Fiona McMahon PT, DPT, PRPC
In this blog, we will discuss painful sex in individuals with female anatomy. Pain with sex affects all genders and sexual orientations. Please keep your eyes on the blog for Part 2: Male Anatomy.
Maybe it was the very first time. You were told that you might experience some pain, and you did. You thought it was normal. But the thing is, it never really went away. Maybe sex had always been pleasurable and fun, but one day, out of the blue, or even gradually pain started to creep into the act. The pain confused you. You thought maybe it was an infection. So you were treated with antibiotics but the pain persisted. Maybe you never were able to have penetration. When you would attempt penetration either with a partner, toy, or tampon it was painful and you felt like there was a wall in your vagina blocking entry even if you desired penetration. Maybe you don't have pain with penetration, rather you experience pain with either arousal or orgasm, making it severely unpleasant to enter into any kind of sexual situation.
These are the common themes in the stories of countless patients I have worked with. If any of these scenarios resonate with you, know you are not alone. Between 25 percent to 33 percent of people with female anatomy will experience pelvic pain in their lifetime. Pain with sex can be incredibly distressing on its own, but even more so when it is dismissed by healthcare providers. The thing that links all of the different scenarios above is that these symptoms deserve to be taken seriously and can be effectively treated. I, myself, have had the opportunity to see hundreds of folks who experienced painful sex recover and have pain-free, pleasurable sex.
My goal in writing this blog is to provide you with an explanation of some of the causes of pain with sexual activity from a pelvic floor perspective as well as insights into how pelvic floor physical therapy can help. I will be introducing you to the pelvic floor as well as pelvic floor dysfunction and common pelvic pain diagnoses. I hope to provide a jumping-off point to start your journey towards feeling better. In this blog, we will cover:
Normal pelvic floor function
Dyspareunia
Vulvodynia/ Vestibulodynia
Vaginismus
Treatment for pelvic floor dysfunction and sexual pain
Normal Pelvic Floor Function
The pelvic floor is an essential part of healthy sexual function. It is composed of skeletal (voluntary) muscles that live between the pubic bone and the tailbone. Think of the area that makes contact with a bicycle seat. These muscles are responsible for so much in our day-to-day lives. They help to support and stabilize our pelvis and spine, they provide lift for our pelvic organs, as well as helping to regulate both our bladder and bowel function
Most importantly, for this blog, the pelvic floor plays a pivotal role in sexual function, throughout arousal and ending in orgasm. Many people who are experiencing sexual pain may notice other pelvic floor symptoms like urinary issues (frequency, hesitancy, leakage, and urinary pain), bowel issues, and more in addition to their sexual pain symptoms. They may also experience sexual symptoms alone.
Let’s now dive into exactly how the pelvic floor aids in sexual function. The pelvic floor is a key player throughout sexual activity, from arousal to orgasm. With sexual excitement, blood enters the clitoris and clitoral bulbs, as well as the labia minora. With this blood flow, these structures become erect to facilitate sexual stimulation. This is where the pelvic floor plays a major role. The bulbocavernosus and the ischiocavernosus muscles reside in the outermost layer of the pelvic floor. Their function is to keep blood within these erectile structures. If these muscles are weak, painful, or tight, sexual sensations can be lessened or one might even experience pain with sexual arousal.
The pelvic floor is also a huge component of the sensations associated with orgasm. Strong pelvic floor muscles are responsible for the rhythmic contractions associated with orgasm and contribute to the pleasurable sensation of orgasm. Pelvic floor dysfunction can diminish the sensation of orgasm or cause pain with orgasm.
For those who engage in receptive penetrative intercourse, whether that be vaginal or rectal, the pelvic floor must be able to stretch in a pain-free manner to accommodate a partner or toy. If the pelvic floor is too tight, or involuntarily clenches in anticipation of penetration, sex may be painful, difficult, or altogether impossible. When receptive intercourse is prevented altogether due to pelvic floor muscles blocking penetration, we refer to it as vaginismus. When sex is possible, but painful we refer to it as dyspareunia.
Pelvic floor dysfunction typically comes in one of two presentations. The first is lax and weak. In cases of pain with sexual activity, lax and weak pelvic floors tend to be more rare. Symptoms one might experience with lax and weak pelvic floors may include decreased sexual sensation or a feeling of heaviness after sexual activity or throughout the day. You may also encounter difficulties with continence both urinary and fecal.
The most common pelvic floor presentation with sexual pain, across genders, is tight and weak pelvic floor muscles. In addition to sexual pain, we can also see issues with continence similar to those seen in folks with lax and weak pelvic floor muscles, as well as constipation, urinary frequency, and hesitancy. The pain associated with tight pelvic floor muscles can come in many different forms. The pain can feel like burning, ripping, and tearing with or without penetration, dull, aching, stabbing, itching, pulling, and burning. It is important that if you are suffering from pelvic pain, that you hold off on Kegels until you have been examined by a skilled pelvic floor specialist. Doing Kegels with a tight pelvic floor can often do more harm than good.
