DYSPAREUNIA
Professor Chris Sutton
Professor of Gynaecological Surgery, University of Surrey, Guildford. UK
The treatment of dyspareunia depends on the cause of the condition and apart from
psychological causes, inducing vaginismus, the differential diagnosis includes
inadequate lubrication, atrophy and vulvodynia (vulvar vestibulitis). The latter is a
complex condition and although it is tempting to treat it by a laser skinning
vulvectomy the problem usually occurs and has deep rooted psychological factors,
sometimes requiring antidepressants and is exceedingly difficult to treat. Other
causes, such as urethral disorders, cystitis and interstitial cystitis can also cause
painful intercourse and are usually within the provenance of the urologists. Certain
causes of superficial dyspareunia, such as imperforate hymen, hymenal tags or ridges
at the posterior fourchette are amenable to carbon dioxide laser treatment directed via
a colposcope using a moistened cotton wool ball as a back stop. The lasered area is
usually left open to heal by primary intention and as with most laser craters there is
very little in the way of stricture formation and fibrosis and the end result is usually a
very neat healed area that is almost identical to the surrounding tissue.
Causes of deep dyspareunia include endometriosis, pelvic congestion, adhesions or
infections and adnexal pathology. The diagnosis usually requires laparoscopy and
other ancillary investigations, such as transvaginal or transrectal ultrasound and many
of these conditions can be treated by laparoscopic surgery.
Endometriosis and pelvic venous congestion
In his excellent monograph on endometriosis, Dan O’Connor reported on 717 patients
that he had treated in his private practice and of these 668 were, or had been sexually
active and 188 (28%) of these women admitted to dyspareunia.
Dyspareunia is usually felt during intercourse, particularly in any coital position that
facilitates deep penetration. The pain is usually fairly localised and can be quite
severe, especially in patients with deposits in the recto-vaginal septum and uterosacral ligaments, to the point that most women will cry out and suggest a change of
position and in some women the pain is so severe that they avoid intercourse
altogether. This can cause considerable psychological problems within a marriage
and is particularly the case if the couple are trying for a pregnancy.
The pain changes in nature after intercourse and is often described as a dull ache
which can last for a few minutes to several hours but it is rare, in my experience, for
patients to have pain the following day. This is by no means a hard and fast rule and
certainly some patients with endometriosis can suffer discomfort the following day,
but usually these patients have associated venous congestion as part of the pelvic
congestion syndrome (2) and occasionally these conditions can co-exist or be found
separately at the time of diagnostic laparoscopy.
In his excellent text book “The Principles of Gynaecology”, Sir Norman Jeffcoate
drew attention to a type of dyspareunia ‘which is not uncommon, in which the patient
describes abdominal and pelvic discomfort as occurring hours after coitus, often the
next day. The cause of this is always psychological; the patient is providing an
excuse to avoid coitus – she may even be bored with it. The mechanism of the pain is
usually colonic spasm, but may occasionally be uterine contractions’. (3)
The pelvic congestion syndrome is a distinct clinical entity which is difficult to treat.
Typically there is pelvic pain of variable intensity which is worse pre-menstrually and
greatly increased by fatigue, standing and especially coitus. The pain associated with
coitus (dyspareunia) leads to anxiety and often frigidity and marital disharmony.
Bladder irritability, presenting as urgency rather than frequency, is often present due
to varicosities in the region of the trigone. The condition is extremely difficult to treat
and although psychotherapy is helpful, these patients often end up having a
hysterectomy and bilateral salpingo-oophorectomy which will provide relief, because
the veins are essentially draining the uterus. If the venous congestion is mainly
involving the ovaries, success has been reported by venous embolisation of the
ovarian and/or internal iliac veins (4) or, by extra-peritoneal resection or ligation of
the ovarian veins. (5,6)
These patient constitute a difficult group of patients to treat. They often have high
levels of anxiety, depression, anger or hostility, somatisation and altered family roles
than those in controlled groups. (7) They often have psychological disturbances and,
in many instances, a history of physical or sexual abuse. (8) The diagnosis can be
confirmed by transvaginal ultrasound with colour Doppler or by pelvic venography.
