Author: The Beauty Nation

When considering intense pain elicited during coital functioning as opposed to vaginal aching or irritation, the therapist generally should look beyond the confines of the vaginal barrel for existent pathology involving the reproductive viscera.

Acute or chronic infections and endometriosis are pathological conditions involving the reproductive viscera; uterus, tubes, and ovaries that consistently may return a painful response as the female partner is sharing coital experience.

Although these two entities will be discussed separately, they do have in common similar physiological creation of painful response patterns during intercourse.

In both instances the response arises from peritoneal irritation resulting in local adhesions not only between folds of peritoneum but also involving tubes, ovaries, bowels, bladder, and omentum.

The combination of involuntary distention of the vaginal barrel created by female sex-tension increment and active male thrusting during coital connection places tension on relatively inelastic pelvic tissues stabilized by minor or even major degrees of fibrosis resulting from the infection or the endometriosis.

In short:
Any clinical condition that creates an untoward degree of rigidity of the soft tissues of the female pelvis, so that they do not move freely during sexual connection can return a painful response to the female partner involved.

Infections in the reproductive organs start with chronic involvement of the cervix (endocervicitis). By drainage through lymphatic channels, long-maintained endocervicitis can involve the basic supports of the uterus (Mackenrodt’s ligament) in a chronic inflammatory process. The resultant low-grade peritoneal irritation initiates painful stimuli when the cervix is moved in any direction, particularly by a thrusting penis.

The uterus itself can be involved with infection in the uterine cavity or endornetritis, or with a residual of infection throughout the muscular walls (myometritis) to such an extent that any pressure upon the organ is responded to with pain.

Retrograde involvement of the peritoneal covering of the uterus and its supports is quite sufficient to cause distress if the uterus is moved, either with involuntary elevation into the false pelvis with female sex-tension increment or during a male thrusting phase in coital connection.

Obviously there are many sources of infection of the oviducts (tubes). Any infections that originate in the cervix have opportunity to spread through the uterine cavity and into the tubal lumina.

The major infective agents are:
Gonococcus, streptococcus, staphylococcus, and coliform organisms. First infections in the tubal lumina frequently spill into the abdominal cavity, causing at least localized pelvic inflammation and at most generalized abdominal peritonitis.

Subsequently, as the acute stage of the infection subsides those areas involved in the infectious process remain open to the development of adhesions between loops of bowel, the omentum, and the pelvic viscera.

There even may be abscess formation involving the tubes and ovaries. In all these situations there is tension on and tightening of the peritoneum and rigid fixation of the pelvic soft-tissue structures to such an extent that vaginal distention and coital thrusting create a markedly painful response for the woman.

In no sense does this brief clinical description of pelvic inflammatory processes imply that whenever any woman acquires infection in the pelvic viscera she is committed thereafter to pain during coital connection.

With early and adequate medical care most pelvic infections do not create a residual of continuing pain with coital exposure. The degree of residual pelvic pain depends upon the severity of the occasional sequelae of the infectious process.

Where are the adhesions and how extensive are they? To what extent is natural expansion of the vaginal barrel restricted by filling of the cul-de-sac with an enlarged tube, by an ovary firmly adhered to the posterior wall of the broad ligament, or by a uterus held in severe third degree retroversion by adhesions? Any of these situations may create painful stimuli with penile thrusting.

There have been three cases referred as problems of dyspareunia in which individual women were involved in gang-rape experiences. In all three instances there were multiple coital connections, episodes of simultaneous rectal and vaginal mountings, and finally traumatic tearing of soft tissues of the pelvis associated with forceful introduction of foreign objects into the vagina.

Superficial and deep lacerations were sustained throughout the vaginal barrel and by other soft tissues of the pelvis. Included in the soft-tissue lacerations were those of the broad ligaments (in each case only one side was lacerated), but these lacerations were quite sufficient to produce severe symptoms of secondary dyspareunia.

For some years after the rape episodes each of the three women was presumed to be complaining of the subsequently acquired pain with intercourse as a residual of the psychological trauma associated with their raping.

