Patients with chronic level 3 dyspareunia (deep dyspareunia), usually exhibit pain during deep thrust vaginal intercourse. The tenderness can be reproduced during a pelvic examination, by moving or pressing against the cervix or uterus. The most common causes of chronic deep pelvic pain are: Endometriosis, pelvic adhesions, and pelvic congestion syndrome.

Endometriosis

Endometriosis is the most common cause of chronic pelvic pain. It is most common in young nulliparous (no pregnancies) women with a family history of the disease.
It is characterized by the growth of endometrium-like implants (endometrium is the tissue lining the uterus) on the pelvic organs &/or bowel. These implants respond to changes in hormones and break down and bleed like the lining of the uterus during the menstrual cycle. This bleeding can cause pain and adhesions (scar tissue). Bleeding into the ovaries may cause the formation of hemorrhagic painful cysts called endometriomas. Etiology is unclear.

The main symptoms of endometriosis are dysmenorrhea (pelvic pain just before or during the menstrual cycle) &/or dyspareunia (pain with deep thrust vaginal sex). If the endometriosis lesions are located on the bladder or recto-sigmoid colon, pain may also occur during urination or bowel movements. Endometriosis can be mild, moderate, or severe. Severe cases may be associated with infertility. Although the amount of pain does not always reflect how severe the condition is, recent studies tend to associate the severity of dyspareunia with the severity of the disease.

The diagnosis of endometriosis can be suspected clinically (history of secondary progressive dysmenorrhea &/or deep dyspareunia), or confirmed by laparoscopy.

Endometriosis may be treated with medication, surgery, or both. Although treatments may relieve pain for sometime, signs and symptoms tend to recur.

Medical therapy is geared towards suppressing the estrogen production by the ovaries. Towards that end a number of medications can be used including: Oral contraceptives, progestins, Danazol, & gonadotropin-releasing hormones (GnRH). The length of therapy (usually 6 months) is tailored to the severity of the disease.

Surgical therapy can be conservative or definitive. Conservative surgery consists of resecting or cauterizing the endometriosis implants and adhesions through laparoscopy or exploratory laparotomy. Symptoms tend to return within one year in about 50% of women who have had surgery. The more severe the disease, the more likely it is to return. In severe, recurrent cases, hysterectomy with bilateral salpingo-oophorectomy (removal of uterus, cervix, tubes & ovaries) may be required.

Pelvic adhesive disease

Adhesions or scar tissue can form as a result of inflammation or healing. Endometriosis, surgery, or a severe infection such as pelvic inflammatory disease, or a ruptured appendix can cause adhesions. Scar tissue causes the surface of organs inside the pelvis to bind to each other. Adhesions can involve the uterus, tubes, ovaries, bladder, or bowels. They can attach any of these structures to each other or to the side walls of the pelvic space. This rigidity or fixation of the pelvic organs can result in chronic deep pelvic pain, and often would cause severe tenderness during vaginal intercourse (deep dyspareunia).

Diagnosis is usually made by laparoscopy.

Resection of the adhesions can often be performed, as an outpatient, through the laparoscope. In cases of severe pelvic adhesive disease, releasing the adhesions through an exploratory laparotomy or even a hysterectomy may be required.

Pelvic congestion syndrome

Pelvic congestion syndrome is a condition of chronic pelvic pain associated with the presence of pelvic varicosities. The pain may be of variable intensity and duration, is usually worse premenstrually and during pregnancy, and is aggravated by standing, fatigue, and coitus. The pain is dull and often described as a pelvic "fullness" or "heaviness." It may extend to the vulva-vaginal area and legs.

The signs and symptoms of the Pelvic congestion syndrome occur after pregnancy and do not persist past menopause, suggesting a strong correlation between hyperestrogenic states and pelvic congestion. This concept is supported by a report of improvement in pain following pharmacologic ovarian suppression.

Diagnosis can be made by laparoscopy which would reveal multiple ovarian and/or pelvic varices or by radiology (CT scan, MRI, or venography) which confirms dilation of the ovarian and pelvic veins and the presence of passive reflux.

Therapy may range from pharmacologic ovarian suppression (e.g. continuous birth control pills), to interventional radiologic treatment by transcatheter embolization, to total hysterectomy with bilateral salpingo-oophrectomy (removal of uterus, cervix, tubes & ovaries).