Deep Dyspareunia : Review of Pathophysiology and Proposed Future Research Priorities

Introduction: Dyspareunia has been traditionally divided into superficial (introital) dyspareunia and deep dyspareunia (pain with deep penetration). While deep dyspareunia can co-exist with a variety of conditions, recent work in endometriosis has demonstrated that co-existence does not necessarily imply causation. Therefore, a re-consideration 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: 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: Potential etiologies for deep dyspareunia include gynecological, urological, gastrointestinal, nervous system, psychological, and musculoskeletal system related. These etiologies can be classified according to anatomic mechanism (contact with a tender pouch of Douglas, uterus-cervix, bladder, or pelvic floor, with deep penetration). They can also be stratified into four categories (as previously proposed for endometriosis specifically), which can be utilized to personalize management: Type I (primarily gynecologic), Type II (non-gynecologic comorbid conditions), Type III (central sensitization and genito-pelvic pain penetration disorder), and Type IV (mixed). Sociocultural and genetic factors and sexual response may also be important for deep dyspareunia. Conclusion: We propose the following eight research priorities for deep dyspareunia: 1) development of deep dyspareunia measurement tools; 2) focus on the population who are avoiding intercourse due to deep dyspareunia; 3) clarification of the role of non-gynecologic comorbidities in the generation of deep dyspareunia; 4) addressing of ethnic and other sociocultural factors; 5) initiation of clinical trials with adequate power for deep dyspareunia outcomes; 6) inclusion of partner variables; 7) elucidation of pathways between psychological factors and deep dyspareunia; and 8) empirical validation of personalized approaches to deep dyspareunia.