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Am Fam Physician. 2000;61(8):2511-2512

Dyspareunia and vaginismus are the two most common sexual dysfunctions in women. Dyspareunia is recurrent genital pain caused by sexual activity. Primary dyspareunia is defined as constant pain during sexual activity, while secondary dyspareunia occurs after a period of pain-free lovemaking. Vaginismus is a conditioned pain caused by involuntary spasm of the muscles around the lower one third of the vagina, resulting from the association of sexual activity with pain and fear. Butcher reviews these two conditions and their respective management approaches and briefly discusses the role of orgasm in women.

Dyspareunia is best described according to the site of pain, either superficial or deep. Superficial dyspareunia occurs in or around the vaginal entrance and is characterized by early, initial discomfort. Common symptoms include superficial vulval pain, itching, burning and stinging. Pain may be constant or may be triggered by nonsexual activities such as walking. Identifying the cause is difficult, and patients quickly become frustrated with treatment. Vaginal pain is less common because of the paucity of nerve endings in the vagina. Common causes are inadequate lubrication, vaginal infection, topical irritants, urethral problems, radiotherapy or sexual trauma. Deep dyspareunia, pain resulting from pelvic thrusting during intercourse, is common and may be caused by pelvic inflammatory disease, local surgery, endometriosis, genital or pelvic tumors, irritable bowel syndrome, urinary tract infections or ovarian cysts. The woman's position during sexual activity is important, because deep thrusting by the partner could be hitting an ovary and causing pain.

The immediate cause of vaginismus is involuntary spasm of the muscles around the lower one third of the vagina. This initial response may be secondary to sexual abuse, frightening childhood medical procedures, painful first intercourse, relationship problems, sexual inhibition or fear of pregnancy. Primary vaginismus is diagnosed in women who have never experienced vaginal penetration, while secondary vaginismus denotes prior successful vaginal penetration. The symptoms can range from minor to severe, when the woman avoids all forms of sexual touching or intimacy. Patients in the latter category often have been unable to complete gynecologic examinations, have difficulty using tampons and fail to present for Papanicolaou tests.

The importance of orgasm varies in women. Some women find it an extremely important part of every sexual encounter, while others are content without it. Involuntary inhibition of the orgasmic reflex in women who are interested in orgasms is called anorgasmia. This inhibitory action is often linked to strong emotional causes, but the possibility of physical causes should be explored in patients with dyspareunia.

The author concludes that management of these problems can be difficult, but success is rewarding for the patient. Initial management of dyspareunia should focus on all physical causes, followed by use of a cognitive behavioral program similar to that used to treat vaginismus. For a list of the components of a cognitive behavioral program, see the accompanying table. The most successful programs help the woman feel that she owns her sexual organs and controls her sexual activity. Treatment of anorgasmia involves working with the patient individually and with the couple, when possible, to resolve conflicts and increase stimulation. Self-exploration, masturbation, resolution of unconscious fears of orgasm, exercises to heighten sexual arousal, and enhancing awareness of pleasure are useful ways to achieve orgasm with sexual activity.

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