Rate and Related Factors of Dyspareunia in Reproductive Age Women: a Cross-Sectional Study

Home , Dyspareunia, Pelvic organ prolapse

ORIGINAL ARTICLE Rate and related factors of dyspareunia in reproductive age women: a cross-sectional study

SS Sobhgol1 and S Mohammad Alizadeli Charndabee2

1Faculty Member of Azad University of Zanjan Branch, Zanjan, Iran and 2Faculty Member of Tabriz University of Medical Sciences, Tabriz, Iran

This study was conducted to determine rate and related factors of dyspareunia. Three hundred and nineteen women aged 15–49 years were surveyed. A questionnaire was used to collect data. Pelvic examinations and connective tissue disorders were investigated. At whole 54.5% had dyspareunia. The means of gravidity, parity, delivery without episiotomy and vaginal length were more in women with dyspareunia. Heavy lifting, chronic pulmonary obstructive disease, arthritis, constipation, pelvic organ prolapse and pelvic muscle strength had significant relation to dyspareunia. The prevalence of urinary infection, stress incontinence, urgency, positional changes to start or complete voiding, fecal straining, low back pain, digital manipulation of vagina, perineum or anus to complete defecation, feeling genital pain or pressure and sensation of a mass in vagina was more in women with dyspareunia. These factors can be considered in the evaluation of women, to prevent those at risk and also have better management of this disorder. International Journal of Impotence Research (2007) 19, 88–94. doi:10.1038/sj.ijir.3901495; published online 22 June 2006

Keywords: rate; related factors; sexual dysfunction; dyspareunia

Introduction diagnosis difficulty. The identification of the initiat- ing and promulgating factors is essential in reaching Sexual dysfunction is highly prevalent in today’s a successful diagnosis.3 As women in reproductive society1 and it is still an important public health age experience different conditions compared with concern.2 Male sexual disorders have received those in menopausal ages physiologically, so we considerable attention, leading to a multitude of conducted this study to determine rate and related treatment options. On the other hand, female sexual factors of dyspareunia in reproductive age women. dysfunction has gone vastly underreported and untreated.1 Dyspareunia as a sexual dysfunction is defined genital pain experienced before, during or Materials and methods after sexual intercourse.3 In a study of primary care practice, the prevalence of dyspareunia was 46 This was a cross-sectional study, which was carried percent among sexually active women, with dyspar- out in 2003, Tabriz, Iran. Three hundred and nine- eunia defined as pain during or after intercourse, teen women aged 15–49 years, married, non-preg- whereas many of those with persistent symptoms do nant, non-breastfeeding and those who were not not seek medical attention. There are few reports of within 6 weeks postpartum, referred to two Alzahra clinical trails relating to dyspareunia and much of and Talaghanee clinics, with easy sampling were the literature derives from expert opinion. The lack surveyed. Informed consent was obtained from all of a single etiology for the pain contributes to the subjects. A questionnaire containing two sets was filled out for all the subjects by a trained interviewer. The first part of questionnaire included demographic factors, medical and reproductive history, urinary Correspondence: Dr SS Sobhgol, Faculty Member of Azad University of Zanjan, Azad University of Zanjan Branch, and bowel symptoms and pelvic organ prolapse Moalem Squar, Mail Box 34185-195, Qazvin, 0098, Iran. symptoms. Medical conditions investigated were E-mail: [email protected] arthritis, chronic pulmonary disease, hypertension, Received 6 October 2005; revised 5 May 2006; accepted 8 constipation, diabetes mellitus, previous pelvic May 2006; published online 22 June 2006 organ prolapse surgery and urinary incontinence Rate and related factors of dyspareunia in reproductive age women SS Sobhgol et al 89 surgery or hysterectomy and familial history of Body mass index (BMI) was calculated as weight pelvic floor dysfunction. Patient’s responses were (kg)/height (m2). Connective tissue disorder was recorded as yes or no. Patient was considered as a determined by using modified Carter–Wilkinson diabetic if she was on treatment for the condition. criteria.8 To determine the presence of dyspareunia, Women were considered to have constipation if they all the women were asked about the episodes of had less than three times a week defecation with pain before, during or after intercourse. Women’s excessive straining.4 The data of the second part of responses were recorded as yes or no. SPSS/win was questionnaire were obtained by examination. Pelvic used to analysis the data. Statistical tests used were organ prolapse was determined by using the pelvic w2 and two-sample Student’s t-test to determine organ prolapse quantification (POPQ) system.5,6 group (with and without dyspareunia) differences in Stage zero and one were considered as good support. the proportions and means for demographic and Pelvic measurements (vaginal length, perineal length reproductive characteristics, medical history and and genital hiatus diameter and depth of posterior other ordinal variables. We considered differences fornix) were performed by using POPQ system.5 significant at Po0.05. Pelvic floor muscle strength was determined too. Two-finger vaginal palpation was performed with the pelvic floor muscles relaxed. The woman was asked to contract her pelvic floor muscles as hard Results and long as she could around the examiner’s fingers. The pelvic floor muscle strength was rated as absent To determine rate and related factors of dyspareunia, (1) (no detectable muscle contractility around the we evaluated 319 women. The average of women examiner’s finger), weak (2) (contractility detectable had 33.878.3 years old. The means of gravidity and but not all around the fingers), moderate (3) parity were 3.772.9 and 3.272.5, respectively. Two (contractility around the fingers but no elevation of hundred and forty-six (77.1 percent) were house- pelvic floor) or good (4) (powerful contractility around keepers and 44 (13.8 percent) were high school the fingers and elevation of pelvic floor).5,7 or college educated. At whole, 54.5 percent had By bimanual palpation, the position of the uterus dyspareunia. was assessed as anteflected, upright, retroflected, The means of gravidity, parity, vaginal length and uncertain or hysterectomized. delivery without episiotomy were significantly more All pelvic examinations were performed in the in women with dyspareunia. But the means of age, dorsal lithotomy position. Hemorrhoid was exam- delivery with episiotomy, BMI, perineal length ined in the same position too. The varicose was and genital hiatus diameter showed no difference examined in the standing position. between two groups (Table 1). In order to confirm the reliability of examinations, The percentage of having macrosomic infant the researcher and a gynecologist familiar with (44000 kg) delivered vaginally in women with POPQ system performed a pilot study and similar dyspareunia (81.0 percent) was significantly more results were obtained after an evaluation. than it in women without dyspareunia (19.0 per-

