Monday, November 23, 2009

Pain with Sex

Dyspareunia is a sexual dysfunction where pain is experienced during, before, or after sex. It often leads to disruption of normal sexual activity and relationships problems. It can be a localized pain or general discomfort.

What else can it occur with? Often, Dyspareunia can be seen with chronic pelvic pain, IBS, urinary urgency, bowel urgency, or tampon discomfort. Only when symptoms are severe enough do we women seek medical treatment, but the actual number of women who experience it is unknown. It can be brought on by physical or psychological events.
Psychological causes can include: Sexual abuse during childhood, feelings of shame or guilt towards sex, and fear of intercourse or pain from first intercourse.

In addition, dyspareunia can be classified as being either superficial or deep, and whether it occurs all the time, or just with certain partners or situations.

What are common causes of superficial pain during sexual intercourse?

Vulvar pain (vulvodynia) may be described as a burning sensation or pain with penetration. It can be lifelong or develop with age. Some common causes are menopause, vulvar infection, lichen sclerosis and idiopathatic reasons.

Vaginismus is rare but is the involuntary spasm of the entryway muscles of the vagina from psychological stress.

What are some of the causes of deep pain during sexual intercourse?

Chronic Pelvic Pain (CPP) which can be pain of the pelvic floor muscles or related to Painful Bladder Syndrome/Interstitial Cystitis.

Endometriosis- common symptoms include abnormal menstrual bleeding, pelvic pain, premenstrual spotting, and sometimes infertility.

Pelvic Inflammatory Disease (PID) if chronic. Pelvic scarring can cause the uterus to become fixed in place and lead to deep pain during sex.

Perineal Trauma from Chiildbirth occurs quite commonly and is often thought to be related to episiotomy. Approximately 90% of woman will have perineal pain after childbirth (which is expected), however, the painful sexual may not resolve for 4-6 months after vaginal delivery. This is not necessarily a sexual dysfunction as much as it is normal tissue recovery. Resumption of sex too soon after childbirth may not be giving the vaginal tissues enough healing time. However, resumption of sex after childbirth depends heavily on: the mode of childbirth (vaginal vs. C-section), the severity of perineal tearing, maternal age, breastfeeding status and cultural issues. Women with 3rd or 4th degree tears were much five times likely to resume sex when compared to women with no tearing. Moreover, approximately ¼ of new mothers report loss of sensation and inability to achieve orgasm at 6 months post partum.

The doctor’s approach to dyspareunia should be thoroughly investigative since most women will not present with this specific complaint. Rather, dyspareunia may be present with other pelvic health conditions and direct question can lead to diagnosis. A physical exam of the abdomen and vagina with careful palpation both without and with a speculum, and often bimanual exam will yield the most information.

How Can Dyspareunia be Treated?

Psychological Assessment if appropriate

Medical treatment depends on the cause of pain. Often, lubricants or topical estrogen can improve dryness. Changing sexual positions may help as well. Vaginal massage or painful trigger points can sometimes help CPP. Pelvic floor relaxation with stretching, yoga or warm baths can aide in this as well. Antibiotic therapy can be given to treat PID. Pain meds or anti-inflammatories can help with CPP. Vulvodynia and CPP can sometimes be addressed with anti-depressants or local topical numbing creams. Vaginismus often responds to a combination of behavior and psychological retraining, and vaginal dilators.

Surgical treatment also depends on the cause of pain. Endometriosis is often diagnosed and treated with laparoscopy. Benign cysts, tumors and cutting adhesions can be performed but are uncommon findings. Treating superficial vulvar skin conditions may require biopsy or cutting scar tissue that can develop from childbirth.

Thursday, November 12, 2009

"Designer Vagina"

Cosmetic vaginal surgery has become increasingly popular, and I have posted blog comments on it in the past. It can include labiaplasty (reducing large inner lips), or vaginoplasty (tightening the vagina).

Sometimes there are true medical indications, such as pain with sex, or tight clothes/biking riding from large inner lips, or a loose vagina that may draw in air or lack sensation during sex. Others may seek it for lesser reasons, such as aesthetics, or perceived (real or false) imperfections in their genitals. Psychological reasons may exist as well.

Here is an interesting brief article from the BBC which reports on this phenomenon.

Monday, November 9, 2009

Is Diabetes and Urinary Incontinence Related?

Diabetes Mellitus, the condition where the body is resistant to insulin, leading to elevated blood sugars, is a common condition that can lead to many detrimental health issues such as heart disease and stroke. Often, if diabetes is poorly controlled, patients will notice they have more urine, and urinate more frequently. The extra sugar in the blood spills into the urine through the kidneys and draws more water into the urine, increasing urinary volume.

This is a somewhat oversimplified look at diabetes, but diabetes can lead to muscle and nerve deterioration of the pelvic organs as well. This I will discuss further below.

Ask yourself, what can happen if you’re constantly making more urinate and have to void every hour? Well, drip, drip, gush sometimes. Controlling diabetes is one very simple and reversible way to treat urinary incontinence.

The number of people with diabetes is rising worldwide, which itself is contributed by increasing obesity rates and an aging population. As an aside, obesity and aging are themselves correlated to urinary incontinence rates as well. I posted a blog entry not too long ago, that weight reduction by 18 lbs showed a significant reduction in urinary incontinence. Aging, simply put, is unavoidable and many women will experience urinary incontinence, whether stress related (exercise-induced) or urge related (overactive bladder), and often times both together.
Women with urinary incontinence are known to experience social or sexual isolation, whether from friends, lovers, or even self-imposed. This adds to psychosocial stress and diminished quality of life. It is important when evaluating diabetes to include all co-morbid conditions that can be associated with it, when eye, kidney, heart or bladder related.

It is believed that the same damage that diabetes causes to small blood vessels and nerves that leads to poor circulation and numbness, also occurs with the bladder and urethral sphincter. I’m sure most of us have a relative with diabetes with “bad feet”. They can’t feel their toes, or they have bad circulation with foot, pain, or non-healing ulcers. Similarly, poor blood flow and nerve injury can lead to incontinence. Bladder muscle injury and bladder nerve injury can lead to overactive bladder. A “numb” bladder may not sense it’s full till it’s “too late”, leading to urge incontinence. Bladder muscle can lose its elasticity and not fill all the way, leading to frequent urges. Poor muscle function may lead to incomplete bladder emptying (that is not perceived due to nerve injury), leading to the constant sense of urge. Incomplete bladder emptying and bad sugar control are ripe conditions for recurrent urinary tract infections.

Poor muscle function or nerve injury of the urethral sphincter can lead to stress incontinence, but diabetes can lead to obesity which itself is a risk for stress incontinence anyway.
A recent large study from Turkey compared groups of women with and without diabetes and found a 2.5 fold increased risk of urinary incontinence with diabetes. Age and BMI were also weakly related to incontinence as well. Among diabetics, 41% had urinary incontinence, while only 22% of non-diabetics had urinary incontinence. This is an astounding set of figures. Other researchers suggest that nearly 50% of severe incontinence could be avoided by preventing diabetes. Where does this lead us? Lifestyle changes, diet regimen and exercise are all important interventions. Since diabetes is an independent risk factor for urinary incontinence, all diabetics should be questioned about it for overall health promotion.