Category: Women’s Health

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.

Infection of Uterus and Ovaries

Infection (acute or chronic) 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 a 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 the 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 of Cervix

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 (endometritis) or with a residual 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 the 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 the 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 a 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.

It arises with deep penetration of the penis. Women describe the pain associated with intercourse to be as if their husbands had “hit something” with the penis during deep vaginal penetration.

These involved women may note other physical irritations frequently seen with chronic pelvic vasocongestion, a constantly nagging backache, throbbing or generalized pelvic aching, and occasionally, a sense that “everything is falling out.”

These symptoms are made worse in any situation requiring a woman to be on her feet for an exceptional length of time, as a full day spent doing heavy housecleaning or working as a saleswoman in a department store.

Most women lose interest in any regularity of sexual expression when distressed by acquired dyspareunia. Handicapped by constant anticipation of painful pelvic stimuli created by penile thrusting, they also may lose any previously established facility for orgasmic return.

The basic pathology of the syndrome of broad ligament laceration is confined to the soft tissues of the female pelvis. The striking features of the pelvic examination are the position of the uterus (almost always in severe third-degree retroversion) and the particularly unique feeling that develops for the examiner with manipulation of the cervix.

This portion of the uterus feels just as if it were being rotated as a universal joint. It may be moved in any direction, up, down, laterally, or on an anterior-posterior plane with minimal, if any, correspondingly responsive movement of the corpus (body of the uterus).

Even the juncture of the cervix to the lower uterine segment is ill-defined. The feeling is one of an exaggerated Hegar’s sign of early pregnancy, in which the cervix appears to move in a manner completely independent of the attached corpus.

In addition to the “universal joint” feeling returned to the examiner when moving the cervix, a severe pain response usually is elicited by any type of cervical movement.

However, pain is primarily occasioned by pushing the cervix in an upward plane.

Painful Cervix

In the more severe cases, either in advanced bilateral broad ligament laceration or in a presenting complaint of five years or more in duration even mild lateral motion of the cervix will occasion a painful response.

During examination the retroverted uterus appears to be perhaps twice increased in size. Pressing against the corpus in the cul-de-sac in an effort to reduce the third-degree retroversion (which usually is readily accomplished) also will produce a marked pain response.

When the examiner applies upward pressure on the cervix or pressure in the cul-de-sac against the corpus, the patient frequently responds to the painful stimulus by stating, “It’s just like the pain I have with intercourse.”

A detailed obstetrical history is the salient feature in establishing the diagnosis of the broad ligament laceration syndrome. The untoward obstetrical event creating the lacerations may be classified as surgical obstetrics, as an obstetrical accident, or even as poor obstetrical technique.

Occasionally, women with both the positive pelvic findings and the subjective symptoms of this syndrome cannot provide a positive history of obstetrical trauma, but this situation does not rule out the existence of the syndrome

Many women are unaware of an unusual obstetrical event because they were under advanced degrees of sedation or even full anesthesia at the time.

Precipitate deliveries, difficult forceps deliveries, complicated breech deliveries, and postmature-infant deliveries are all suspect as obstetrical events that occasionally contribute to tears in the maternal soft parts. If these tears are established in the supports of the uterus (broad ligaments) the immediate postpartum onset of severe dyspareunia can be explained anatomically and physiologically.

It is important to emphasize clinically that although a woman may not be able to describe a specific obstetrical misfortune in her past history, she well may be able to date the onset of her acquired dyspareunia to one particular obstetrical event.

Extensive Dilation of The Cervix

Three cases have been seen in which a criminal abortion was performed by extensively packing the vaginal barrel, leading ultimately to dilation of the cervix and expulsion of uterine content. These extensive vaginal packing episodes created tears of the broad ligaments, completely parallel to those occasioned by actual obstetrical trauma.

Each woman, although unaware of the etiological significance, dated the onset of the symptoms of acquired dyspareunia to the specific experience with the vaginal-packing type of abortive technique.