Table 1 Distribution of demographic, reproductive data and pelvic measurement in women with dyspareunia and those without dyspareunia

Variable With dyspareunia (n ¼ 145) Without dyspareunia (n ¼ 174) P-value Mean7s.d. Mean7s.d.

Age (year) 34.078.8 33.778.6 0.745 Gravida 4.273.0 3.172.6 o0.0001 Vaginal delivery 3.472.8 2.672.4 0.004 Parity 2.570.8 2.370.9 o0.0001 Cesarean 0.370.7 0.170.3 0.008 Delivery with episiotomy 0.670.9 0.671.0 0.712 Delivery without episiotomy 2.872.9 1.972.5 0.005 BMI (kg/m2)a 27.375.4 27.475.4 0.924 Wt. of largest infant (g)b 3382.67732.4 3192.67623.9 0.06 Vaginal length (cm) 9.671.08 9.271.1 0.006 Genital hiatus (cm) 3.370.9 3.170.93 0.209 Prineal diameter (cm) 3.270.82 3.170.7 0.116 Depth of posterior fornixc (cm) 2.770.99 2.571.1 0.185

Abbreviations: BMI, body mass index; s.d., standard deviation, Wt., weight. a From 171 women with dyspareunia and 141 without dyspareunia. b From 118 women with dyspareunia and 79 without dyspareunia. c From 172 women with dyspareunia.

