DYSPAREUNIA and URINARY INFECTION or URINARY INFECTION and DYSPAREUNIA?

Some studies indicate that the presence of pain during sexual intercourse (dyspareunia) occurs in two-thirds of women throughout their lives.

This theme was revisited in the study conducted by Dominguez-Bali (Florida Atlantic University, Boca Raton, Florida) which was presented, at the end of 2023, during the event “Menopause Meeting of the North American Menopause Society”. Dominguez-Bali and colleagues commented that dyspareunia (painful sexual intercourse) is an important indicator of urinary tract infections (UTI), being present in 83% of cases. The symptom can identify a UTI in women who are not in menopause.

Despite the importance of this dyspareunia-urinary infection binomial, dyspareunia can have several causes.

However, it is a fact that dyspareunia is a common symptom of UTI, but it is rarely questioned during patient evaluation, according to the comments of these researchers. The numbers from this study are important. In the investigation of 5,500 patients (aged between 17 and 72 years), 83% of those who had UTI complained of dyspareunia. And when we look at the other side of the problem, we see that 80% of women of reproductive age with dyspareunia had an undiagnosed UTI.

An additional finding of this study, of fundamental importance, was the fact that 94% of women with dyspareunia associated with UTI had a positive response to the use of antibiotics.

Dominguez-Bali and colleagues also presented some interesting conclusions indicating that medicine has sometimes been influenced by religion, culture, and social norms that are distant from science. They emphasize that dyspareunia is extremely important as part of UTI symptoms and is often found together with the classic symptoms, however, it is not commonly discussed in medical consultations.

Why?

The answer is not difficult. Often, doctors and patients do not talk about sex during the consultation, despite dyspareunia being more of a clinical symptom than a sexual one.

Photo for authorized use — courtesy Pixabay

Perhaps it is important to comment more on dyspareunia here.

Data from the Gynecology outpatient clinic at the University of Ribeirão Preto, São Paulo (Brazil), presented by Abdo (2002) and revisited by Matthes (2019), revealed that pelvic pain was present in 30% of patients with gynecological complaints and of these, 50% had dyspareunia. The estimated prevalence of dyspareunia was 14.4% to 18%, and the publication by Abdo (2004) indicated that, in Brazil, around 18% of women report pain during sexual intercourse.

More recently, some authors revealed that, despite the prevalence and impact of dyspareunia, many women do not seek care. Gerin’s reports show that, usually, women with dyspareunia often suffer in silence and often realize that their pain is not valued, even during medical evaluation.

“Many women still submit to sexual activity without desire, in the presence of pain, to satisfy their partner and fulfill their duty as a wife, in addition to demonstrating ignorance of the etiology of the pain, which although they described as a weak, uncomfortable pain; in reality, it was a pain of great intensity that generated intense suffering” (Gerin).

This often reinforces the possibility of disqualifying pain, as if its presence were expected. In other words, it would seem to be normal for a woman to feel pain during sexual activity.

There is no doubt that the education received and the relationship with the partner have a strong influence on the development and maintenance of dyspareunia. Therefore, patients often do not find ways to solve the problem.

It seems highly likely that there are different dyspareunia syndromes (Binik, 2010).

According to Matthes and colleagues (2012), the pain that is felt during penetration, in the vulva and/or in the vaginal ostium, whose definition is superficial dyspareunia, has a completely different cause from the pain felt deep in the vagina and characterizes deep dyspareunia, caused by Relative Short Vagina Syndrome (RCVS).

Identification and individualization of the complaint are fundamental for adequate definition and management, including guidance for each patient in particular.

Primary dyspareunia is defined as pain during coitus without an organic cause, with the pain occurring exclusively due to the incompatibility between the size of the penis or what penetrates it and the size of the vagina, in superficial and deep conditions. “The size of the penis and the depth of penetration influence the presence and severity of symptoms” (Basson, 2013). Here, the sexual organ is the causal factor for the pain felt during sexual intercourse. Therefore, in this clinical situation, there may be pain-free intercourse, when the sexual organ has reduced dimensions to what causes pain, as mentioned in the RCVS.

In secondary dyspareunia, unlike primary, it always has an organic cause and, therefore, does not depend on the size of what penetrates the vagina. Pain can occur at the time of penetration (superficial/introital) and/or deep penetration, due to penile sexual movement and/or internal organs affected by some pathology (pelvic inflammatory diseases, endometriosis, pelvic tumors), but, according to Basson (2013), pain can be aggravated by size incompatibility.

A woman can have primary dyspareunia, exclusively, when there is no organic pelvic cause, and the pain felt during intercourse is due to maximum stretching of the vaginal ligaments and tissues, even after many years of sexual activity.

A woman can have secondary dyspareunia, exclusively, when she has any organic pelvic cause, which causes pain when touched or moved, and the sexual organ, which penetrates her, is insufficient to cause vaginal distension, even if it is during the first sexual intercourse.

However, a woman can have mixed dyspareunia (primary and secondary at the same time) when she has any organic pelvic cause that causes pain when touched or moved and the sexual organ that penetrates her is enough to cause traumatic vaginal distension.

On the other hand, dyspareunia, as we have seen, can be defined as superficial (or entry) and deep dyspareunia. Superficial dyspareunia is pain felt at the entrance to the vagina — therefore, vaginismus is also superficial dyspareunia (we will comment later) — and deep dyspareunia is pain felt at the bottom of the vagina.

Vaginismus is the involuntary contraction of the vaginal muscles that prevents penetration and affects between 1% and 6% of sexually active women. Some anecdotal research data indicates that vaginismus is present in 7% of women and some researchers believe that this number is possibly much higher, as many women do not seek help. The main symptom is pain during attempted penetration, which also occurs during gynecological examination.

Unfortunately, in the vast majority of cases, this clinical situation is seen as “curdling” and women are seen as neurotic. However, vaginismus has a cure and deserves attention.

It is worth noting that pain in relationships is not normal. A woman should seek medical help for an accurate diagnosis and appropriate treatment. Pain during or after sex contributes to a decrease in libido and can even lead to an aversion to sex.

Sometimes, the causes of pain can be superficial, at the entrance to the vagina, due to low vaginal lubrication (can occur in women who are breastfeeding, women in the postpartum period, women in menopause, or women using contraceptives), cracks in the skin in the region, due to vaginismus or even anatomical changes.

Organic dyspareunia is very common, especially in older women. Psychogenic dyspareunia can only be defined after a clinical examination (gynecological and abdominal). It is often necessary to request additional tests (abdominal ultrasound, endovaginal ultrasound, magnetic resonance imaging, laparoscopy, and other tests).

Women complaining of dyspareunia should always seek help to achieve a better quality of life. As we have seen, the cause of dyspareunia may be related to small imbalances in the vaginal flora or hormonal imbalances that cause vaginal dryness, or it may be related to psychological factors or more serious gynecological problems.

So, a specialist can help and give the best guidance, including in cases of primary dyspareunia.

References

• MATTHES ACS — RBSH 2019, 30 (1), 14–22
• DOMINGUEZ-BALI A — Menopause Meeting (North American Menopause Society) — 2023
• VARGAS B — Medscape — Sep 29, 2023
• BASSON R — Merck Manual MSD, 2013
• FIORELLI L — Saúde — 26 de fevereiro de 2016
• BINIK YM — Archives of Sexual Behavior v.39 (2), 292–303, Apr 2010
• GERIN LA — Dissertação (Mestrado — USP), 2008