Pain duringsexualintercourse. There are many causes of dyspareunia, including vaginal infection or dryness. Treatment is directed toward the underlying cause and vaginal lubricant jelly can be of help.

Dyspareunia is painfulsexual intercourse, due to medical or psychological causes. The term is used almost exclusively in women, although the problem can also occur in men. The causes are often reversible, even when long-standing, but self-perpetuating pain is a factor after the original cause has been removed.

Dyspareunia is considered to be primarily a physical, rather than an emotional, problem until proven otherwise. In most instances of dyspareunia, there is an original physical cause. Extreme forms, in which the woman's pelvic floor musculature contracts involuntarily, is termedvaginismus.

Numerous medical causes of dyspareunia exist, ranging from infections candidiasis, chlamydia, trichomoniasis, urinary tract infections, endometriosis  tumors, xerosis - dryness, especially after the menopause - and LSEA.
Dyspareunia may result from female genital mutilation, when the introitus has become too small for normal penetration - often worsened by scarring.

Physical Causes

Because there are numerous physical conditions that can contribute to pain during sexual encounters, a careful physical examination and medical history are always with such complaints. In women, common physical causes for coital discomfort include infections of the vagina, lower urinary tract, cervix, or fallopian tubes e.g., mycotic organisms - esp. candidiasis, chlamydia, trichomonas, coliform bacteria; endometriosis; surgical scar tissue - following episiotomy; and tumors.

In addition to infections and chemical causes of dyspareunia such as monilial organisms and herpes, anatomic conditions, such as hymenal remnants, can contribute to coital discomfort. Estrogen deficiency is a particularly common cause of sexual pain complaints among postmenopausal women, although vaginal dryness is often reported by lactating women as well.

Women undergoing radiation therapy for pelvic malignancy often experience severe dyspareunia due to the atrophy of the vaginal walls and their susceptibility to trauma. Vaginal dryness is sometimes seen in Sjögren's syndrome, an autoimmune disorder which characteristically attacks the exocrine glands that produce saliva and tears.

Dyspareunia is now believed to be one of the first symptoms of a disease called interstitial cystitis - IC. Patients may struggle with bladder pain and discomfort during or after sex. For men with IC, pain occurs at the moment of ejaculation and is focused at the tip of the penis. For women with IC, pain usually occurs the following day, the result of painful, spasming pelvic floor muscles. Interstitial cystitis patients also struggle with urinary frequency and/or urinary urgency.

Physical Causes in Men

In men, as in women, there are a number of physical factors that may cause sexual discomfort. Pain is sometimes experienced in the testicular or glans area of the penis immediately after ejaculation. Infections of the prostate, bladder, or seminal vesicles can lead to intense burning or itching sensations following ejaculation. Men suffering from interstitial cystitis may experience intense pain at the moment of ejaculation. Gonorrheal infections are sometimes associated with burning or sharp penile pains during ejaculation. 

Urethritis or prostatitis can make genital stimulation painful or uncomfortable. Anatomic deformities of the penis, such as in Peyronie's disease, may also result in pain during coitus. One cause of painful intercourse is due to the painful retraction of a too-tight foreskin, occurring either during the first attempt at intercourse or subsequent to tightening or scarring following inflammation or local infection. During vigorous intercourse or masturbation, small tears may occur in the frenum of the foreskin and can be very painful.

A rare form of male dyspareunia - postejaculatory pain syndrome - is characterized by persistent and recurring pain in the genital organs during ejaculation or immediately thereafter. The painful sensations are experienced as sharp, stabbing, and/or burning. Although the duration of pain is usually brief, it can persist and be quite intense. Although the immediate cause of psychogenic postejaculatory pain syndrome is the involuntary painful spasm or cramping of certain pain-sensitive muscles in the male genital and reproductive organs, the excruciatingly painful muscle cramps may be attributable to a man’s conflict about ejaculating.

A pelvic floor disorder can also be the cause of pain during and after sex. Spasming, inflammed, overtoned or shortened pelvic muscles can result in the compression or sometimes the entrapment of the pudendal nerve. Guilt about sexual pleasure or about the paraphiliac nature of the erotic fantasies can lead to pain with orgasm. In other cases, men with liberal sexual attitudes might feel general resentment, or be angry at their current sexual partners for unconscious or conscious reasons.

