Hello everyone!

Here at Pelvic Care Physical Therapy, we specialize in helping clients resolve painful sex. Healthy intimacy is important for our relationships and marriages, our mental health, and our physical health. Sex can be such a wonderful, happy part of our lives! But unfortunately, a lot of people have pain with sex or other sexual problems like erectile dysfunction. Sex problems affect women and men. Physical therapy can help.

What are the different kinds of sexual dysfunction PT can help with?

• Vaginismus (penetration triggers reflexive muscle guarding around the vagina)

• Vulvodynia (the outer vulva–the area surrounding the vagina–is painful at rest or during sex)

• Superficial dyspareunia (pain with initial penetration)

• Deep dyspareunia (pain with deep thrusting)

• Penile, testicular, or anal pain during sex or after sex

• Erectile dysfunction (difficulty initiating or sustaining erection)

• Orthopedic/pain impairment of movement during sex, comfort with certain sex positions, orgasm or ejaculation

• Altered/impaired sensation or numbness in the genital and/or abdominal regions

Why do people have pain and sexual dysfunction?

One common reason is that they have knots and tension in their pelvic floor. People get elevated muscle tone in their pelvic floor for a variety of reasons. It can be associated with hip, low back, or tailbone pain. Some people just “hold their stress” in their pelvic floor. Chronic GI distress like IBS or colitis can lead to pelvic floor dysfunction. So can chronic bladder conditions like interstitial cystitis, recurrent UTIs, recurrent kidney stones. People who have multiple abdominal surgeries can get a wonky pelvic floor (e.g., you had your gallbladder removed, c-sections, and an ovarian cyst removed). Cancer survivors who receive abdominopelvic surgery and/or radiation can get a fibrotic pelvic floor (eg, post prostatectomy and radiation). When the pelvic floor gets too tight, it can’t flow and respond to the internal and external movements of arousal and sex, and pain can result.

There are other reasons sex can be painful: Sometimes people’s pain is not in their pelvic floor, the problem is that their hip or low back pain is aggravated by certain sexual positions or movements. Aggravated pain in the low back, hips, or other areas can create pain inhibition of movement, arousal or sustained erection, and orgasm/ejaculation. Sometimes pain with sex is associated with a history of trauma. Sometimes decreased sensation in the genital area has to do with a central (spinal) or peripheral (muscle, tendon, or ligament) nerve impingement. 

It’s the job of your physical therapist or whoever you see first for your concern, to discern whether the issue is likely musculoskeletal or a systemic/organ issue. If your sex problem seems to be coming from tight muscles, achy joints, or pinched nerves, then PT can help. If it seems to be referred pain from an organ, or more of a cardiovascular issue than a skeletal muscle issue, then your PT may refer you to another specialist after your initial PT evaluation. For example, maybe you are getting very specific cervical (end of the vagina) pain during sex, or you are having low blood flow to your genital region, and that is why you are having sexual dysfunction. If the problem is not within the PT scope of practice, it’s our job to figure this out real fast and get you referred to the perfect practitioner to quickly assess and treat your problem–a gynecologist, urologist, cardiovascular specialist, oncologist, or your primary care doctor. 

What does an initial evaluation look like?

When you come in for your initial evaluation, the first thing we want to figure out is your baseline, your pain profile. Where is the pain located? We get really specific! Is it at the tip of your penis? Behind your testicles? Inside your anus?  Around your vagina? Deep inside? All throughout your lower abdomen and radiating around to your low back? Your inner thighs? What aggravates and what alleviates the pain? How intense does the pain get, and how long does the pain last after it is aggravated? Physical therapy for pain is like a well controlled science experiment, where we thoughtfully change variables over time and measure the response. If we have some clear data on your current pain and symptom profile, then we can chart your progress over time and know for sure whether the interventions we’re performing are moving you as efficiently as possible toward your goal–pain-free, enjoyable sex. 

Many people are scared to talk about sex with a healthcare provider. Unfortunately, a lot of healthcare providers are scared to have these conversations, too! There’s one thing I can guarantee you: Your pelvic floor PT wants to talk about sex with you. It’s part of why we do this job! We are here to help you heal your body and to bring balance and ease to your life. Every part of your body, including your genital region, is a wonderful part of you. It’s ok if you don’t know all the medical jargon for what you’re talking about–use the words you know, and we’ll get on the same page with clear, respectful communication in an intentionally safe space. It’s ok if you and I have different sexual identifications, histories or preferences. I intend to honor and respect your whole self, and I ask the same of you, so that we can establish fabulous therapeutic rapport and get you better.

After we chat about what you’re experiencing, we start working with your body. If a client’s chief concern is pain with sex, an external or internal pelvic floor exam is useful. Is a pelvic floor examination required at the first appointment? Is an internal exam required? Heck, no! There are so many other things we need to look at that are relevant to your situation, and often I work with clients on the areas surrounding the pelvic floor for several sessions, before we start working directly on the pelvic region.  Depending on the client and their pain profile, we may do a movement screen, assessing how your body moves when you squat, lunge, or jump. We may want to do a detailed, orthopedic evaluation of your low back, your hips, or your bony pelvic alignment. These evaluations give us important data and help us start working on relevant neighboring regions. Big picture, treating the areas surrounding the pelvis is important because–ya know–the knee bone’s connected to the thigh bone and all that. And it gives us time to get to know each other, to learn how to communicate clearly with each other, and to establish trust before we do specific pelvic floor work.

