The Heart Says Yes but the Vagina Says No
Ashley had secretly suffered with painful sex throughout her 8 year marriage. While her husband had been very patient and supportive of her, she admitted that it was taking a toll on their marriage. She had seen several health care practitioners over the years and had heard it all… “have a glass of wine before you have sex”, “try an antibiotic in case it’s a urinary tract infection”, “you just have really tight muscles”, and the worst of all….”maybe it’s just in your head that it’s painful.”
This is the kind of patient I see frequently at my clinic, women who have suffered in some cases years with pelvic pain including painful sex before the right diagnosis is discovered. They believe that something must be wrong with them, and that they are the only ones who are going through this. In many cases they feel too embarrassed to even discuss that they are having painful sex with their doctor. Unfortunately some doctors are not aware of certain pelvic pain dysfunctions and available treatments. This can lead to a dismissal of their symptoms which can add to women’s stress levels and feelings of hopelessness.
There can be many reasons for pelvic pain to develop which can lead to painful intercourse, also known as dyspareunia. Vaginal deliveries during child birth can lead to tearing along the perineum, which is the stretch of skin between the vagina and rectum. This can result in scar tissue which in turn can make intercourse painful. Symptoms related to Endometriosis and painful bladder syndromes such as Interstitial Cystitis can also lead to painful intercourse.
In Ashley’s case she had something that many women have not heard about called vaginismus. Vaginismus is when the pelvic floor muscles tighten on their own as almost like a reflex when anything comes near the vagina. This can start in the teenage years as when trying to insert a tampon and the tampon will not go in. It can also present itself during pap smears when the doctor tries to insert a speculum, and the pelvic floor muscles tighten and it is very painful for the speculum to enter the vagina, if at all.
It may also present with the first attempts of sexual intercourse. While the first time or 2 can be uncomfortable when someone has not had intercourse before, further attempts of intercourse should get easier in most cases without reports of painful sex.
With vaginismus what happens during attempts of intercourse is that the pelvic floor muscles tighten and penetration becomes painful or impossible. The pelvic floor muscles tighten and squeeze with the woman unable to relax the muscles voluntarily.
A good example I have heard in describing this is imagine seeing a bear in the woods and he is creeping closer to you. What do you think would happen? You become anxious and scared, your heart rate goes up and you want to run to get the heck out of there!
Same thing with vaginismus and the pelvic floor muscles. Instead of a bear it can be a speculum or penis and the mere thought of something “down there” sets off anxiety. The thought of attempting intercourse becomes very stressful and our nervous system takes over. This results in almost like a reflex where our pelvic floor muscles tighten on their own without the ability to voluntarily relax them. Attempts of intercourse produces pain, and the pain itself reinforces the reflex response of our pelvic floor muscles….Thus a pain cycle starts …
As a result women fear the thought of intimacy, and lack of desire may develop. Unfortunately this can make a women feel “less than” in a relationship which can further add to her stress level.
So if this sounds like what you are experiencing first thing I would say to you is YOU ARE NOT ALONE! This happens to other women more frequently than what you think! Another thing I would like to say is that I am sorry that you have had to live with this as long as you have.
I am always amazed and disheartened as to how long women suffer before they get the help they need. In most cases they have told at least a couple of doctors about their symptoms but are just simply blown off as exaggerating their pain level or just told to “keep trying.” (in regards to intercourse)
How do pelvic floor physical therapists help women resolve painful sex once and for all?
Let’s go back to Ashley and talk about her story including the treatments that helped her…
Ashley had recently moved to Indianapolis from another state and was referred to me from a gynecologist in the area. Ashley said she had never heard of a pelvic floor therapist before. Her previous gynecologist of 8 plus years had never offered her a solution or ever mentioned a pelvic floor physical therapist.
She said that during her 8 years of marriage that attempts of intercourse with her husband had always been painful and they had basically stopped trying. She did not know help was even available until her recent visit to her new gynecologist in Indianapolis.
Upon examination Ashley was found to have some pain along her abdomen, with reports of constipation and bowel movements only every few days. She was noticed to keep her abdominal muscles tight and “guarded” while looking at her posture and with general mobility patterns.
Some tightness was noted along her hip flexor muscles (along the front of the lower abdomen) as well which may have contributed to her abdominal tenderness and tightness. General hip tightness was discovered as well.