International Journal of Impotence Research Rate and related factors of dyspareunia in reproductive age women SS Sobhgol et al 90 cent) (P ¼ 0.012). In the present study, education The frequency of urinary infection more than two showed a significant relation to dyspareunia. The times a year, stress urinary incontinence, urgency, percentage of dyspareunia decreased from 91.0 positional changes to start or complete voiding, fecal percent to 8.6 percent with increasing education straining, low back pain, digital manipulation of level from illiterate, elementary and guidance to vagina or perineum to complete defecation, feeling high school or university, respectively (P ¼ 0.0003). mass in vagina, genital pain or low abdominal There was no relation between exercise and employ- pressure was significantly more in women with ment with dyspareunia (P ¼ 0.913, P ¼ 0.059, respec- dyspareunia. But there were no correlations be- tively). Heavy lifting had significant relation to tween fecal incontinence and nocturia with dyspar- dyspareunia. So that 80.0 percent and 74.0 percent eunia (Table 3). of women who lifted heavy tools always or most of the time had dyspareunia compared with 59.1 percent and 40.4 percent of women who had dyspareunia and never or rarely lifted heavy tools Discussion (P ¼ 0.0001) (data not shown). w2 Analysis revealed significant relations between The purpose of this study was to determine the rate chronic obstructive pulmonary disease, arthritis, and related factors of dyspareunia. constipation, pelvic organ prolapse and dyspareu- In the present study, the prevalence of dyspar- nia. But there was no significant relation between eunia was 54.5 percent. There are few reports of hypertension, varicose, connective tissue disorder, clinical trails relating to dyspareunia. According to familial history of pelvic floor dysfunction, previous the definition of dyspareunia several studies have pelvic surgery (hysterectomy, urinary incontinence reported different prevalence. In a study, as many as surgery, pelvic organ prolapse surgery) and dyspar- 60.0 percent of women experienced dyspareunia eunia. The history of pelvic inflammation disease when the term is broadly defined as episodes of pain also showed significant relation to dyspareunia with intercourse. Women with symptoms severe (Table 2). enough to require medical attention comprise a Pelvic floor muscle strength also had significant much smaller group. Many of those with persistent relation to dyspareunia, so that 62.9% of women symptoms do not seek medical attention. In a with absent or week pelvic muscle strength had national probability sample, the prevalence of dyspareunia compared with 48.0 percent of women dyspareunia was 7.0 percent. In a study of primary who had moderate or good pelvic floor muscle care practices, the prevalence of dyspareunia was strength (P ¼ 0.008). We saw no relation between 46.0 percent among sexually active women.3 uterus position and dyspareunia. Although 68.8 Shokrollahi et al.9 found 10.0 percent of 300 percent of women with retroflected uterus position women who were seeking services at family plan- had dyspareunia against 55.6 percent of those with ning centers in Tehran had dyspareunia. Rosen upright uterus or 55.7 percent with anteflected et al.10 in a study on 329 women aged 18–73 showed uterus, relation was not significant (P ¼ 0.528) (data the prevalence of dyspareunia about 11.3 percent. not shown). According to the broad definition of dyspareunia in

Table 2 Distribution of medical conditions, previous pelvic surgeries and familial history of pelvic floor disorder in women with and without dyspareunia

Variable With dyspareunia (n ¼ 174) Without dyspareunia (n ¼ 145) P-value n (%) n (%)

Previous hysterectomy 0 2 (1.4) 0.363 Before POP surgery 5 (2.9) 4 (2.8) 0.951 Diabetic mellitus 5 (2.9) 3 (2.1) 0.647 Hypertension 11 (6.3) 11 (7.6) 0.657 Chronic pulmonary disease 25 (14.4) 8 (5.5) 0.01 Arthritis 60 (34.5) 27 (18.6) 0.002 Constipation 74 (44.5) 39 (26.9) 0.004 Hemorrhoida 49 (28.2) 27 (18.6) 0.054 Varicosea 40 (23.0) 28 (19.6) 0.426 Connective tissue disorderb 10 (5.8) 13 (9.0) 0.281 Familial history of pelvic floor dysfunction 20 (12.7) 16 (12.0) 0.855 Pelvic organ prolapse 119 (68.4) 83 (57.2) 0.04 Pelvic inflammation disease 51 (29.3) 16 (0.11) o0.0001

a From 143 women without dyspareunia. b From 173 women with dyspareunia and 144 without dyspareunia.

International Journal of Impotence Research Rate and related factors of dyspareunia in reproductive age women SS Sobhgol et al 91 Table 3 Distribution of urinary, bowl and pelvic organ prolapse symptoms in women with and without dyspareunia

Variable With dyspareunia (n ¼ 174) Without dyspareunia (n ¼ 145) P-value n (%) n (%)

