You see it in the movies, you read about it online, you hear your friends' stories—sex is fabulous, right? It's the ultimate enjoyment, isn't it?
What if it's not? What if having sex hurts? Or you're not able to have intercourse at all? Or the idea of it makes you nervous? Or nauseous? Does that make you a freak? Is something wrong with you? Do you just have to live with it?
Are you the only one??
ABSOLUTELY NOT!
Painful sex is super common and super treatable.
It is so common in fact, that according to the American College of Obstetrics and Gynecologists (ACOG), nearly 3 out of 4 women have pain during intercourse at some time during their lives.
And approximately 5 percent of men suffer from pain with sexual intercourse, which is almost certainly an underestimation; dyspareunia in men is woefully understudied.
But common is not the same as normal. SEX SHOULD NOT HURT! Let me repeat, sex should not hurt.
Pain with sex can take a huge toll on one's self-esteem, relationships, emotional health, and physical health. In short, it can be devastating. So let’s dive in to learn what sexual pain is, and what can be done about it.
What is dyspareunia?
Dyspareunia is the medical word for pain with sex. It is defined as persistent or recurrent genital pain that occurs just before, during or after sex. It can start at the very first attempt at sexual activity, or it can start after you’ve had a period of time when you’ve been having sex pain-free.
What is vaginismus?
Vaginismus is a related condition in which the pelvic floor muscles in a woman involuntarily and powerfully tighten so much that they interfere with or prevent vaginal penetration.
This means that intercourse, pelvic exams, even using tampons can be difficult or even impossible and can cause significant distress and pain.
With vaginismus, pain often results from attempts at intercourse. This pain in turn results in anticipation of pain in future attempts, and can set up a vicious cycle of fear and pain.
Vaginismus can occur at any age. In fact, the first sign of possible vaginismus often arises at a young age, with a girl’s first attempt at inserting a tampon. It can begin when vaginal intercourse is first attempted, but it can also start after a period of pain-free sex.
Physical symptoms of dyspareunia
In women, the physical symptoms of dyspareunia can range from vaginal pain at initial penetration, deep pain, or both; it can also include vulvar pain. Pain can be experienced in other areas as well, such as the perineum, lower abdomen, groin, buttocks and/or inner thighs. With vaginismus, women often describe attempts at having intercourse as "like hitting a wall"; vaginal penetration just isn't possible.
The pain might include burning, itching, stabbing, searing, cramping, and/or aching, and can be short-lived or last hours after intercourse. These symptoms can range from mild to severe, making intercourse difficult or impossible.
In men, there might be pain with arousal, erections, ejaculation, and/or pain after sex. The pain can be in the genitals, perineum, lower abdomen, groin, buttocks and/or inner thighs. Just as in women, sexual pain in men can range from mild to severe and be short- or long-lasting.
Psychological and emotional symptoms of dyspareunia
In addition to physical symptoms, there is often significant psychological and emotional distress related to sexual pain. Unmanaged dyspareunia can profoundly impact one's body image, relationships, and mental health. It often leads to self-esteem issues, fertility challenges, intimacy issues, and significant distress.
In many people with dyspareunia and vaginismus, even the prospect of sexual intimacy can trigger powerful feelings like anxiety. Women may want to avoid situations that may lead to sex, but they also may want to please their partner so much that they have sex anyway. Which causes anxiety and pain. Which then sets up the cycle to repeat again and again.
When there is pain with sexual function, it is important to treat both the physical and psychological/emotional symptoms together.
What causes dyspareunia?
The term “dyspareunia” can be deceiving—it’s a single word, but there are a myriad of reasons one might have pain with sex. And determining the specific cause(s) is crucial to getting the best and most effective treatment.
Common causes of dyspareunia in women include:
Pelvic floor muscle dysfunction: the muscles may be shortened and tight, have trigger points, and/or hold tension so they cause pain with penetration. And just like someone may clench their jaw with increased stress, many people clench their pelvic floor muscles subconsciously in response to stress, leading to increased tension and pain in the muscles.