Both pain and lack of sexual response can dampen desire. This can become a vicious cycle that can worsen over time. In the book, Come as You Are: The Surprising New Science that Will Transform Your Sex Life, Emily Nagowski speaks about the dual control mechanism of female sexual desire. Using the metaphor of a car, she talks about brakes and accelerators when it comes to libido. Brakes dampen our desire. Brakes can include stress, fatigue, self-image issues, and as you can imagine, pain. Pain can be a huge barrier to wanting to have sex.
Don’t panic. If you are reading this and you have pain, there are many things we can do to treat pelvic pain. Let’s dive into different pelvic pain conditions and how pelvic floor physical therapy can help
Dyspareunia
Dyspareunia is the medical name for genital pain before, after, or during intercourse. It can have many different causes. Having a good understanding of the terminology associated with pelvic pain as well as its causes can empower you to start a dialogue about symptoms with your healthcare provider.
Pelvic floor therapists will usually make the distinction between deep and superficial dyspareunia. As you most likely have guessed, deep dyspareunia is pain with deeper penetration. It is typically caused by restriction and dysfunction in the deepest part of the pelvic floor muscles. It can feel like a dull ache, or be acutely painful. Superficial dyspareunia occurs with restriction and tightness in the most superficial muscles and/or due to changes to the vulvar tissue. Patients often refer to the pain as feeling like a burning, tearing, or ripping sensation at the vaginal opening.
Now that we have defined the most broad terms, let’s get specific.
Vulvodynia/ Vestibulodynia
Vulvodynia is the term for pain that occurs in the vulva. The vulva is the name for the entirety of the external female genitalia, which comprises the mons pubis or area above the labia majora (big lips), the labia majora, labia minora ( little lips), the vestibule (the area between both labia minora), clitoris, and vagina. Vulvodynia is obviously a very broad term, so we like to refine it a bit.
We can get more specific when we describe vestibulodynia. Vestibulodynia is pain that occurs within the vestibule, which is the area between the two labia minora (the little lips of the vulva).
We can further divide vulvodynia into two subtypes: provoked and unprovoked. Provoked means the pain only occurs with touch. Touch can be in a sexual context, but it also can occur with tight clothing, sitting, or using a tampon. Unprovoked vulvodynia is characterized by persistent pain regardless of whether or not something is physically touching the vulva.
We can also see vulvodynia that has consistently been present throughout someone’s life or pain that has developed over time. These distinctions are important for your provider to know about because this information can help to steer treatment as well as inform what other healthcare providers should get involved.
These distinctions get us one step closer to determining the cause and thus, treatment. Vulvodynia can have many different causes. We often see pelvic floor dysfunction as a cause of vulvodynia. Trigger points and tightness in the pelvic floor can refer pain to the vulva. Vulvodynia can also be caused by irritation to the pudendal nerve. This can happen due to pelvic floor dysfunction, hip dysfunction, back dysfunction as well as injury. This is why your pelvic floor physical therapist may want to incorporate traditional orthopedic rehabilitation into your pelvic floor treatment.
Certain vulvar skin conditions and hormonal imbalances can cause vulvodynia as well as pelvic floor dysfunction. If your physical therapist suspects additional causes, they will partner with a qualified healthcare practitioner usually a doctor or physician extender to treat any other underlying causes that are outside a pelvic floor therapist’s scope of practice. In some presentations, the pelvic floor will exhibit dysfunction alongside medical causes for vulvodynia, so it is important that your pelvic floor therapist recognize when there may be an additional driver of vulvodynia beyond pelvic floor dysfunction to ensure you are getting the most from your time in physical therapy. Failing to recognize and address underlying medical causes for vulvodynia can slow or even halt progress in pelvic floor physical therapy.
Vaginismus
Vaginismus is an extremely common form of sexual pain and dysfunction. Vaginismus occurs when the pelvic floor muscles clench involuntarily in response to attempted penetration. This can make receptive intercourse or even the use of menstrual products like tampons or a cup painful to impossible. The spasm that occurs in the pelvic floor muscles, occurs whether or not penetration is desired. This condition can be extremely distressing, what you might not know is that it is also extremely common with an estimated prevalence rate of 5-17% in clinical settings.
The pain associated with attempted penetration can be intense and can perpetuate a pain-spasm-pain cycle which can be very difficult to remove oneself from. One of the key pillars of treating vaginismus in pelvic floor PT is to break this cycle by reducing clenching and pain simultaneously. We will discuss more of the specifics in the pelvic floor treatment section.
