Deep Dyspareunia: Review of Pathophysiology and Proposed Future Research Priorities

Natasha Orr, Natasha L. Orr, Kate Wahl, Angela Joannou, Dee Hartmann, Lisa Valle, Paul J. Yong, Paul Yong, International Society for the Study of Women’s Sexual Health’s (ISSWSH) Special Interest Group on Sexual Pain, Corey Babb, Catherine W. Kramer, Susan Kellogg‐Spadt, Roberta I. Renzelli-Cain
Sexual medicine reviews · 2019 · vol. 8(1) , pp. 3–17 · doi:10.1016/j.sxmr.2018.12.007 · PMID:30928249 · W2931701384
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⚙ AI-generated summary by claude@2026-06, 2026-06-07 ⓘ

This review examines deep dyspareunia's pathophysiology across gynecologic, urologic, gastrointestinal, nervous, psychological, and musculoskeletal systems and proposes research priorities for measurement tools, patient populations, and clinical trial design.

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⚙ AI-generated deep summary by claude@2026-06, 2026-06-07 ⓘ

This paper is a narrative review that examines the pathophysiology of deep dyspareunia (pain with deep penetration), using an appraisal of published frameworks and a literature search that included terms combining dyspareunia with endometriosis and deep-related pathophysiology/etiology. The authors identify multiple potential etiologies across gynecologic, urologic, gastrointestinal, nervous system, psychological, and musculoskeletal domains, and propose classifying mechanisms by anatomical structures involved (e.g., tender Douglas pouch, uterus-cervix, bladder, pelvic floor) as well as stratifying into four types (I gynecologic, II non-gynecologic comorbidities, III central sensitization/genito-pelvic pain penetration disorder, IV mixed). They also propose key future research priorities including better measurement tools, studying people avoiding intercourse, clarifying comorbidities, addressing sociocultural/ethnic factors, conducting adequately powered trials, incorporating partner variables, mapping psychological pathways, and validating personalized approaches, while noting the review format as a limitation in terms of evidence synthesis rather than primary experimental testing. Relevance to endometriosis: the introduction explicitly draws on “recent work in endometriosis” to argue that co-existence of conditions with deep dyspareunia does not necessarily indicate causation, though the paper’s main focus is a broad review and research agenda for deep dyspareunia pathophysiology.

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Abstract

INTRODUCTION: Dyspareunia has been traditionally divided into superficial (introital) dyspareunia and deep dyspareunia (pain with deep penetration). While deep dyspareunia can coexist with a variety of conditions, recent work in endometriosis has demonstrated that coexistence does not necessarily imply causation. Therefore, a reconsideration of the literature is required to clarify the pathophysiology of deep dyspareunia. AIMS: To review the pathophysiology of deep dyspareunia, and to propose future research priorities. METHODS: A narrative review after appraisal of published frameworks and literature search with the terms (dyspareunia AND endometriosis), (dyspareunia AND deep), (dyspareunia AND (pathophysiology OR etiology)). MAIN OUTCOME VARIABLE: Deep dyspareunia (present/absent or along a pain severity scale). RESULTS: The narrative review demonstrates potential etiologies for deep dyspareunia, including gynecologic-, urologic-, gastrointestinal-, nervous system-, psychological-, and musculoskeletal system-related disorders. These etiologies can be classified according to anatomic mechanism, such as contact with a tender pouch of Douglas, uterus-cervix, bladder, or pelvic floor, with deep penetration. Etiologies of deep dyspareunia can also be stratified into 4 categories, as previously proposed for endometriosis specifically, to personalize management: type I (primarily gynecologic), type II (nongynecologic comorbid conditions), type III (central sensitization and genito-pelvic pain/penetration disorder), and type IV (mixed). We also identified gaps in the literature, such as lack of a validated patient-reported questionnaire or an objective measurement tool for deep dyspareunia and clinical trials not powered for sexual outcomes. CONCLUSION: We propose the following research priorities for deep dyspareunia: deep dyspareunia measurement tools, inclusion of the population avoiding intercourse due to deep dyspareunia, nongynecologic conditions in the generation of deep dyspareunia, exploration of sociocultural factors, clinical trials with adequate power for deep dyspareunia outcomes, partner variables, female sexual response, pathways between psychological factors and deep dyspareunia, and personalized approaches to deep dyspareunia. Orr N, Wahl K, Joannou A, et al. Deep Dyspareunia: Review of Pathophysiology and Proposed Future Research Priorities. Sex Med Rev 2020;8:3-17.

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Condition tags

dyspareuniaendometriosis

MeSH descriptors

Dyspareunia Dyspareunia Dyspareunia Female Gastrointestinal Diseases Gastrointestinal Diseases Humans Musculoskeletal Diseases Musculoskeletal Diseases Research Sexual Dysfunction, Physiological Sexual Dysfunction, Physiological Sexuality Urologic Diseases Urologic Diseases Women's Health

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