Infections of the urethra, such as nonspecific urethritis, can be sexually transmitted and can cause a burning sensation during urination and pain during intercourse, as can bladder infections.
Infections
The epididymis (ducts within the testes) and the prostate gland are both susceptible to acute infections. In the case of epididymitis (inflammation/ infection of the epididymis), a testicle swells up, making ejaculation painful. Acute infection of the prostate gland, called prostatitis, can also cause painful urination and ejaculation. Both of these conditions respond to antibiotics.
Cancer
Prostate cancer is a common condition among older men. A conservative estimate is that one in eleven men in the United States will develop prostate cancer at some time in their lives. Prostate cancer can cause difficulty urinating and ejaculating, as well as pain upon doing so. The development of prostate cancer is often preceded by benign enlargement of the prostate. Even if the prostate gland has not developed cancer, enlargement can still cause pain during urination and ejaculation.
Another common form of male genital cancer is testicular cancer, which tends to affect younger men (Lance Armstrong is a famous example of an otherwise healthy man who developed testicular cancer in the prime of life). Symptoms include a lump on a testicle, swelling of a testicle, or a sense of heaviness or dragging in a testicle. Pain with erection or ejaculation is also a symptom of testicular cancer.
Other forms of male genital cancers exist—for example, cancer of the penis—but they are extremely rare in the United States.
Other Medical Conditions
Hernias can cause genital pain. In a common form of hernia, part of the intestine sags into the scrotum, causing the scrotum to swell up, often to the size of a grapefruit. Such a condition could obviously cause a lot of pain during intercourse.
Another condition called phimosis can cause painful erections. In phimosis, which affects uncircumcised men, the foreskin of the penis is too tight, preventing the man from having a full erection. The solution is to have the foreskin cut or stretched. In cases in which it is really tight, a full circumcision may have to be performed.
A less-understood condition is called Peyronie’s disease, in which hardened areas or plaques form in the erectile tissue, causing the penis to curve to one side. In very severe cases of Peyronie’s disease, the erectile tissue forms multiple plaques and takes on a corkscrew-like appearance. This can be very painful and can eventually prevent erection. If the plaques are identified at an early-enough stage, they can be removed surgically. Peyronie’s disease can be caused by injury to the penis, which is sometimes called penile fracture. What generally causes this condition is that a man is having intercourse with a really hard erection, pulls all the way out of the vagina, and misses the vaginal opening on the next stroke. The trauma causes injury to the erectile tissue, forming a long-lasting bruise and possibly a plaque that creates a permanent curve. It kind of goes without saying that the condition is extremely painful.
Being located outside the body, the testicles are susceptible to injury, often during sports. Another type of injury is testicular torsion, in which the cord that supports a testis inside the scrotum gets twisted.
Physical Causes of Sexual Pain in Women
Many women, especially young women, expect sexual intercourse to be painful, and for about 15 percent of young women it is. This is not right. Sexual intercourse should never cause pain. The sections that follow describe some of the most common medical and behavioral causes of sexual pain for women. You’ll note that the list is longer for women than it is for men.
When talking about women’s sexual pain, I usually distinguish between what’s called outer pain and inner pain, or pain that’s felt at the vulva or vaginal opening versus pain that occurs with deep penetration. Some authors call this insertional or superficial dyspareunia versus deep dyspareunia. Superficial dyspareunia is similar to vaginismus.
Sexually Transmitted Diseases
The bacterial sexually transmitted diseases gonorrhea and chlamydia can cause itching and burning either with urination or with sexual intercourse. Vaginal infections, which are caused by imbalances in the vagina’s normal pH, can also be a source of pain. They include conditions such as bacterial vaginosis, trichomoniasis (also called trichomonas or trich), or yeast infections. All of these cause itching. They can be transmitted sexually, or they can occur as a result of stress or other problems that cause a lowered immune system. They are generally felt at the vaginal opening.
Yeast infections are especially known for causing pain during intercourse. The most obvious symptom of a yeast infection is a thick, white discharge. When the discharge comes into contact with the vulva, it can cause the skin to become inflamed and become so irritated that it cracks. This can cause the vaginal opening to be intensely painful during the first few strokes of intercourse. Women who take birth control pills are more vulnerable to yeast infections. So are women who have diabetes. Wearing clothing that is too tight or sitting around in wet clothing after swimming can also trigger yeast infections.
The viral sexually transmitted disease genital herpes causes blisters that can be intensely painful when they rupture. This is because the herpes virus typically inflames one particular nerve and causes it to fire repeatedly. If you have herpes sores on your inner or outer vaginal lips or in your vaginal opening, even the thought of sexual intercourse would probably cause you to cringe. In fact, some women experience outbreaks of genital herpes that are so painful they can’t wear clothes. In order to urinate they have to sit in a bathtub full of either cold or hot water. Herpes sores higher up in the vaginal canal or on the cervix would probably not be as painful.