Complaints of sexual pain - that is, dyspareunia orvulvodynia- typically fall into one of three categories - vulvar pain (pain at the opening or at the external genitalia), vaginal pain, or deep pain - or some combination of all three. There is some evidence for the existence of several subtypes of dyspareunia: vulvar vestibulitis (the most common type of premenopausal dyspareunia), vulvar orvaginal atrophy(which typically occurs postmenopausally), and deep dyspareunia or pelvic pain (associated with such gynecological conditions asendometriosis,and pelvic adhesions, inflammatory disease, or congestion).

Vulvar vestibulitis syndrome (VVS) is the most common subtype of vulvodynia affecting premenopausal women. It tends to be associated with a highly localized “burning” or “cutting” type of pain. The feelings of irritation and burning can persist for hours or days following sexual activity, engendering a sense of hopelessness anddepression.

The prevalence of VVS is quite high: the syndrome has been cited as affecting about 10%-15% of women seeking gynecological care. It is characterized by severe pain with attempted penetration of the vaginal introitus and complaints of tenderness with pressure within the vulvar vestibule. Usually there are no reports of pain with pressure to other surrounding areas of the vulva.

Diagnosis is readily made by the cotton-swab test, in which pressure is applied in a circular fashion around the vulvar vestibule to assess complaints of pain. Laboratory tests are used to exclude bacterial or viral infection, and a careful examination of the vulvo/vaginal area is conducted to assess whether anyatrophyis present.

VVS involves multiple tiny erythematous sores in the vulvar vestibule. A number of etiological factors may be involved, including subclinicalhuman papillomavirusinfection, chronic recurrentcandidiasis, or chronic recurrent bacterialvaginosis. Muscular causes have been implicated as well, since chronic vulvar pain may be the result of chronic hypertonic perivaginal muscles, leading to vaginal tightening and subsequent pain. Some investigators have postulated the existence of neurological causes such as vestibular neuralhyperplasia.

Finally, psychological factors may contribute to or exacerbate the problem, since the anticipation of pain often results in a conditioned spasmodic reflex along with sexual desire and arousal problems. Relationship problems are generally the result of chronic frustration, disappointment, and depression associated with the condition.

Vaginal atrophyas a source of dyspareunia is most frequently seen in postmenopausal women and is generally associated with estrogen deficiency. 
Estrogendeficiency is associated with lubrication inadequacy, which can lead to painful friction during intercourse.

In women with VVS and vulvar/vaginal atrophy, the pain is associated with penetration or with discomfort in the anterior portion of the vagina. There are some women, however, who report deeper vaginal or pelvic pain. Little is known about these types of pain syndromes, except that they are thought to be associated with gynecological conditions such as endometriosis, pelvic adhesions, or inflammatory disease.

Failure to achieve orgasm during sexualintercourse. Anorgasmia has many causes, including stress,anxiety,depression, fatigue, worry, guilt, fear of painful intercourse, fear ofpregnancy, the undesirability of a partner, the undesirability of a setting, and the use of alcohol or prescription or illicit drugs.

Anorgasmia is an inability to reach orgasm. A man with anorgasmia may experience delayed orgasm or may not achieve orgasm at all, even after sexual stimulation and excitement. He is usually able to have a suitable erection and penetrate his partner, but no orgasm results. This situation often causes great personal distress.

Despite what you see in the media, orgasm is no simple, sure thing. This pleasurable peak is actually a complex reaction to many physical, emotional and psychological factors. If you're experiencing trouble in any of these areas, it can affect your ability to orgasm.

Physical causes

A wide range of illnesses, physical changes and medications can interfere with orgasm:

Medical diseases.Any illness can affect this part of the human sexual response cycle, including and neurological diseases, such as multiple sclerosis.

Gynecologic issues.Orgasm may be affected by gynecologic surgeries, such as hysterectomy or cancer surgeries. In addition, lack of orgasm often goes hand in hand with other sexual concerns, such as uncomfortable or painful intercourse.

Medications.Many prescription and over-the-counter medications can interfere with orgasm, including blood pressure medications, antihistamines and antidepressants  particularly selective serotonin reuptake inhibitors (SSRIs).

