Among the most distressing of the many factors in dyspareunia are the complaints of burning, itching, or aching in the vagina during or after intercourse.
The existence of chronic vaginal irritation frequently robs women of their full freedom of sexual expression, for they are well aware that any specific coital connection may be severely irritative rather than highly stimulative.
Presuming adequate production of vaginal lubrication, rarely, if ever, does a woman complain of burning, itching, or aching during coition or describe these symptoms immediately after or even in a delayed postcoital time sequence without concomitant evidence of established pathology in the vaginal barrel.
This form of dyspareunia registered as a complaint by the female partner should have an important connotation to the co-therapist. This specific response pattern is not described by women who are subjectively impelled to register an excuse to avoid impending or threatened coital connection.
When women use the complaint of pain to avoid or delay the necessity for submitting to psycho genetically unappealing coital experience, their most frequent complaint is one of severe pain with penile thrusting, “a hurting” deep in the pelvis.
When considering the complaints of burning, itching, or aching in the vagina, initially clinical concern is focused on infectious vaginal invaders. The primary sources of vaginal infection are coition and rectal contamination; secondary sources are manual contact, clothing material, insertion of foreign material, and functional disuse.
Support of and control of the acidity of the vaginal environment is the fundamental means of protection against the bacterial pathogens that can create symptoms of burning, itching or aching.
The vagina naturally maintains a strongly acid environment as a protective mechanism against all forms of infectious invasion. With an experimentally controlled environment, vaginal acidity has been established as varying clinically from pH 3.5 to pH 4.0.
Thus, there is a rather wide margin for error in vaginal protection against concurrent infectious agents, for acidity must be sufficiently neutralized to raise the pH level to five or above before bacterial invaders can flourish freely in the vaginal environment.
The one time that natural vaginal protection against infection breaks down is during the period of established menstrual flow. For many women, vaginal acidity consistently registers in the neighborhood of pH 5 or above during menstrual flow, particularly if vaginal tampons are employed. The neutralizing effect of blood serum constrained to the vaginal tract by retentive tampons directs vaginal acidity into pH 5 levels routinely. It is not surprising, then, that most vaginal infections either have clinical onset or flourish during menstrual flow.
Bacteria are the infective organisms
Most constantly encountered in vaginal infections, yet trichomonal and fungal forms of infection are seen frequently enough to provide additional causes for clinical concern. Probably the most persistent vaginal-tract invader in any woman’s lifespan is the coliform organisms (Streptococcus faecalis, Escherichia coli, and the type of Streptococcus viridans), which are the basic contaminants of the bowel environment.
From the point of view of patterns of sexual functioning alone, persistent vaginitis, from which pathogenic organisms repeatedly are cultured in the adult, sexually functioning woman, should always make the therapist question the possibility of occasions of rectal intercourse.
A popular technique employed during rectal intercourse includes the expected format of initial rectal penetration during the excitement phase and repetitive thrusting during the plateau phase of the male sexual response cycle.
But many men withdraw from the rectum and plunge the bacterially contaminated penis into the vaginal barrel just before or during the stage of ejaculatory inevitability, terminating the orgasmic phase of their sexual cycle by ejaculating intravaginally. Recurrent coliform vaginal infections that are resistant to treatment may have originated in this coital technique.
When rectal intercourse is practiced, the ejaculatory episode should be confined to the lumen of the bowel. There should never be penetration of both rectal and vaginal orifices during any single coital episode if the woman wishes protection against the probability of recurrent vaginal infections.
If coliform vaginitis persists despite both adequate treatment and patient denial of rectal intercourse, a direct rectal examination frequently will solve the therapist’s diagnostic dilemma. If a woman is experiencing rectal intercourse with some regularity, there may be a specific involuntary reaction of the sphincter to the rectal examination.
When the examining finger is inserted, the response of the rectal sphincter at first will be one of slight to moderate spasms, following the expected reactive pattern of most men or women undergoing routine rectal examinations.
But if the examining finger is retained rectally for a few seconds, the sphincter may relax quite rapidly in a completely involuntary manner, as opposed to the routine response pattern of continuing in spastic contraction for the duration of the examination. If involuntary sphincter relaxation develops, this response pattern, while certainly not reliably diagnostic, should make the co-therapist skeptical of the patient’s denial of rectal coital episodes.
The involuntary sphincter relaxation develops because the retained examining finger stimulates a pleasurable response for those women enjoying regularity of rectal coital exposure as opposed to those finding rectal examinations subjectively objectionable and objectively painful.
As a clinical note, the same type of involuntary sphincter relaxation may develop in male homosexuals whose preferred pattern of sexual expression includes an interest in the regularity of rectal penetration. Again, the involuntary sphincter response pattern has been used by the Foundation’s professional staff as a clinical diagnostic aid when dealing with homosexual male patients employing the rectum as the means of providing an ejaculatory release for sexual partners or partners.
When the therapist can be reasonably certain by both history and examination of some regularity of rectal intercourse, techniques to avoid vaginal contamination with fecal material should be discussed at length with the women involved.
Although the basic premise of the clinical advice is to avoid recurrent episodes of coliform vaginitis if possible, there is an accrued secondary effect of reducing dyspareunia during occasions of intravaginal coitus.