Dyspareunia

20 May

Dyspareunia

INTRODUCTION
What  Does the Term Dyspareunia Mean?

In 1874, Barnes (1) coined the term dyspareunia. He felt that it would be a convenient way  of  summarizing  the  different  conditions underlying  painful intercourse: “ … just as ‘dyspepsia’ is used to signify difficult or painful diges- tion, we want a word to express the condition of difficult or painful performance of the sexual function” (p. 68). Although the usefulness of the term dyspepsia is a matter  of some controversy (2), the  diagnosis of dyspareunia has not been seriously challenged and is still used by all major classificatory systems, such as the DSM-IV-TR (3) and the ICD-10 (4). The lack of specificity of the word dyspareunia is evidenced by the growing number of overlapping terms (e.g., vul- vodynia, vulvar vestibulitis syndrome, dysesthetic vulvodynia, vestibulodynia) denoting presumed “disease entities.” The majority of these terms originate from  a  recent  renewed  interest  in  painful  vulvar conditions. Even  prior  to this increased interest, the term dyspareunia was often used interchangeably with the terms vaginismus or chronic pelvic pain. This unrestricted creation of diagnostic labels plagues many mental health and medical domains and often results in much confusion. In our view, the term dyspareunia has outlived its utility as a nosological entity. Although this suggestion might be considered radical, we believe that it is justifiable both on the basis of logical/theoretical considerations as well as on empirical data.

In this chapter, we will standardize our use of the terminology as follows: The term dyspareunia denotes any form of recurrent or chronic urogenital pain that  interferes  with  sexual  and  nonsexual activities  in  women  of  any  age, and which may be experienced in a variety of different locations (e.g., at the vaginal opening or deep inside the pelvic area) with various qualities and patterns (e.g., as an acute stabbing sensation on contact, or a chronic throbbing pain that waxes and wanes throughout the day). It is important to note that dyspareunia also occurs in men (5), but is relatively rare compared with its frequency in women. Why there is such a gender disparity remains unclear and is worthy of study; however, this chapter will focus on dyspareunia in women. Following the criteria outlined by Friedrich (6), vulvar vestibulitis syndrome refers to severe pain experienced in the vulvar vestibule upon contact. Unlike vestibulitis, vulvodynia denotes chronic vulvar pain or discomfort that can occur in the absence of overt stimulation.

Why Is it Important to Study and Treat Dyspareunia?

Recent epidemiological surveys indicate that dyspareunia affects between 15% and 21% of women between the ages of 18 and 59 (7 – 9). Although dyspareunia is  a  common problem, many  sufferers do  not  pursue treatment  because  of the embarrassment associated with talking about genital pain and sexuality. Of those who do consult, many do not receive adequate care; it is reported that 40% of dyspareunic women who sought treatment did not receive any diagnosis even after multiple consultations (8). These women may also be told, after several potentially invasive and painful evaluations, that all is well physically, implying either that their pain is “not real” or that they suffer from psychological problems.

In addition to problems encountered in the health care system, women with dyspareunia suffer negative impacts in both sexual and nonsexual areas of their lives. In terms of sexuality, women with dyspareunia report lower frequencies of intercourse, lower levels of sexual desire, arousal, and pleasure, and less orgas- mic success than non-affected women (10 – 12). It is therefore not surprising that women with dyspareunia also report difficulties with relationship adjustment and  psychological  distress,  including  depression  and  anxiety  (10).  Outside of sexuality and intimate relationships, activities such as gynecological examin- ations, bicycle riding, or sitting for long periods of time may also be affected (10,11,13,14).  Given  the  significant negative  impact  dyspareunia  can  have on multiple aspects of life, it is crucial to provide women suffering from this condition with information, validation of their pain, and appropriate treatment. However, the classification of dyspareunia has precluded this in many cases by focusing on the sexual aspects of dyspareunia, to the exclusion of focusing on the pain and the complexity of factors (e.g., emotional, interpersonal) that are involved.

CLASSIFICATION

Barnes derived the term dyspareunia from the Greek term meaning “difficult or painful mating” (1). This definition, based on interference with sexual inter- course, is understandable given that it is this interference that brings many women  to  clinical  attention.  Unfortunately, the  focus  on  “difficult mating” has resulted in the classification of dyspareunia as a sexual dysfunction (3), and has deflected attention away from the major clinical symptom of pain. The nosological  questions  concerning  dyspareunia  are  further  complicated  by  a more general theoretical issue: the distinction between organic and psychogenic. For example, both the DSM-IV-TR (3) and the ICD-10 (4) differentiate between organic (i.e., due to a medical condition) and idiopathic (i.e., no known physical cause, usually attributed to psychogenic origin) dyspareunia. The apparent pre- sumption in the case of psychogenic dyspareunia is that it is a distinct category, though there is little specification of its underlying determinants. In contrast, organic dyspareunia is seen as the result of many underlying types of gynecolo- gical pathologies, as well as a symptom of inadequate lubrication or of naturally occurring menopausal vulvovaginal atrophy.

