Sexual pain disorders

Sexual pain disorders are divided into two dysfunctions: non-organic dyspareunia and vaginismus. Dyspareunia, genital pain in either a male or female, is characterized by recurrent and persistent genital pain before, during, and after sexual activity. Exclusively a female dysfunction, vaginismus is an involuntary spasm of the musculature of the outer third of the vagina which makes penetration difficult or impossible. Non-organic dyspareunia and vaginismus may only be diagnosed in the absence of detectable physical pathology. However, when the aetiology is entirely physical there is likely to be a conditioned psychological response that may require subsequent psychological intervention after medical treatment. (79> Tabje.8 and Iable.9 list the DSM-IV and ICD-10 diagnostic criteria for sexual pain disorders.

Dyspareunia is currently the only female sexual dysfunction in which organic factors are hypothesized to play a major role. Abarbanel (80) has devised a useful tripartite classification of medical aetiologies associated with dyspareunia: anatomical, pathological, and iatrogenic. Anatomical factors comprise congenital or developmental impairments such as a rigid hymen or vaginal atrophy. Pathological factors include acute and chronic infections of the genital tract, such as endometriosis. Iatrogenic factors are conditions induced by a physician usually as a consequence of a surgical procedure such as episiotomy.

Pain during and after sexual activity is always the presenting problem in dyspareunia, although penetration is not always necessary to induce pain. It ranges from mild to unbearable and is experienced in a number of anatomical areas ranging from very specific localizations in the vulvar vestibule to a general burning or ache traversing the entire pelvic region. (81> These authors criticize the traditional dualistic conceptualization of dyspareunia as either organic or psychogenic, and suggest that it be conceptualized in a more sophisticated dynamic, interactive, and biopsychosocial schema.

Dyspareunia in men is a rare condition generally associated with organic factors such as Peyronie's disease, prostatitis, or sexually transmitted diseases. Pain is reported to occur in the penis with erection and during and after ejaculation.

Vaginismus is not necessarily limited to sexual situations. Typically, women with this disorder have been unable to insert tampons or permit insertion of a speculum during gynaecological examination. Interestingly, many women with vaginismus are quite capable of becoming sexually aroused, lubricating, and experiencing orgasm. Leiblum et al.(82) write, 'What is so striking in so many of these cases is the number of years the couple tolerates the difficulty before seeking treatment,...because of ambivalence about resolving the problem...often, it is the desire to have children that ultimately propels the couple to seek assistance'.

Vaginismus is hypothesized to be the body's expression of the psychological fear of penetration, but is also characterized as a psychosomatic disorder, a phobia, a conditioned response, and a conversion reaction.(82) A spectrum of aetiological factors, such as specific traumas, interpersonal and intrapsychic conflict, penetration anxiety, and multiple organic pathologies, may cause this dysfunction. Vaginismus may be triggered by real or imagined attempts at penetration. After several unsuccessful and painful attempts at intercourse a pernicious pattern develops. Anticipatory fear of pain now coupled with feelings of inadequacy, leads to further experiences of vaginismus.

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