Pelvic varicosities are usually obvious at laparoscopy, particularly if the pelvic
sidewalls are examined with the patient flat or with the head raised and a probe used
to displace the bowel from the pelvis.
Uterine retroversion
A retroverted uterus can cause deep dyspareunia, particularly in the presence of
adenomyosis or an adenomyotic nodule in the upper posterior wall, which is then in
direct relation with the posterior fornix. The altered position of the ovaries in uterine
retroversion can also cause discomfort during intercourse and the pre-operative use of
a Hodge pessary to antevert the uterus is recommended as a diagnostic test before
operative correction by laparoscopic ventrosuspension (9) or laparoscopic plication
and suspension of the round ligament. (10) Such operations can be extremely
uncomfortable for a few days postoperatively and great care must be taken to avoid
distorting the course of the fallopian tube. Laparoscopic ventrosuspension appears to
be performed less often nowadays, although relief of deep dyspareunia can be very
dramatic and Raslin et al (11) reported reduction of deep dyspareunia in 81% of
patients at least one year after operation.
Deep infiltrating endometriosis (adenomyosis)
Probably the commonest reason for deep dyspareunia in young women is the presence
of deep infiltrating endometriosis in the rectovaginal septum and in the uterosacral
ligaments. In our department we use the CO2 laser via the laparoscope and the
colposcope to vaporise the adenomyotic nodules and the associated fibromuscular
hyperplasia. This is associated with a 70% reduction in dyspareunia and this problem
is dealt with in the previous paper “Can surgery relieve pain and sexual activity?”
(vide supra).
References
1
O’Connor D.T. Clinical features and diagnosis of endometriosis in: O’Connor
(Eds) Endometriosis. Ch.5 pp 68-84. Churchill Livingstone, London
2
Beard R.W. Chronic pelvic pain. Br. J. Obstet. Gynecol. 1998; 105 : 8-10
3
Jeffcoate T.N.A. (1967) Problems of sex and marriage. In: Principles of
Gynaecology (3rd Edition) Chapter 37 p 733. Butterworths, London
4
Venbrux A.C. and Lambert D.L. Embolisation of the ovarian veins as a
treatment for patients with chronic pelvic pain caused by pelvic venous
incompitence (pelvic congestion syndrome) In: Sutton C. (Ed) Endoscopic
Surgery. Current Opinion in Obstetrics and Gynaecology. 11; 4:395-399. 1999
Lippincot, Williams and Wilkins, London, UK
5
Rundqvist E. Sandholm L.E., Larsson G. Treatment of pelvic varicosities
causing lower abdominal pain with extraperitoneal resection of the left ovarian
vein. Ann. Chir. Gynaecol. 1984; 73: 339-341
6
Hobbs J.T. The pelvic congestion syndrome. Br.J.Hosp.Med. 1990; 43:200206
7
Reiter R.C. A profile of women with chronic pelvic pain.
Clin.Obstet.Gynaecol. 1990; 33: 130-6
Walling M.K. Reiter R.C., O’Hara M.W., Milburn A.K. Lilly G., Vincent S.D.
Abuse history and chronic pain in women. 1: Prevalences of sexual abuse and
physical abuse. Obstet. Gynaecol. 1994; 84: 193-9
8
9
Gomel V. Taylor P.J. Uterine displacement In: Gomel V., Taylor P.J. (Eds)
Diagnostic and operative laparoscopy. St. Louis; Mosby, 1995: 299-308
10
Batioglu S., Zeyneloglu H.B. Laparoscopic plication and suspension of the
round ligament for chronic pelvic pain and dyspareunia. JAAGL. 2000. 7 (4):
547-51
11
Raslan S., Lynch C.B., Rix J. Symptoms relieved by endoscopic
ventrosuspension. Gynaecol. Endosc. 1995; 4: 101-4