital ulcers, Gonorrhea, Herpes simplex virus, Herpes virus 2, Trichomonas vaginalis, Trichomonas, Trichomoniasis
Trauma	Allen-masters syndrome , Anal fissure, Cystitis, Trauma
Urologic	Interstitial cystitis, Urethral caruncle, Urethritis, Urinary tract infection, Uterine sarcoma , Uterine tumour
Miscellaneous	Relationship dysfunction

Medical causes	sexually transmitted infections ( STIs) including herpes, thrush or male candidiasis,tight foreskin (Phimosis), prostatitis,growths, cysts, warts, and lumps in the penis,testicular cancer,little tears in the foreskin,problems with ejaculation when the testicles swell and become painful as a result of being sexually stimulated but not ejaculating, penile fracture,Peyronie’s disease, Isolated painful ejaculation due to:Urethritis,Prostatitis,Epididymitis,Orchitis,Abdominal abscess, Penile prosthesis, Bladder cancer,Intra-abdominal tumors, Prostate cancer, Vesical calculi,Benign prostatic hyperplasia (BPH),Urethral stricture,Pelvic musculature spasm,Radical prostatectomy,Transurethral resection of the prostate (TURP),Vasectomy,Frenulum breve), dermatologic conditions of the penis such as:( lichen planus,lichen sclerosis, Zoon’s (plasma cell) balanitis,balanoposthitis)
Psychological causes	history of sexual abuse or trauma,stress,fear,depression,guilt,anxiety around sex,emotional instability,strict religious upbringing
Other causes	allergic reaction and skin irritation to a particular brand of condom or spermicide, sharp pain during penetration can be caused by threads of an intrauterine contraceptive device (for birth control) that protrude from the woman’s cervix

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vishnu Vardhan Serla M.B.B.S. [2]; Jesus Rosario Hernandez, M.D. [3]

Genito-pelvic/penetration disorder(GPPPD) must be differentiated from other medical causes of dyspareunia.

Possible medical causes of dyspareunia should be ruled out or treated before considering a diagnosis of “Genito-Pelvic Pain/Penetration Disorder”. GPPPD is actually an umbrella term for two sexual pain disorders:dyspareunia and vaginismus. (see the following table for differential diagnosis in females)

Cardiovascular	Hemorrhoids,Anal fissure, Renal nutcracker syndrome , Thrombosed piles
Dermatologic	Allergic contact dermatitis, Healed perineal lacerations, Irritant contact dermatitis, Kraurosis vulvae, Lichen planus, Lichen sclerosus, Obstetric perineal injury
Ear Nose Throat	Sjögren’s syndrome
Endocrine	Menopause, Perimenopause, Prolactin secreting pituitary tumour, Prolactinoma, Reduced estrogen, Reduced libido
Gastroenterologic	Inflammatory bowel disease , Irritable bowel syndrome
Genetic	Congenital absence of lower part of vagina, Müllerian anomalies
Iatrogenic	Episiotomy, Gynecologic surgery, Obstetric surgery, Vaginal surgery
Infectious Disease	Atrophic vaginitis, Atrophic vulvitis, Atrophic vulvovaginitis, Autoimmune interstitial cystitis , Bartholin gland cyst, Bartholinitis, Candida albicans, Candidiasis, Chlamydia, Cystitis, Herpes simplex virus, Herpes virus 2, Pelvic infection, Trichomonas vaginalis, Trichomonas, Trichomoniasis , Urethritis, Urinary tract infection, Vaginitis, Vulva infection, Vulvovaginitis
Musculoskeletal/Orthopedic	Parkinson’s disease, Vaginismus, Vulval dystrophy
Neurologic	Parkinson’s disease, Peripheral neuropathies
Obstetric/Gynecologic	Atrophic vaginitis, Atrophic vulvitis, Atrophic vulvovaginitis, Autoimmune endometriosis , Autoimmune interstitial cystitis , Bartholin gland cyst, Bartholinitis, Chronic pain syndromes, Congenital absence of lower part of vagina, Endometrial conditions, Endometriosis, Episiotomy, Estrogen deficiency, Estrogen-based contraceptives, Female genital mutilation, Genital system cancer , Genital tract tumor, Genital ulcers, Gonorrhea, Gynaecological conditions , Gynecologic surgery, Healed perineal lacerations, Hemorrhoids, Imperforate hymen, Inflamed hymeneal orifice, Lactation, Myofascial pelvic pain syndrome, Narrow vagina, Obstetric perineal injury, Obstetric surgery, Ovarian tumour, Pelvic adhesions, Pelvic disorders, Pelvic infection, Pelvic inflammatory disease, Pelvic malignancy, Pelvic organ prolapse, Pelvic tumor, Perimenopause, Poor vaginal lubrication, Post-childbirth, Prolapsed tender ovaries with retroverted uterus, Remnants of the hymen, Salpingo-oophoritis, Unruptured hymen, Vagina cancer, Vaginal abnormality, Vaginal dryness, Vaginal surgery, Virilising ovarian tumour , Vulva infection, Vulval dystrophy, Vulval neoplasia, Vulvar vestibulitis syndrome , Vulvitis, Vulvovaginitis, Vulvodynia, Provoked vestibulodynia,
Oncologic	Genital system cancer , Genital tract tumor, Ovarian tumour, Pelvic malignancy, Pelvic organ prolapse, Pelvic tumor, Prolactin secreting pituitary tumour, Prolactinoma, Uterine sarcoma , Uterine tumour, Vagina cancer, Virilising ovarian tumour , Vulval neoplasia, Yolk sack tumour
Psychiatric	Anxiety, Depression, Psychological disorders, Reduced libido, Relationship dysfunction
Renal/Electrolyte	Interstitial cystitis, Renal nutcracker syndrome
Rheumatology/Immunology/Allergy	Arthritis of the hips, Fibromyalgia, Kraurosis vulvae, Lichen planus, Menopause, Scleroderma, Sicca syndrome, Sjögren’s syndrome
Sexual	Chlamydia, Estrogen-based contraceptives, Female genital mutilation, Genital ulcers, Gonorrhea, Herpes simplex virus, Herpes virus 2, Trichomonas vaginalis, Trichomonas, Trichomoniasis
Trauma	Allen-masters syndrome , Anal fissure, Cystitis, Trauma
Urologic	Interstitial cystitis, Urethral caruncle, Urethritis, Urinary tract infection, Uterine sarcoma , Uterine tumour
Miscellaneous	Relationship dysfunction

