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Medical: your history and examination should expose the type of disorder you have, and treatment can then be undertaken according to your problem.
History: the doctor will ask you to describe when the pain first started, what type of pain it is, where it is felt and under what circumstances- does it occur every time you have sex, with all or certain positions/partners, and is it at the entrance or deep in the pelvis? Do you have any associated symptoms? [vaginal discharge, lower abdominal pain]. Are there other problems associated with sex? What is the intensity and duration of pain and effect on sexual response and activity. Do you continue having sex while gritting your teeth, or stop altogether?
Did you have any traumatic experience as a child, teenager or adult that made you feel disturbed about your body or about sex, or an operation or disease involving your genitals or pelvic organs?
Sex response cycle: does the pain occur during arousal, at the entrance, or with deep penetration or thrusting, during orgasm or after intercourse, or is it associated with body movements.
Previous sexual function: inadequate stimulation prior to entry may have resulted in insufficient lubrication and burning which precipitated the pain.
Examination: should be gentle, and you should talk to your doctor before the examination to make sure that you are in control and he/she will stop the examination if it becomes too painful for you. You can ask for a mirror as it may be helpful to you to see what your genitals look like, and watch what the doctor is doing. Ask your doctor if you wish to have your partner present.
Laboratory investigations: may include checking your urine or swabs to determine the cause of infection. Treatment of infections usually resolves both the inflammation and the pain Surgery may be indicated e.g.: to cut away a thickened hymen or a strand, or vaginal septum, or for endometriosis, or VVS [6], or for removal of plaque on the penis for Peyronie’s disease for a male partner [see: Pain During Sex in Men].
Specific conditions:
Vaginismus: intercourse is painful, or penetration is impossible due to involuntary contraction of the muscles at the entrance of the vagina. As a result of anticipation, fear of or experience of pain, these women tend to avoid sex.
Causes: infection, previous vaginal surgery, thick hymen or strand across the hymen, infection of the vulva, vagina or fallopian tubes, or endometriosis; past sexual abuse/trauma, forced sex or examination, abortion, genital mutilation, misinformation: anticipation of and fear of pain with penetration usually associated with religious or cultural taboos; punishment for e.g. masturbation or sex play, conflict /stress in the relationship, lack of privacy, inadequate foreplay.
Treatment: history and examination should determine the factors that caused the condition. Faulty attitudes to sex, fears and myths should be dealt with, as well as relationship and communication problems. Both you and your partner should be involved and understand the reflex nature of the problem. Ask your doctor to explain about the anatomy of the vagina and how the muscles contract as a reflex, and you will realize that it is not something you are doing on purpose. It is useful to liken learning to control the vaginal muscle contraction to the control of blinking in someone who attempts to use contact lenses while overcoming the reflex to blink.
Learning to control vaginismus:
Initially you should become accustomed to touching yourself at the entrance to the vagina, and then to insert your own finger a short way and then all the way into the vagina.
Try the following: relax on your bed, and insert your clean index finger well lubricated with KY jelly into your vagina, and "knuip" - [contract the outer part of your vagina], and then let out your breath and 'let go', then push in your pelvis as if you were going to pass urine. This should 'break the spasm', and you should notice that the vaginal opening widens considerably, then gently move your fingers in and out, and you should find that this is no longer painful. Do this with 2 fingers for a few minutes every day for about 7 days. Also do the Kegel’s exercises while your fingers are in your vagina [see: Kegel’s exercises].
Once you are comfortable with this, get your partner to put one and then 2 fingers into your vagina for a few minutes every day for about 7 days until you are not having any discomfort, learning to control the muscle contraction well by pushing when you feel any discomfort. Then you should begin to associate penetration with pleasure rather than pain. Then apply KY jelly or any water based lubricant to your vulva, and gently ease yourself onto your partner's erect penis while you are ‘pushing’ gently, relax, and then move up and down slowly. If you feel any discomfort, then stop, and ‘push’ before you continue. You must be in control during the exercises, but later you will be able to 'let go' as you wish. You should find that you are able to have intercourse without pain after practicing this a few times.
It is important to set aside time to make love, and ensure that you become aroused, guiding your partner’s caresses before penetration, and be sure to use a vaginal lubricant to ensure your comfort.
This approach is usually successful but if it does not help you, you should see your gynaecologist or a sex therapist for treatment.
Vulvar Vestibulitis Syndrome [VVS]: the following 3 conditions are present:
Special nerves of the vulva that transmit pain and touch sensations can become sensitized possibly through minor tissue injury, like stretching or chronic infection [thrush], or irritation [from repeatedly applying anti-fungal medicines] which can change the threshold to pain. This results in an exaggerated pain response making the sensations feel worse. The affected area becomes hypersensitive, and any contact even light touch is perceived as pain or burning, – that is the pain sensation no longer matches the painful stimulus [1].