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 the 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:

• The uterus usually is in third-degree retroversion and enlarged from chronic vasocongestion.
• 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.
• 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.

Vaginal Lubricant

Probably the most frequent cause for dyspareunia originating with symptoms of burning, itching, or aching is the lack of adequate production of vaginal lubrication with sexual functioning.

During attempted penile intromission or with long-maintained coital connection, there must be adequate lubrication or there will be irritative distress for either or both coital partners.

Adequate production of vaginal lubrication is for women the physiological equivalent of erective attainment for men and her representation to her male partner of psychological readiness for vaginal penetration.

A consistent lack of functional levels of vaginal lubrication is as near as any woman can come to paralleling a man’s lack of effective erection.

Inadequate development of vaginal lubrication has many causes, but by far the most common is lack of interest in the particular opportunity or identification with the involved sexual partner. Women must experience positive input from their sexual value systems if they are to respond repetitively and effectively to their mate’s sexual approaches.

Women who cannot think or feel sexually, those reflecting fears of sexual performance, and even those acting out a spectator’s role in sexual functioning, either do not develop sufficient vaginal lubrication to support a painless coital episode or, if penetrated successfully, they cease production of the necessary lubricative material shortly after intravaginal penile thrusting is initiated.
Additionally, women fearful of pain with deep vaginal penetration, fearful of pregnancy with any coital connection, fearful of exposure to social compromise, and fearful of sexual inadequacy are frequently poor producers of vaginal lubrication.

Any Component of fear present in sexual experiences reduces the receptivity to sensate input, thereby blunting biophysical responsivity.

If there is insufficient vaginal lubrication, there may or may not be acute pain with full penile intromission, depending primarily upon the parity of the woman, but they’re usually will be vaginal burning, irritation, or aching both during and after coital connection.

There are tens of thousands of women who become markedly apprehensive at the onset of any definitive sexual approach, simply because they know severe vaginal irritation will be experienced not only during but frequently for hours after any significantly maintained coital connection.

Not to be forgotten as a specific segment among the legions of women afflicted by inadequate production of vaginal lubrication are those in their postmenopausal years.

If they are not supported by adequate sex-steroid-replacement techniques, the production of vaginal lubrication usually drops off markedly as the vaginal mucosa routinely turns atrophic.

There well may be aching and irritation in the vagina for a day or two after coital connection for women contending with this evidence of sex-steroid starvation.

A major category of women tending to be poor lubrication producers during coital connection is that significant segment of the female population with overt lesbian orientation.

Many women psychosexually committed to a homophile orientation attempt regularity of coital connection for socioeconomic reasons. Frequently, they may not lubricate well during heterosexual activity, although there usually is ample lubrication when they are directly involved in homosexual expression.

In most instances, inadequate production of vaginal lubrication can be reversed with a definite therapeutic approach. Certainly, women burdened by a multiplicity of sex-oriented fears can be provided psychotherapeutic relief of their phobias and subsequently reversed with relative ease from their particular pattern of sexual inadequacy.

Those women with chronic vaginal itching and irritation can be protected from continuing dyspareunia because both infectious and chemical vaginitis are reversible under proper clinical control. Senile vaginitis responds in short order to adequate sex-steroid-replacement techniques.

There are only two major categories of women for whom the co-therapists have little to offer in an effort to constitute effective production of vaginal lubrication:

1. Women mated to men for whom they have little or no personal identification, understanding, affection, or even sexual respect.
2. Homosexually oriented women practice coition for socioeconomic reasons with no interest in their male companions as sexual partners.

Vagina and Penile Thrusting

As opposed to the symptoms of aching, irritation, or burning in the vagina, complaints of severe pain developed during penile thrusting provide the most difficulty in delineating between subjective and objective etiology.

Although many women register this type of complaint when seeking to avoid undesired sexual approaches, there are some basic pathological conditions in the female pelvis that can and do engender severe pain in response to active coital connection.