Vaginismus: Women with vaginismus, in comparison to dyspareunia, demonstrate significantly higher pelvic muscle tone and lower muscle strength.
Scars: healing perineal scars, such as postpartum episiotomy or tear, or pelvic surgery can cause pain with sex
Drop in vaginal lubrication: for example, with a loss of arousal due to recurrent pain and anticipation of pain; from drops in estrogen levels from oral contraceptives, pregnancy, breastfeeding, or menopause; also from surgically- or medically-induced menopause.
Clitoral adhesions: when the clitoral hood adheres to the clitoris, it can cause pain with sexual activity.
Skin inflammation or infections: such as eczema, psoriasis, lichen sclerosus, urinary tract infection, yeast infection, sexually transmitted infections
Certain medical conditions: such as endometriosis, pelvic inflammatory disease, uterine fibroids, vulvodynia, pudendal neuralgia, painful bladder syndrome, interstitial cystitis
Scarring: from pelvic surgeries such as hysterectomy and endometriosis, and cancer treatments such as radiation and chemotherapy
A history of sexual abuse: if you have been a victim of sexual abuse, it can powerfully contribute to pain during sex
Psychological conditions: Many psychological conditions can negatively affect sexual functioning, as can some of the medications used to treat those conditions.
Religious and cultural beliefs: can affect how you approach sexual encounters, relationships and intimacy, and can contribute to dyspareunia and vaginismus.
Common causes of dyspareunia in men include:
Pelvic floor muscle dysfunction: just as in women, these muscles may be shortened and tight, have trigger points, and/or hold tension so they cause pain with sexual function
Foreskin damage: Damage to the foreskin (skin that covers the head of the penis) caused by rubbing or tearing can lead to pain.
Skin inflammation or infections: Yeast infections or infections under the foreskin, as well as common sexually transmitted infections like genital herpes or gonorrhea, can make sex painful.
Certain medical conditions: conditions such as priapism, Peyronie’s disease or other deformities of the penis can cause painful intercourse and/or painful erections.
Scarring: from pelvic surgeries and cancer treatments such as radiation and chemotherapy, prostatectomy
A history of sexual abuse: if you have been a victim of sexual abuse, it can powerfully contribute to pain during sex
Psychological conditions: Many psychological conditions can negatively affect sexual functioning, as can some of the medications used to treat those conditions.
Religious and cultural beliefs can affect how you approach sexual encounters, relationships and intimacy, and can contribute to dyspareunia.
(Tip: If you google dyspareunia in men, most articles completely ignore a very real and very common cause: pelvic floor muscle dysfunction. If you want to find discussion of these muscles, search the terms chronic pelvic pain syndrome in men or non-bacterial prostatitis instead.)
Treatment for dyspareunia
Because there are many possible reasons you may be having pain with sexual intercourse, there are many possible treatments. And finding the specific cause(s) for your own sexual pain is paramount for getting effective treatment. If you have a yeast infection but I treat you for vaginismus, you are certainly not getting the best and most effective treatment for you!
Some common treatments for dyspareunia:
Pelvic floor physical therapy—to help normalize your pelvic floor muscle tone, eliminate any trigger points, break the negative connection your brain has between pain and sex, and help your brain regain confidence so it knows that touch at the vagina can be pleasurable
Dilators—the use of graduated dilators can help you gain confidence over your pelvic floor muscles, reduce the guarding and gradually teach them to let go; they also help reduce anxiety regarding penetration, making vaginal penetration less painful and more enjoyable.
Medications—to treat any infections, skin disorders, address any hormonal deficiencies, etc
Sex therapy or other counseling—to address mental health issues, relationship issues, history of abuse, religious and cultural beliefs, emotional concerns or other things which may be affecting a person’s sexual function, drive, and/or desire for intimacy.
Why is dyspareunia so important to treat?
