Painful intercourse

Painful intercourse (dyspareunia) is a clinical symptom defined as persistent or recurrent pain associated with sexual activity, occurring before, during, or after penetration. It can be superficial (localized within the vulva and vaginal vestibule) or deep (felt within the minor pelvis). Dyspareunia is not a separate disease entity, but rather a manifestation of gynecological, dermatological, neurological, myofascial, or psychosexual disorders. The contemporary clinical approach is based on the identification of the pain mechanism (nociceptive, neuropathic, mixed) and the implementation of causal treatment, which is crucial for the effectiveness of therapy.

Painful intercourse - causes

The etiopathogenesis of dyspareunia is complex and involves the interaction of local, systemic, and functional factors. In clinical classification, superficial and deep causes are distinguished.

Superficial causes primarily include disorders within the vulva and the vaginal vestibule:

genitourinary syndrome of menopause (GSM) – associated with estrogen deficiency, leading to thinning of the epithelium, reduced vascularization, and decreased lubrication,
infections (Candida spp., bacteria, viruses, including HSV),
dermatoses (lichen sclerosus, lichen planus),
scars after childbirth or surgical procedures,
vulvodynia – chronic pain of a neuropathic nature.

Deep causes relate to the structures of the lesser pelvis:

endometriosis – the presence of ectopic endometrial tissue, leading to chronic inflammation and adhesions,
pelvic inflammatory disease (PID),
postoperative adhesions,
uterine fibroids and ovarian cysts,
bladder disorders (e.g., interstitial cystitis).

Pelvic floor muscle dysfunctions also play a significant role, including their excessive tension (hypertonia), leading to penetrative pain and secondary defensive reactions.

At the neurobiological level, the phenomenon of central sensitization often occurs, which is an increased sensitivity of the nervous system to pain stimuli, perpetuating symptoms even after the primary cause has resolved.

Painful intercourse - situations

The nature and timing of the pain are an essential element of differential diagnosis.

Superficial (initial) pain:

appears during attempted penetration,
suggests mucosal disorders, inflammation, vulvodynia, or excessive pelvic floor muscle tension.

Deep pain:

occurs during deep penetration,
is often associated with pelvic organ pathology (e.g., endometriosis, adhesions).

Clinical situations that increase the risk of dyspareunia are of particular importance:

postpartum period (especially with perineal scarring),
lactation (hypoestrogenism),
perimenopausal and postmenopausal periods,
post-gynecological procedures,
chronic pelvic pain syndromes.

Diagnosis should also include accompanying symptoms, such as:

burning, itching,
vaginal discharge,
contact bleeding,
lower abdominal pain,
urinary tract symptoms.

Their presence may indicate a specific etiology and requires further diagnostics.

What for painful intercourse

Therapeutic management of dyspareunia should be staged, causal, and multidirectional, taking into account the pain mechanism (nociceptive, neuropathic, or mixed). Proper diagnostics is of key importance, as symptomatic treatment without identifying the source of symptoms leads to the consolidation of pain and worsening of sexual function.

Causal treatment

The first stage of therapy is the elimination or control of the factor inducing pain:

treatment of intimate infections and inflammation,
local hormone therapy (e.g., estrogen) in genitourinary syndrome of menopause (GSM),
treatment of underlying diseases (e.g., endometriosis, pelvic inflammatory diseases),
dermatological management in vulvar diseases (e.g., lichen sclerosus),
neuropathic pain therapy (e.g., vulvodynia).

At this stage, surgical interventions are not the first-choice treatment if the cause has not been removed.

Functional therapy and tissue support

In the second stage of treatment, a key role is played by improving tissue function and normalizing pelvic floor muscle tone:

urogynecological physiotherapy – especially in the case of muscle hypertonia,
moisturizers and lubricants – mucosal barrier support,
psychosexual therapy – in the case of secondary anxiety-pain disorders.

At this level of treatment, regenerative therapies are also included, which improve tissue quality and reduce pain symptoms.

Procedural and regenerative therapies

In chronic, recurrent cases or those associated with the deterioration of tissue quality, a multimodal approach is used, combining different technologies:

radiofrequency (e.g., INDIBA)

– improvement of microcirculation, fibroblast stimulation, increasing tissue elasticity, and analgesic effect,

gynecological laser therapy

– remodeling of the vaginal mucosa and improvement of its trophics,

platelet-rich plasma (PRP)

– activation of regenerative processes and angiogenesis,

hyaluronic acid

– improvement of hydration, volume, and tissue elasticity,

urogynecological physiotherapy (continuation)

– integration of the effects of procedural therapy with muscle function.

The role of INDIBA in combination therapy

The INDIBA radiofrequency is an element of supportive therapy and is used mainly in cases of:

dryness and mucosal atrophy (e.g., in GSM),
reduced tissue elasticity,
postpartum and postoperative scars,
excessive pelvic floor muscle tension.

Its action consists of tissue biostimulation and pain modulation; however, it does not eliminate causes such as endometriosis or infections. For this reason, it should be used as part of a combination therapy, rather than as a standalone treatment method.