Let's Talk About Sex, Baby!

Okay guys and gals, it's time that we talk. It's Valentine's Day on Sunday, and I thought it was a good time to discuss everyone's favorite topic, sex. Sex is great! It's a way to show love to your partner, a way to express yourself, and a way to make yourself and partner feel good. But what about those who can't stand sex? Not because they necessarily don't want to have sex, but because it is actually painful. Unfortunately, for those suffering in the bedroom, sex is often a hush-hush topic. We sometimes talk about it with our friends, if you are lucky maybe with your significant other. But it's really hard to admit that you aren't enjoying sex when you hear your friends bragging about how they just had the best orgasm ever. You start to think, what's wrong with me? Not to mention the pressure you feel to make your partner happy, so you have sex anyway, even though you can't stop thinking about when this pain will just be over, just finish already!

For those ladies suffering, you aren't alone.

It has been found that over one-third of females have pain during intercourse, which is probably under reported. It doesn't matter the age, whether you are 18-years-old in your first sexual relationship, 30 years old in a happy, healthy marriage, or post-menopausal, all women can be affected. The North American Menopause Society (NAMES) found between 17-45% of post-menopausal women say that they find sex to be painful. According to the same survey, only 25% of women seek treatment. This may be in part due to the fact that women aren't being asked by their healthcare providers if they are having trouble in the sack. According to the International Menopause Society, 70% of women reported that  their healthcare provider did not ask about sexual health.

Sex. Should. Not. Be. Painful.

Ladies, have you ever checked out your vagina? Chances are you haven't. Or even if you have, you have no idea what's what. Here is a QUICK anatomy lesson of the female pelvic floor:

Yeah, there is a lot going on down there. (and yes men, you also have a pelvic floor too)... Basically, the pelvic floor is like a muscular sling, a trampoline of muscles that run from the tailbone, to the pubic bone, and between the sits bones. It has "passageways" through it, three in women (vagina, urethra and anus) and two in men (anus and urethra).

It is made up three layers of muscles that help with:
1) sphincter control (so we don't poo/pee ourselves, and hold in gas)
2) support for the pelvic organs such as the bladder, urethra, and rectum
3) sexual function including ejaculation for men and arousal in women
4) It works with the abdominals and back muscles for stabilization of the spine.

Okay, I told you it was going to be quick. So, I'm going to continue discussing the third function listed above, specifically different pelvic pain disorders that can cause painful intercourse, aka dyspareunia.

Types of pelvic pain:

Vaginismus: I'm sure this is a term that you have never heard of before, however approximately 17% of females worldwide suffer from vaginismus. Generally this is when there is pain during penetration, whether it be during intercourse, with tampon use, or during a pelvic exam. This occurs when the vaginal muscles involuntarily  spasm, making it virtually impossible to penetrate. In other cases, penetration may occur, but is followed by periods of involuntary muscular tightness. It may feel like a burning and/or stinging with tightness on entry. Often times this leads to avoidance of sexual intercourse, because it hurts! The cause is unknown, however it often can follow childbirth, yeast/urinary infections, STDs, hysterectomy, cancer, surgery, rape, and menopause. Symptoms can come on at any point in a women's life, even after years of non-painful, enjoyable sex. If left untreated, symptoms can get worse since the experiences of sexual pain can increase in intensity and duration due to the anticipation that pain will occur. If we fear that we will feel pain, then we will involuntarily muscle guard due to fear/anxiety reality to pain, which perpetuate the cycle.

The good news is, you don't have to live with this and there is hope. Physical therapists can teach relaxation exercises to decrease muscular guarding, desensitization techniques to decrease reflexive pelvic floor activation, help to manually relax and stretch tight pelvic floor muscles, provide dilators to increase vaginal canal size, and treat additional musculoskeletal issues related to the core, pelvis, and back. For more information, check out: https://www.vaginismus.com/

Example of different dilator sizes.

Vestibulodynia: aka Vulvar Vestibulitis Syndrome, but the term 'itis' infers that there is an inflammatory process occuring, however with vestibulodynia, there is no active inflammation. Symptoms for each women can be look very different, however it is overall a hypersensitivity to light touch at the vestibule, or opening of the vagina. Some women explain the intense symptoms as being felt like "acid being poured on my skin" and "constant stabbing, knife-like pain".  The picture below outlines with red circles the areas most commonly affected. In the clinic, we perform what is called the Q-tip test in which we gently place a Q-tip at these areas to assess for hypersensitivity, or what we would call elevated pain levels.

Why hypersensitivity occurs isn't entirely known, but it may be due to an overgrowth of the nerves to this area. There may or may not be redness associated with vestibulodynia, however itching is not usually a symptom. This can also make tampon use, intercourse, or vaginal examination painful due to the hypersensitivity to touch. Lifestyle habits such as prolonged sitting and wearing of fitted pants can also increase the symptoms. Physical therapists can help to educate patients on safe hygiene for the vulva.  For more information, check out: http://www.vulvalpainsociety.org/vps/index.php/vulval-conditions/vestibulodynia


Vulvodynia: another type of vulvar pain similar to vestibulodynia, however symptoms are considered more general, and not specific to the vestibule. Symptoms are often constant, with intermittent periods of symptom relief. Pain may be found at the inner thigh, clitoris, labia, and/or vestibule. The picture below depicts there most commonly affected areas with the red circles.

Interstitial Cystitis: (IC) aka Painful Bladder Syndrome. This diagnosis includes pelvic pain, pressure and/or discomfort with urination or directly after urination, as well as urinary urgency (strong urge to go), and frequency (needing to go often). Ten percent of women with IC also suffer from ulcers, and a hardened bladder. This condition is very difficult to diagnosis, and is often misdiagnosed as urinary tract infections, treated with ongoing antibiotics. Usually it is diagnosed after additional treatments are utilized without success. Currently, there isn't really a gold standard test for IC since the current tests have low sensitivities. Obviously, this can lead to chronic, persistent pain since these individuals are often bounced around from one healthcare provider to another. For more information, check out : http://www.ichelp.org/


Additional causes of pelvic pain can also include endometriosis, pelvic organ prolapse (POP), low estrogen, scarring from surgeries/child birth, radiation treatments, and persistent muscular tension.


PHYSICAL THERAPY is a treatment option! Yes, physical therapists can help you improve your sex life.

This is what your physical therapy evaluation will include:
- History/systems review of symptoms, exercise habits, bowel/bladder habits, etc.
- Brief discussion about the anatomy & function of the pelvis/pelvic floor.
- Internal pelvic floor muscular exam through the vaginal canal to assess muscle symmetry, strength, "tone"/tension, and pain.
- External musculoskeletal exam of the hips/pelvis/core. Your PT should ask, but just in case make sure to tell your PT if you are currently or have a history of low back, hip, or abdominal pain, or if you have issues with constipation.
- You will be given homework at the end of the evaluation. Some homework may include -- mindfulness, posture, relaxation techniques, strengthening, and stretching.


If you are having pain with intercourse, tampon use, and/or gynecological exams, let your doctor know! Although it is common, it is not normal, and there is help out there.



Check out the International Pelvic Pain Society at: http://pelvicpain.org/home.aspx for more information and a healthcare provider near you.