Alcohol and smoking.Too much alcohol can cramp your ability to climax; the same is true of smoking, which can limit blood flow.

The aging process.As you age, normal changes in your anatomy, hormones, neurological system and circulatory system can affect your sexuality. A tapering of estrogen levels during the transition to menopause can decrease blood flow to the vagina and clitoris, which can delay or stop orgasm entirely.

• Medications
• Hypertension
• Excessive drug and alcohol use
• Chronic pain
• Spinal cord injury
• Multiple sclerosis
• Hormonal problems

Psychological causes

• Many psychological factors play a role in your ability to orgasm, including:
• Mental health problems, such as anxiety or depression
• Poor body image
• Stress and financial pressures
• Cultural and religious beliefs
• Fear of pregnancy or sexually transmitted infections
• Embarrassment
• Guilt about enjoying sexual experiences
• Past sexual or emotional abuse
• Performance anxiety
• Stress
• Problems in relationship
• Past sexual trauma or abuse
• Negative attitudes about sex
• Guilt about sex

Relationship issues

Many couples who have problems outside of the bedroom also experience problems in the bedroom. Overarching issues may include:

• Lack of connection with your partner
• Unresolved conflicts or fights
• Poor communication of sexual needs and preferences
• Infidelity or breach of trust
• Intimate partner violence

An orgasm is a feeling of intense physical pleasure and release of tension, accompanied by involuntary, rhythmic contractions of your pelvic floor muscles. But it doesn't always look - or sound - like it does in the movies. The way an orgasm feels varies from woman to woman, and in an individual woman, it may even differ from orgasm to orgasm.

By definition, the major symptoms of anorgasmia are inability to experience orgasm or long delays in reaching orgasm. But there are different types of anorgasmia:

Lifelong anorgasmia.This means you've never experienced an orgasm.

Acquired anorgasmia.This means you used to have orgasms, but now    experience difficulty reaching climax.

Situational anorgasmia.This means you are able to orgasm only during certain circumstances, such as during oral sex or with a certain partner. Most women can't reach orgasm through vaginal penetration alone.

Generalized anorgasmia.This means you aren't able to orgasm in any situation or with any partner.

Usually, healthcare providers start by treating the cause of the problem. For example, some medications have sexual side effects. If a medication appears to cause orgasm problems, a change in medication might help. Or, if is the suspected cause, a man might need to take different steps to control his blood sugar.

Some men benefit from lifestyle changes, like cutting down on drug and alcohol use or learning stress management techniques. In some cases, counseling and sex therapy – either alone or with a partner – is warranted. Couples counseling may help partners work through their issues. Therapy can also help a man address any past sexual trauma or work through any negative feelings he has about sex.

Paraphilia

Type of mental disorder characterized by a preference for obsession with unusual sexual practices, as pedophilia, sadomasochism, or exhibitionism. Abnormal sexual desires, typically involving extreme or dangerous activities.

A paraphilia is a condition in which a person's sexual arousal and gratification depend on fantasizing about and engaging in sexual behavior that is atypical and extreme. A paraphilia can revolve around a particular object (children, animals, underwear) or around a particular act (inflicting pain, exposing oneself). Most paraphilias are far more common in men than in women. The focus of a paraphilia is usually very specific and unchanging.

A paraphilia is distinguished by a preoccupation with the object or behavior to the point of being dependent on that object or behavior for sexual gratification.

Paraphilias include sexual behaviors that society may view as distasteful, unusual or abnormal. In descending order, the most common are pedophilia (sexual activity with a child usually 13 years old or younger), exhibitionism (exposure of genitals to strangers), voyeurism (observing private activities of unaware victims) and frotteurism (touching, rubbing against a nonconsenting person), while fetishism (use of inanimate objects), sexual masochism (being humiliated or forced to suffer), sexual sadism (inflicting humiliation or suffering) and transvestic fetishism (cross-dressing) are far less common.

Some of these behaviors are illegal and those who are under treatment for paraphilias have often encountered legal situations surrounding their behaviors. There is also a category called Paraphilia Not Otherwise Specified to cover paraphilias not falling into the already named diagnoses such as those involving dead people, urine, feces, enemas and obscene phone calls.

