​Kembara Xtra - Medicine - Dyspareunia

​Kembara Xtra - Medicine - Dyspareunia 
Introduction 

recurrent and chronic genital or pelvic discomfort linked with sexual activity that is not solely attributable to the intensity of intercourse, lack of lubrication, or vaginismus. pain that occurs in the genital or pelvic region.
It is possible that it is linked to unhappiness and that it may have a detrimental effect on relationships, self-esteem, and sexual satisfaction.
● In the past, dyspareunia and vaginismus were considered to be two independent conditions. However, in the DSM-5, these two conditions were grouped together under the heading of genito-pelvic pain and penetration disorder. This is a significant fact to keep in mind. – There are a lot of people who engage in sexual behaviors that don't involve penetration, and even these people are susceptible to these illnesses if they engage in those behaviors.

May originate from physiological, psychological, or purely psychological factors. - Primary dyspareunia refers to a condition that has been present throughout an individual's sexual history. There may be a connection between primary dyspareunia and vaginismus, poor libido, and arousal problems.
– Secondary: arising from a specific event or condition (for example, menopause, endometriosis, pelvic inflammatory disease [PID], depression, drugs). – Superficial: pain at, or near, the introitus or vaginal barrel associated with penetration. – Deep: pain after penetration located at the cervix or lower abdominal area. – Complete: present under all circumstances.
- Situational: only occurs in certain contexts and under certain conditions
- Idiopathic: no apparent cause or presence despite treatment 
Affected System(s): the Reproductive System

Epidemiology 

All ages make up the majority of the population
● Predominant sex: female > male 
It is estimated that more than fifty percent of all sexually active women may experience dyspareunia at some point in their lives.
Considerations Regarding the Aged
Vaginal atrophy is the primary factor contributing to the significant rise in incidence seen in postmenopausal women.

Prevalence

Dyspareunia is something that will affect nearly all sexually active women at some point in their lives.
15% (4–40%) of adult women will experience dyspareunia on one or more occasions throughout the course of the year.
1% to 2% of women will have painful sexual encounters on a regular basis that is more frequent than infrequent.

● Male predominance is ~1%.

Causes and effects: etiology and pathophysiology 
Disorders of the vaginal exit might include adhesions, condyloma, clitoral discomfort, episiotomy scars, fissures, hymenal ring abnormalities, inadequate lubrication, and infections.
Psoriasis, postmenopausal atrophy, lichen planus, and lichen sclerosus are some of the causes of psoriasis.
– Vulvar papillomatosis – Vulvar vestibulitis/vulvodynia – Disorders of the vagina – Abnormality of vault caused to surgery or radiation – Congenital abnormalities – Insufficient lubrication – Infections
– Inflammatory or allergic response to a foreign substance – Masses or tumors – Pelvic relaxation leading to rectocele, uterine prolapse, or cystocele Disorders of pelvic structures – Endometriosis – Levator ani myalgia/spasm – Malignant or benign tumors of the uterus – Ovarian pathology – Pelvic adhesions Inflammatory or allergic response to a foreign
– Pelvic venous congestion – Previous pelvic fracture – Uterine fibroids – Pelvic inflammatory disease
Disorders of the gastrointestinal tract, such as constipation, diverticular disease, fistulas, hemorrhoids, and inflammatory bowel diseases Disorders of the urinary tract, such as interstitial cystitis, ureteral or vesical lesions, and urethritis Chronic diseases, such as Behcet syndrome, diabetes, Sjogren syndrome, fibromyalgia, multiple sclerosis, neuropathies, and
Male – Peyronie disease – Cancer of the penis – Genital muscle spasm – Infection or irritation of the penile skin – Infection of the seminal vesicles – Lichen sclerosus – Musculoskeletal problems of the pelvis and lower back 
- Penile anatomy disorders
- Phimosis – Infections of the prostate and enlargement of the prostate (for example, chronic prostatitis) – Disease of the testicles – Blockage of the ejaculatory duct (caused by things like twisting of the spermatic cord, calculus, or cyst) - Urethritis Mental health conditions – Nervousness – Alternating Reactions
– A state of depression; – Anxiety; – Antagonism toward one's partner; – Phobic reactions
- Psychological trauma/PTSD

RISK FACTORS Exhaustion, stress, depression, and anxiety, diabetes, estrogen deficiency, menopause, and lactation, previous pelvic inflammatory disease, vaginal surgery or trauma, consumption of alcohol or marijuana, medication side effects (antihistamines, tamoxifen, bromocriptine, low-estrogen oral contraceptives, SSRIs, depo-medroxyprogesterone, desipramine), and a history of

Things to Think About When You're Pregnant Pregnancy has a significant impact on a woman's sexuality; dyspareunia is rather prevalent in the later stages of pregnancy and after delivery. In the postpartum period, characteristics that could be considered risk factors include breastfeeding, perineal discomfort, exhaustion, and stress.
It has been shown that episiotomies do not have a protective effect. Women who undergo delivery interventions, such as an episiotomy, are at a larger risk than women who deliver over an intact perineum or who had a tear that was not repaired after birth.


Condition Associated With It Vaginismus

Providing an Account of the Past 

Determine the features of the pain: – Onset – Duration – Location: entrance versus deep, single versus several sites; positional – Pattern (precipitating or exacerbating factors): when pain occurs (at entry, during, or after intercourse) – Intensity and quality: varied degrees of pelvic and/or vaginal pressure, aching, tearing, and/or burning – When the pain happens (at entry, during, or after intercourse) - Relieving measures include refraining from sexual contact, switching postures, and limiting sexual activity to particular periods of the month.
Menstrual, anatomic, obstetric/gynecologic, sexual, domestic violence, and sexual assault histories should be included together with the patient's past medical, surgical, and psychosocial history. 
More specifically, in order to be diagnosed with male dyspareunia, symptoms must have been present for at least three months.