One of the difficulties in delineating the severity of the complaint of dyspareunia is to identify pelvic pathology of a quality sufficient to support the female partner’s significant complaints of painful coition. Pelvic residual from severe infection or pelvic implants of endometriosis usually is easily identified by adequate pelvic and rectal examinations.

These clinical entities will be discussed briefly in context later in the topic. Current attention is drawn to probably the most frequently overlooked of the major physiological syndromes creating intense pelvic pain during coital connection.

Uterine Support

One of the most obscure of pelvic pathological syndromes, yet one of the most psychosexually crippling, is traumatic laceration of the ligaments supporting the uterus.

Five women have been referred to the Foundation for relief of subjective symptoms of dyspareunia after referral sources had assured the husbands that there was no plausible physical reason for the constant complaint of severe pain with deep penile thrust.

These 5 postpartum women had severe broad ligament lacerations and were relieved of their distress by definitive surgical approaches, not by psychotherapy. Therefore, they do not represent a component of the statistical analysis of treatment for sexual dysfunction.

Three women reflecting the onset of dyspareunia subsequent to criminal abortion techniques also have been seen in consultation and are not reflected in the statistics of the sexual inadequacy study. Three more women have been seen in gynecological consultation for acquired dyspareunia subsequent to gang-rape experiences.

They also have not been an integral part of the sexual dysfunction study. These clinical problems will be mentioned in context.

When first seen clinically, women with traumatic lacerations of the uterine supports, acquired with delivery or by specific criminal abortion techniques, present complaints that commonly accrue from pelvic vasocongestion, dyspareunia, dysmenorrhea, and a feeling of being excessively tired.

These complaints are secondary or acquired in nature. The traumatized women consistently can relate the onset of their acquired dyspareunia to one particular obstetrical experience even from among three or four such episodes.

When chronic vaginal irritation 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 opportunities 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 the 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.

The chronic fungal infection creates a debilitating situation for the recipient woman. Burning and itching are 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.

Symptoms of dyspareunia

Aside from direct infective agents, there are many other sources of burning, itching, or aching in the vaginal barrel that can produce chronic dyspareunia. Among those most frequently encountered are the sensitivity reactions associated with intravaginal chemical contraceptive materials.

Many women develop vaginal sensitivity to chemical factors included in contraceptive creams, jellies, suppositories, foams, or foam tablets.

When persistent itching or burning is intense enough to engender the symptoms of dyspareunia during or shortly after intercourse, and when any of these above-mentioned intravaginal chemical contraceptive agents are employed routinely during coital connection, the possibility of sensitivity to the chemical agents should always be kept in mind.

There also are occasional irritations created by the rubber used in manufacturing both diaphragms and condoms. In a few women, the response of the vaginal mucosa to latex products (condom sensitive) is quite irritative in character.

When these contraceptive techniques are employed with regularity and chronic noninfectious irritation in the vagina causes obviously increasing dyspareunia, sensitivity to rubber products should be suspected.

The sensitivity to rubber is quite infrequent but must be kept in mind in the differential diagnosis of non-infectious, irritative, vaginal dyspareunia.

Agents frequently most often responsible for making the vaginal mucosa sensitive to infective processes and emphasizing the potential irritation of maintained penile thrusting are the various douching preparations.

Many women feel they must douche after every coital exposure to maintain cleanliness. This is one of the most persistent and widespread misconceptions in the folklore of human sexual functioning.

From a cleanliness point of view, there is not the slightest need for douching after intercourse. The vagina returns to its natural protective pH value within 6 to 8 hours after seminal-fluid deposition.

Repeated douching usually accomplishes only the untoward result of washing protective levels of residual acidity from the vagina. Thereafter, secondary infection frequently develops from the elevated levels of pH usually found in the post-douching vaginal environment.