The immediately necessary surgical repair to pelvic tissues had been conducted, but beyond the clinically obvious lacerations of vaginal barrel, bladder, and bowel, the remainder of the pelvic pathology understandably had not been described at the time of surgery.

Before gaining symptomatic relief by a second surgical procedure, these three women underwent a combined total of 21 years of markedly crippling dyspareunia, involving a total of five marriages.

The only way that broad-ligament lacerations can be handled effectively is by surgery. Operative findings are relatively constant: (1) The uterus usually is in third-degree retroversion and enlarged from chronic vasocongestion; (2) A significant amount of serous fluid (ranging from 20 to 60 ml in volume) arising from serous weeping developing in the broad-ligament tears is consistently found in the pelvis; (3) There may be unilateral or bilateral broad ligament and/or sacrouterine-ligament lacerations.

It is the inevitable increase in pelvic vasocongestion associated with sexual stimulation added to the already advanced state of chronic pelvic congestion in these traumatized women that can elicit a painful pelvic response.

Particularly does such a response arise when the chronically congested pelvic viscera are jostled by the vaginally encased thrusting penis.

It is not within the range of this textbook to describe the surgical procedures for repair of the traumatic tears of the uterine supports. The reader is referred to the bibliography for more definitive consideration. Subsequent to the definitive surgery, the symptoms of acquired dyspareunia, dysmenorrhea, and the sensations of extreme fatigue usually show marked improvement or may be completely alleviated.

These pelvic findings have been described in far more than usual detail for this type of text, primarily to alert examining physicians to the possibility of the broad-ligament laceration syndrome.

When these pelvic findings have been overlooked, the complaining woman frequently has been told by authority that the pain described with intercourse is due to her imagination. The intelligent woman bas grave difficulty accepting this suggestion. She knows unequivocally that coital activity particularly that of deep vaginal penetration is severely painful.

Actually, she finds that with vaginal acceptance of the full penile shaft, pain is almost inevitable.

Even if she has been orgasmic previously, it is rare that she accomplishes orgasmic release of her sexual tensions during intercourse after incurring broad-ligament lacerations, simply because she is always anxiously anticipating the onset of pain.

Any woman with acquired pelvic disability restraining her from the possibility of full sexual responsivity is frustrated. Without orgasmic release with coital connection there will be a marked residual of acute vasocongestion to provide further pelvic discomfort during a long, irritating resolution phase.

Probably the most frustrating factor of all is to have the acquired dyspareunia disbelieved by authority when the pain with penile thrusting is totally real to the woman involved. The vital question for the therapist to ask should be, “Did this pain with deep penile thrusting develop after a specific delivery?”

If the woman can identify a particular pregnancy subsequent to which the dyspareunia became a constant factor in her attempts at sexual expression, the concept of the broad-ligament-laceration syndrome should come to mind.

Many men complain:
Burning, itching, and irritation after coital connection with women contending with chronic or acute vaginal infections.

Not infrequently small blisters appear on the glans penis, particularly around the urethral outlet. If there are any abrasions on either the glans or shaft of the penis, secondary infection can occur in these local sites.

Irritative Penile Reaction

The same type of irritative penile reaction may develop from exposure to a non infectious vaginal environment as a response to the chemicals in contraceptive creams, jellies, foams, etc.

It may not be the female that responds in a sensitive manner to an intravaginal chemical contraceptive agent but rather her male partner. Sensitivity to intravaginal chemical contraceptives is seen quite frequently in the male and, if symptoms develop, contraceptive technique should be changed.

The same sort of irritative penile reaction can be elicited by a repetitive pattern of vaginal douching.

There are some douche preparations to which not the female but the male partner becomes sensitive.

Not infrequently, vesicles form on the glans penis. If these blisters rupture, the raw areas on the glans are quite painful, particularly during sexual connection.

Gonorrhea

In the actual process of ejaculation there are many situations that return painful stimuli to the involved male. If the individual has had gonorrhea there may be strictures (adhesions) throughout the length of the penile urethra, and attempts to urinate and/or to ejaculate may cause severe pain spreading throughout the penile urethra and radiating to the bladder and prostate.

