Painful Sex/Dyspareunia
Condition Overview
Painful sex also known as dyspareunia, occurs when a patient has pain with penetrative sex, oral sex, or external touch to the vulvar or penile tissues.
This is a common diagnosis with up to 18% of the population suffering with these symptoms; however, this number could be skewed because of the lack of communication from patient to provider whether due to embarrassment or not knowing there is a treatment to mitigate these symptoms. Since this is an issue, many of these people do not seek treatment for years leading to fear-avoidance behaviors, relationship/intimacy issues, mental health difficulties, and an overall decreased quality of life.
Fortunately, when diagnosed appropriately, dyspareunia can be treated by a multidisciplinary team.
What causes dyspareunia?
Inflammatory conditions of the pelvic floor:
Endometriosis: a condition in which cells similar to the lining of the uterus grow outside the uterus.
Adenomyosis: occurs when the tissue that normally lines the uterus grows into the muscular wall of the uterus
PCOS (polycystic ovarian syndrome): numerous small cysts form on ovaries
Interstitial cystitis or bladder pain syndrome: causing urinary frequency, urgency, incontinence, and pain with all of the above
Vulvar or vaginal infection
UTI, yeast infection, bacterial vaginosis, lichen sclerosis
Sexual and/or pelvic trauma
Including childbirth/delivery, vaginal trauma, perineal tearing
Hormonal changes due to menopause or postpartum
Pelvic floor muscle overactivity
Vaginismus: Muscle spasms at the vaginal opening. Feels like nothing can enter the vagina – it just “hits a wall”
Vulvodynia/vestibulodynia: Discomfort at the vulva causing burning, rawness, itching with no known cause that has been lasting for 3 months or longer
What are the symptoms of dyspareunia?
There are a variety of symptoms based on what the underlying cause of your pain is. These can include: sharp, burning, tearing, rawness, dull, achy, or deep pressure sensations. These symptoms can occur with insertion, deeper penetration, thrusting, or can be based on the position you are in. You may feel the pain in your abdomen, rectum, vulva, vaginal or penile region. This pain can occur during or after intercourse and often causes fear/avoidance of intercourse. In addition to dyspareunia, there can also be pain with orgasm which is known as climacturia.
How can physical therapy help?
Based on the root underlying cause of dyspareunia, it may be important to have a multi-disciplinary approach to treating your symptoms. One part of that team should be a pelvic floor physical therapist. In pelvic health therapy we will discuss your symptoms and go over each of the systems of the pelvic floor (bladder, bowel, sexual health, and gynecological health) in order to diagnose your symptoms appropriately. With your consent we will perform an external and internal pelvic floor muscle assessment. We will assess your abdominal wall, low back/hips, adductors, and superficial and deeper pelvic floor muscles. We will determine your muscle function, strength, endurance, and coordination. If you cannot tolerate an internal vaginal assessment we always stop at your tolerance and never push you to handle more than you can. We move at a slow pace to ensure we are not generating a larger pain response which can slow progress down.
From our findings we will set-up a treatment plan depending on your pelvic floor characteristics! Manual treatment can include but is not limited to dry needling, myofascial release, cupping, and connective tissue mobilization.We also may include dilator or pelvic wand training in order to teach these muscles how to relax and lengthen. Typically, but not always, dyspareunia is associated with more overactive pelvic floor muscles because these muscles respond to stress, pain, and fear by tightening. Since this is the case, we will avoid kegels for the time being to ensure we are not worsening muscle spasms and therefore symptoms. We will most likely focus on downtraining/pelvic floor stretches and then progress as able with each session.
If you are experiencing pain with tampon insertion, pelvic exams, or sexual activity schedule an appointment!
