One of the most common diagnoses we treat at our clinic is dyspareunia or pain with intercourse. A related diagnosis and one that can co-exist with dyspareunia is vaginismus. While dyspareunia is a symptom (pain), vaginismus represents the inability to have vaginal penetration. This inability is caused by spasming of the pelvic floor musculature, closing off the opening and therefore making penetration of a penis, finger, or object extremely difficult or impossible (this includes pelvic exams). Vaginismus can be a cause of dyspareunia as can hormonal changes that occur during menopause or tissue changes/injury that occur peri-partum. Patients that have experienced trauma may experience dyspareunia as well due to their muscles guarding which can cause additional pain.
Dyspareunia can be experienced by those who identify as male or female, with vaginal or anal penetration. It is also classified as either pain with initial penetration (more superficial), deeper penetration, or both. People can also experience pain at the opening which eases as a penis, finger, or object moves deeper in the canal (vaginal or anal). Dyspareunia can be treated so that penetrative intercourse and or pelvic exams can be pain free.
When dealing with issues like vaginismus, an unfortunate side effect is avoidance and anticipation of fear which perpetuates the problem. Studies have found that those diagnosed with vaginismus have increased muscle activity of the pelvic floor muscles when watching sex scenes, whether threatening or non-threatening. This is a conditioned response of tightening when these individuals are exposed to the idea of penetration. This is a natural response when we experience pain. Our bodies will guard and tense up to avoid any further pain. The problem is that the tightening of the pelvic floor muscles while guarding increases the pain which then reinforces more guarding, thus starting a negative feedback loop.
The psychological component associated with pain and tensing of muscles is by no means to say the experience of pain isn’t real. There is a very strong link between our neural pathways sending the pain signals and the sensations we are actually feeling or sensing. I highly suggest taking a look at the blog on pain science, found here to get a better understanding of this.
The “why” associated with pain is multi-faceted. Experiences of pain in this area of the body can be from sexual trauma, negative feelings around sexual acts that could have been established at a young age (i.e. religious reasons or family dynamics), and/or previous pelvic floor related diagnoses, among others. Receiving a pelvic floor diagnosis of endometriosis, interstitial cystitis (or painful bladder syndrome), pelvic congestion syndrome, levator ani dysfunction, or uterine retroversion can also be the primary driver for experiencing pain with intercourse. These underlying diagnoses may give a little more information as to why your pelvic floor could be so tight thus causing pain with penetrative intercourse.
So how can pelvic floor physical therapy help? The hands on manual techniques we use are not only gentle, but very effective in helping the tissue gently stretch and release. Additionally, we provide relaxation and stretching techniques to improve tissue mobility and extensive education on the importance of lubricant and what type of lubricant you should use so as to not irritate the tissue further. There are also tools like dilators that are very helpful for home use. The dilators help to maintain the release of tension gained in your session, while also helping you become more comfortable with the idea of something entering into a (previously) painful space. The dilators allow you to have control of penetration to allow you to re-train the guarding and eventually put a stop to the negative feedback loop. We can also recommend lidocaine use to desensitize the nerves in this space, as well as communicating and working with your doctor to potentially prescribe suppositories to further assist the musculature in releasing. Every patient is a little different and even if you have the same diagnosis, an individualized approach to this issue is extremely important and effective!
We also encourage a multi-disciplinary approach. Some patients may need additional support from other providers such as sex therapists or EMDR trained therapists to help work through trauma or negative thoughts about sex. In the case of a more complicated diagnosis like endometriosis, it is important that we are working directly with your OBGYN or pelvic pain specialist to make sure we are managing your pain while treating the musculature to ensure that you are making progress.
As always, we are here to help and provide guidance. Whether you’re in the state of Colorado or from afar, contact your local pelvic floor physical therapist and know you don’t have to suffer with this pain!