August 4, 2017

Pain with Intercourse (A.K.A. Dyspareunia)

Let’s talk about painful sex, also known as dyspareunia. Pain with intercourse is often not talked about but more common than you would believe.
  • Amanda Moe photo
    Amanda Moe

    Amanda Moe, DPT, is a former employee of Restorations PT. She currently practices in Texas.

Girl laying in bed appearing scared

Let’s talk about painful sex, also known as dyspareunia! Dyspareunia is defined as painful vaginal penetration in the absence of disease. Pain with intercourse is often not talked about but more common than you would believe. It is a common short-term problem after pregnancy occurring in 40-50% of women at 3 months post-partum. There are many causes and contributing factors to dyspareunia, some of which I will briefly discuss in this post. Luckily, a lot of these factors can be addressed by an experienced pelvic health physical therapist---leading to pain-free and enjoyable intercourse!

Let’s first discuss another buzz word for today and cause of dyspareunia—VAGINISMUS! Vaginismus is defined as persistent or recurrent difficulties in allowing vaginal entry of a penis, finger, or any object due to spasm of the muscles. I like to use a metaphor when discussing vaginismus. Think of the vaginal entrance as a doorway. When attempting to enter the “room” (vaginal canal) the “door” is shut (muscles contract or spasm) and thus no entry is allowed! Oftentimes there is fear, anticipation, or an experience of pain which can cause involuntary contraction of pelvic muscles (i.e. “shutting the door”). Luckily, this condition is easily treated by an experienced pelvic physical therapist.

Second buzz word for the day---VULVODYNIA! Vulvodynia as defined (by ISSVD) as vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or specific, clinically identifiable, neurologic disorder. Common symptoms of vulvodynia include complaints of burning, stinging, rawness, irritation, discomfort, or even itching in the vulvar region. These symptoms can be in one area (local) or present in a more general region. Vulvodynia is classified by region as well as if it’s provoked or not. Symptoms can limit a person’s ability to urinate, defecate, move, sit, participate in intercourse, or even affect the choice of clothing one wears! The cause of vulvodynia is unknown with multiple causes being likely. Unfortunately, there isn’t universal intervention that works for every person when treating vulvodynia. Treatment usually requires a multidisciplinary approach---with OB/GYN and physical therapy often working closely together. Physical therapy addresses contributing factors to vulvodynia such as muscular tightness or trigger points, nerve irritation, fascial restrictions, coordination impairments of pelvic floor/girdle musculature, as well as identifies biomechanical contributions and remedies to pain during intercourse (i.e. sex position modifications). Other treatment options provided by the multidisciplinary team include pharmacology, surgery, and topical formulations to name a few.

Other causes of pain with intercourse (often times more so with deep penetration) can include levator ani dysfunction, coccydynia, interstitial cystitis (a.k.a. painful bladder syndrome), endometriosis, and pain due to scar tissue. These conditions are discussed briefly below due to the fact that other symptoms often persist (i.e. bowel or bladder issues). Thus, dyspareunia may not be the chief complaint a patient is seeking treatment for however this, along with the chief complaints, typically can be addressed by physical therapy. Future blog posts may go into more detail regarding these conditions, their presentation, and specifics on physical therapy treatment.

Levator ani dysfunction involves the muscle spasm, tightness, or dysfunction in the levator ani muscles of the pelvic floor which can be addressed by a trained pelvic physical therapist. Coccydynia includes pain in the tailbone or anal region. Physical therapy can address alignment issues, muscular tightness, spasm, or dysfunction associated with this type of pain. Interstitial Cystitis is defined as pelvic pain, pressure, or discomfort perceived to be related to the urinary bladder, however it has a strong correlation to pelvic floor dysfunction (87% according to Peters et al., 2007). This pelvic floor muscle dysfunction can be assessed and treated by an experienced pelvic health physical therapist leading to reduction in comparable pain associated with intercourse. Endometriosis is a painful condition where normal endometrial tissue or lesions are found outside the uterus. With endometriosis, it is common to have issues with the muscles of the abdomen, pelvic girdle, and pelvic floor muscles—again an experienced pelvic physical therapist can assist with addressing these issues. Lastly, pain with intercourse due to scar tissue can occur as a result of episiotomy, perineal tear (such as with child birth), or surgical scar tissue. For these issues it is important to allow proper healing time and consult an experienced pelvic health physical therapist who can provide manual therapy techniques to reduce discomfort often associated with scar tissue/healing.

Remember, pain with intercourse is not normal! If you experience pain before, during, or after intercourse such as with many of the conditions mentioned above, please consult your OB/GYN or medical provider and seek care from an experienced pelvic health physical therapist.

***Disclaimer---it is always best to consult an OB/GYN or MD for medical advice prior to seeking pelvic floor physical therapy to rule out potential serious causes, diagnoses, or conditions not discussed today or treated by physical therapy.