Infection in the Bladder, Prostate, or the Seminal Vesicles

There may be the sensation of intense burning during and particularly in the first few minutes after ejaculation. Particularly if the offending agent has been the gonococcus, the pain with ejaculation sometimes is exquisite. Immediate medical attention should be given to any complaint of burning or itching during or immediately after the ejaculatory process.

Prostate and Ejaculation

There is a spastic reaction of the prostate gland seen in older men during the stage of ejaculatory inevitability. In this situation the prostate contracts spastically rather than in its regularly recurring contractile pattern, and the return can be one of very real pelvic pain and/or aching radiating to the inner aspects of the thighs or into the bladder and occasionally to the rectum.

This pathologic spastic contraction pattern can be treated effectively by providing a minimal amount of testosterone replacement therapy.

Care should be taken to evaluate the possibility of concurrent infection in the prostate. Occasionally, chronic prostatitis has caused significant degrees of pain during an ejaculatory process.

As a point in differential diagnosis, the painful response with prostatic infection is with the second, not the first, stage of the orgasmic experience, while that of prostatic spasm has just the reverse sequence. Careful questioning usually will establish specifically the timing in onset of the painful response and thus suggest a more definitive diagnosis.

Prostate

Benign hypertrophy of the prostate gland primarily and carcinoma of the prostate rarely may be responsible for onset of pain with the ejaculatory process. The pain is secondary (acquired) in character and radiates to bladder and rectum.

Usually confined to older age groups, onset of this type of dyspareunia should be investigated immediately by competent authority. This review of the major causes of dyspareunia has been primarily directed toward the female partner, for from her come by far the greater number of complaints of painful coital connection.

However, male dyspareunia no longer should be ignored by the medical and behavioral literature. The review of the etiology of male dyspareunia has not been exhaustive, nor is it within the province of this text to do so.

In concept, the entire chapter has been designed to suggest to cotherapists, faced daily with a myriad of problems focusing upon both male and female sexual dysfunction, that there are physiological as well as psychological causes for sexual inadequacy.

Combined pelvic and rectal examinations for the female and rectal examination for the male partner are a routine part of the total physical examination provided for both members of any marital unit referred to the Foundation for treatment of sexual dysfunction.

To attempt to define and to treat the basic elements of sexual dysfunction for either sex without including the opportunity for thorough physical examination and complete laboratory evaluations as an integral part of the patient’s diagnostic and therapeutic program is to do the individual and the marital unit a clinical disservice.

Painful Coition Is Not Limited to Women.

Many men are distracted from and even denied effective sexual functioning by painful stimuli occasioned during or after sexual functioning.

The symptoms will be described in relation to the anatomical site of pain, the external anatomy, such as the surface of the penis and the scrotal sac, or the internal anatomy, such as the penile urethra, the prostate, or the bladder.

No attempt will be made to provide definitive discussion for the varieties of male-oriented dyspareunia. Situations are mentioned only to emphasize their existence and to provide the therapist with an awareness of the fact that, in truth, there are badly mated men.

Penis Exterior Anatomy

Many men complain of severe sensitivity of the glans penis, not only to touch but to any form of containment, including intravaginal retention, immediately after ejaculation. This severity of glans pain recalls the intensely painful response that may be elicited from the clitoral glans when it is approached during forceful male manipulative attempts to incite sex-tension increment for his female partner.

Once a man is fully aware that immediately after his ejaculatory episode there may be exquisite tenderness of the glans, he realizes that he must immediately withdraw from intravaginal containment.

Generally there is marked variation in the severity of the individual response pattern. Men noting variation in the severity of glans pain have no pre-ejaculatory warning of the intensity of the particular response pattern, which may range from minor irritation with containment to crippling pain with the slightest touch.

The glans
Occasionally is irritated rather than protected, as might be presumed, by a retained foreskin. Two men have been referred to the Foundation complaining that relief from painful stimuli immediately after ejaculation can be obtained only by retracting the foreskin well back over the glans and in this fashion relieving the irritation of glans confinement.