Additionally, proprietary products used in douching can create reactive, chemical-type vaginitis of the same pattern as that stimulated by intravaginal chemical contraceptives.

Esthetically concerned women should be reassured by the authority that the simple expedient of external washing with soap and water is all that is necessary to maintain security from post-ejaculatory drainage and to avoid any suggestion of postcoital odor.

Senile Vaginitis

There is another type of chronic vaginal irritation that should be highlighted. It frequently is seen associated with clinical complaints of dyspareunia and is described as senile vaginitis.

Older women not supported by steroid protection techniques develop thin, atrophic mucosal surfaces in the vagina.

These tissue-paper-thin areas crack and bleed easily under duress of forceful or maintained penile thrusting.

Many women in the 50 to 70 year age group complain of vaginal burning and irritation not only during but even for hours and occasionally days after coital exposure due to the atrophic condition of the mucosal lining of the vagina.

Aging women can be fully protected from these distressing symptoms by the initiation of adequate sex steroid support. Although seen infrequently, yet in the same physiological category as senile vaginitis, is a radiation reaction in the vagina.

After local radiation for carcinoma, the vaginal barrel shrinks, the mucosa becomes atrophic, and dyspareunia usually develops not only from the atrophic mucosa but also on the basis of loss of vaginal wall elasticity and marked reduction of lubrication production.

Vaginal irritation

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 expression, 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 co-therapist. This specific response pattern is not described by women who are subjectively impelled to register an excuse to avoid impending or threatened coital connection.

Penis thrusting

When women use the complaint of pain to avoid or delay the necessity for submitting to psycho genetically 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 are 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 is the coliform organisms (Streptococcus faecalis, Escherichia coli, and the type of Streptococcus viridans), which are the basic contaminants of the bowel environment.

From the point of view of patterns of sexual functioning alone, 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.

Rectal intercourse

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 originated 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 spasms, 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 co-therapist 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.

As a clinical note, the same type of involuntary sphincter relaxation may develop in male homosexuals whose preferred pattern of sexual expression includes an interest in the 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 an ejaculatory release for sexual partners or partners.

When the therapist 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.

Intercourse Pain

For years, a woman’s complaint “it hurts when I have intercourse” has been an anathema to the therapist. Even after an adequate pelvic examination, the therapist frequently cannot be sure whether the patient is complaining of definitive but undiagnosed pelvic pathology or whether, as has been true countless thousands of times.

A sexually dysfunctional woman is using the symptomatology of pain as a means of escaping completely or at least reducing markedly the number of unwelcome sexual encounters in her marriage.

For it is true that once convinced that there is no recourse for reversal of his or her dysfunctional status, the sexually inadequate partner in any marriage manufactures excuse after excuse to avoid sexual confrontation. As women have long since learned, a persistent, aggressive male partner can overwhelm, neutralize, or even negate the most original of excuses to avoid sexual exposure.

However, presuming any degree of residual concern for or interest in his partner as an individual, the husband is rendered powerless to support his insistence upon continuity of sexual contact when the wife complains of severe distress during or after sexual connection.

If the female partner complains and flinches with penile insertion, moans, and contracts her abdominal and pelvic musculature during the continuum of male thrusting, cries out or screams with deep vaginal penetration, sheds bitter tears after the termination of every sexual connection, or complains angrily of aching in the pelvis or burning in the vagina during or even hours after a specific coital episode, the male partner’s sexual approach must be accepted as the probable potentiator of a physiological basis for his female partner’s evidenced sexual dysfunction.

Thereafter, the husband has minimal recourse. There is little he can do other than to avoid or at least reduce marital couple sexual exposure on his own cognizance, and/or to insist that his wife seek professional consultation. Once consulted, the twofold problem that constantly baffles authority is first whether a specific physiological basis can be defined for the objective existence of pain.

