What causes painful sex?

There are many potential reasons why sex may be painful for some women.  One common cause is provoked vestibulodynia (PVD), a syndrome in which there is increased sensitivity to touch at the vaginal entry.  In addition to causing pain with sex, PVD can interfere with tampon insertion and gynecological examinations. Painful intercourse may also occur as a result of dryness and thinning of the vaginal walls, as commonly occurs with menopause, extended use of low dose contraceptive pills, and certain medications. Another cause of painful sex may be scar tissue related to childbirth or surgery.  Lastly, tightness of the pelvic muscles around the vagina may lead to pain with sex.

Why are these conditions painful?

Inflexible tissues (such as tight muscles, thinned skin and connective tissue, and scars) do not have the capacity to stretch well.  In this situation, many forms of sexual activity may be uncomfortable because the genital tissues are not able to expand and accommodate a partner’s penis, finger, or other object that is being used for sexual stimulation. There are also many nerves that run through the pelvic area; inflammation of these nerves can be another potential source of pain. For example, the pudendal nerve, which runs through the lower pelvis, may become irritated or inflamed from prolonged sitting or bicycling. 

What role does the pelvic musculature play in sexual pain?

The pelvic floor is comprised of muscle and connective tissue. It attaches from the bone of the pubis in front to the bone of the coccyx in back, so that it is situated as a bowl-like structure right underneath the pelvic organs and surrounding the genitalia. Pelvic floor muscles may be weakened by pregnancy, childbirth, chronic coughing or constipation, or even an occupation that has involved prolonged standing, heavy lifting, or straining. Weak pelvic floor muscles contribute to conditions such as pelvic organ prolapse, urinary and fecal incontinence, and sexual dysfunction.  While weak pelvic muscles can lead to certain sexual problems, overly active muscles may also be related to sexual problems such as painful penetration. Tight and contracted pelvic floor muscles also appear to play a role in vaginismus.

What is vaginismus?

Vaginismus is the condition in which a woman is unable to allow vaginal penetration despite her desire to do so.  This situation is often related to contraction of the muscles around the vagina, which may be secondary to anxiety.  The source of this anxiety may be fear of pain, and hence this condition often occurs together with other painful conditions such as PVD.  While anxiety is a common characteristic of vaginismus, some women may also have conditions of the pelvic floor that make the vagina prone to excessive tightness; this may make penetrative sex impossible.

How does sexual pain from tight pelvic muscles develop?

A woman who experiences repeated episodes of painful intercourse may develop a habit (perhaps even unwittingly) of contracting her pelvic floor muscles in anticipation of pain. Her ability to concentrate on the pleasurable sensations of sex may be affected, and often her sex drive will decline. This will perpetuate her pain, as decreased sexual excitement may lead to less vaginal lubrication and tight, contracted muscles, all of which may increase unpleasant friction in the vagina during sex.  Emotional anxiety, which often results from painful sex and the resultant effects of this on the sexual relationship,  will likely increase a woman’s perception of pain as well. Obviously, sexual pain creates a vicious cycle which needs to be addressed from multiple perspectives in order to be resolved.

How can combined  physical and sex  therapy help sexual pain?

On   a   purely   mechanical   level,   engaging   in   comfortable and   enjoyable sexual activity requires the ability to feel, touch, and    move. Physical therapists are trained to provide treatment to restore function, facilitate movement   and relieve   pain, and this applies to the treatment of  pelvic floor disorders as well. With the help of specially trained physical therapists, pelvic floor physical therapy may be very useful in the treatment of physical problems with bowel, bladder, and sexual function.  

Physical therapists are integral members of the team of specialists treating sexual pain disorders and provide particular expertise in addressing the physical components of treatment. They are trained to examine and evaluate the connective tissue integrity of the perineal area, the thickness of the patient’s hymen, and muscular tone in that area. Particular techniques that may be utilized for treatment include behavioral therapy, home exercises, general and pelvic floor exercise and relaxation techniques, manual therapy, pelvic floor biofeedback, and low current electrical stimulation of the pelvic region (see side bar for more details).

The involvement of a physical therapist is of particular importance in instruction on the home use of vaginal dilators, which help  women adjust to vaginal penetration.  Many women find vaginal dilators intimidating and  difficult to use without proper guidance; pelvic floor physical therapists provide important direct instruction and encouragement on the best ways to use this important therapeutic tool. 

What can I expect to occur during my first visit with a pelvic floor physical therapist?

The physical therapist will most likely take a history and do an evaluation. This involves checking your posture, mobility, and strength. The therapist might also observe how you breathe, touch to find areas of muscular tightness or tenderness, and evaluate abdominal organs using light touch on the belly. S/he may also check the alignment of your spine and pelvis.

A pelvic floor physical therapist will also assess the vulva and vagina. The exam will include assessment of the mobility and integrity of the skin, muscosa, and soft tissues in that area, including the hymenal tissue. Assessment of the individual muscles around and in the vagina for balance, symmetry, strength, endurance, muscle tension, and tenderness is also part of this examination.

What treatments do pelvic physical therapists offer?

Treatment tools utilized by the physical therapist may include education on anatomy and physiology; behavioral therapy and home exercise regimens; strength training, for weak muscles and relaxation training for overactive muscles; biofeedback; and palliative treatment methods to decrease pain and improve tissue mobility.

Behavioral Therapy and Home Exercises

The patient is instructed in self-care including avoidance of irritants such as synthetic garments/detergents and feminine hygiene products. Patients with PVD often demonstrate behaviors of avoidance of direct touch or contact to the genital area, which tends to make the genitals even more sensitive over time. Introduction of daily light self-touch with applications of vitamin E oil may provide the therapeutic benefit of increasing body awareness and decreasing local tissue hypersensitivity.

In conditions of superficial dyspareunia, tightness at the vaginal opening, or vaginismus, the patient may be instructed in home use of vaginal dilators and in therapeutic exercise including deep breathing, relaxation, pelvic floor awareness and relaxation exercises, and independent manual stretching of the hymenal tissues.

General and Pelvic Floor Exercise

Therapeutic exercises are designed to strengthen weak muscles, stretch tight muscles, improve mobility and flexibility, increase endurance and decrease pain. For women with sexual pain, specific exercises are taught to improve circulation, increase healing of the vulva and pelvis, and increase mobility of the vagina. Patients are instructed in proper performance of pelvic floor muscle exercise. For pelvic floor muscle exercises to be effective, it is important not just to contract muscles, but also to coordinate the contraction with proper breathing, timing and simultaneous recruitment of other core postural muscles.

Manual Therapy

Various hands-on techniques are applied to treat musculoskeletal abnormalities, postural and skeletal asymmetries and soft tissue immobility. Techniques include massage, connective tissue and scar tissue release and osteopathic techniques such as visceral and urogenital manipulation. Other interventions include muscle energy techniques, strain-counter strain, contract/relax, and passive and resisted stretching. These mobilization and soft tissue techniques are designed to normalize postural imbalances, improve blood circulation in the pelvic and vulvar area, and improve pelvic and vulvar mobility.

Dilators

Dilators are used not only to help overcome penetration anxiety but to stretch the vaginal opening. Patients are given very specific guidance in using the dilators, including proper positions that facilitate greater opening of the vaginal entrance. Dilators are generally provided in a gradual manner, beginning with a narrow one and progressing to thicker ones