Foreskin
There are occasional irritative responses created by the retained foreskin of uncircumcised men. In almost all instances these irritative responses have to do with lack of effective hygienic habits.

Primarily, smegma and, secondarily, various bacterial, trichomonal, or fungal infections sometimes collect beneath the foreskin. If the foreskin is not retracted regularly and the area washed with soap and water, chronic irritation can easily develop.

With chronic irritation or even frank infection present, there usually will be pain with coital thrusting or with any form of penile containment. In almost all instances the dyspareunia responds readily to adequate cleansing principles.

Phimosis

A tightness or constriction of the orifice of the prepuce, clinically is marked by a foreskin that cannot be retracted over the glans penis. With an excessively constrained foreskin, infection is almost always present to at least a minor degree, and penile irritation is a consistent factor for men so afflicted.

Adhesions frequently develop between the foreskin and the glans proper so that there is no freedom of movement between the two structures.

Engorgement of the penis with sex-tension increment may bring pressure to bear on the foreskin constraint of the glans. Without freedom of foreskin movement, this constriction frequently causes local pain with penile erective engorgement. When any male is diagnosed as having a degree of clinical phimosis sufficient for chronically recurrent infectious processes and/or pain or irritation with coital connection, circumcision certainly is in order.

There are also occasional men with a true hypersensitivity of the penile glans. These men are almost constantly irritated by underclothes or by body contact. They are continually aware of a multiplicity of irritants and are particularly susceptible to trauma to the glans.

One man referred for consideration found glans constraint in the vaginal environment intolerable. There was a constant blistering and peeling of the superficial tissues of the glans surface.

Despite a history of numerous changes in sexual partners, the postcoital results were identical. This individual simply could not tolerate the natural pH levels of the vagina. Since the reaction was confined to the glans area and never involved the penile shaft, there is room for presumption that if he had not been circumcised routinely, he might not have been so handicapped.

Protective coating of the glans area precoitally resolved his problem but was a nuisance factor for him and possibly for his sexual partners.

There are occasional instances of referred pain from the posterior urethra (usually occasioned by posterior urethritis) that produce pain in the glans penis. Very rarely, this type of glans pain is a factor in coition.

Among the most distressing of the many factors in dyspareunia are the complaints of burning, itching, or aching in the vagina during or after intercourse. The existence of chronic vaginal irritation frequently robs women of their full freedom of sexual expresssion, for they are well aware that any specific coital connection may be severely irritative rather than highly stimulative.

Presuming adequate production of vaginal lubrication, rarely, if ever, does a woman complain of burning, itching, or aching during coition or describe these symptoms immediately after or even in a delayed postcoital time sequence without concomitant evidence of established pathology in the vaginal barrel.

This form of dyspareunia registered as a complaint by the female partner should have an important connotation to the cotherapist. This specific response pattern is not described by women who are subjectively impelled to register an excuse to avoid impending or threatened coital connection.

When women use the complaint of pain to avoid or delay the necessity for submitting to psycho genically unappealing coital experience, their most frequent complaint is one of severe pain with penile thrusting, “a hurting” deep in the pelvis.

When considering the complaints of burning, itching, or aching in the vagina, initially clinical concern is focused on infectious vaginal invaders. The primary sources of vaginal infection are coition and rectal contamination; secondary sources are manual contact, clothing material, insertion of foreign material, and functional disuse.

Support of and control of the acidity of the vaginal environment is the fundamental means of protection against the bacterial pathogens that can create symptoms of burning, itching or aching. The vagina naturally maintains a strongly acid environment as a protective mechanism against all forms of infectious invasion.

With an experimentally controlled environment, vaginal acidity has been established as varying clinically from pH 3.5 to pH 4.0. Thus, there is a rather wide margin for error in vaginal protection against concurrent infectious agents, for acidity must be sufficiently neutralized to raise the pH level to five or above, before bacterial invaders can flourish freely in the vaginal environment.

The one time that natural vaginal protection against infection breaks down is during the period of established menstrual flow. For many women vaginal acidity consistently registers in the neighborhood of pH 5 or above during menstrual flow, particularly if vaginal tampons are employed.

