Abstract:
Dyspareunia--painful intercourse--is a common cause of sexual difficulty. The following paper discusses, for both males and females, the common causes of dyspareunia and in many instances the appropriate treatment. Painful intercourse for the male is related either to the prepuce, glans penis, penile shaft, testicles, or urethra and prostate gland, whereas painful intercourse for the female is related to the vaginal opening, clitoris, vagina, or uterus, tubes, and/or ovaries. Each of the above is discussed.

A common - and perhaps the most common - cause of sexual difficulties is dyspareunia, or painful intercourse. Although the term is applied most often to females, male dyspareunia is a very real entity, and both females' and males' dyspareunia need to be understood by sexual therapists.

A logical approach to diagnosing dyspareunia is anatomical, that is, focus in on that part of the anatomy, male or female, that could be causing painful intercourse. To meet that end, the present paper relates male dyspareunia to the following structures: (a) prepuce, (b) glans penis, (c) penile shaft, (d) testicles, and (e) urethra and prostate gland.

MALE DYSPAREUNIA

Prepuce
For reasons that relate primarily to sexual attitudes, many parents whose sons are not circumcised have inadequately stressed the importance of retracting the foreskin during bathing or during a shower. Oftentimes, the phrase "Wash it" or "Wash down there" may mean simply taking a wash-cloth and rubbing it rather quickly over the penis with no particular emphasis on retracting the foreskin and specifically cleaning the base of the glans penis. If this is not done, it is possible that smegma will accumulate beneath the foreskin. This can cause irritation of the glans penis which may in turn, become secondarily infected by either bacteria or fungi. The net result is to cause pain, and later some filmy or dense adhesions betwenn the glans penis and the foreskin which could certainly be responsible for pain during intercourse.

A second cause of male dyspareunia, also related to the foreskin, is phimosis. In this condition the foreskin cannot be retracted back over the glans, whereas in paraphimosis the foreskin cannot be pulled foreward over the glans. In cases of phimosis there is almost always infection present. There is an ideal setup for an infection - the area is moist, dark, warm, and bacteria are readily available. When the infection heals, scar tissue will form. During thrusting of the penis, this scar tissue will pull on either the foreskin or on the glans, causing pain. To cure phimosis, either a dorsal slit of the foreskin or a complete circumcision would be required. During one examination of a male patient, the foreskin did retract and there did not seem to be any difficulty, and yet later in counseling the patient stated that there was pain and tenderness of his foreskin during intercourse. Subsequent history revealed that his foreskin could be retracted over the flaccid penis but could not be retracted over the erect penis. During the physical examination, most males don't get an erection, so it is difficult to find out if the foreskin will retract over the erect glans; therefore, this must be elicitated by history. The teaching point is that just because the foreskin slides over the flaccid penis does not mean it is going to slide over the erect penis.

A tight frenulum can also cause dyspareunia. In the course of healing, scar tissue forms which shortens the frenulum even more and predisposes it to even more tearing and scarring, and a vicious cycle is set up.