For years, woman's complaint "it hurts when I have intercourse" has been an anathema to the therapist. Even after an adequate pelvic examination, the therapist frequently cannot be sure whether the patient is complaining of definitive but undiagnosed pelvic pathology or whether, as has been true countless thousands of times.
A sexually dysfunctional woman is using the symptomatology of pain as a means of escaping completely or at least reducing markedly the number of unwelcome sexual encounters in her marriage.
For it is true that once convinced that there is no recourse for reversal of his or her dysfunctional status, the sexually inadequate partner in any marriage manufactures excuse after excuse to avoid sexual confrontation. As women have long since learned, a persistent, aggressive male partner can overwhelm, neutralize, or even negate the most original of excuses to avoid sexual exposure.
However, presuming any degree of residual concern for or interest in his partner as an individual, the husband is rendered powerless to support his insistence upon continuity of sexual contact when the wife complains of severe distress during or after sexual connection.
If the female partner complains and flinches with penile insertion, moans and contracts her abdominal and pelvic musculature during the continuum of male thrusting, cries out or screams with deep vaginal penetration, sheds bitter tears after termination of every sexual connection, or complains angrily of aching in the pelvis or burning in the vagina during or even hours after a specific coital episode, the male partner's sexual approach must be accepted as the probable potentiator of a physiological basis for his female partner's evidenced sexual dysfunction.
Thereafter, the husband has minimal recourse. There is little he can do other than to avoid or at least reduce marital couple sexual exposure on his own cognizance, and/or to insist that his wife seek professional consultation. Once consulted, the twofold problem that constantly baffles authority is first whether a specific physiological basis can be defined for the objective existence of pain.
Second, if not, whether the existence of pelvic pathology should arbitrarily be ruled out, thereby defining the registered complaint of dyspareunia as subjective in origin. When a woman complains of pain during or after intercourse, there are very few diagnostic landmarks to follow for treatment, so that consideration of the etiology of the painful response seems appropriate.
As in vaginismus, a differential diagnosis cannot be established for a complaint of dyspareunia unless careful pelvic and rectal examinations are conducted. Even then there can be no sure diagnosis if the existence of pelvic pathology is denied purely on the basis of negative examinations by competent authority.
Yet, in a positive vein, there are obvious pelvic or rectal findings that can and do support objectively a woman's subjective complaint of coital discomfort. The female partner's persistent complaint of pain with any form of coital connection must not be authoritatively denied or, for that matter supported, purely on the basis of interrogation, regardless of how carefully or in what depth the questioning has been conducted.
There are many varieties of dyspareunia, varying from postcoital vaginal irritation to severe immobilizing pain with penile thrusting. Symptomatic definition relating not only to the anatomy of the vaginal barrel but also to the total of the reproductive viscera is in order.
In no sense will the discussion include all possible forms of pelvic distress. Considered, however, will be the major sources of pelvic pathology engendering painful response from the female partner during or after coital connection. The dyspareunia will be considered in relation to specific areas of the vaginal barrel, the reproductive viscera, and the soft tissue components of the pelvis, and to painful stimuli developing, in a time-related sequence during or after coital connection.