By Liz Rummer Akincilar
Chronic pain can put a damper on anyone’s sex life no matter the location of the pain, but pelvic pain impacts a patient’s sex life on another level. The reason for this is that the pelvic floor plays a major role in sexual functioning. For instance, if you have vulvar burning or post-ejaculatory pain, you’ll understandably develop hesitation around sex. For some patients, their symptoms might even make sex all but impossible.
This is why as pelvic floor PTs, we make our patients’ sexual health one focus in their treatment plan. For many patients, regaining healthy sexual function is a major goal of their treatment.
In this post, the first in a series on sexual health, we’re going to take a look at the physical issues that arise with pelvic pain/sexual functioning.
Symptom or Sole Complaint
For many with pelvic pain, painful sex is either one of their symptoms or their sole complaint.
Some common ways in which sexual pain manifests itself within the umbrella of chronic pelvic pain include: pain with vaginal penetration, pain with intercourse, pain with orgasm, inability to orgasm, decreased lubrication in women, erectile dysfunction in men, pain with or following ejaculation in men, clitoral pain in women, and genital or perineum pain in both men and women, among other symptoms. (There is also a list of diagnoses that are associated with sexual pain, but for the sake of brevity, we’ve included them at the end of the post.)
Jessica is an example of a patient whose sole symptom was pain with sex. Jessica, a 30-year-old patient of Liz’s had been dating the same guy for seven years. The couple had never had intercourse because it was too painful for Jessica. On top of that, her muscles were so tight that her boyfriend’s penis physically could not penetrate her vagina. Jessica was even unable to tolerate a gynecological exam using a speculum.
The condition Jessica suffered from is referred to as “vaginismus,” and is caused by the involuntary spasm of the pelvic floor muscles surrounding the vagina. When Liz examined Jessica, she found that she had extremely tight pelvic floor muscles.
My approach to treating Jessica involved two main strategies. One, I did internal work to loosen Jessica’s tight muscles, and two, she had Jessica purchase a set of dilators that she herself could apply vaginally to get used to inserting something into her vagina to desensitize the tissue. The dilators come in four progressive sizes, and Jessica began with the smallest size using it for up to 30 minutes at a time to not only stretch the muscles, but also to desensitize the tissue.
When she eventually grew comfortable with a dilator, she would move up to the next size. As a result of the manual treatment she receivesweekly along with her own work with the dilators, Jessica is now using the largest dilator before sex to stretch her muscles thus allowing her to have pain-free intercourse. The hope is that she will reach a place where she no longer has to use a dilator before having sex.
In Justin’s case, his pain with sex was a symptom of a larger pelvic floor issue. At 32 Justin had been an avid cyclist for nearly 15 years. When he decided to compete in a triathlon, he upped his riding by 20 miles a week. Unfortunately for Justin, more time spent on his bike resulted in pelvic pain.
Specifically, he began having right-sided buttock pain and perineum pain. In addition, he developed erectile dysfunction that did not respond to medication. Justin ultimately made his way to PHRC for therapy with Stephanie.
What Stephanie found were trigger points in his perineum, which were causing his perineum pain, connective tissue restrictions in his buttocks causing his buttock pain, and lastly, a tight obturator internus muscle. Most likely it was a combo of all of these findings that contributed to his erectile dysfunction.
After about six months of PT, Justin’s symptoms cleared up. However, because he continues to ride, he sees Stephanie about every two months for maintenance.
I’d like to note here that when it comes to erectile dysfunction or “ED”, more often than not it is not a musculoskeletal issue, but a vascular one. That said, when a young male is experiencing ED, and the typical drugs used for treatment fail, then a PT evaluation is warranted.
PT and Sexual Health
So now that I’ve established that a patient’s sexual functioning is tied into his or her treatment, now let’s talk about the process of communication involved with getting information from the patient about what’s going on in that department. First, it’s important to get a full history from the patient. Because some people have a hard time talking about their sexual functioning, we ask very detailed questions. Below are some of those questions:
- Where is it painful during sex?
- When is it painful? (For instance, at the beginning during penetration or afterward or only during certain positions or only with intercourse or masturbation?)
- If it’s a woman, is the pain superficial or deep?
- Has your ability to orgasm changed?
- If it’s a woman, do you feel like you’re producing adequate lubrication?
- If it’s a man, is there pain during or after ejaculation?
