Dyspareunia is a term that denotes a recurrent genital pain present just before, during or after sexual intercourse. This is a complex entity linked to multiple medical, biological, psychological, interpersonal and socio-cultural dimensions. Generally the condition is almost unique to women, albeit men can also be affected in rare instances.

Organic Causes of Dyspareunia

A specific type of dyspareunia that refers to spasms of perineal muscles and musculus levator ani (making in turn sexual intercourse painful, difficult and undesirable) is known as superficial dyspareunia or vaginismus. Although often linked to anxiety and grouped with psychological conditions, organic disorders of external genitalia and introital parts may result in such grave discomfort that any penetration attempt usually leads to spasms.

Among the most common causes of dyspareunia are interstitial cystitis and pelvic inflammatory disease. Interstitial cystitis can be defined as recurring pain or discomfort in the bladder and surrounding region, whereas pelvic inflammatory disease represents an infection of the uterus, cervix, Fallopian tubes and adjacent structures in the pelvis (with potential further progression into the peritoneal cavity).

Causes of dyspareunia that presents with deep pain include endometriosis, uterine retroversion, uterine myomas or fibroids, ovarian diseases (like ovarian remnant syndrome), adenomyosis, pelvic congestion syndrome, bladder leiomyoma, as well as irritable bowel syndrome.

Neuronal sensitization in the spinal cord and certain parts of the brain has been proposed as the most likely cause of deep dyspareunia. This theory hypothesizes that intense stimulation of peripheral tissue, as a result of repetitive abrasive stimulation or a physical trauma, may sensitize the neurons that are responsible for conveying painful information to the brain.

As a consequence, the sensitized neurons necessitate less stimulation for their activation, or may even be activated without any stimulation at all. Therefore the individual may experience pain after only a slight touch, or even no touch. Women with this type of dyspareunia may also report genital pain during non-sexual situations.

Psychological Causes of Dyspareunia

Anxiety that is associated with sexual activity and (often irrational) fear of pain has been proposed as a cause of dyspareunia, although it can also be considered a symptom of the condition (thus forming a vicious circle). In any case, various research studies have shown a strong correlation between pain during sexual intercourse and high trait anxiety.

Even though anxiety can be linked to dyspareunia, not all women with sexual anxiety present with the symptoms of sexual pain. It is known that women with dyspareunia often fear sexual interactions and harbor increased phobic anxiety of sexual activity when compared to women without sexual pain. The explanation is that after initial experience of sexual pain, anxiety about sexual activity (and dyspareunia) remains present, since the awareness for sexual pain is increased.

In addition to anxiety, negative attitudes towards sexuality have been found to be correlated with dyspareunia. Several studies have found that women presenting with dyspareunia generally have more negative attitudes towards sexual intercourses than sexually functional women.

When it comes to depression, longitudinal studies have failed to show its direct relationship with this condition. However, from a relational point of view, women with dyspareunia tend to report more painful incidents when their relational distress increases – an indication that pain during sex may partially be associated with negative sentiments between partners.