Second, if not, whether the existence of pelvic pathology should arbitrarily be ruled out, thereby defining the registered complaint of dyspareunia as subjective in origin. When a woman complains of pain during or after intercourse, there are very few diagnostic landmarks to follow for treatment, so that consideration of the etiology of the painful response seems appropriate.

As in vaginismus, a differential diagnosis cannot be established for a complaint of dyspareunia unless careful pelvic and rectal examinations are conducted. Even then there can be no sure diagnosis if the existence of pelvic pathology is denied purely on the basis of negative examinations by the competent authority.

Yet, in a positive vein, there are obvious pelvic or rectal findings that can and do support objectively a woman’s subjective complaint of coital discomfort. The female partner’s persistent complaint of pain with any form of coital connection must not be authoritatively denied or, for that matter supported, purely on the basis of interrogation, regardless of how carefully or in what depth the questioning has been conducted.

There are many varieties of dyspareunia, varying from postcoital vaginal irritation to severe immobilizing pain with penile thrusting. Symptomatic definition relating not only to the anatomy of the vaginal barrel but also to the total of the reproductive viscera is in order.

In no sense will the discussion include all possible forms of pelvic distress. Considered, however, will be the major sources of pelvic pathology engendering painful response from the female partner during or after coital connection. The dyspareunia will be considered in relation to specific areas of the vaginal barrel, the reproductive viscera, and the soft tissue components of the pelvis, and too painful stimuli developing, in a time-related sequence during or after coital connection.

Vagina Pain

The complaint of pain with penile intromission should demand clinical inspection of the vaginal outlet and the labial (major and minor) area. Direct observation can easily delineate any of the following minor areas of concern, minor only in the sense of easy reversibility of physical distress by adequate clinical measures.

An intact hymen or the irritated or bruised remnants of the hymenal ring can and do cause outlet pain during attempted coital connection. Less obvious is an unprotected scar area just at the mucocutaneous juncture of the vaginal mucosa and the perineal body. These scars, primarily residuals of episiotomies sustained during childbirth, occasionally have been observed to result from criminal abortion techniques or gang-rape episodes.

The Bartholin-gland area in the minor labia should be carefully palpated for enlargement in the gland base, which can contribute to a locally painful reaction as the vaginal outlet is dilated by the penile glans at the onset of intromission. Finally, in postmenopausal women, the labia and vaginal outlet may have so lost elasticity and become so shrunken in size that any penile insertive attempt will return a painful response.

Clitoris Irritation

With any complaint of outlet pain, the clitoral area also should be inspected carefully. Many women simply cannot define anatomically or are too embarrassed to discuss objectively the exact location of the outlet distress occasioned by attempts at coital connection. Smegma beneath the clitoral foreskin can cause chronic irritation and burning that becomes severe as the penis is introduced into the vaginal orifice.

Rarely adhesions beneath the minor labial foreskin anchoring the foreskin to the clitoral glans can cause distress when the foreskin is moved or pulled from its specific pudendal-overhang position by manipulative approaches to the mons area or by intromissive attempts. When the minor labial hood of the clitoris is pulled down toward the perineum by the act of penile intromission, an intense pain response from the presensitized clitoral glans or even the clitoral shaft may become of the major clinical moment.

The same type of reaction can be elicited if foreplay in the clitoral area has been irritative rather than stimulative in character, as so often happens when the sexually uneducated male tries to follow “authoritative” directions in attempts to stimulate his partner sexually. Heavy-handed manipulation or frequent masturbatory irritation can elicit painful responses from the clitoral-glans area. This irritative reaction may develop rapidly to a full-fledged painful response subsequent to dilation of the vaginal outlet by penile intromission.

Although emphasis has been placed upon the role of premature ejaculation in the etiology of primary orgasmic dysfunction, primary or secondary impotence also contributes. Again the basic theme of man and woman coital interaction must be emphasized.

If there is not a sexually effective male partner, the female partner has the dual handicap of fear for her husband’s sexual performance as well as for her own.

If there is no penile erection there will be no effective coital connection.