- And has the quality of your erection changed? Is it weaker now versus before your pelvic floor symptoms started?
There’s a myriad of ways the responses to these questions can guide us as PTs.
For example, if a male patient complains of pain with sitting or perineum pain, and he also has sexual dysfunction, I’ll ask him if it started concurrently with the pain. If his answer is “yes,” then that tells me that his sexual dysfunction is likely musculoskeletal in nature, so I’ll hone in on the muscles that are responsible in men for erection and ejaculation during my evaluation, which are the more superficial muscles.
For a female patient, if I uncover that she has pain with penetration, then again, that’s going to direct me towards her more superficial muscles. Conversely, if she only complains of pain deeper with thrusting during sex, then I’ll focus on the deeper pelvic floor musculature, i.e. the levator ani muscle group or the obturator internus muscle.
Two other issues that are important to consider are hormones, especially for female patients, and what medications the patient is taking. Many different medications can affect sexual function. For instance, certain blood pressure medications cause erectile dysfunction.
As for hormones, for women, low estrogen can make sex painful or can interfere with the production of lubrication. One way to tell if a woman is de-estrogenized is to take a look at her vulvar tissue. If the tissue appears to have tears, or looks thin, red, papery or fragile she may be de-estrogenized. If the tissue does look de-estrogenized, then I will refer the patient back to her gynecologist to figure out if topical estrogen is warranted.
Here I’d like to point out that not every one of our patients will have regaining normal sexual function as a goal. Everyone is different, and sex is not a priority for everyone. That said, if regaining normal sexual function is a goal for the patient, it’s a goal for me as a PT, and during his or her regular appointment I will ask relevant questions about progress when it comes to sex.
Will Sex make my Pain Worse?
This is a question we often get from our patients, whether sex is painful for them or not, and the answer is not always a simple “yes” or “no”.
For instance, we had one male patient whose symptom of penile pain, which was caused by trigger points in the ischiocavernosus and bulbospongiosus muscles, did intensify after sex and/or masturbation. That’s because sex and masturbation can worsen trigger points in these muscles or interfere with the process of releasing them. So understandably, he was concerned that sexual activity was making his pain worse, and he wanted to know if he should discontinue having sex altogether.
My answer: As a general rule, I never tell my patients to discontinue sexual activity. Because the fact is the benefits can outweigh any negatives.
For instance, the intimacy that is gained with sex with a partner; the release of stress that masturbation can achieve; and the overall endorphin rush that sex produces all have benefits that can help someone dealing with a chronic pain issue. So, it really is a personal decision for a patient to make: whether the benefit he or she gets from sexual activity is worth potentially slowing healing.
All that said, there are two particular situations where a patient should be cautious. One, if a woman is experiencing tearing every time she has penetration then it is important to treat whatever underlying problem is causing this prior to resuming intercourse.
Also, patients should be aware that having sex “through the pain” may cause them to identify sex with pain, and that could set them up for avoidance issues that may not resolve even after their pain does. (More on this in part two of this series.)
An Emotional Toll
While physical pain is at the heart of many patients’ struggles with sexual functioning, emotional pain might also be a culprit.
Indeed, dealing with a chronic pain issue can have a slew of different negative effects on a person’s sex life. For example, many people with pelvic pain become so used to viewing the pelvic floor as the source of their pain that they struggle to connect that part of their body with sexuality and pleasure. Others simply lose their feelings of desirability in the midst of the many challenges that come along with dealing with a chronic pain issue. And, as already touched on, for others, there exists a fear of “making their pelvic pain worse” if they have sex, even when pain with sex is not a problem for them.
To tackle the many emotional aspects of pelvic pain on a person’s sexual well being please stay tuned for a post from Dr. Rose Hartzell, one of our favorite sex therapists.
Diagnoses Associated with Pelvic Pain/Sexual Dysfunction
Vaginismus, vulvodynia, dyspareunia, vestibulodynia, dysorgasmia, aorgasmia, male pelvic pain, erectile dysfunction, persistent genital arousal disorder, and pudendal neuralgia. In addition, endometriosis, pelvic organ prolapse, and anal fissures can also be associated with sexual dysfunction.
Additional Resources on Pelvic Pain/Sexual Pain
If you have any questions about pelvic pain/sexual function, please leave them in the comment section below!
All my best,