We see a lot women of all ages who are seeking help for painful sex. Its difficult to know who to turn to when sex hurts. A sex therapist? A Doctor? A Gynaecologist? A Psychologist? All of the above perhaps. But often the source of pain is within the muscles of the pelvic floor and that is the job of a Pelvic Health Physiotherapist. A Pelvic Health Physiotherapist is a good place to start. If a Doctor is needed the Physiotherapist will communicate with your Doctor as you work towards solutions.
This blog is about pain due to tight pelvic floor muscles which is often referred to as “vaginismus”.
There are many causes of “pelvic pain” but the aim here is to focus on tight muscles.
Here are some of situations we hear about:
- Pain from first sexual experience.
A young woman comes to see us from late teens or early twenties. She has never been able to have sex without pain. Penetration was initially painful from when she first had sex and has become more and more painful to the point that penetration is impossible. The vaginal entrance becomes “like a wall”. She may have tried to use tampons and they have been painful to insert or impossible to insert. She feels guilty, unhappy, doesn’t know where to find help. She tries to push through the pain because she feels bad for her partner.
- Pain develops later in a relationship
We also see women for whom sex was initially fine, pain free and enjoyable but starts to become painful over time. They may be with a new partner, or the same partner. Something triggers a negative sensation and discomfort starts to become worse over time. Eventually discomfort becomes pain and sex with penetration is impossible.
- Pain after delivery of a baby
It is not unusual for sex to feel different after the delivery of a baby. After all, a vaginal delivery will change the muscle tone and there may be some stretch to ligaments in the area.; there may be an episiotomy scar that is slightly sensitive. So whilst the vagina and sexual response may seem different for a while, it shouldn’t be painful. Even women who have had caesareans can feel quite guarded at the abdominal surgery scar which could be enough to cause some guarding and tension in the pelvic floor. This then causes pain.
What is happening in these cases?
There are many things at play:
The most obvious is Pelvic floor muscle tightness. The pelvic floor muscles sit like a cradle at the base of our pelvis, supporting the bladder, bowel and uterus/vagina. They hold up the organs and provide closure for bladder, bowel and vagina. We should be able to voluntarily tighten these muscles and voluntary relax them. In other words, we have control of tightening and relaxing. Sometimes though, the pelvic floor muscles become tight and go into spasm and we cannot relax them. This causes a closing effect at the vaginal entrance.
The often used medical word for this is “vaginismus”.
Physiotherapists also call it “increased tone pelvic floor”.
Unfortunately, it doesn’t take much for the muscles to go into this protective spasm in some people. It might just be some slight discomfort from initial experience and the memory of this stays in the brain: You may well want to have sex but the muscles, without you knowing, are going into a protective spasm and the cycle of tightness and pain is reinforced.
Many of the women we see with this problem, realise that they are prone generally to muscle tightness in the body. They may be prone to anxiety and muscle tension, making it much easier for their pelvic floor muscles to become tight.
Tight muscles tend not to work so well leading to other problems such as bladder leakage in some people.
So how do we make this problem better?
It is a process of working on all aspects of the problem:
We can learn to relax the muscles by practicing pelvic floor exercise focused on relaxation after contraction . We call this PELVIC FLOOR DOWN TRAINING. You need to learn about where the muscles are, what they look like, how they contract and how then do they relax. You almost need to VISUALISE the muscles letting go in your mind.
Some women have to do this as part of WHOLE BODY RELAXATION. If your body is tight everywhere, its very difficult to relax one small part without relaxing the whole. There are resources to help you relax your whole body and your pelvic floor.
There is evidence that doing relaxing, calm general exercise like YOGA or TAI CHI can help you to bring down the tension in your whole body and pelvic floor.
You will most likely be invited to bring your partner. YOUR PARTNER CAN LEARN HOW TO BE PART OF THE SOLUTION. Studies have shown that partners experience a great deal of distress due to this problem too. They don’t know what to do or how to begin to find solutions.
We may recommend use of “VAGINAL DILATORS”. These are also called “VAGINAL TRAINERS”. Physios like to use the latter term because we feel that “training” sounds more positive than just “dilating”. Either way, these are devices like little tubes which gradually increase in size. You start with a little one and let it slide into the vagina as you relax. You may find your partner will be able to assist. You gradually expose yourself to the larger dilators to build your ability to relax.
Some dilators/trainers combine vibration so that women can use the sensation of VIBRATION to desensitise the feeling of pain and induce muscle relaxation. Many women are encouraged to re-connect to pleasurable sexual sensation with vibration using any of the more traditional sex toy vibrators on the market. Interestingly, a study of men’s attitudes to sex where a vibrator is used, showed that a male partner can find the vibration very positive too.
The pathway to pain-free sex is not easy, but we are here to help. We should remember though, that pain free sex doesn’t always equal good sex. So if relationship issues are at the heart of the problem, then we will refer to our Psychologist or Sex Counsellor colleagues ..