So y’all know that here at Recharged Performance Therapy, we do not shy away from sensitive or *taboo* topics. And what we’re going to address today is particularly important – because it is so common, but never talked about.

Dyspareunia is persistent or recurrent internal or external genital pain occurring before, during or after sex.

Most women will experience pain with intercourse at some point in their lives. This can be anything from *discomfort* with 1-2 positions to debilitating pain. Pain or discomfort may most often occur with initiation, deep thrusts and during Orgasm – lasting for a few minutes to a few days after. Besides the physical symptoms, there are often negative mental or emotional components that can affect your intimacy and relationships. 

Dyspareunia is an umbrella term used to describe a multitude of causes, locations and symptoms. It is a broad topic that can affect any person at any age or stage of life, but we will try to tackle the basics today. 

Causes

Some common causes of pain with intercourse include: 

• Recent birth or C-section

• Fascial restrictions in the pelvis or abdomen

• Organ position and pelvic prolapse

• Vaginismus (spasms of the (Pelvic Floor Muscles)

• Hormone imbalance (decreased estrogen limits the vagina’s ability to lubricate properly)

• Anxiety and Depression

• Infections or certain medical conditions like Endometriosis 

Whatever the cause is, the vast majority of people with dyspareunia have Hypertonic (super tight) Pelvic Floor Muscles. But *where* that tightness occurs differs from person to person. The Pelvic Floor System is a vast muscle complex comprising three main layers. And the type of Dyspareunia you have can depend on which layer is involved. This is where a Pelvic Floor PT can help by performing an initial examination. 

External (Superficial) Layer

The external layer of Pelvic Floor Muscles is the most superficial and can be palpated on the outside of the body. Almost all the muscles of this layer connect into the clitoris and can lead to pain/discomfort. if there are restrictions of the Clitoral Hood, this can lead to a decrease in Orgasm strength/frequency and lead to pain with Orgasm. For some- if the muscle is restricted then it can tighten and “lock down,” often causing a “no or low” orgasm or pain. Vaginal scarring or torn/injured muscles in this area can also contribute to dysfunction. 

Your PFPT will begin with an external examination, palpating all the relevant muscles of this layer. They may ask you to squeeze and relax certain muscles to determine what the issue is. The therapist may also assess how even your pelvis is, as well as lumbar movement and hip/core strength – all of which play a significant role in appropriate Pelvic Floor Function.

Middle Layer

The second layer comprises the muscles in the first area of the vaginal tunnel. These muscles are cocooned within a separate fascial layer that squeeze down on the urethra, vagina and anus. If the muscle bellies are squeezing and rubbing together too tightly during penetration, there may be a feeling of dryness and not enough lubrication.  The vaginal wall contains rugae, a series of ridges produced by the folding of an organ. In a properly lubricated vagina, rugae help decrease friction. But if there is dryness, the rugae increase friction and facilitate pain. When the muscles of this layer are overly tight, penetration can be painful. You may also have trouble starting the flow of urine, experience leaking, or need to bear down when going to the bathroom.  

Your Physical Therapist may palpate the lining of your vaginal wall to check for tightness as well as repeat the squeeze/relax test for this layer. 

Deep (Internal) Layer

The third layer of the Pelvic Floor is the one often shown in anatomy books. It forms a hammock connecting your pubic bone to your tailbone and across both hip bones. Pain often occurs with deep thrusting. You can also experience deep hip/SIJ/tailbone pain that isn’t resolved with traditional therapy (because the PF muscles are often forgotten about). It is common for one side of your Pelvic Floor Muscles to activate more strongly than the other. This can lead to pelvic asymmetry and possible hip/back pain. 

The muscles of this layer are susceptible to trigger points and it is common for your PFPT to perform internal work to get these muscles to relax. 

Treatment

Treating Dyspareunia often require a lot of hands-on manual work. An important first step is to recognize when and how the pain occurs. It is often recommended to keep a symptom diary so that your PFPT may better understand where the underlying dysfunction is. After this, your therapist may recommend that you cease certain aspects of intercourse while the pain is uncontrolled. When symptoms have begun to resolve, you may begin to slowly progress with “outercourse” and then to penetration. This is often done in conjunction with relaxation techniques your PT will give to help your Pelvic Floor relax. It is important to work on combining these techniques to recreate the offending activity without tension or pain. Your PFPT will then progress you to muscle strengthening. It is also important to work on desensitization for pain in the middle and deep layers. Your PFPT may also use manual therapy to help with Abdominal/Pelvic Organ Positioning to take stress off the Deeper Pelvic Floor Muscles. This is especially important for anyone that does contact sports and recently gave birth. 

So! The main takeaway is that Pain with Intercourse is NOT normal. There are a variety of factors that may contribute to Pelvic Pain. And this is where your favorite Pelvic Floor PT can help!

<3 The Recharged Performance Therapy Team

www.RechargedPerformanceTherapy.com

(321) 802-1630

References

https://my.clevelandclinic.org/health/diseases/12325-dyspareunia-painful-intercourse

https://www.mayoclinic.org/diseases-conditions/painful-intercourse/symptoms-causes/syc-20375967

Dr. Paige’s voice memos :)