The neutralizing effect of blood serum constrained to the vaginal tract by retentive tampons directs vaginal acidity into pH 5 levels routinely. It is not surprising, then, that most vaginal infections either have clinical onset or flourish during menstrual flow.

Bacteria

The infective organisms most constantly encountered in vaginal infections, yet trichomonal and fungal forms of infection are seen frequently enough to provide additional causes for clinical concern. Probably the most persistent vaginal-tract invader in any woman’s lifespan are the coliform organisms (Strepto coccus faecalis, Escherichia coli, and the type of Streptococcus viridans), which are the basic contaminants of bowel environment.

From the point of view of patterns of sexual functioning alone, a persistent vaginitis, from which pathogenic organisms repeatedly are cultured in the adult, sexually functioning woman, should always make the therapist question the possibility of occasions of rectal intercourse.

A popular technique employed during rectal intercourse includes the expected format of initial rectal penetration during the excitement phase and repetitive thrusting during the plateau phase of the male sexual response cycle.

Infected Penis

But many men withdraw from the rectum and plunge the bacterially contaminated penis into the vaginal barrel just before or during the stage of ejaculatory inevitability, terminating the orgasmic phase of their sexual cycle by ejaculating intravaginally. Recurrent coliform vaginal infections that are resistant to treatment may have origin in this coital technique.

When rectal intercourse is practiced, the ejaculatory episode should be confined to the lumen of the bowel. There should never be penetration of both rectal and vaginal orifices during any single coital episode, if the woman wishes protection against the probability of recurrent vaginal infections.

If coliform vaginitis persists despite both adequate treatment and patient denial of rectal intercourse, a direct rectal examination frequently will solve the therapist’s diagnostic dilemma. If a woman is experiencing rectal intercourse with some regularity, there may be a specific involuntary reaction of the sphincter to the rectal examination.

When the examining finger is inserted, the response of the rectal sphincter at first will be one of slight to moderate spasm, following the expected reactive pattern of most men or women undergoing routine rectal examinations. But if the examining finger is retained rectally for a few seconds, the sphincter may relax quite rapidly in a completely involuntary manner, as opposed to the routine response pattern of continuing in spastic contraction for the duration of the examination.

If involuntary sphincter relaxation develops, this response pattern, while certainly not reliably diagnostic, should make the cotherapist skeptical of the patient’s denial of rectal coital episodes.

The involuntary sphincter relaxation develops because the retained examining finger stimulates a pleasurable response for those women enjoying regularity of rectal coital exposure as opposed to those finding rectal examinations subjectively objectionable and objectively painful.

Clinical note:
The same type of involuntary sphincter relaxation may develop in male homosexuals whose preferred pattern of sexual expression includes interest in regularity of rectal penetration. Again, the involuntary sphincter response pattern has been used by the Foundation’s professional staff as a clinical diagnostic aid when dealing with homosexual male patients employing the rectum as the means of providing ejaculatory release for sexual partner or partners.

When the cotherapist can be reasonably certain by both history and examination of some regularity of rectal intercourse, techniques to avoid vaginal contamination with fecal material should be discussed at length with the women involved.

Although the basic premise of the clinical advice is to avoid recurrent episodes of coliform vaginitis if possible, there is an accrued secondary effect of reducing dyspareunia during occasions of intravaginal coitus.

Uncircumcised Penis

When trichomonal vaginitis is suggested by direct inspection of the vaginal barrel and confirmed by adequately stained vaginal smear or hanging-drop preparation of the vaginal discharge, which may be profuse and irritating.

The husband also should be suspected of harboring the trichomonads, possibly beneath the foreskin if he is uncircumcised, but more frequently in the prostate gland, the seminal vesicles, or the urinary bladder.

If both husband and wife are not treated simultaneously for this particular distress, the infection may become a source of chronic dyspareunia, as it may be exchanged frequently between marital partners during repeated opportunity at coital connection.