Pain with intercourse does not tend to go away on its own, and as we've discussed, can take a huge emotional toll on those who suffer from it, as well as on their partners.
People with chronic unexplained pain during sex can often develop other sexual dysfunctions like lower drive, arousal, satisfaction, and ability to orgasm.
Don't put it off—the longer you have pain with sex, the more engrained the problem can become. Be your own best advocate and search out the help you need now.
Who to see if you have pain with sex
Obstetricians, gynecologists, urogynecologists, urologists, pelvic floor physical therapists and other healthcare providers all can help with the medical and physiological causes of sexual pain, while sex therapists and counselors can help with not only the disorder itself, but with the emotional fallout of dealing with sexual pain as well.
One word of caution:
It may take some work and persistence to find the right individuals to help you. Many practitioners are uncomfortable or inexperienced broaching topics of sexual health, or have not had adequate training to help you.
For instance, a surprisingly common piece of medical advice given to women with dyspareunia is the suggestion to simply drink a glass of wine before sex to relax better. What?!
Umm, I’m sorry mr/ms healthcare provider—If simply relaxing more was what was needed, the sufferer would have stumbled on this “solution” long ago, and would not be sitting in your office risking abject embarrassment to discuss their sexual pain with you.
As a health professional treating sexual pain for the past 20 years, I’d like to officially give this randy piece of advice the boot—not only does it encourage drinking, which is linked to riskier sexual behaviors, it does nothing to address the causes of sexual pain, and it diminishes the depth of psychological and physical suffering that the person is experiencing.
If you feel that your healthcare provider is minimizing or dismissing your complaints of sexual pain, then it’s time to search for another provider. Pain with intercourse is NOT normal, and you should keep searching until you find someone who will take your concerns seriously, take the time to get to the bottom of what is causing your dyspareunia, and advocate for you until that pain is resolved.
When to see a pelvic floor Physical Therapist
Musculoskeletal pain and dysfunction are seen in up to 90% of people with pelvic pain, so chances are that if you have pain with sexual function, a pelvic floor PT can help. Once you and your medical practitioner have ruled out and/or treated any medical conditions as the cause for your sexual pain, it’s time to see a pelvic floor physical therapist.
If you want to discuss more about dyspareunia or vaginismus, how PT can help with the treatment of painful sex, or if you just need someone to guide you towards taking that first step in getting help, schedule time to talk with me.
It's secure and private (and it’s free :)
So let's sum up!
Many people are reluctant or too embarrassed to discuss pain with sex, or they mistakenly believe it is just a normal part of life that they have to live with. But we've just learned that this is not true! So don't hesitate to get help:
Find a healthcare provider who takes your complaints seriously and helps you find the cause(s) of your pain
Include your sexual partner at every stage of treatment—dyspareunia can be extremely stressful on your partner as well, and by honestly communicating with them and engaging them in your treatment, you both win
Don’t judge yourself–sexual pain is extremely common and is of no fault of your own.
Follow your prescribed treatment and therapy and don’t give up; it can take some time to resolve the sometimes-complex issues that cause painful sex
Consider including counseling and couples therapy to address the significant psychological and emotional components of dyspareunia
Bottom line: It’s important not to ignore and just endure pain with sex. You are not alone, and there is help available. Speak up about sexual pain, and don’t stop until you get effective treatment.
Soon you'll be well on your way to enjoying sex, like they do in the movies…
About the Author:
Angela is the owner of My Pelvic Therapy, PLLC and a licensed physical therapist. Prior to starting her telehealth private practice, she worked as a senior physical therapist for 17 years at Advocate Lutheran General Hospital in Park Ridge, IL, specializing in helping both women and men overcome their pelvic floor challenges. She received her physical therapy degree from Duke University, biology degree from University of Illinois, and is a lifelong learner of all things PT.
Click here to schedule an appointment with Angela, or you can contact her at angela@mypelvictherapy.com.