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Jesus Rosario Hernandez, M.D. [2]

The World Health Organization reported a global prevalence of dyspareunia ranging between 8% and 21.1% in 2006, which varied by country.

• The World Health Organization reported a global prevalence of dyspareunia ranging between 8% and 21.1% in 2006, which varied by country.^[1]

• Although clinical data suggest that dyspareunia can begin during adolescence, no large-scale epidemiological study has been conducted yet with this population.^[2]

• There is no racial predilection to dyspareunia, although African-American race was found to be a risk factor for pelvic pain.^[3]

• Dyspareunia affects women more than men. It can be seen in men rarely.

• The prevalence of dyspareunia in the United States is approximately 10% to 20%, with the underlying causes varying by age group.^[4]

• The World Health Organization reported a global prevalence of dyspareunia ranging between 8% and 21.1% in 2006, which varied by country. The prevalence of dyspareunia in Brazil is reported ranged from 1.2% to 56.1%, which differs from Puerto Rico’s prevalence rate of 17% to 21%.^[4]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Jesus Rosario Hernandez, M.D. [2]

Risk factors vary base on the underlying cause of dyspareunia.For example, Physical abuse, Sexual abuse are risk factors of vaginismus.

Risk factors vary based on the underlying cause of dyspareunia, for example, risk factors of vaginismus, are:^[1]

• Physical abuse
• Sexual abuse
• Tampon insertion

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Vishnu Vardhan Serla M.B.B.S. [2]; Jesus Rosario Hernandez, M.D. [3]

The symptom of dyspareunia is pain during intercourse/penetration, which could be either introital (at the vaginal entrance), deep (in the vagina or pelvis), or both. Dyspareunia can have a negative impact on a patient’s mental and physical health, body image, relationships with partners, and efforts to conceive. It can affect the quality of life. It can lead to, or be associated with other female sexual dysfunction disorders, such as decreased libido, decreased arousal, and anorgasmia. Prognosis may vary based on the cause of dyspareunia.

• The symptom of dyspareunia is pain during intercourse/penetration which could be either introital (at the vaginal entrance), deep (in the vagina or pelvis), or both.

• Common complications of dyspareunia include:
• Negative impact on a patient’s mental and physical health, body image, relationships with partners, and efforts to a conceive in women.
• Decreased libido
• Decreased arousal
• Anorgasmia

The prognosis may vary depending on the underlying cause of dyspareunia. After the treatment of medical causes, it may fully be resolved. or in vaginismus, poor prognostic factors are:^[1]

• History of physical abuse
• History of sexual abuse
• Inability to insert tampons
• Pain during tampon insertion