Frequently women married to impotent men cannot accept the idea of developing a masturbatory facility or being manipulated to orgasm as a substitute for tension release.

However, if there has been a masturbatory pattern established before coital inadequacy assumes dominance, most women can return to this sexual outlet. In this situation, there is sufficient dominance of the previously conditioned biophysical structure to overcome negative input from a psychosocial system distressed by sexual performance fears.

But if there have been no previous substitute measures established, many women cannot turn to this mode of relief once impotence halts effective coital connection. In this situation, the psychosocial structure, unopposed by prior biophysical conditioning, assumes the dominant influence in the woman’s sexual response pattern.

Mr. and Mrs. D

were referred to the treatment of orgasmic inadequacy after four years of marriage. When seen in therapy she was 27 and her husband 43 years old. He had been married twice previously. There were children of both marriages and none in the current marriage.

The husband also was sexually dysfunctional in that he was secondarily impotent.

His second marriage had been terminated due to his inability to continue the effective coital connection. Although, when the unit was seen in consultation the marriage had been consummated, coitus occurred only once or twice a year.

Mrs. D’s background reflected somewhat limited financial means. Her father had died when the three siblings were young, and the family had been raised by their mother, who worked while the grandmother took care of the children.

Clothes were hand-me-downs, food the bare essentials. Her education had of necessity terminated with high school, and she worked as a receptionist in several different offices before her marriage. She continued to live at home while working and contributed to what salary she made to help with the family’s limited income.

Mrs. D met her future husband when he visited the office where she worked. He invited the young woman to lunch. She accepted and married him four months later without knowledge of his sexual inadequacy, although she had been somewhat puzzled by his lack of forceful sexual approach during the brief courtship.

Mrs. D’s own sexual history had been one of a few unsuccessful attempts at masturbation, numerous petting episodes with boys in and out of high school, but no attempted coital connection. She had never been orgasmic.

Her husband had inherited a large estate and his financial situation certainly was the determining factor in his wife’s marital commitment. Since the girl had been distressed by a family background of genteel poverty, she felt the offer of marriage to be her real opportunity both to escape her environment and to help her two younger siblings.

The wedding trip was an unfortunate experience for Mrs. D when she realized for the first time that her husband had major functional difficulties. She knew little of male sexual response beyond the petting experiences but did try to help him achieve an erection by a multiplicity of stimulative approaches in his direction. There was no success in erective attainment.

The marriage was not consummated until six months after the ceremony. In the middle of the night, Mr. D awoke with an erection, moved to his wife, and inserted the penis. She experienced mild pain but reacted with pleasure, feeling that progress had been made.

However, following the usual pattern of a secondarily impotent male, progress was fleeting. As stated, there were only a few other coital episodes in the course of the four-year marriage. In these instances, she always was awakened from sleep by her husband when he awoke to find himself with an erection.

Quick Ejaculation

Then there was rapid intromission and quick ejaculation. There was no history of a successful sexual approach by her husband under her conscious direction, insistence, or stimulation. Mr. D tried repetitively during long-continued manipulative and oral-genital sessions to bring his wife to orgasm, without result.

When they were referred for treatment, neither husband nor wife described sexual activity outside the marriage.

There have been 193 women treated for primary orgasmic dysfunction during the past 11years. Basically, in this method of therapy, the sexually dysfunctional woman is approached through her sexual value system.

If its requirements are non-serving limited, unrealistic, or inadequate to the marital relationship-by suggestion she is given an opportunity, with her husband’s help, to manipulate her biophysical and psychosocial structures of influence until an effective sexual value system is formed.

Probably the most frequent cause for dyspareunia originating with symptoms of burning, itching, or aching is a lack of adequate production of vaginal lubrication with sexual functioning.

During attempted penile intromission or with long-maintained coital connection, there must be adequate lubrication or there will be irritative distress for either or both coital partners.

