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Understanding Painful Intercourse

To continue on our previous topic of pelvic pain, I wanted to cover a topic that affects many women  but one that is often ignored or mis-treated.  Painful Intercourse or dyspareunia in women.  A typical presentation in our clinic are women who have experienced pain with vaginal penetration for the past 5-7 years. They have discussed this with multiple practitioners with little guidance, recognition or recommendation for what to do.  These young women sought out answers and ended up finding us either through a web search or in finding a physician who understood how to manage dyspareunia.  Painful sex can be caused by a lot of things; past sexual trauma, past spinal injury, previous pelvic dysfunction, any abdominal or pelvic surgery, childbirth, pregnancy and menopause to name a few.

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Pain can be felt vaginally, abdominally, or may travel into the buttock, thigh or groin. It can be during intercourse or pelvic exam or may not come on until afterward. Some women are completely unable to have any vaginal penetration at all due to the spasm of the pelvic floor musculature.  The muscles of the pelvic floor are a group of muscles that function to:

1.) support pelvic organs
2.) control the openings of the urethra, vagina and anus
3.) provide stability to the pelvis, hips and lumbar spine
4.) play a role in sexual function
5.) assist in venous and lymphatic return through the pelvis 

When these muscles do not function as they are supposed to, there a myriad of symptoms that can present themselves.  Dysfunction can be caused by weak muscles after pregnancy or with age. It can be caused by scar tissue after surgeries or delivery of baby. It can be due to radiation after cancer treatment. It can be caused by muscles that are tight and cannot relax. There are many causes for pelvic muscle dysfunction. For this blog, I want to discuss the most common reason women have pain with sex, muscle tightness.

When something hurts, your muscle system responds with tightening as a means of protecting our bodies. It is the natural response to pain. Our bodies create an inflammatory process to try and heal or flush out the source of the pain. Initially the source of pain may have been tissue healing from surgery or childbirth for example. Sometimes these muscles never learn to relax again. Or they keep that pain memory in their cells and anticipate the pain, and spasm at the mere thought of penetration.  When this happens there are changes to the muscles, nerves and connective tissues in the area. The body’s pain sensation is different and now has a lower threshold for what is perceived as painful.  As that continues, our body mechanics for activities and functional tasks are altered, often causing more irritation and aggravation to joints, tendons and ligaments. More inflammation, more pain and more muscle guarding!

Imagine if you walked around for a day with a 2 pound weight in your hand, and had to keep your elbow bent, holding that weight all day. Your bicep (upper arm) would be SORE!! And it would be hard to straighten your elbow. Now imagine if you did that for years.  Your arm would be tremendously painful, your muscles and tissues extremely tight and tender, your joint stiff and your arm function would be a mess.  That is similar to what happens when women have painful intercourse for years. Plus you add to that the emotional stress of not being able to enjoy one of human beings most natural activities.  When stress is involved, pain is significantly worsened. There is  a strong correlation between depression/anxiety/stress and pain. Stopping the pain/stress cycle is an important step to getting well. Which is why it is important that you include a mental health practitioner in your treatment to ensure you are addressing the whole body.

My experience with dyspareunia has been that once a client finds me, and we are able to discuss the pelvic anatomy, it’s function in sex and what the source of pain is, there is a light at the end of the dark tunnel they had been in.  I can see a weight lifted from their shoulders.  Many women who see me ask how often I have seen someone with this problem, indicating they feel it is rare and embarrassing.  I answer confidently, I have specialized in this for 12 years now, and I opened a practice that exclusively treats pelvic dysfunction, because so many women have this problem.  I can say that this week alone I have seen 11 women with pain during intercourse. The other statement I make to my clients is that we can and absolutely will make this better. It will take time, consistent follow through and patience, but it will improve.

Just how you may ask can we fix such a longstanding pain? There are often many layers to peel away. As physical therapists we examine your body head to toe to put together the imbalances throughout the body that may contribute to or be a result of your pelvic dysfunction.  We take a look at the muscles of the pelvic girdle, along with your abdominal, spinal and hip musculature, joints and connective tissue to determine what the dysfunction is.  We spend time working with those pelvic girdle muscles using manual techniques vaginally so that they learn to relax.  Yes, it has to be vaginally (or rectally, but that is a topic for a whole other blog) and quite frankly, as one doctor put it at the International Pelvic Pain Society conference, ” if your therapist has not put their finger in your vagina, you should find another therapist!” , well said.  I have seen too many clients who saw a “women’s health PT” who only used biofeedback and strengthening for pain over many visits with little to no improvement.  In looking for the right practitioner, ask them how long they have treated these conditions, what training they have had, and expect that they will perform an internal pelvic exam and follow up visits with internal muscle work. If they don’t, don’t waste your time or money.

It is also important that your physical therapist examine your spine, pelvic and hip joints as well as look at your abdominal wall and diaphragm.  Our bodies are an amazing system of intricate relationships between muscle, joint, nerves and connective tissue and it is important to examine all of these in treating pelvic dysfunction. Understanding how these function together, and how you ought to be using your core in daily tasks is an important piece to fixing your dysfunction.  If you have a hip joint with decreased motion and it is not being treated, it will just continue to feed into the tightness in the pelvic musculature. While the tight hip may not be what is painful during sex, it could be the trigger for the muscle tension you are holding.  That is just one example. Another one I see very often is overuse of the large upper abdominal muscles. Tightness in these muscles causes increased abdominal pressure, decreased use of the diaphragm and tension in the pelvic floor. But if it is never examined, you wouldn’t know it was a player in the problem.  Ask questions, put us on the spot, we are trained to educate you!

The stress and emotional pain that painful sex brings can be devastating.  You should not and do not have to live with it.  There are answers. There is help.  Do some reading, do some Google searching. Find a doctor who specializes in pelvic pain, or find a physical therapist who does and they can recommend a physician who can help you. They can also refer you to a mental health practitioner who specializes in sexual pain/dysfunction. This condition is not one that is treated with medication alone, or vaginal creams or lubrication. It is not treated with PT alone, or counseling alone. It is imperative you take a multidisciplinary approach to get better.  It is not in your head, you are not alone and you do not have to continue to live with the pain.

Sarah Dominguez, PT, MSPT, CLT, WCS

This blog is here for your help. It is the opinion of a Licensed Physical Therapist. If you experience the symptoms addressed you should seek the help of a medical professional who can diagnose and develop a treatment plan that is individualized for you.  If you enjoyed this blog, check out our website at foundationalconcepts.net for more blog entries and to learn more about our specialty PT practice, Foundational Concepts.  Follow us on Twitter @SarahpelvicPT or @Jenn_pelvic_PT and like us on Facebook at Foundational Concepts for updates.


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