What does an external pelvic floor exam look like? You have the option to remain clothed, or to be unclothed from the waist down. Your pelvic floor PT palpates your external pelvic floor musculature with a gloved hand, feeling for bands of tension and knots. For people with vulvas, this looks like pressing gently over the pubic mound, along the labia majora on each side, on the perineum (the tissue between the vagina and anus), and around the anus. For people with penises, this looks like pressing gently on the lower abdomen, along the edges of the penis and testicles, underneath the testicles and on the perineum, and around the anus. With your permission, your therapist may visualize your genital region and ask you to do some deep breathing, and some kegels, to see if the area can shift downward and upward in response to muscle relaxation and contraction. 

What does an internal examination look like? A vaginal or rectal exam may be completed, depending on the sex of the client and the location of their symptoms. A single finger is inserted so that the therapist can palpate the internal pelvic floor musculature. Our goal is to locate areas of tension that reproduce the pain that is your chief concern. It sounds a little mean, doesn’t it, that we want to reproduce your pain? But its for a good reason–we know if we find the spot that is generating pain for you, we can focus our work on that spot and get you better faster. We work gradually, at first just inserting the tip of the finger and working on the muscles near the opening of your vagina or anus, and then progressing to a further depth if you are having minimal discomfort. As with the external examination, we will also ask you to do breathing and kegels, to assess your pelvic floor muscular coordination.

What does treatment look like?

For most people who have pain with sex, treatment consists of a combination of manual therapy, therapeutic exercise, and lifestyle changes. Your pelvic floor PT will apply trigger point release and other manual therapy techniques to the external and internal pelvic floor to help the muscles surrounding your genitals to relax and become fluidly responsive to movement and internal arousal mechanisms again. At Pelvic Care Physical Therapy, you will also be trained to do some of this work at home. There are a variety of wonderful options for releasing your own pelvic floor. For clients with posterior pelvic pain (deep inside the vagina, or around the anus, tailbone, or buttox), sitting on a squishy hand therapy ball, with the ball positioned between the anus and sits bones, can be so useful! You may be instructed in use of a pelvic floor release wand for internal vaginal or anal work. Or you may decide to recruit your partner onto your therapy team, and we will have them attend a therapy session with you to learn how to perform internal pelvic floor release with you at home.

Therapeutic exercise to treat painful sex varies by case. Many people with elevated muscle tone in their pelvic floor need to focus on stretching and relaxing the pelvic region for quite a while before we begin to consider anything strength focused. These folks benefit from hip opening-type yoga poses like happy baby, wide legged child’s pose, adductor stretches/butterfly stretch. We work on diaphragm breathing, learning to take breaths that expand the lower ribs in all directions (360 degrees!), or perhaps sending the breath to particular regions to promote a stretch. For example, we might rest in a supported child’s pose and breathe deeply into the back, intentionally relaxing the tissues around the tailbone and anus on each inhale, imagining the sits bones widening and then relaxing back to their initial position with each breath. Other folks with painful sex need to resolve specific issues in their low back or hips to make the most efficient progress. For example, sometimes the pelvic floor is tight because there is a general lack of core stability or a chronic pelvic bony alignment issue, and exercise needs to consist of a thoughtful balance between strength and relaxation training. There’s not a right or wrong way to stretch or breathe if you have a tight pelvic floor or pain with sex–what we do depends on your pain location and which tissues are contributing.

Lifestyle change advice for painful or dysfunctional sex involves careful consideration of the information you bring about your symptoms, and how they are impacting your life. Sometimes, we chat about foreplay and what’s happening for you in this arena. We may recommend you try using more lubricant, or a different kind of lube than you do now. We may recommend you talk with your partner(s) about your foreplay needs and desires. Sex is multifactorial, and sometimes pelvic floor PT is a useful space for you to problem-solve non-physical issues that are obstructing the quality sex life you desire–emotional, psychological, and interpersonal issues are all at play in arousal and intimacy. The majority of the clients I see for painful sex, also see a sex and relationship therapist, and I cannot recommend this dual treatment highly enough. Sex and relationship therapists can help you and your partner(s) communicate better and collaborate to improve your intimacy.

Seeking care for sexual dysfunction can be intimidating. My sincere hope is that reading this information helps you understand what to expect, and makes the prospect less daunting. I want to be very clear about a few things in closing. Men and women can have pain with sex, and sexual dysfunction. If you are having pain with sex–or even if you are just not having pleasure–I encourage you to assemble a medical team who is eager to talk to you about the issue. Make sure that a great pelvic floor PT and a sex therapist are on that team, if your physical tissues and your cognitions/emotions are involved :) Your genitals are beautiful and worthy of care. And you deserve the nourishment of fulfilling intimacy. My best to you, this month! Don’t hesitate to be in contact with questions.