Acute Infections
Other infections in the pelvic area can cause sexual pain. Acute infections of the urethra or the bladder can result in pain at the vaginal opening. The vulva or the opening to the vagina can sometimes become temporarily inflamed.
Sexual Habits
Sometimes sexual pain is caused by doing certain things during intercourse. For example, if a woman’s partner attempts to penetrate her vagina before she has lubricated and without using any externally applied lubrication, it can cause pain at the opening and along the walls of the vagina. Sometimes all that is needed to free a woman from sexual pain is to use lubricant, proceed to intercourse more slowly, and shift positions if the woman is uncomfortable.
Another thing that can cause sexual pain is a night of rough sex. Having sexual intercourse in a rough manner can cause abrasions or even tears in the vaginal walls. These will heal up quickly, but if you attempt to have sex again soon after the rough sex, you will probably feel some pain, both at the vaginal opening and along the vaginal walls.
Childbirth
The aftermath of childbirth can cause sexual pain because it is traumatic to the vagina and cervix. On average, most women resume sexual intercourse by about seven weeks after childbirth. However, an incompletely healed or incorrectly performed episiotomy can be painful for some time.
Surgery
Certain types of pelvic surgery can result in painful intercourse. Sometimes hysterectomy or other pelvic surgery can inadvertently cause nerve damage that produces not only pelvic pain but also difficulty with arousal and orgasm. Scar tissue left over from surgery can be painful.
Menstruation
Menstrual problems can cause pain during intercourse. The most common menstrual problem is cramps during a woman’s period. These can cause deep pain during sexual intercourse. On the other hand, some women report that having sexual intercourse during menstruation helps menstrual cramps, because the contractions and spasms associated with orgasm often relieve the cramps.
Menopause
Menopause brings changes to the vagina due to the decrease in estrogen. This can cause what’s called atrophic vaginitis, or vaginal atrophy. A decrease in estrogen causes a lack of lubrication and causes the walls of the vagina to become thinner. This can make intercourse
very painful. A solution is to use an estrogen cream or suppository that is applied directly to the vagina.
Growths
Various nonmalignant growths in the pelvic area can also cause pain. Some of these include uterine polyps, uterine fibroids, or ovarian cysts. All of these conditions can cause a sense of deep pain, as can endometriosis, which is a condition in which the inner lining of the uterus (the endometrium) spreads beyond the uterus to other pelvic structures.
Cancer
There are many forms of female reproductive cancers that can cause sexual pain. Cervical cancer does not usually cause pain in its early stages, although the main symptom of cervical cancer is bleeding after intercourse. The cervix itself does not have the type of cells that can sense discrete pain information. In fact, biopsies can be done from the cervix and upper vaginal walls without anesthetic. However, the area around the cervix is extremely sensitive to pressure, and some women find it painful if their partner’s penis hits this area during intercourse.
Uterine cancer could cause pain and abnormal cramping and bleeding. Ovarian cancer could cause pain if there is a large tumor present. Cancers of the vulva or vaginal walls are very rare but could also cause pain.
Other Conditions
Gastrointestinal problems such as irritable bowel syndrome, cramps, a full intestine, or gas can cause intercourse to be painful. Women with orthopedic problems, such as back problems or hip problems, often experience pain during intercourse. The PC muscle can cramp up, especially if a woman is anxious, and this can be very painful.
Vulvar Vestibulitis
Vulvar vestibulitis is a sort of “mystery condition” that can cause pain during intercourse. I call it a mystery condition because there is no agreement about whether it’s physical or psychological; there is no agreement about what causes it; and there is no agreement as to whether it’s primarily an immune system problem, a muscle problem, a skin problem, a blood flow problem, a nervous system problem, or a psychological problem. It is a condition that involves a sensation of burning and/or itching at the opening of the vagina (the vulva). Sometimes it is accompanied by obvious redness or inflammation, but often it is not. It is sometimes called burning vagina syndrome. Another synonym for it is vulvodynia.
To understand what this condition feels like, you have to understand the difference between what it feels like to have a penis and what it feels like to have a vagina. Men are much more aware of their penises on a minute-by-minute basis than women are of their vaginas. One man described to me the sensation of having a penis in the following way: “Having a penis is kind of like having a live fish in your pants. You can always feel it in there, but sometimes it starts flopping around.” (He was an avid fisherman; can you tell?) In contrast, having a vagina is more like having a nose. Unless you’re aroused or it’s causing you pain, you’re just not aware of it. For the woman who has vulvar vestibulitis, this is not true. Her vagina suffers a constant burning sensation that often makes it difficult to wear clothes, let alone masturbate or enjoy oral sex or sexual intercourse.