The reality of the situation is that there are no empirically or theoretically valid guidelines to distinguish psychogenic vs. organic dyspareunia. The notion that these terms reflect easily diagnosable qualitative categories is questionable both on empirical and theoretical grounds. The typical presumption made by many health professionals and the general public is that there must be an under- lying physical cause for the pain. In clinical practice, this typically results in numerous physical investigations ranging from standard gynecological exami- nations and tests for infections, to invasive procedures such as colposcopy and laparoscopy. If such investigations yield negative findings, the default is to assume a psychogenic causation (“it is all in your head”) and refer the patient to a mental health professional. Depending on the orientation of the mental health  professional, dyspareunia  may  be  attributed  to  factors  ranging  from inadequate arousal to childhood sexual abuse. Because most women with dyspar- eunia present without an identifiable physical explanation for their pain, rarely is there a primary focus on the pain or on direct pain control in the case of dyspar- eunia. However, other idiopathic pain conditions are afforded this approach. For example, 85% of back pain patients present without identifiable pathology (15), yet they are still provided with treatment alternatives, such as analgesic medication and/or physical therapy.

As in the case of back pain, we recommend a similar multidimensional pain approach to the understanding and treatment of dyspareunia (16). This approach is consistent with current biopsychosocial pain perspectives that evolved from the Gate Control Theory of Pain, which states that the experience of pain includes sensory and emotional components and that psychological factors play a role in pain control (17). This theory has helped explain the powerful influence of cog- nitive processes on pain perception via descending modulation from the brain, and scientists have since learned that the complex experience of pain cannot be simply equated with tissue damage (18). The Classification of Chronic Pain manual published by the International Association for the Study of Pain (IASP) (19) has also inspired a new multidimensional approach for dyspareunia treatment and research (16). According to the IASP classification system, pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (italics added; page 210). The italicized portion of this definition is reserved for pain patients without identifiable physical pathology, as in most cases of dyspareunia and other chronic pain conditions. Within this framework, the study of underlying physiology is ascribed great importance, but is not sufficient in order to charac- terize the whole pain experience. Therefore, pain classification is further organized according to five axes assessing the region affected, system involved, temporal characteristics, intensity, and duration.

ASSESSMENT  AND  DIAGNOSIS

Once treatable causes for the pain of dyspareunia (e.g., infections, dermatological conditions, sexually transmitted diseases) are ruled out, the pain needs to be care- fully characterized. Questions about the location, quality, and temporal charac- teristics (e.g., When did the pain start? When does the pain occur? How long does it last?) of the pain are crucial to obtain a solid understanding of the pain experienced and may also help in diagnosis. In terms of pain history, many women link the pain onset to their first intercourse experience, but it may actually have long preceded this. Similarly, women with vulvar vestibulitis have been found  to  describe  their  pain  in  a  consistent  manner  (14).  Some  patients, however,  may  have  limited  knowledge  of  their  pelvic/genital  anatomy,  in which case a diagram is often helpful. It is also important for the physician to try and locate the affected region by attempting to replicate the pain through pal- pation and/or pelvic examination. This, however, can be a very painful and upsetting experience for the patient, therefore, it is vital to adequately prepare the patient and inquire about the intensity of the pain prior to the examination. If upon examination, pain is experienced, the physician should then determine whether this  is  the  same  pain  experienced  during intercourse. This can  be assessed by inquiring about pain location, quality, and intensity during both inter- course and examination. In the case that the gynecologist fails to replicate the pain, it is important to clarify to the patient that the gynecological examination is not the same scenario as the bedroom and that there are many factors that could produce variability in the pain experienced. For example, emotional reac- tions to the pain may vary; some women may react very strongly by vocalizing and moving away from the painful stimulation, whereas others may “grin and bear it.” It is therefore necessary to distinguish between the intensity of the pain and the unpleasantness associated with it, as these two components form separate  dimensions of  the  pain  experience.  A  further  assessment of  these factors includes inquiring about activities that produce the pain (e.g., different sexual positions, certain kinds of exercise) and assessing the temporal character- istics of the pain (e.g., does the pain vary with menstrual cycle) to name a few. To this end, keeping a pain diary can be extremely informative for both the physician and the patient.

Asking questions about the pain not only provides useful diagnostic infor- mation, but is also of therapeutic benefit to the patient by validating her experi- ence, since many times, the pain is the last thing that medical professionals may inquire about, if at all. Asking about past treatments, previous diagnoses, and remedies that helped/worsened the pain are also key in obtaining a complete picture of the problem. Furthermore, careful questioning about how the pain has  affected  the  patient’s  relationships,  sexuality,  psychological  well-being, and overall quality of life will provide a more thorough understanding of the pain and clarify potential treatment options (e.g., physical therapy, psychological treatment for the pain and/or couple problems).

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