Treatment:
Vulvodynia: chronic burning, stinging, irritation or rawness of the vulva when there is no infection or skin disease. Pain may occur without contact, and be constant or intermittent, localized or over the whole area of the vulva.
Pain occurs even without touch, but the vulva is very sensitive to touch, and penetration during intercourse is painful.
A burning vulva is a distressing symptom which can lead to depression and breakdown in sexual relations.
Treatment:
After menopause: the vaginal lining is thinner than before and lubrication is diminished, making intercourse uncomfortable. Treatment: your doctor may prescribe hormone replacement treatment to take by mouth, a skin patch or vaginal tablets or cream, or advise regular intercourse using a vaginal lubricant.
Diabetic vaginitis: if you have thrush it should be treated, use a lubricant, and make sure that the diabetes is well controlled.
Chemicals: stop using any sprays or deodorants on the genitals. External washing is all that is necessary, don’t douche as this reduces the natural vaginal protection against infection.
General Advice on Care of the Vulva:
History: the doctor will ask you to describe when the pain first started, what type of pain it is, where it is felt and under what circumstances- does it occur every time you have sex, with all or certain positions/partners, and is it at the entrance or deep in the pelvis? Do you have any associated symptoms? [vaginal discharge, lower abdominal pain]. Are there other problems associated with sex? What is the intensity and duration of pain and effect on sexual response and activity. Do you continue having sex while gritting your teeth, or stop altogether?
Did you have any traumatic experience as a child, teenager or adult that made you feel disturbed about your body or about sex, or an operation or disease involving your genitals or pelvic organs?
Sex response cycle: does the pain occur during arousal, at the entrance, or with deep penetration or thrusting, during orgasm or after intercourse, or is it associated with body movements.
Previous sexual function: inadequate stimulation prior to entry may have resulted in insufficient lubrication and burning which precipitated the pain.
Examination: should be gentle, and you should talk to your doctor before the examination to make sure that you are in control and he/she will stop the examination if it becomes too painful for you. You can ask for a mirror as it may be helpful to you to see what your genitals look like, and watch what the doctor is doing. Ask your doctor if you wish to have your partner present.
Laboratory investigations: may include checking your urine or swabs to determine the cause of infection. Treatment of infections usually resolves both the inflammation and the pain Surgery may be indicated e.g.: to cut away a thickened hymen or a strand, or vaginal septum, or for endometriosis, or VVS [6], or for removal of plaque on the penis for Peyronie’s disease for a male partner [see: Pain During Sex in Men].
Specific conditions:
Vaginismus: intercourse is painful, or penetration is impossible due to involuntary contraction of the muscles at the entrance of the vagina. As a result of anticipation, fear of or experience of pain, these women tend to avoid sex.
Causes: infection, previous vaginal surgery, thick hymen or strand across the hymen, infection of the vulva, vagina or fallopian tubes, or endometriosis; past sexual abuse/trauma, forced sex or examination, abortion, genital mutilation, misinformation: anticipation of and fear of pain with penetration usually associated with religious or cultural taboos; punishment for e.g. masturbation or sex play, conflict /stress in the relationship, lack of privacy, inadequate foreplay.
Treatment: history and examination should determine the factors that caused the condition. Faulty attitudes to sex, fears and myths should be dealt with, as well as relationship and communication problems. Both you and your partner should be involved and understand the reflex nature of the problem. Ask your doctor to explain about the anatomy of the vagina and how the muscles contract as a reflex, and you will realize that it is not something you are doing on purpose. It is useful to liken learning to control the vaginal muscle contraction to the control of blinking in someone who attempts to use contact lenses while overcoming the reflex to blink.
Learning to control vaginismus:
Initially you should become accustomed to touching yourself at the entrance to the vagina, and then to insert your own finger a short way and then all the way into the vagina.
Try the following: relax on your bed, and insert your clean index finger well lubricated with KY jelly into your vagina, and "knuip" - [contract the outer part of your vagina], and then let out your breath and 'let go', then push in your pelvis as if you were going to pass urine. This should 'break the spasm', and you should notice that the vaginal opening widens considerably, then gently move your fingers in and out, and you should find that this is no longer painful. Do this with 2 fingers for a few minutes every day for about 7 days. Also do the Kegel’s exercises while your fingers are in your vagina [see: Kegel’s exercises].
Once you are comfortable with this, get your partner to put one and then 2 fingers into your vagina for a few minutes every day for about 7 days until you are not having any discomfort, learning to control the muscle contraction well by pushing when you feel any discomfort. Then you should begin to associate penetration with pleasure rather than pain. Then apply KY jelly or any water based lubricant to your vulva, and gently ease yourself onto your partner's erect penis while you are ‘pushing’ gently, relax, and then move up and down slowly. If you feel any discomfort, then stop, and ‘push’ before you continue. You must be in control during the exercises, but later you will be able to 'let go' as you wish. You should find that you are able to have intercourse without pain after practicing this a few times.