Urinary infection 42 times a year 85 (48.9) 33 (22.8) o0.001 Stress incontinence 72 (41.4) 29 (20.0) o0.001 Urgency 55 (31.6) 24 (16.6) 0.002 Frequency 58 (33.3) 26 (17.9) 0.002 Nocturia 37 (21.3) 23 (15.9) 0.219 Positional change to urinate 28 (16.1) 11 (7.6) 0.021 Fecal straining 56 (32.2) 28 (19.3) 0.009 Digital manipulation to defecate 46 (26.4) 22 (15.2) 0.014 Fecal incontinence 3 (1.7) 1 (0.7) 0.408 Low abdominal pain 137 (78.7) 89 (61.4) 0.001 Low back pain 154 (88.5) 70 (48.3) o0.0001 Feeling mass in vagina 78 (44.8) 32 (22.1) o0.0001

the present study, this prevalence is in agreement In the present study, the mean of delivery with with similar studies.3 This finding can be related to episiotomy did not show any difference between our sampling setting where gynecologic patients two groups, and of course, we did not include referred them more in addition to our broad breastfeeding women and those in postpartum definition of dyspareunia and shows that the period. It has been said that painful episiotomy scar prevalence of dyspareunia will be higher than our after vaginal delivery with an incomplete repair of expectation when it is really investigated. episiotomy or laceration can induce pain through We did not see any relation between age and intercourse after delivery.13 But this result can be dyspareunia. The data on age and its relation to owing to our inclusion criteria and low number of dyspareunia are rare and different. Rosen et al.10 women within first 6 months after delivery, so these found age as an important predictor of sexual may affect the final result. There were low number dysfunction. Laumann et al.2 studied 1749 women of women with macrosomic infant delivered vagin- and 1410 men aged 18–59 years and showed age as ally in this study and we saw no significant relation an important factor for sexual dysfunction. They between this variable and dyspareunia. showed with increasing age, the prevalence of We did not see any relation between BMI and dyspareunia decreased. However, Haim3 did not dyspareunia. Kapoor et al.14 also did not demon- find any relation between age and dyspareunia. strate any relation between obesity and sexual So according to our findings, the effect of age on function. In a study by Vermeulen and Scholte,15 dyspareunia in reproductive age women is not no difference was demonstrated in satisfaction of prominent. sex life between fatigue patients and controls. It was In the present study, gravidity and parity had their perception of fatigue that was different, not significant relation to dyspareunia. Their effects on quality of their sexual life. dyspareunia may be owing to the impairment of Education showed significant relation to dyspar- pelvic floor during pregnancy and delivery11 as we eunia. Women with high school or university level found a significant relation between pelvic floor education had less experiences of dyspareunia muscle strength and pelvic organ prolapse to compared with low educated women. Consistent dyspareunia in the present study. Halvorsen and characteristics of patients with dyspareunia are Metz1 also described gravidity as an organic factor in rare.3 A meaningful association was found between inducing sexual dysfunction. In another study, there education and sexual dysfunction in a study.2,3 was no relation between parity and dyspareunia.3 Gottlieb16 also demonstrated that people who have We did not evaluate the effect of first or second got university education are less likely to experience delivery on dyspareunia in this study. But in a sexual problems than their less well-educated study, it has been said that only a slight difference in counterparts. Haim,3 and Rosen et al.10 did not find pain existed between women having a first delivery any relation between dyspareunia and education. versus those having second delivery.3 People with differences in educational level may Cesarean section showed significant relation to have different lifestyles like smoking habits, medi- dyspareunia in the present study. In a study, over cation, food intake,17 exercise and number of one-quarter of women who underwent cesarean pregnancy or delivery. In the present study, we did section had dyspareunia.12 Cesarean as a surgical not see any relation between employment status, factor can cause dysapareunia. Halvorsen and exercise and dyspareunia. Probably this is because Metz1 described surgical and traumatic factors as most of the women (96%) in this study did not organic causes of dyspareunia. exercise regularly and were housekeepers (77.1%).

