Deep Dyspareunia: Review of Pathophysiology and Proposed Future Research Priorities

Abstract

Introduction: Dyspareunia has been traditionally divided into superficial (introital) dyspareunia and deep dyspareunia (pain with deep penetration). While deep dyspareunia can co-exist with a variety of conditions, recent work in endometriosis has demonstrated that coexistence does not necessarily imply causation. Therefore, a reconsideration of the literature is required to clarify the pathophysiology of deep dyspareunia. Aims: To review the pathophysiology of deep dyspareunia, and to propose future research priorities. Methods: Narrative review after appraisal of published frameworks and literature search with the terms (dyspareunia AND endometriosis), (dyspareunia AND deep), (dyspareunia AND (pathophysiology OR etiology)). Main Outcome Variable: Deep dyspareunia (present/absent or along a pain severity scale). Results: Potential etiologies for deep dyspareunia include gynecological, urological, gastrointestinal, nervous system, psychological, and musculoskeletal system related. These etiologies can be classified according to anatomic mechanism (contact with a tender pouch of Douglas, uterus-cervix, bladder, or pelvic floor, with deep penetration). They can also be stratified into four categories (as previously proposed for endometriosis specifically), which can be utilized to personalize management: Type I (primarily gynecologic), Type II (nongynecologic comorbid conditions), Type III (central sensitization and genito-pelvic pain Page 1 of 49 penetration disorder), and Type IV (mixed). Sociocultural and genetic factors and sexual response may also be important for deep dyspareunia. Conclusion: We propose the following eight research priorities for deep dyspareunia: 1) development of deep dyspareunia measurement tools; 2) focus on the population who are avoiding intercourse due to deep dyspareunia; 3) clarification of the role of non-gynecologic comorbidities in the generation of deep dyspareunia; 4) addressing of ethnic and other sociocultural factors; 5) initiation of clinical trials with adequate power for deep dyspareunia outcomes; 6) inclusion of partner variables; 7) elucidation of pathways between psychological factors and deep dyspareunia; and 8) empirical validation of personalized approaches to deep dyspareunia.

Six-month follow-up of minimally invasive nerve-sparing complete excision of endometriosis: What about dyspareunia?

“…Women with dyspareunia experience orgasm less often, which is correlated with a decrease in reported overall well-being [13]. There are several promising avenues for exploration of the pathophysiology and treatment of deep dyspareunia [14].…”

Deep Dyspareunia, Superficial Dyspareunia, and Infertility Concerns Among Women With Endometriosis: A Cross-Sectional Study

“…The differentiation of sexual pain by type was also a strength, given that deep and superficial dyspareunia are often measured in aggregate. 1 In addition, sampling and nonresponse error were unlikely to have biased the results, given the low rates of partial questionnaire completion (Figure 1, Table 1).…”

“…Endometriosis is known to cause deep dyspareunia, which is defined as pelvic pain occurring with deep penetration during sexual activity. 1 Women with endometriosis may also experience superficial dyspareunia, or pain at the vaginal introitus, as a consequence of comorbidities such as provoked vestibulodynia or pelvic floor dysfunction. 2,3 Deep and superficial dyspareunia seem to co-occur in populations seeking tertiary care; in 1 study approximately 40% of women with dyspareunia reported both types of pain.…”

Characterization of Pelvic Floor Activity in Healthy Subjects and with Chronic Pelvic Pain: Diagnostic Potential of Surface Electromyography

“…One of the most common syptoms associated with its appearance is dyspareunia, defined as recurrent or persistent genital pain during sexual intercourse [2]. In women, dyspareunia is labeled as "deep" or "superficial", depending on whether it appears on vaginal introitus at the beginning of the penetration or within the pelvis when penetration is deeper, respectively [3]. Dyspareunia has been estimated to affect between 8% and 21.1% of the worldwide population, a value that is highly variable among countries [4].…”