It is important to set aside time to make love, and ensure that you become aroused, guiding your partner’s caresses before penetration, and be sure to use a vaginal lubricant to ensure your comfort.
This approach is usually successful but if it does not help you, you should see your gynaecologist or a sex therapist for treatment.
Vulvar Vestibulitis Syndrome [VVS]: the following 3 conditions are present:
- pain is provoked with touch or pressure such as with penetration during intercourse, a gynaecological examination, inserting a tampon, cycling, or wearing tight pants, and even to light touch with a cotton applicator
- tenderness is localized to the vestibular area [between 4 and 8 o’clock looking at the entrance to the vagina]
- redness of the vestibular area.
Special nerves of the vulva that transmit pain and touch sensations can become sensitized possibly through minor tissue injury, like stretching or chronic infection [thrush], or irritation [from repeatedly applying anti-fungal medicines] which can change the threshold to pain. This results in an exaggerated pain response making the sensations feel worse. The affected area becomes hypersensitive, and any contact even light touch is perceived as pain or burning, – that is the pain sensation no longer matches the painful stimulus [1].
Treatment:
- Counselling
- Surgery to cut out the affected part of the vulva does bring relief [1].
- Medication: antidepressant or anticonvulsant medications, or lidocaine [local anaesthetic cream] help give pain relief. These must be prescribed by a doctor.
- Pelvic floor physical therapy: includes biofeedback, electrical stimulation, and homework exercises designed to heighten awareness of the pelvic floor muscles and enable women to train the tight and tender muscles of their pelvic floor to relax to stretch and lengthen. 50% of patients report complete to great improvement and another 20% experience moderate gains [1].
Vulvodynia: chronic burning, stinging, irritation or rawness of the vulva when there is no infection or skin disease. Pain may occur without contact, and be constant or intermittent, localized or over the whole area of the vulva.
Pain occurs even without touch, but the vulva is very sensitive to touch, and penetration during intercourse is painful.
A burning vulva is a distressing symptom which can lead to depression and breakdown in sexual relations.
Treatment:
- Medication: an anti-depressant [amytryptaline] may be prescribed by your doctor in small then increasing doses, or an anti-convulsant drug [carbamazepine] can relieve the pain of vulvodynia [6]
- Biofeedback physiotherapy to relax the pelvic floor
- Minimise irritation to the vulva, no perfumes or local applications, use cotton underwear
- Treat secondary vaginismus if it has developed [see above]
After menopause: the vaginal lining is thinner than before and lubrication is diminished, making intercourse uncomfortable. Treatment: your doctor may prescribe hormone replacement treatment to take by mouth, a skin patch or vaginal tablets or cream, or advise regular intercourse using a vaginal lubricant.
Diabetic vaginitis: if you have thrush it should be treated, use a lubricant, and make sure that the diabetes is well controlled.
Chemicals: stop using any sprays or deodorants on the genitals. External washing is all that is necessary, don’t douche as this reduces the natural vaginal protection against infection.
General Advice on Care of the Vulva:
- don’t wear pantyhose [wear knee highs or socks], wear white cotton underwear, and wear loose fitting pants or skirts, double rinse your panties, don’t use fabric softener for your panties
- remove your wet bathing suit or exercise clothing promptly, don’t swim in highly chlorinated water
- use soft white soap unscented toilet paper, use aqueous cream soap for your genitals or lukewarm water only, don’t use bubble bath, feminine hygiene products or any perfumed creams soaps or sprays
- rinse your vulva after you pass urine, pass urine before your bladder gets full
- prevent constipation by adding fibre to your diet, and drink plenty of fluids
- use a water based lubricant [KY jelly or Astroglide], ask your doctor to prescribe a local anaesthetic cream for when you have intercourse, pass urine as soon as convenient after you have intercourse and rinse your vulva with cool water
- avoid exercises that put pressure on your vulva [horse or bicycle riding]
Relationship and sex therapy may be indicated even after the trigger cause has been relieved, as the pain–avoidance response may have become entrenched.
Sensual exercises: in order to break the vicious cycle of avoidance-guilt and rejection it is useful to start with lovemaking that is not ’threatening’ or painful, and restores intimacy and communication. See: Sensate Focus, Genital Stimulation and Intercourse exercises.
In most cases specific treatment should relieve dyspareunia, and should b e supported by counselling both partners
The goal of treatment is to ensure that you and your partner can be comfortable making love and that it includes sexual pleasure.
