When Sex Hurts

Andrew Siegel MD  7/6/19

When Sex Hurts and Pain Replaces Pleasure

Today’s entry is a short break from the prostate theme, which will be resumed next week.

Sex should be a pleasurable and enjoyable experience, but sadly, that is not always the case. The pleasure aspect is a brilliant bait-and-switch design of nature that ensures reproduction of the species; members of the animal kingdom, “baited” by the pursuit of pleasure are actually “switched” to reproduction. 

“Dyspareunia” is doctor-speak for difficult or painful sexual intercourse, derived from “dys,” meaning “difficult” and the Greek term “pareunos,” meaning “lying with.” Although more typically a female complaint, dyspareunia does not spare men.

An Overly Mechanistic View of Sexual Intercourse

Sexual intercourse is a physical activity that involves moving parts that need to be lubricated and fit together properly for optimal function.  The “piston” component of an engine moves up and down within the “cylinder,” requiring appropriate fitting together of these component parts and sufficient lubrication to avoid excessive friction among the moving parts. “Piston clearance” is the clearance or gap between piston and cylinder.  If piston clearance is too small, the piston can “seize” inside the cylinder on expansion. If the piston fits too tightly within the cylinder, it can result in excessive friction and damage to the cylinder wall.  The bottom line is that problems can arise if the piston does not properly fit the cylinder or if there is inadequate lubrication of contact points.


Internal combustion engine with pistons and cylinders, Attribution: Mj-bird [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)%5D

 Causes of Female Dyspareunia

  • Size discrepancy with partner – The vagina is an incredibly accommodating organ capable of tremendous stretch and expansion—think vaginal delivery of a 10-lb. baby—so this is relatively rare, but the combo of a woman with petite anatomy  coupled with an outsized male can be a formula for pain. A lengthy penis can strike the cervix or vaginal fornix and a penis with formidable girth may prove excessive for a narrow vagina, resulting in “collision dyspareunia.”
  • Vaginal scarring – Scar tissue from pelvic or vaginal surgery, birth trauma, or poor healing of episiotomies can alter vaginal anatomy and make sexual intercourse painful and challenging.
  • Menopause – Estrogen nourishes and nurtures the genital tissues.  Declining levels of estrogen after menopause cause thinning, fragility and less suppleness of the vaginal walls as well as diminished vaginal lubrication.
  • Infection – Vaginitis (vaginal infections), bacterial cystitis (bladder infections), interstitial cystitis, pelvic inflammatory disease, and infections of the para-urethral glands (Skene’s glands) a.k.a. Skenitis that can give rise to painful intercourse.
  • Endometriosis –The lining tissue within the uterus (endometrium) can implant outside the uterus, causing painful intercourse.
  • Excessively tight pelvic floor – This is a condition—a.k.a. vaginismus– in which the pelvic floor muscles are over-tensioned and fail to relax properly, which can cause painful intercourse, if sex is even possible at all.
  • Vulvodynia – This is a condition marked by hypersensitive vulvar tissues that are extremely tender to touch.
  • Loss of vaginal lubrication – This can happen from menopause (natural or from surgery), side effects of medications, breast-feeding, as well as insufficient foreplay.
  • Disuse atrophy – Use it or lose it; if one has not been sexually active for prolonged times, there can be loss of tissue integrity and vaginal atrophy. Staying sexually active keeps one’s anatomy toned and supple.
  • Urethral diverticulum – This is an acquired out-pouching from the urethra causing a cystic mass in the vagina that can result in pain with sex.
  • Psychological/emotional – “The mind suffers…the body cries out.” Emotionally or physically traumatic sexual experiences can negatively affect future sexual experiences.

Causes of Male Dyspareunia

Urologists sometimes refer to male dysparenuia as “his-pareunia”–not a legitimate medical word, but to the point!

  • Infections —Infections of the prostate (prostatitis) and urethra (urethritis) can cause pain with ejaculation.
  • Peyronie’s disease – Scarring of the sheath of the erectile cylinders can cause an angulated and painful penis, particularly so with erections.
  • Phimosis — This is a condition is which the foreskin is tight and cannot be drawn back, leading to inflammation, pain and swelling.
  • Tethered frenulum — The frenulum is the narrow band of tissue that attaches the head of the penis to the shaft; at times it can tear during sexual intercourse, causing bleeding and pain.
  • Excessively tight pelvic floor – This condition in which the pelvic floor muscles are over-tensioned and fail to relax properly is not unique to females and can result in pelvic pain and pain with sexual activity.
  • Penile enlargement procedures – Efforts to “bulk up” the penis with injections of fat, silicone and other tissue or prosthetic grafts can result in an unsightly, lumpy, discolored, and painful penis.
  • Improperly sized penile implants – Penile prostheses can be lifesavers for the sexually non-functional or poorly functional male, but need to be sized precisely, like shoes for one’s feet.  If too large, they can result in penile pain and pain with sex.
  • Her issues causing his pain – Mesh exposure is a condition in which a mesh implant–used in females to help support dropped pelvic organs and to cure stress urinary incontinence–is “exposed” in the vagina, which feels on contact like sandpaper and can result in both female and male dyspareunia.

Wishing you the best of health,

2014-04-23 20:16:29

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

Dr. Siegel’s latest book: PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

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Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health


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4 Responses to “When Sex Hurts”

  1. The Ryan (@RyanDanielst) Says:

    You mention the vagina is capable of incredible expansion and use childbirth as an example. Childbirth is painful, so even the average vagina will feel pain from a very thick penis.

  2. The Ryan (@RyanDanielst) Says:

    t’s not merely friction. Just because a very thick penis can fit, doesn’t mean it won’t hurt. Men with very thick penises can fit into normal-sized condoms, but they hurt.

    Friction can be a source of pain, as well as stretching of the pelvic floor due to a thick penis.

  3. Larger Penis = Better Sex? – Challenging Everything Says:

    […] Our Greatest Wealth is Health; When Sex Hurts […]

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