When considering intense pain elicited during coital functioning as opposed to vaginal aching or irritation, the therapist generally should look beyond the confines of the vaginal barrel for existent pathology involving the reproductive viscera.
Acute or chronic infections and endometriosis are pathological conditions involving the reproductive viscera; uterus, tubes, and ovaries that consistently may return a painful response as the female partner is sharing coital experience.
Although these two entities will be discussed separately, they do have in common similar physiological creation of painful response patterns during intercourse.
In both instances the response arises from peritoneal irritation resulting in local adhesions not only between folds of peritoneum but also involving tubes, ovaries, bowels, bladder, and omentum.
The combination of involuntary distention of the vaginal barrel created by female sex-tension increment and active male thrusting during coital connection places tension on relatively inelastic pelvic tissues stabilized by minor or even major degrees of fibrosis resulting from the infection or the endometriosis.
Any clinical condition that creates an untoward degree of rigidity of the soft tissues of the female pelvis, so that they do not move freely during sexual connection can return a painful response to the female partner involved.
Infections in the reproductive organs start with chronic involvement of the cervix (endocervicitis). By drainage through lymphatic channels, long-maintained endocervicitis can involve the basic supports of the uterus (Mackenrodt's ligament) in a chronic inflammatory process. The resultant low-grade peritoneal irritation initiates painful stimuli when the cervix is moved in any direction, particularly by a thrusting penis.
The uterus itself can be involved with infection in the uterine cavity or endornetritis, or with a residual of infection throughout the muscular walls (myometritis) to such an extent that any pressure upon the organ is responded to with pain.
Retrograde involvement of the peritoneal covering of the uterus and its supports is quite sufficient to cause distress if the uterus is moved, either with involuntary elevation into the false pelvis with female sex-tension increment or during a male thrusting phase in coital connection.
Obviously there are many sources of infection of the oviducts (tubes). Any infections that originate in the cervix have opportunity to spread through the uterine cavity and into the tubal lumina.
The major infective agents are:
Gonococcus, streptococcus, staphylococcus, and coliform organisms. First infections in the tubal lumina frequently spill into the abdominal cavity, causing at least localized pelvic inflammation and at most generalized abdominal peritonitis.
Subsequently, as the acute stage of the infection subsides those areas involved in the infectious process remain open to the development of adhesions between loops of bowel, the omentum, and the pelvic viscera.
There even may be abscess formation involving the tubes and ovaries. In all these situations there is tension on and tightening of the peritoneum and rigid fixation of the pelvic soft-tissue structures to such an extent that vaginal distention and coital thrusting create a markedly painful response for the woman.
In no sense does this brief clinical description of pelvic inflammatory processes imply that whenever any woman acquires infection in the pelvic viscera she is committed thereafter to pain during coital connection.
With early and adequate medical care most pelvic infections do not create a residual of continuing pain with coital exposure. The degree of residual pelvic pain depends upon the severity of the occasional sequelae of the infectious process.
Where are the adhesions and how extensive are they? To what extent is natural expansion of the vaginal barrel restricted by filling of the cul-de-sac with an enlarged tube, by an ovary firmly adhered to the posterior wall of the broad ligament, or by a uterus held in severe third degree retroversion by adhesions? Any of these situations may create painful stimuli with penile thrusting.