Health experts have different hypotheses about what causes vulvar vestibulitis. Some doctors believe it’s a chronic cramp in the PC muscle as a result of long-term vaginismus. Others believe it’s primarily a skin inflammation, although in many cases even though the skin feels like it’s inflamed, there’s no obvious redness. Some doctors believe it results from highly increased activity in a particular nerve to the genitals. Still others believe it’s an autoimmune disorder in which a woman literally becomes allergic to the skin of her own vulva. The prospect that this condition is psychological also exists. Problems that tend to go along with it include somatizing disorder, irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, depression, and interstitial cystitis (chronic bladder infections).
Obviously, doctors attempt to treat this condition differently depending on what they think the cause is, and depending on whether they think the cause is a medical one or a psychological one. Some of the psychologically based treatments that have been used include hypnotherapy, sex therapy, cognitive-behavioral therapy, and biofeedback. Acupuncture has also been used.
Two types of surgery have also been used to treat this condition: laser surgery to remove the outer layers of skin of the vulva, and vestibulectomy, a surgical procedure in which the shiny tissue surrounding the opening of the vagina, the vestibule, is removed in order to remove the sensitive nerve endings located there. Although a vestibulectomy sounds like an extremely radical procedure, one recent study showed that it worked better than cognitive-behavioral therapy and biofeedback. This result is in line with several medical articles I read years ago on the topic, which indicated that most women who had surgery for vulvar vestibulitis reported an improvement in their condition.
In the past, vulvar vestibulitis was diagnosed with a cotton swab, which was used to poke at various areas of the vulva with increasing pressure. During the probing, a measuring device called a vulvagesiometer was also used to detect vulvar sensitivity.
Although experts agree that vulvar vestibulitis is a very serious problem, they currently don’t know exactly what to do about it. If you have these symptoms, it would probably be best to consult with both a medical doctor and a psychologist, as well as with any available support groups. I honestly don’t know whether the self-help program I outline for dyspareunia in Chapter 31 can be used to treat vulvar vestibulitis because I’ve never attempted to treat a case of it. Sometimes the symptoms last for a while and then go away on their own. If you would like to read a first-person account written by a woman who has dealt with this problem, I recommend a book called The Camera My Mother Gave Me, by Susanna Kaysen (see Recommended Reading).
Symptoms of Sexual Pain in Women
The specific symptoms of sexual pain will vary with each woman. The following are some examples from Private Pain, the book I mentioned in the last chapter:• Superficial vulval pain or tenderness
• Vulvar itching, burning, or stinging
• Pain or pressure behind the pubic bone
• Pain at the vaginal opening upon initial entry
• The sensation of being torn at the vaginal entry
• Mid-vaginal pain such as burning, sharp searing, or cramping
• Vaginal dryness, friction, and irritation
• Deep pain with thrusting, as if something is being bumped into
• Urinary burning and urgency
• Pain with orgasm (if the woman was aroused to completion of the sexual act)
Physical or Psychological Pain?
As I stated at the beginning of the chapter, dyspareunia is psychologically based pain experienced during sexual intercourse. This means that all of the medical conditions listed above must be ruled out before a diagnosis of dyspareunia can be made. It also means that in order for dyspareunia to be diagnosed, a man or woman must undergo a very thorough medical evaluation. For a woman, this will obviously include a pelvic examination, which can be incredibly painful for a woman with dyspareunia.
There are other ways to determine whether a woman’s pain is psychological. Everybody experiences pain differently, but some types of pain simply aren’t possible physically. For example, some women describe their pain as a sharp, piercing pain at the entrance to the vagina. From an anatomical standpoint, this is physically possible. Other women describe their pain as a sharp piercing pain about halfway up the side of the vagina or higher. From a physical standpoint, this is highly unlikely because most areas of the vaginal wall lack the nerve receptors to feel that type of discrete sensation, although the whole length of the vagina can feel a sensation of stretching.
Deep throbbing pain on one side of the abdomen or the other with intercourse is definitely possible, especially if the pain only happens once a month or every other month. In my experience this is usually caused by nonmalignant ovarian cysts.
Psychological Issues Related to Dyspareunia
Psychological causes of lifelong dyspareun
ia are similar to those that cause vaginismus: lack of sex education, fear of the genitals, or being taught that sex is painful. Psychological causes of acquired dyspareunia are somewhat more complicated. Acquired dyspareunia could be caused by sexual trauma such as rape. It is also commonly caused by sexual guilt or remorse over perceived sexual transgressions. I’ve read of many cases in which a woman developed dyspareunia after having an extramarital affair. Relationship issues can also cause dyspareunia. Some women develop sexual pain after their partner has been sexually unfaithful or has caused them other problems.
Some controversy exists about whether dyspareunia and vaginismus should be considered two different problems or whether they should be considered the same problem, because they both involve sexual pain during intercourse. I believe they should be thought of as different problems and treated differently. Vaginismus has only to do with the PC muscle, whereas superficial dyspareunia may cause pain at the vaginal opening, but it’s usually caused by vulvar vestibulitis.
Sexual Healing Page 14