It does little good to treat the wife for trichomonal vaginitis and then have her reinfected by her husband. And it obviously does little good to treat the husband individually and have him reinfected by his wife. With chronic trichomonal vaginitis there may be recurrent bouts of dyspareunia, particularly with coital connection of any significant duration.

Fungal vaginitis is seen clinically more and more frequently. Incidence of this particular infectious entity used to be primarily confined to the late spring, summer, and early fall months, but now such pathogens as Monilia and Candida albicans are encountered regularly throughout the year.

Chronic fungal infection creates a debilitating situation for the recipient woman. Burning and itching is intense and swelling and weeping of soft tissues are frequent complications. Coital connection is virtually impossible due to the pain involved when a fungal infection dominates in the vaginal environment.

Infections with antibiotics frequently will protect women from the complications of fungal vaginitis.

Curve Penis

Peyronie
A disease produced by induration and fibrosis of the corpora cavernosa of the penis and evidenced as an upward bowing of the penis, plus a gradually increasing angulation to the right or left of the midline, makes coital connection somewhat difficult, and in advanced stages coition is virtually impossible.

There also may be pain attached to attempts at coital connection due to the unusual angulation of the penis creating resultant penile shaft strain, both with inserting and with thrusting experience.

Penile Chordee or Curved Penis

It is seen rarely in situations of penile trauma and only occasionally with neglected gonorrheal urethritis. Consultation has been requested by four men with severe penile chordee as a post traumatic residual.

In two instances the fully erect penis was struck sharply by an angry female partner. The remaining two men each described severe pain with a specific coital experience. During uninhibitedly responsive coital connection with the female partner in a superior position, the penis was lost to the vaginal barrel. In each case, the women tried to remount rapidly by sitting down firmly on the shaft of the penis.

The vaginal orifice was missed in the hurried insertive attempt and the full weight of the woman’s body sustained by the erect penis.

Each of the four men gave the remarkable verbal description that he felt or heard something snap. Shortly thereafter an obvious hematoma appeared on the anterior or posterior wall or lateral walls of the penile shaft.

Over a period of weeks, as the local hemorrhage was absorbed, fibrous adhesions developed and, with subsequent scar formation, there slowly developed a downward bowing and (in three cases) mild angulation of the penis.

Urologists state that due to the type of tissue involved in the penile trauma, there is little to offer in the way of clinical reprieve for men afflicted with these embarrassing erective angulations, Peyronie’s disease or chordee.

Attempts at surgical correction currently are of relatively little value and not infrequently make the situation worse. Any of these situations create responses of pain and tenderness during both masturbation and coital connection.

It always should be borne in mind that the erect penis can be traumatized by a sudden blow, by rapidly shifting coital position, by applying sudden angulation strain to the shaft, or from violent coital activity that places sudden weight or sudden pressure on the fully erect penis. The unfortunate residuals of such trauma have been described above.

Direct trauma of the penis occasioned by major accidents, war injuries, or direct physical attack sometimes requires that treatment for sexual dysfunction be patterned to include marked variation in the anatomical structuring of the penis. In anatomical deformity of the penis, the complaint of dyspareunia can be raised by either the male or female sexual partner.

Testicular Pain

Usually of the dull, aching variety, develops for some men who spend a significant amount of time in sexual play or in reading pornographic literature, concurrently maintaining erections for lengthy periods of time without ejaculating within the immediate present.

Frequent returns to excitement or even plateau-phase levels of sexual stimulation without ejaculatory relief of the accompanying testicular vasocongestion can cause an aching in either or both testes, particularly in younger men. Relief is immediate with ejaculation, which disperses the superficial and deep vasocongestion and returns the testicles to their normal size.

No permanent damage is occasioned by maintaining chronic testicular congestion for a period of days. Men with this syndrome of testicular pain occasioned by long-maintained sexual tension are in the minority.

Usually, the syndrome of involuntary testicular pain is relieved somewhat as the man ages.

There are painful reactions that develop during or shortly after coital connection that particularly reflect the influence of the vaginal environment. These situations are mentioned only in passing, but the therapist should keep in mind the fact that the basic pathology involved rests within the vaginal environment.