Numerous enquiries from our customers and clients have made it clear that more information distinguishing between vaginismus and dyspareunia would be helpful. Both conditions cause significant pain during penetrative sex or make intercourse impossible, yet they differ quite noticeably.

The official medical diagnoses relating to dyspareunia, vaginismus and other forms of sexual pain are highly complex. Since they also vary in some aspects, they are often difficult for laypeople to understand, especially given that even healthcare professionals describe the boundaries between these „disorders“ as fluid. Both complaints are categorized as sexual dysfunctions that cause pain during sex.

In this guide, I aim to clarify the terms "vaginismus" and "dyspareunia".

Contents:

What is dyspareunia?

The term “dyspareunia” refers to different types of pain in the female genital area.

The official definition according to ICD-10 (International Statistical Classification of Diseases and Related Health Problems) of the WHO (World Health Organization) recognises two main types:

• Organic dyspareunia (code N94.1)
• Nonorganic (psychogenic) dyspareunia (code F52.6)

Both forms of dyspareunia are considered long-term conditions.

A more detailed definition is found in the DSM-IV, the manual of the American Psychiatric Association. It describes dyspareunia as “recurrent genital pain associated with penetration (lasting more than 6 months), not due to lack of lubrication or a medical condition.”

This means that a woman has had pain during sex (intercourse) for more than half a year, and the pain is not caused by dryness or any medical issue. This part can be confusing, as the definition excludes medical causes – even though these are precisely what characterise the organic form of dyspareunia.

A) Organic dyspareunia

Organic refers to clearly identifiable physical causes of pain or discomfort.

There are also two variants here:

• Deep organic dyspareunia

The best known and most common forms are as follows:

• • Atrophy (thinning of the tissue of the vagina and possibly the vulva)
  • Inflammation of the vagina, bladder or urethra
  • Endometriosis (abnormal growth of the uterine lining outside the uterine cavity in the abdomen)
  • Retroflexed uterus (uterus bent backwards)
  • Tumors, cysts
  • Scar tissue
  • Hemorrhoids
  • Irritable colon (irritable bowel syndrome)
  • High-tone pelvic floor dysfunction (hypertonus, meaning excessive tension in the pelvic floor muscles)

• Superficial organic dyspareunia

The most common causes include:

• • Inflammation of the vulva, vagina, urethra or Bartholin's glands
  • Atrophy (see above)
  • Vulvodynia - pain affecting the vulva, with a wide range of possible causes
  • Vestibulitis vulvae syndrome - similar to vulvodynia, but more localised at the vaginal entrance
  • Hymen anomaly (unusual structure of the hymen – though its existence and relevance are highly debated)
  • Skin conditions such as lichen or psoriasis
  • Scarring
  • Radiation damage
  • Penis oversize

It is easy to see how any of these conditions may hinder or prevent intercourse – and in all cases, cause pain.
Treatment naturally focuses first on relieving the physical symptoms – and ideally, curing the underlying cause. Still, possible psychological factors should also be taken into account, even when dealing with organic dyspareunia.

B) Non-organic dyspareunia

This term refers to people who experience pain during sex without any visible or diagnosable physical cause – more specifically, pain during penetration, that is, during vaginal intercourse. Interestingly, this condition does not only occur in women, but also in men. The ICD-10 definition (see above) already highlights key differences from vaginismus:

ICD-10 Code F52.6: Non-organic dyspareunia
"Dyspareunia (pain during sexual intercourse) occurs in both women and men. It can often be attributed to a local pathological event and should then be classified under the corresponding disorder. This category should only be used if there is no other primary non-organic sexual disorder (e.g. vaginismus or lack of vaginal lubrication)."

Differences between dyspareunia and vaginismus

I hope it has become clear that the distinction between vaginismus and dyspareunia mainly applies to the non-organic form. In both dysfunctions, the muscles are the cause of the symptoms, more specifically the pelvic floor muscles: in vaginismus, they contract involuntarily – which is where the term “vaginismus” (derived from “spasm”) originates. You can find all information about vaginismus / vaginismus at https://theros.de/en/blogs/advisor/vaginismus-and-vaginal-cramps

Non-organic dyspareunia is frequently linked to excessive muscle tension. For many years, pelvic floor dysfunction was thought to result from muscle weakness. However, experience and recent studies have shown that overly tight muscles – excessive tension and a lack of flexibility – are often to blame. This phenomenon is increasingly common and is often attributed to modern life: high social pressure, constant stress, and a fast-paced lifestyle. In non-organic dyspareunia, the primary issue is often an overly tense or cramped pelvic floor. Even when lubrication is sufficient, penetration may be difficult or impossible – and often painful. This painful experience can lead to a vicious cycle of fear and pain. As a result, arousal often decreases over time and may eventually disappear altogether.

Diagnosis of dyspareunia

In clinical practice, many cases of pain during sex cannot be clearly diagnosed or assigned to a specific cause. Furthermore, not all gynaecologists are well-versed in this area. Interdisciplinary collaboration – involving gynaecologists, and where appropriate dermatologists, urologists, sexologists and specialists in pelvic floor function – can be helpful in reaching a more precise diagnosis and offering effective treatment. In cases of organic dyspareunia, the initial goal is to treat the physical symptoms. Another key aspect is helping the affected women understand the complexity of the condition. Many patients initially focus solely on physical explanations. It is often necessary to gently guide them towards recognising the possible psychological or emotional dimensions involved.

Treatment of dyspareunia

To begin effective treatment, it is often helpful to temporarily abstain from penetrative sex – to stop reliving the pain and to gradually let go of its memory. This gives the physical symptoms space to heal without added strain, while also breaking the cycle of pain and fear.

The following is a summary excerpt from a scientific text by Dr Karoline Bischof, gynaecologist and sexologist, Zurich:
"Women with chronic dyspareunia seem to process pain differently from those unaffected: pain is perceived as especially intense. There is anxiety, along with hypervigilance or hypersensitivity to pain (comparable to patients with fibromyalgia, for example). Broadly speaking, these women tend to overinterpret pain symptoms and particularly experience strong feelings of helplessness.An important part of therapy is desensitisation and resensitisation. This means the woman learns to reconnect with the painful areas of her genitals and to stimulate non-painful sensations through regular, gentle touch using care products – first neutral, then gradually pleasant, and eventually sexually arousing. A key prerequisite for this is the conscious use of movement and relaxation in the pelvic floor – over time also incorporating abdominal breathing, pelvic circles and pelvic rocking – since excessive muscular tension plays such a crucial role in the origin of pain."

It is also essential to explore your sexual biography and identity: How have I experienced being a woman? How do I relate to my femininity? What values are connected to it? Do I accept my gender? Do I enjoy touching, looking at, and smelling myself? Another important aspect of treatment is developing awareness of your pelvic region – especially the state of muscle tension. To support physical relief, I recommend using Theros® FMS dilators – inspired by forms found in nature – to gently release tension in the tissue. Theros® vaginal stents can then help to maintain and stabilise the progress achieved with the FMS dilators. Learning new, flowing, gentle movements also supports the relaxation of the pelvic floor – ideally as part of a comprehensive therapeutic approach. To support your emotional wellbeing, I recommend relaxation techniques such as meditation, breathing exercises or guided visualisations.

On the topic of "Pain during sex“ you might also be interested in:

• Guide to Vaginismus and Vaginal Cramps
• Guide Lichen sclerosus

Are you interested in other topics? Here you can find all of Theros®'s guides.