Let's talk about sex - dyspareunia
Intimacy can be a big part of a woman's relationship and identity. When sexual pain gets in the way, it can begin to affect the connection you have with your partner, your femininity, sexuality and confidence.
Seems like an unusual topic for a physio to be involved in, however sexual pain and dysfunction makes up around 40% of my current caseload! At a recent group meeting with other Pelvic Health Physiotherapists, a number of them expressed that in another life/different career they would probably be sex therapists. And now I can see why. It is a incredibly rewarding area to treat as you see the results and each individual's confidence grow.
While it is an area not often talked about between women of previous generations, there is now a lot more research emerging about female sexual pain and I'm pretty excited to be spreading the word about this growing field. There are now a lot of helpful books and resources available that have been published in the last ten years (see Resources).
The main message from today's post is:
Consensual intimate touch and sexual intercourse should never be painful.
The term for painful intercourse is Dyspareunia and can be further broken down into Superficial (felt around the entrance of the vagina) or Deep Dyspareunia (deeper inside). Pain and discomfort from touch and/or penetration can be due to a number of different reasons in the absence of infection:
Decreased arousal (both deep/superficial)
Certain positions (usually deep)
Lack of lubrication (superficial)
Spasm and tightness of the pelvic floor muscles (both deep/superficial)
It is highly unlikely that a woman can be too small for a man's penis. Remember that the muscles and tissues lining the vagina are very stretchy and are designed for a baby be able to pass through!
Decreased Arousal, Positioning and Lubrication
When a woman is aroused and ready for intercourse, a few things happen: Increased blood flow to the vagina stimulates secretion of lubricating fluids to decrease friction and the cervix actually rises up and moves out of the way. Some women take a bit more time to become aroused and prepared for intercourse so don't be afraid to take your time with foreplay. Contact with the cervix can be quite uncomfortable and often feels like a deeper pain. This can be avoided by trying different positions.
External lubrication in the form of a gel or oil can be useful for superficial dyspareunia but remember to check the labels! Certain lubricants contain harmful chemicals, such as glycerin which can irritate sensitive skin, as well as parabens (known carcinogens). I've recently found a lubricant at the local grocery store (in Canada) that I recommend to my patients called Aloecadabra which is made of 95% organic aloe vera and all natural ingredients. However, it does contain some essential oils so if you are sensitive to fragrances then it may not be best for you.
Pelvic Floor Muscle Dysfunction
Increased tone/tightness or spasm of the pelvic floor muscles can be a cause of deep dyspareunia. As with any tight muscle, repeated pressure can cause either immediate or latent discomfort. Trigger points within the muscles of the pelvic floor can also refer pain to the abdomen, creating menstrual cramping sensations and also hip and groin. Pelvic floor muscle spasm and dysfunction can also contribute to Vaginismus and Vulvodynia.
Vaginismus is a reflexive action of the pelvic floor muscles around the opening of the vagina with attempted penetration, or even the thought of penetration. It can be a mild tightening which causes pain initially with penetration and then eases but can be more severe with penetration being impossible. Read more about Vaginismus.
Often characterised by a burning, itching or raw pain, this has previously been one of the least understood forms of sexual and pelvic pain. Even though the burning and itching mimics symptoms of an infection, there may only be a slight redness visible and cultures for yeast or bacteria will often come back negative. Vestibulodynia is due to irritation of the nerves that supply the vaginal area, in particular the vulva and vestibule and can respond very well to Pelvic Health Physiotherapy. Read more about Vulvodynia and Vestibulodynia.