We can see vaginismus present in one of two ways. Primary vaginismus, in which penetration has always been painful. Typically folks will first notice that something is wrong when they find they are unable to tolerate using tampons or find it impossible to have a speculum exam. I have seen many patients with primary vaginismus who have had traumatic experiences when they attempted their very first gynecological exam but could not “relax” their pelvic floor to allow for a speculum exam. They were left with shame and guilt surrounding that experience. Please, if you are relating to these experiences, know that it’s not your fault and with vaginismus, it can be difficult to impossible without effective treatment to “just relax” no matter how much you may want to.
Vaginismus can also be classified as secondary vaginismus. Secondary vaginismus occurs after a period of pain-free intercourse or penetration. Secondary vaginismus can develop after a painful penetration experience or traumatic event.
Stress, anxiety, and trauma history are all common contributors to the development of vaginismus, though these factors are not always necessary for the development of vaginismus. Keeping this in mind when treating individuals with vaginismus is foundational to ensuring safe and effective treatment. Treatment without respect for a patient’s individual history can be retraumatizing and can cause more harm than good.
Vaginismus can be treated successfully with physical therapy. Treatment often consists of gently stretching the muscles of the pelvic floor, dilator training, and treating any tender areas in or around the pelvic floor as well as helping the patient to gain more control over pelvic floor clenching. Because pain is so often part of the cycle, it is really important whether you are working with yourself or the clinician to not push into pain. You may experience discomfort in treatment, but you should not experience pain. When treatment elicits extreme pain it often does more harm than good.
Treating Sexual Pain Conditions
Most people who have pain with sex caused by a dysfunctional pelvic floor experience pain because their pelvic floor is spasmed, tight, and restricted. Your pelvic floor physical therapist can confirm the presence of pelvic floor dysfunction with an internal or external pelvic floor examination. Musculoskeletal pain with sex can also occur with hip and back dysfunction as well, so it may be necessary for your physical therapist to examine these areas of the body.
If you present with a tight and painful pelvic floor, there are many techniques you and your therapist can use to restore your pelvic floor mobility and comfort. Pelvic floor therapists are trained to perform internal and external myofascial and trigger point release in and around the pelvic floor. Additionally, many of us are trained in visceral and neural mobilization to help reduce any pain coming from restrictions around the nerves and organs of the pelvis. You may also receive treatment that is reminiscent of the work ortho and sports physical therapists do. This is because injuries and dysfunction in other parts of the body can lead to fascial tightness or overwork of the pelvic floor muscles. We also couple the hands-on work with a technique called neuromuscular re-education (NMRE). NMRE helps to teach us how to move and hold our bodies differently. For folks with pelvic floor dysfunction, NMRE is helpful to reduce clenching or holding patterns as well as teach them how to actively relax their pelvic floor muscles
What if I don’t think I am ready for internal work?
When you have pain in your pelvic floor, the thought of an internal exam or treatment can be rather overwhelming. Especially for folks with vaginismus. The key is to move slowly and start where you are. For most of us, we have succeeded in life with a more-is-more effort. Unfortunately, with the pelvic floor, super aggressive and painful treatments and exams can cause even more guarding and clenching as well as instill a sense of dread around coming to your appointment, which we definitely don’t want!
Many folks may not complete the internal assessment on the first visit if they find it too uncomfortable or intimidating. These folks get better too, we just start in a different spot. For folks who are not yet ready for internal work, we may start by examining the pelvic floor externally, teaching pelvic floor muscle relaxation skills, as well as different treatments to reduce sensitivity and guarding in the area. It usually does not take long for folks to be ready to start internal work.
What keeps my pelvic floor dysfunction from coming back?
At Ember, I work to not only eliminate the symptoms but also the drivers of pelvic floor dysfunction. The hands-on work to reduce muscle spasms is sealed in by working together to improve pelvic floor muscle holding patterns, improve toileting habits, reduce stress, and optimize overall well-being.
My primary goal is to give you all of the tools you need to manage your pelvic floor symptoms independently. A huge part of the work we do is teaching you how to perform your own pelvic floor muscle release with tools like dilators and pelvic wands. These tools help to speed up therapy and can help address any flares after you complete pelvic floor physical therapy.
There are instances where pain does come back. This typically happens after an illness, injury, or severe life stress. In the vast majority of these cases, the second round of treatment is much shorter than the first one. This is because a relaxed pelvic floor is not new to the body, it just needs a little help to remember how to get there.
What are my next steps if I think pelvic floor physical therapy is right for me?
If you are interested in finding out if Ember Physical Therapy is right for you, give me a call. I offer all potential clients a 15-minute phone consult to see if pelvic floor physical therapy is right for them. 551-244-1186. During this call, we will go over your condition, and goals, and develop a plan to get you feeling better. I am looking forward to hearing from you.
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