International Journal of Impotence Research Rate and related factors of dyspareunia in reproductive age women SS Sobhgol et al 92 Heavy lifting had significant relation to dyspareunia The pelvic inflammatory disease (PID) also in the present study. This factor may also impose showed significant relation to dyspareunia in this some effects on pelvic floor, which can cause study. PID also can be associated with dyspareunia.13 dyspareunia indirectly.11 Health professionals can In the present study, pelvic muscle strength had consider heavy lifting as a risk factor when they are significant relation to dyspareunia (P ¼ 0.008), so evaluating patient’s lifestyle. that women who had absent or week pelvic floor We found no association between previous pelvic muscle strength had more dyspareunia. This can be surgery and dyspareunia in the present study. associated with several disorders like pelvic organ Although both of the women with hysterectomy prolapse or impairment during childbirth or surgical had dyspareunia, the relation was not significant trauma.11 Uterus position shows no relation to because of low cases of hysterectomy in our study. dyspareunia in this study. Although it has been said In a study, Weber et al.18 found that sexual function that the minority of women with retroflected uterus and satisfaction improved or did not change in most may have dyspareunia,3 just 2.4 percent of women women after surgery for either prolapse or urinary had third- or fourth-degree prolapse in this study, incontinence or both. In another study, Lemack and which can be associated with retroflected uterus.7 Zimmern19 also found no difference in the inci- Perineal length, genital hiatus diameter and depth of dence of dyspareunia after vaginal surgery for stress posterior fornix did not have any relation to incontinence. It has been said that hysterectomy and dyspareunia, whereas vaginal length had significant vaginal wall trauma during surgery can induce relation to dyspareunia. Data on pelvic measure- dyspareunia.13 According to different studies18,19 ments and dyspareunia are rare. The mean length of and our finding, the possible role of surgery on vagina in women with dyspareunia was more than sexual dysfunction requires more research. mean length of vagina in those without dyspareunia Chronic pulmonary disease, arthritis and consti- in this study. Normally the length of posterior pation showed significant relation to dyspareunia in vaginal wall is 7–11 cm.18 In the present study, the present study. Chronic illness and its treatment the length of 8.5–9.0 cm was with the less percent can have a negative impact on sexual function. The of dyspareunia (49.0 percent). Vaginal length more mechanism of interference may be neurologic, or less than this range was associated with more vascular, endocrinologic, musculoskeletal or psy- percent of dyspareunia. Whether short or long chologic.20 Arthritis can make some difficulties length of vagina was owing to congenital factor or about positional changes that may improve comfort aging, POP, delivery was not possible to be evalu- during sexual activity.21 Chronic illness can influ- ated in this study. To evaluate vaginal anatomy to ence hypothalamic, hypophysis, ovarian and end predict dyspareunia, the measurement of depth and organs (vulva, vagina, cervix, uterine) directly. It is caliber of vagina has been suggested.18,19 There are important to know that sexual dysfunction owing few data on which to judge the objective adequate to medical condition can persist even after medical vaginal dimensions that permit symptom-free sexual treatment.22 activity. It has been found that vaginal anatomy Patients with chronic illnesses often have diffi- assessed by introital caliber, vaginal length and culties with sexual functioning. Understanding of vulovaginal atrophy does not correlate well with the impact that chronic illness can have on sexual sexual function, particularly symptoms of dyspar- functioning can be helpful in the evaluation of eunia. To attribute correctly changes in sexual patients. function to changes in vaginal anatomy, it has been Although more percent of women with dyspar- suggested to correlate patient’s symptoms with eunia experienced diabetes mellitus, hypertension, vaginal dimensions both before and after surgical hemorrhoid, varicose and family history of pelvic treatment.18,19 In a study, Weber showed that vaginal floor dysfunction, the relation was not significant. dimensions decreased slightly after surgery; how- In a study, diabetes mellitus was associated with ever, this did not correlate with any changes in decreased sexual desire and difficulties in reaching sexual function and women who described the an orgasm, but not to dyspareunia as we did not vaginal length as too short were more likely to obtain any relation in this study.23 Pelvic organ experience dyspareunia. But it was not statistically prolapse had significant relation to dyspareunia in significant.18 According to several studies and our this study. It has been suggested that some women results, it seems the measurement of vaginal length with pelvic organ prolapse have dyspareunia too.3 is more helpful in the evaluation of dyspareunia Bradshow et al.24 found that sexual dysfunction than other pelvic measurements like perineum or commonly accompanies pelvic floor disorders and hiatus diameter. symptoms should be actively sought. The most We found significant relations between urinary prominent sexual symptom was dyspareunia in symptoms like urinary infection more than two their study. It has been said that pelvic organ times a year, stress incontinence, urgency, frequency prolapse not only can cause some bothering and need to positional change to urinate with symptoms but it can also affect quality of life dyspareunia in this study. Urinary system can be a and sex.25 source of dyspareunia. Cystitis or interstitial cystitis