Adequate production of vaginal lubrication is for women the physiological equivalent of erective attainment for men and her representation to her male partner of psychological readiness for vaginal penetration.

A consistent lack of functional levels of vaginal lubrication is as near as any woman can come to paralleling a man’s lack of effective erection.

Inadequate development of vaginal lubrication has many causes, but by far the most common is lack of interest in the particular opportunity or identification with the involved sexual partner. Women must experience positive input from their sexual value systems if they are to respond repetitively and effectively to their mate’s sexual approaches.

Women who cannot think or feel sexually, those reflecting fears of sexual performance, and even those acting out a spectator’s role in sexual functioning, either do not develop sufficient vaginal lubrication to support a painless coital episode or, if penetrated successfully, they cease production of the necessary lubricative material shortly after intravaginal penile thrusting is initiated.

Deep Penetration

Additionally, women fearful of pain with deep vaginal penetration, fearful of pregnancy with any coital connection, fearful of exposure to social compromise, and fearful of sexual inadequacy are frequently poor producers of vaginal lubrication. Any Component of fear present in sexual experiences reduces the receptivity to sensate input, thereby blunting biophysical responsivity.

If there is insufficient vaginal lubrication, there may or may not be acute pain with full penile intromission, depending primarily upon the parity of the woman, but they’re usually will be vaginal burning, irritation, or aching both during and after coital connection.

There are tens of thousands of women who become markedly apprehensive at the onset of any definitive sexual approach, simply because they know severe vaginal irritation will be experienced not only during but frequently for hours after any significantly maintained coital connection.

Not to be forgotten as a specific segment among the legions of women afflicted by inadequate production of vaginal lubrication are those in their postmenopausal years. If they are not supported by adequate sex-steroid-replacement techniques, the production of vaginal lubrication usually drops off markedly as the vaginal mucosa routinely turns atrophic.

There well may be aching and irritation in the vagina for a day or two after a coital connection for women contending with this evidence of sex-steroid starvation.

A major category of women tending to be poor lubrication producers during coital connection is that a significant segment of the female population with overt lesbian orientation. Many women psychosexually committed to a homophile orientation attempt regularity of coital connection for socioeconomic reasons. Frequently, they may not lubricate well during heterosexual activity, although there usually is ample lubrication when they are directly involved in homosexual expression.

In most instances:

Inadequate production of vaginal lubrication can be reversed with a definite therapeutic approach. Certainly, women burdened by a multiplicity of sex-oriented fears can be provided psychotherapeutic relief of their phobias and subsequently reversed with relative ease from their particular pattern of sexual inadequacy.

Those women with chronic vaginal itching and irritation can be protected from continuing dyspareunia because both infectious and chemical vaginitis are reversible under proper clinical control. Senile vaginitis responds in short order to adequate sex-steroid-replacement techniques.

There are only two major categories of women for whom the co-therapists have little to offer to constitute effective production of vaginal lubrication: first, women mated to men for whom they have little or no personal identification, understanding, affection, or even sexual respect; and second, homosexually oriented women practicing coition for socioeconomic reasons with no interest in their male companions as sexual partners.

Undesired Sex

As opposed to the symptoms of aching, irritation, or burning in the vagina, complaints of severe pain developed during penile thrusting provide the most difficulty in delineating between subjective and objective etiology.

Although many women register this type of complaint when seeking to avoid undesired sexual approaches, there are some basic pathological conditions in the female pelvis that can and do engender severe pain in response to active coital connection.

One of the difficulties in delineating the severity of the complaint of dyspareunia is to identify pelvic pathology of a quality sufficient to support the female partner’s significant complaints of painful coition. The pelvic residual from severe infection or pelvic implants of endometriosis usually is easily identified by adequate pelvic and rectal examinations.

These clinical entities will be discussed briefly in context later in the topic. Current attention is drawn to probably the most frequently overlooked of the major physiological syndromes creating intense pelvic pain during coital connection.