Symptoms

Although many paraphilias seem foreign or extreme, they are easier to understand if one thinks of those behaviors that, in less extreme versions, are quite common. For instance, having a partner "talk dirty" may be a "turn-on" for some people, but when talking dirty is the only way that sexual arousal or satisfaction can occur, it would be considered a paraphilia. Others want to be bitten, or spanked, or become aroused by watching their partner. Viewing a nude person or watching sexually explicit videos can be arousing for most people. Paraphilias are magnified to the point of psychological dependence.

               Causes
It is unclear what causes a paraphilia to develop. Psychoanalysts theorize that an individual with a paraphilia is repeating or reverting to a sexual habit that arose early in life. Behaviorists suggest that paraphilias begin through a process of conditioning. Nonsexual objects can become sexually arousing if they are repeatedly associated with pleasurable sexual activity. Or, particular sexual acts such as peeping, exhibiting, bestiality that provide especially intense erotic pleasure can lead the person to prefer that behavior. In some cases there seems to be a predisposing factor such as difficulty forming person-to-person relationships.

Behavioral learning models suggest that a child who is the victim or observer of inappropriate sexual behaviors learns to imitate and is later reinforced for the behavior. Compensation models suggest that these individuals are deprived of normal social sexual contacts and thus seek gratification through less socially acceptable means. Physiological models focus on the relationship between hormones, behavior and the central nervous system with a particular interest in the role of aggression and male sexual hormones.

Treatments
Treatment approaches have included traditional psychoanalysis, hypnosis, and behavior therapy techniques. More recently, a class of drugs called antiandrogens that drastically lower testosterone levels temporarily have been used in conjunction with these forms of treatment. The drug lowers the sex drive in males and reduces the frequency of mental imagery of sexually arousing scenes. This allows concentration on counseling without as strong a distraction from the paraphiliac urges. Increasingly, the evidence suggests that combining drug therapy with cognitive behavior therapy can be effective.

Regarding medication for paraphilias, level of sex drive is not consistently related to the behavior of paraphiliacs and also high levels of circulating testosterone do not predispose a male to paraphilias. That said, hormones such as medroxyprogesterone acetate (Depo-Provera) and cyproterone acetate decrease the level of circulating testosterone thus reducing sex drive and aggression. These hormones result in reduction of frequency of erections, sexual fantasies and initiations of sexual behaviors including masturbation and intercourse. Hormones are typically used in tandem with behavioral and cognitive treatments. Antidepressants such as fluoxetine (Prozac) have also successfully decreased the sex drive but have not effectively targeted sexual fantasies.

Research suggests that cognitive-behavioral models are effective in treating paraphiliacs. Aversive conditioning, for example, involves using negative stimuli to reduce or eliminate a behavior. Covert sensitization entails the patient relaxing, visualizing scenes of deviant behavior followed by a negative event such as getting his penis stuck in the zipper of his pants. Assisted aversive conditioning is similar to covert sensitization except the negative event is made real most likely in the form of a foul odor pumped in the air by the therapist.

The goal is for the patient to associate the deviant behavior with the foul odor and take measures to avoid the odor by avoiding said behavior. Aversive behavioral reversal is commonly known as "shame therapy" as the goal is to shame the offender into stopping the deviant behavior.

For example, the offender might be made to watch videotapes of their crime with the goal that the experience will be distasteful and offensive to the offender. Vicarious sensitization entails showing videotapes of deviant behaviors and their consequences such as victims describing desired revenge or perhaps even watching surgical castrations.

There are also positive conditioning approaches that might center on social skills training and alternate behaviors the patient might take that are more appropriate. Reconditioning techniques center on providing immediate feedback to the patient so that the behavior will be changed right away. For example, a person might be connected to a plethysmographic biofeedback machine that is hooked to a light. The person is taught to keep the light within a specific range of color while the person is exposed to sexually stimulating material. Or masturbation training might focus on separating pleasure in masturbation and climax with the deviant behavior.

Cognitive therapies described include restructuring cognitive distortions and empathy training. Restructuring cognitive distortions involves correcting erroneous beliefs by the patient, which may lead to errors in behavior such as seeing a victim and constructing erroneous logic that the victim deserves to be party to the deviant act. Empathy training involves helping the offender take on the perspective of the victim and in identification with the victim, understand the harm that has been done.