International Journal of Impotence Research Rate and related factors of dyspareunia in reproductive age women SS Sobhgol et al 93 causes pain as the bladder fills. Reports of symp- evaluation of patients. A stratified and representa- toms include suprapubic pressure, frequency, tive sample of population with diagnostic criteria nocturia and urgency without dysuria.3 Other and laboratory tests in addition to incidence rates symptoms like fecal straining, digital manipulation may refine the results and make it more possible to of the rectum to defecation, and feeling a mass in the derive generalization from collected data. Further vagina also showed significant relations to dyspar- studies are necessary to evaluate dyspareunia from eunia in the present study. These symptoms can be other aspects of possible etiologic factors. associated with pelvic organ prolapse too.26 Low back pain, genital or low abdominal pain or pressure had significant relation to dyspareunia in the present study. It has been suggested that dyspareu- Acknowledgments nia as a special kind of chronic pelvic pain can be a clinical appearance of chronic low abdominal The support provided by the research Department of pain or pelvic congestion.27,28 Dyspareunia can be Tabriz University of medical sciences is gratefully a primary appearance and then proceeds to chronic acknowledged. persistent pain.3 Steege and Ling29 also described dyspareunia as a specific type of chronic pelvic pain. Although this condition has historically been classified as a sexual disorder, an integrated and References pain-model approach to the problem is gaining support. The current thinking about pain initiation 1 Halvorsen JG, Metz ME. Sexual dysfunction, part 1: classifica- tion, etiology and pathogenesis. J Am Board Fam Prac 1992; 5: and promulgation suggests an initial instigating 51–61. factor that is then perpetuated by confounding 2 Laumann EQ, Paik A, Rosen RC. Sexual dysfunction in the factors. These factors may be physical or psycholo- United States: prevalence and predictors. JAMA 1999; 281: gic.16 A study by Meana et al.,30 who investigated 537–544. women with dyspareunia physically and psycholo- 3 Haim LT. Evaluation and differential diagnosis of dyspareunia. Am Fam Physician 2001; 63: 1535–1544. gically, described that the current sexual impair- 4 Nam Y, Dikarsky AJ, Wexner SD. Reproducibility of colonic ment of women suffering from dyspareunia transit study in patients with chronic constipation. Dis Colon notwithstanding the results, supports the considera- Rectum 2001; 44: 86–92. tion of dyspareunia as primarily a pain syndrome 5 Bump RC, Mattiasson A, Bo K. The standardization of terminology of female pelvic organs prolapse and pelvic floor rather than a sexual dysfunction. dysfunction. Am J Obstet Gynecol 1996; 175: 10–17. 6 Swift MD. Distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Am Obstet Gynecol 2000; 183: 277–285. Conclusion 7 Samuelsson EC, Victor FTA, Tibblin G, Svardsudd KF. Signs of genital prolapse in a Swedish population of women 20–59 years of age and possible related factors. Am J Obstet Gynecol We could evaluate some related factors to dyspar- 1999; 180: 299–305. eunia. From the results of this study, it can be said 8 Norton PA, Baker RN, Sharp HC, Warensky J. Genitourinary that dyspareunia may be a symptom of organic prolapse and joint hypermobility in women. Obstet Gynecol 31 1995; 85: 225–228. disease. So eliciting a sexual history helps in the 9 Shokrollahi P, Mirmohamadi M, Mehrabi F, Babaeei G. early diagnosis of disorder and it is also an Prevalence of sexual dysfunction in women seeking services opportunity for primary preventive care like educa- at family planning centers in Tehran. J Sex Marital Ther 1993; tion or contraception in order to reduce possible 25: 211–215. direct or indirect effect of pregnancy and delivery on 10 Rosen RC, Taylor JF, Leiblum SR, Bachmann GA. Prevalence of sexual dysfunction in women: results of survey study of 329 developing dyspareunia and also in the manage- women in an outpatient gynecology clinic. J Sex Marital Ther ment of this disorder. Family physician can screen 1993; 19: 171–188. for and manage sexual dysfunction, thereby enhan- 11 Herny MM, Parks AG, Swash M. The pelvic floor musculature cing quality of life of their patients. A question about in the descending perineum syndrome. Br J Surg 1982; 69: 470–472. the experiencing pain with intercourse can be 12 Goetsch MF. Postpartum dyspareunia. An unexplored pro- helpful in the recognition of dyspareunia. From blem. J Reprod Med 1999; 44: 963–968. our findings, it can be suggested that treatment of 13 Mckay DH, Norman J, Callender R, Ramsden I. Gynecology chronic disease, improved medical prevention and Illustrated, 5th edn. Churchill Livingstone: Edinburgh, 1996, pelvic floor exercise are probably useful in the pp 366–367. 14 Kapoor DS, Davila GW, Rosenthal KJ, Ghoniem GG. Voiding prevention or treatment of dyspareunia. Attention to and sexual dysfunction in morbidly obese women using urinary, bowel and pelvic symptoms can be useful to validated symptom inventories and quality of life question- diagnose the source of pain. Educating women about naires. A case–control study. Int Urogynecol J Pelvic Floor the related factors of dyspareunia like parity or Dysfunct 2001; 12(Suppl 1): 54. 15 Vermeulen RCW, Scholte HR. Chronic fatigue syndrome and cesarean section, gravidity and also lifestyle can be sexual dysfunction. J Psychosomat Res 2004; 56: 1999–2001. considered in primary care practices. Measurement 16 Gottlieb S. Educated adults have fewer sex problems in the of vaginal length can also be considered in the US. BMJ 1999; 318: 415–417.