The Patient's Clinical Examination 

A comprehensive examination, including an in-depth examination of the pelvis, to diagnose any pathology – The examination needs to include inspection and palpation of the urethra, vulva, and vaginal areas; palpation of the uterine, bladder, and adnexal structures; rectovaginal exam; penis, scrotum, pelvic floor muscles; and digital rectal exam. – Sensory mapping with a cotton-tipped applicator to identify sensitive and painful areas. 
Because the examination frequently causes the pain to return, the examiner needs to exercise caution and be attentive to the patient's fear.

Vaginismus, also known as genito-pelvic pain penetration disorder, is a condition that can be diagnosed using differential diagnosis. If pain hinders penetration, severe vaginismus may be present.

Results From the Laboratory 
Initial Tests Based on History and Exam Findings (Laboratory, Imaging) Wet Mount

Gonorrhea and chlamydia cultures Urinalysis and urine culture Pap smear Glycohemoglobin GAD-7 and PHQ-9 Gonorrhea and chlamydia cultures Herpes culture of lesions if present Urinalysis and urine culture Pap smear Glycohemoglobin GAD-7 and PHQ-9

Additional Examinations, as well as Other Important Factors
If you have vulvodynia or atrophic vaginitis, you should get a serum estradiol test. If your urinary system is involved, you should get a voiding cystourethrogram. If you have gastrointestinal symptoms, you should get GI contrast tests. Ultrasound and CT scans have limited usefulness and should only be performed if they are clinically required.


Diagnostic Procedures/Other Based on the history and findings of the exam: a colposcopy and biopsy if there are vaginal or vulvar lesions; a laparoscopy if there is complex deep-penetration discomfort; a cystoscopy if there is urinary tract involvement; a colonoscopy if there is gastrointestinal involvement. The Meaning of Test Results Is Determined by Etiology

Education of both the patient and the spouse about the nature of the issue should be the first step in the management process. Both should be reassured that the issue can be resolved in some way.

After an initial evaluation has ruled out the possibility of an organic cause, treatment should involve a multidimensional and interdisciplinary approach rather than relying solely on drugs.
- Individualized treatment for behavioral issues
Couple behavioral therapy is recommended for the purpose of assisting the patient in coping with intrapersonal concerns and evaluating the role of the partner.
Suggested to assist in the resolution of interpersonal conflicts
Designed to desensitize systemically uncomfortable sexual responses and intercourse through a series of interventions over the course of weeks Interventions range from muscle relaxation and mutual body massage to sexual fantasies and erotic massage May involve a short-term structured intervention or sexual counseling.

The First Line Of Defense Is Medication
It Depends on the Etiology of the Problem
Antibiotics, antifungals, or antivirals, according to the indication, for infection treatment
Lubricants and moisturizers for the vaginal canal in cases of dryness
Pain relievers such as nonsteroidal anti-inflammatory drugs (NSAIDs) and local anesthetics
● Topical/vaginal estrogen for vaginal and vulvar atrophy – Although studies currently available support the use of estrogen over alternative vaginal therapies for postmenopausal vaginal symptoms, it is crucial to note that vaginal lubricants play a significant role in the management of atrophy-associated symptoms and should be tested first because they may be just as beneficial.
Neuropathic pain that is linked with vulvar vestibulitis or vulvodynia may respond to treatment with gabapentin or one of the tricyclic antidepressants (amitriptyline or nortriptyline). Tamsulosin was shown in observational studies to relieve or totally eliminate discomfort related with ejaculation.
Can also explore imipramine or gabapentin given their success in the treatment of persistent pain if there is no identifiable source of the discomfort.

Two-Thirds Line

Ospemifene is used for patients experiencing moderate to severe symptoms associated with menopause-related vulvovaginal atrophy.

Intravaginal DHEA (prasterone) for moderate to severe symptoms owing to menopause-related vulvovaginal atrophy in women who have had vaginal birth control.


Referral 

It's possible that you'll need to be referred to a long-term therapy program.

Extra Medical Intervention 

Treatment with physical therapy for pain in the pelvic floor muscles (If vaginismus is present, you should start with this line.) 

Surgical procedures The possibility of surgical procedures for dyspareunia caused by alterations in anatomy, uterine position, fibroids, or previous pelvic surgery. — The removal of pelvic adhesions or endometriotic lesions using laparoscopic surgery In the event that medical treatment is not successful in treating vulvar vestibulitis, a vestibulectomy may be an option to explore.
Despite the fact that this treatment should only be used in research settings, studies have shown that fractional CO2 laser treatments can alleviate some of the symptoms of vulvovaginal atrophy.

The Food and Drug Administration (FDA) issues a warning against the use of medical devices for uses that have not been licensed, such as "vaginal rejuvenation" operations.

Alternative Medication 
It's possible that sitz baths, perineal massage, and antioxidants can help alleviate the uncomfortable inflammation associated with endometriosis.

Keep in Touch 

Monitoring of the Patient
The outpatient follow-up care that comes after therapy varies.
Once the issue has been corrected, every 6 to 12 months DIET
If constipation is a contributing factor, eating foods that are high in fiber might be helpful.
Information about the Kegel exercise Provide information to couples on approaches for sexual arousal.

The prognosis is contingent on the underlying reason, however the vast majority of patients will react favorably to treatment.