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Pain with shhhh.... Aka Dyspareunia

Updated: Dec 20, 2023

Pelvic Floor Physical Therapy for Painful Sex

Dyspareunia Painful Sex

Like many issues related to the pelvic floor, pain during or after sex (dyspareunia) is often

untreated. When we ask our patients who have endured painful sex for years why they didn’t seek help sooner, many of them say they were too embarrassed to discuss it with their physicians and others simply considered it “normal” after having children or after menopause.

Pain during or after intercourse is not normal, and you don’t have to live with it! Furthermore, you are not alone and we should be talking about painful sex and ways to treat it without shame and embarrassment.

It is important to see a physician to rule out infection if you experience pain with intercourse. Here are a few contributing factors to why one may have pain with sex:

  • Muscle tension of your pelvic floor (“kegel”) muscles: Just like other muscles in your body, the muscles that make up your pelvic floor (the sling of muscles from your pubic bone to your tailbone) can get tight and sore. This happens if they are worked too hard (too many kegels), held tightly throughout the day (fear of leaking or feeling like your insides are falling down), or if they are overused to support the pelvis and back (compensation for weak or uncoordinated core muscles). A pelvic health physical therapist can help determine what is causing over activation and pain in the muscles, and can reduce the tension by working directly on the muscles (manual therapy) and helping you learn how to keep them from overworking.

  • Scar tissue: Tissue around the pelvis, perineum and vagina is meant to be mobile. Imagine trying to move around in jeans that are way to tight in the pelvic region- it is uncomfortable and limiting! When scars form around the perineum, vagina or pelvis (c-section or other abdominal surgeries), motion can be restricted causing pain with movement. This is particularly true around the perineum and vagina as the vaginal tissue must slide and glide during intercourse. Sometimes even sitting with the legs in a more open position (butterfly or criss-cross applesauce position) is enough to create pelvic pain. Gentle scar tissue mobilization or other manual therapy techniques can improve scar tissue mobility reducing or eliminating pain with movement or intercourse!

  • Nerve irritation: The pudendal nerve innervates the perineum and vaginal region, and it can be injured during labor/delivery, with chronic constipation or via direct pressure (biking, prolonged sitting etc). Burning, itching or general pain in certain areas of the perineum may indicate nerve irritation. While the pudendal nerve is usually blamed for burning, itching perineal pain other nerves can certainly cause similar symptoms. This is particularly true in postpartum women as some labor positions or c-section incisions can cause injury to other nerves creating symptoms of pelvic pain. When these nerves are irritated or injured, intercourse can be excruciating and often not even possible. A pelvic health physical therapist can help determine which nerve is injured and help facilitate healing by protecting the nerve through postural and behavioral modifications and manual therapy techniques if scars are contributing to neural irritation.

  • Hormonal changes: Hormonal changes are often a significant factor for females who have pain with intercourse. Estrogen makes tissue plump, soft and pink. Low estrogen levels can cause vaginal tissue to be dry, thin and fragile. Postpartum and perimenopausal women are likely to experience changes in vaginal tissue which can sometimes lead to pain with intercourse. If this is the case, using a good amount of high quality lubrication and speaking with your doctor about the possibility of topical estrogen cream can be helpful.

  • Emotions: Sex is intimate and emotional. Whether we recognize it or not, engaging in a sexual relationship can elicit emotions that can make the body tense up or react in a way that makes sex uncomfortable. The mind and the body both play a role in painful sex- maybe pain is causing an emotional reaction or visa versa. In my practice, I frequently ask people to explore emotions/feelings around intercourse and this can be facilitated by a sex therapist if needed.

According to research, most women experiencing painful sex have both overactive yet weak pelvic floor muscles. Working with a pelvic floor physical therapist can therefore “help to strengthen the pelvic floor and at the same time reduce pelvic floor resting tone,” which makes it an important part of treatment.

In other words, pelvic floor therapy can help you strengthen and relax your muscles as necessary, which can help relieve pain during sex.

A therapist may also use dilators or their fingers in a systematic way, to help women with vaginismus learn how to get more comfortable with insertion, or to determine trigger points and painful areas.

Note, however, that physical insertion is not required for successful pelvic floor physical therapy. Your therapist may use deep tissue massage, skin rolling, and other types of manual therapy, as well as modalities like heat, ice and electrical stimulation. They will understand your medical history, and, assuming you find a high quality doctor you trust, they will be gentle and not force you into anything you’re uncomfortable with.

Note that pelvic floor physical therapy may help to relieve pelvic pain that is not associated with sex as well.

If you are suffering from painful sex, know that you don’t have to! See your physician to rule out infection or systemic causes of pain, and ask for a referral to a pelvic health specialist.

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