International Journal of Impotence Research Rate and related factors of dyspareunia in reproductive age women SS Sobhgol et al 94 17 Lyngdorf P, Hemmingsen L. Epidemiology of erectile dysfunc- 24 Bradshow HD, Radley SC, Bottcher B, Wyle KR, Shorthouse tion and its risk factors: a practice-based study in Denmark. Int AJ, Chapple CR. Sexual function in women with pelvic floor J Impot 2004; 16: 105–112. disorders. Int Urogynecol J Pelvic Floor Dysfunct 2001; 18 Weber AM, Walters MD, Piedmonte MK. Sexual function and 12(Suppl 1): 60. vaginal anatomy in women before and after surgery for pelvic 25 Okonkow JEN, Obinu CO, Obiechina NJA. Factors contribut- organ prolapse and urinary incontinence. Am J Obstet Gynecol ing to urinary incontinence and pelvic organ prolapse in 2000; 182: 1610–1650. Nigeria. Int Gynecol Obstet 2001; 72: 301–303. 19 Lemack GE, Zimmern PE. Sexual function after vaginal 26 Stanton SC, Monga AK. Pelvic Organs Prolapse. Churchill surgery for stress incontinence: results of a mailed question- Livingstone: London, 2000, pp 357–373. naire. Urology 2000; 56: 223–227. 27 American College of Obstetrics and Gynecology. Chronic 20 Nusbaum MH, Hamilton C, Lenahan P. Chronic illness and Pelvic Pain, Technical Bulletin No. 223. ACOG: Washington, sexual functioning. Am Fam Physician 2003; 67: 347–354. DC, 1996. 21 Read J. ABC of sexual health: sexual problems associated with 28 Bread RW, Reginald PW, Wadsworth J. Clinical features of infertility, pregnancy and aging. BMJ 1999; 318: 587–589. women with chronic lower abdominal pain and pelvic 22 Tercstia Mc, Fromm LM, Roberts LW, Dorin M, Harrington DJ. congestion. Br J Obstet Gynecol 1988; 95: 153–161. Biopsychosocial topics in women’s sexual health. In: Cope- 29 Steege JF, Ling FW. Dyspareunia: a special type of chronic land JJ, Jarrell JF (eds). Textbook of Gynecology, 2nd edn. WB pelvic pain. Obstet Gynecol Clin N Am 1993; 20: 779–793. Sunders Company: Philadelphia, 1999, pp 324–359. 30 Meana M, Binik YM, Khalife S, Cohen D. Dyspareunia: sexual 23 Adbo Jr C, Ooliveira Jr WM, Moreira ED, Fittipald JAS. dysfunction or pain syndrome. J Nerv Ment Dis 1997; 185: Prevalence of sexual dysfunction and correlated conditions in 561–569. a sample of Brazilain women-results of the Brazilian study on 31 Nusbaum MRH, Hamilton CP. The proactive sexual health behavior (BSSB). Int J Impot Res 2004; 16: 160–166. history. Am Fam Physician 2002; 66: 1705–1712.

International Journal of Impotence Research