Ashley gave consent for a pelvic floor exam. A vaginal exam is performed to see how the pelvic floor muscles respond to touch and pain level. (Pelvic floor physical therapists are specially trained in performing vaginal exams which help to guide treatment for treating certain pelvic floor dysfunctions.) With attempts of inserting one gloved finger vaginally her pelvic floor muscles were noted to immediately become tight and painful. She was able to tolerate about one inch in length for about 5 minutes. She was unable to release voluntarily when asked to relax her pelvic floor muscles.
Throughout treatment I asked her what her anxiety levels are based on 1-10 with even light touch outside the vaginal area, such as the perineum (the area of skin between the vagina opening and rectum) and upper thigh. This is done to try and decrease her anxiety and reprogram the body as to how to respond to light touch. She reported the first visit to be between a 7 and 8/10. Pain level between 1 and 10 with 10 being the worst pain ever, was rated a 5/10 during the internal exam, however did lower to 2/10 after 5 minutes.
We discussed using dilators to help her train the pelvic floor muscles in getting used to tolerating touch and pressure again. Dilators come in different sizes, with size one being the smallest. She was given a size one dilator to take home to start. Instructions are to insert the size 1 dilator as she can tolerate, maybe 2 minutes, 5 minutes… Once she is able to insert the dilator all the way for 10 minutes at a time without pain she could advance to the next size.
Relaxation techniques including breathing strategies, visualization to decrease the pelvic floor muscle tone, as well as certain hip flexibility stretches was shown for her to do at home.
We also discussed ways to help with her constipation. This may help to lessen her abdominal pain and tightness which can overflow into the pelvic floor making the muscles stay tight as well.
Next visit she was able to tolerate a full gloved finger exam with less reports of anxiety, a 4/10 with reports of anxiety and pain level a 2/10 during the vaginal exam. She had success with inserting the size 1 dilator at home consistently for 10 minutes without reports of pain. We did incorporate biofeedback that visit, which is external sensors placed along the rectal opening that when the pelvic floor muscles contract, shows on a computer the ability of the muscles to both contract and relax. She reported this was a big help as it helped to teach her how to consistently relax her pelvic floor, as she tends to keep the muscles contracted when stressed at work or home.
Abdominal massage was also initiated to help decrease her abdominal tenderness and help facilitate regular bowel movements. Fiber intake was being monitored daily with the goal of 25-30 grams of fiber a day to promote daily bowel movements. She also started back with yoga as she had not done yoga in a number of years and had remembered that was one thing that used to relax her.
She was encouraged to continue with her relaxation techniques, abdominal massage, stretches and begin with dilator size 2
So let’s fast forward with Ashleys outcomes….After 7 more visits, 12 weeks after her initial visit she was happy to report her and her husband were able to have intercourse without pain!! She did say there were some days when the muscles felt “tighter” than others, as when having more of a stressful day, but the anxiety she had felt was gone.
She was so grateful to have conquered the painful sex she had experienced for years. She was also dissapointed and upset that she was made to live 8 years with a problem that could have been solved. She felt that her doctor had let her down.
Be your own advocate if you are having ANY pelvic floor pain or dysfunction
If something is not right please speak up until you are heard! I see this happen to women just over and over again.
If you are experiencing painful sex then please stop having intercourse until you can get checked out! A good source to refer to until you can be seen by someone is a website https://www.vaginismus.com/ This has been a good resource for my patients and can almost be a good first step in relieving some of their anxiety just knowing they are not alone!
Next is talk to your doctor about any pelvic floor symptoms you may be having not just painful sex, but leakage, feelings of presure down there which could be prolapse symptoms and any chronic pain around the pelvis in general. Tell them you would like to be refered to a pelvic floor physical therapist. They may want to rule a couple other things out first, like a urinary tract infection, but otherwise should want to be on board with helping you resolve your pelvic pain. If not…seek a second opinion…
That being said, in most states you do not have to have a doctor’s order to start treatment with a pelvic floor Physical Therapist. In the state of Indiana we can directly see and treat a patient the first 42 days without a doctor’s order. After that 42 days we are supposed to by law get a referral from a health care provider to continue physical therapy. This can be a family doctor, chiropractor, ob/gyn, nurse practitioner to name a few.
If you are having other pelvic floor symptoms, such as leakage during exercise or leakage with the “gotta go” feelings of urgency please check out these other blogs which may helpful as well!
Postpartum Peeing, Pressure “Down There” and Pain
3 Ways To Train Your Bladder Like A BOSS
I do offer free 15 minute consultations either over the phone or in person where we can discuss your individual situation and see if PT would be a good fit for you. Please reach out to me if you would like to chat! I would love to help you!
Owner of Indy Women Physical Therapy