What is Dyspareunia?
Dyspareunia is the medical terminology for painful intercourse. The pain may occur with or after intercourse. Altered anatomy, post-operative changes, or physiologic conditions can all promote dyspareunia. Altered anatomy including uterine position or fibroids can become uncomfortable when manipulated during intercourse. Prior pelvic surgery and placement of vaginal mesh kits can affect the normal dimensions of the vagina thereby producing dyspareunia. Physiologic conditions that occur with aging, such as thinning of the vaginal wall or a decrease in lubrication, may leave the vagina friable and vulnerable to pain during intercourse.
What Can Cause Dyspareunia?
Our practice cares for patients who present with dyspareunia following a previous surgery. When the vagina is shortened or narrowed, it can make intercourse painful because the vagina cannot stretch to accommodate penetration.
Patients may also experience dyspareunia after a urethral sling, particularly a transobturator sling, or a vaginal mesh kit. As the mesh contracts around the vagina, it can cause pain, even at rest. In our practice, we find that most patients report resolution of the pain at the sling sites after removal of the sling almost immediately.
Thinning of the vaginal wall (vaginal atrophy) and a decrease in lubrication both occur as women become post-menopausal due to a decrease in estrogen. Topical estrogen can help to treat these physiologic changes.
A narrowed vaginal opening can also make initial penetration uncomfortable, leading to dyspareunia. Commonly we describe this as a skin bridge – it is like a bridge of skin across the opening that is irritated with palpation. This can also be treated as an outpatient procedure to take down this ridge of skin.
Treatment for a Shortened or Narrowed Vagina
When the shortened/narrowed vagina is encountered, the surgical planning must consider the restoration of normal anatomical relationships. Often a patient will have a history of a previous hysterectomy with cystocele and/or rectocele repair and notably did not have the vaginal vault fixed as well. These patients may be treated with an abdominal vaginal vault procedure called an abdominal sacrocolpopexy, which can lengthen and restore the anatomical relationships.
Utilizing a full-thickness skin graft is another modality to increase the caliber of the vagina to allow comfortable intercourse. This is a novel technique that Dr. Veronikis developed based upon his extensive expertise and technical skill in constructing vaginas for girls who are born without one, also known as vaginal agenesis. Typically a strip of skin from the abdomen is taken and placed within the vagina. Within a few weeks, the abdominal skin takes on the appearance of vaginal mucosa and women are able to enjoy intimacy again.
Dyspareunia Treatment Following Mesh Placement
When mesh is placed judiciously and with the appropriate surgical skill and dissection, it can be useful in the treatment of prolapse and incontinence. However, several women have suffered from the placement of too much mesh inserted superficially or deep. When placed superficially the mesh can become exposed in the vagina, causing both the patient and her partner to feel pain. When placed too deep, the mesh can erode into the adjacent organs, such as the bowel or bladder. It may also involve nerve and muscle complexes causing pain at rest. Unfortunately many of these patients still have prolapse as well.
Our practice has experience with mesh removal, and Dr. Veronikis has a national reputation for removal of mesh whether exposed or eroded into other organs. Depending on the location and amount of mesh, if prolapse or incontinence remain, a second surgery may be required for reconstruction. The first surgery serves to remove all the mesh followed by a healing period for the vagina before the reconstructive operation.