Sex shouldn’t hurt

One of the most common reasons patients are referred to me is for dyspareunia, which means “pain with intercourse” Dyspareunia is much more common than most people realize.  Research has revealed that any where between 15% to 60% of women have pain with intercourse.  Some, have pain just occasionally, and others have always had pain with sex.  Although there are many things that increase the likelihood of dyspareunia, such as sexual abuse, endometriosis, and menopause, many times we don’t know what the initial cause is.  The most startling thing is, most women do not discuss this issue with their doctors or other healthcare providers.  Some may be embarrassed to mention it, or think that nothing can be done to help.

Luckily, with treatment, pain with intercourse can be reduced or even eliminated 

The impact of dyspareunia can go far beyond the physical discomfort of the woman.  It can have a negative psychological effect on self esteem and sense of value as a wife or partner.  It can have negative effects on relationships, as women may avoid any intimacy for fear that it may lead to sex.  Surprisingly, many women continue to engage in sexual intercourse despite pain.  This can be for many complex reasons, varying from trying to maintain a closeness to their partner, to fear that their partner may cheat or leave the relationship.

Treatment needs to address the physical, emotional and relationship aspects of painful sex

 One common factor that contributes to pain with sex is pelvic floor muscle tightness or muscle spasm.  The walls of the vaginal canal are formed by the pelvic floor muscles.  These are the same muscles that are responsible for controlling bladder and bowel function.  During intercourse, a pelvic exam, or child birth these muscle need to be able to relax and stretch to allow the vaginal canal to open and widen.  The ability of these muscle to be able to relax and contract without pain or muscle spasm is very important for sexual activity and sexual pleasure.

Injury to the pelvic girdle, childbirth, or a negative sexual experience can all contribute to physical strain or injury to the pelvic floor muscles.  The pelvic floor muscles are also highly reactive to emotional stress.  Part of the the body’s natural fight/flight response to a potential threat is to tighten the pelvic floor muscles. Just like a scolded dog will pull its tail between its legs, we tighten our pelvic floor muscles when we are upset or fearful. In our 24-7 society, many people spend most of their day in a low level fight/flight response.  This can have a significant impact on the pelvic floor muscle’s ability to let go and relax with sexual activity.

 How can pelvic physical therapy help?

Pelvic floor physical therapists have many options available to address pelvic floor muscle issues.  Manual therapy can be used to address trigger points, muscle or fascial tightness, muscle spasm and guarding, of the pelvic floor muscles or any surrounding muscles that may refer pain. Biofeedback can be used to see if the muscles are contracting involuntarily, and can be useful when practicing exercises that help to decrease this involuntary activity.  Breathing exercises can be used to help relax and lengthen pelvic floor muscles.  Exercises or manual treatments that address issues in the spine, pelvis and hip can address orthopedic issues that may be contributing to pelvic floor muscle tightness.  A pelvic floor physical therapist can help you identify what self treatment options are right for you such as, use of vaginal dilators, positioning modifications, self massage or  a home exercise program.

What should I expect from my first physical therapy appointment? 

During your first appointment, I want to take a very thorough history.  Just like any other pain condition, it is important to know when it started? what makes it better? or worse? what treatments have you tried? and did they help?.  I also what to know about other medical conditions, injuries, any medical tests or medications.  I always do a thorough orthopedic evaluation, looking at posture, range of motion, and overall mobility.   Issues in the spine, pelvic joints or hips can all affect the pelvic muscles.  In some cases  simply addressing these issues can resolve pain.

Lastly,  a pelvic floor muscle exam is extremely helpful in identifying pelvic floor muscle issues and is often considered essential for the treatment of dyspareunia.  However, with many years experience providing “trauma sensitive care” for patients with pelvic dysfunction, I realize that staying within a patient’s comfort level is way more important than the information gained in doing an internal pelvic muscle exam.   I will do vaginal or rectal pelvic floor muscle evaluation if the patient is both physically and emotionally ready.   There are many treatment approaches that we can offer that don’t require vaginal or rectal treatment of the pelvic floor muscles.  Direct pelvic floor muscle treatment can be very helpful, but can also be avoided or delayed and indirect approaches can be used instead.  Treatment of dyspareunia should always provided with an awareness to both the physical and emotional aspects of pain. 

Pain with sex is common, but does not have to be.  There are treatments that can help!


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