Pain during sexual intercourse, called dyspareunia, is a common (but under-reported) experience. This pain can be due to a variety of factors, but unfortunately because of the taboo nature of the subject, many women suffer for years without getting help. They assume that there’s nothing that can be done about the pain they’re experiencing and so they simply choose to live with it instead.
The truth is, a lot can be done to help women who suffer from pain during sex, including physical therapy. To help shed light on this topic and increase awareness of possible treatments, I interviewed Pelvic Floor Physical Therapist Sandy Hilton about this topic.
Tell us about yourself:
I am a Doctor of Physical Therapy and have been practicing since 1988. I am the co-owner of Entropy Physiotherapy and Wellness, serving Chicago to restore hope and movement in those dealing with persistent pain, incontinence or painful sex. I serve as the Director of Programming of the Section on Women’s Health of the American Physical Therapy Association and am a member in several international organizations dedicated to providing top-notch health care.
What are some reasons that men and women might find sex to be painful?
Over 1 in 7 people experience pelvic pain and roughly 90% of those will have painful sex. There are multiple causes of pelvic pain in men and women. If it hurts in your pelvis, groin, belly, genitals or the hips during or after sex, you should see a physician for a good evaluation! Find a pelvic health specialist in your area, look for Urologists, Urogynecologists or Gynecologists who are experts in pelvic pain and sexual dysfunction.
Common causes that we see in the clinic are related to stiffness of the muscles of the pelvic floor (those that you tighten when you do a Kegel), sensitive nerves in the area (from injury, repetitive use like long bike rides, following an infection or even sudden onset with no traceable cause), back pain and gut problems. Diagnosis like Vulvodynia, Dyspareunia, Pudendal Neuralgia, Prostatitis and Painful bladder Syndrome may all result in pain in the perineum and painful sex. Many endure this pain for years and treatment can be delayed by delayed diagnosis, insurance limitations or being incorrectly told that there is no help available.
What type of treatment can physical therapy offer for these issues?
Physical therapists provide essential care in eliminating painful sex. The right treatment plan starts with a thorough evaluation that includes your history, your goals and a full movement screen, check your strength and coordination and importantly, test the muscles and movements inside and around the pelvis.
It’s pretty common in painful situations to have a “non-relaxing pelvic floor.”
We teach you to be able to tell when your pelvic muscles are contracted/held tight and how to relax those muscles again. This is the opposite of doing a Kegel contraction. Strength is important, but to be strong you need to be fluid, supple and coordinated.
Pain neuroscience education is an essential part of comprehensive treatment. Understand how the pain system works will give you daily reassurance and hope that the movements and function you have lost will come back with careful, coordinated treatment. We teach you to understand pain and ultimately, to change your pain. Part of this is learning to do Graded Imagery and Graded Exposure, tools that train your brain and your body (we really can’t separate those things!)
Other treatments may be using biofeedback (EMG) to show you on a screen the activity of the pelvic muscles, the use of dilators or vibrators for tissue stretch or relaxation, instruction in Mindfulness/Meditation and movement re-training that may include Yoga, Feldenkrais or Franklin Method exercises.
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How long does it take to see progress?
I expect to see change from one visit to the next. It’s going to take some time, but really, you should see and feel measurable improvement each week. I think it’s faster to make change if you get to treatment quickly! I’d love to see people within the first 6 weeks of their condition rather than they typical “I haven’t been able to have comfortable or pleasurable sex for 5 years." That’s way too long to wait before getting help!
What if the OB/GYN says the patient doesn’t need physical therapy (or says they need surgery?)
Some physicians don’t know what physical therapy can do to help. They may think that physical therapy for pelvic health is just teaching kegels – and I agree that wouldn’t be helpful for pelvic pain. When the doctor understands that physical therapy is a great way to get the brain, mind and body doing better, to bring the pain response down and restore healthy motion to the irritated parts, then they often are agreeable to a trial.
If it isn’t a life threatening condition then a qualified pelvic health physical therapist is a sensible first try!
Besides pain, what are some other reasons that folks might avoid sex?
Incontinence will certainly play a part in wanting to avoid sex. Pelvic organ prolapse is another condition that may make it uncomfortable to have sex. For both men and women there may be changes in hormonal levels that make sex not interesting, not comfortable or you may be concerned with changes that come with age. There is help for many of these things, often with coordination between your MD and the physical therapist.
What if a patient says, “I had surgery to “fix” my problem, but I still have pain, why?”
Pain is a protective response that has to do with if your brain thinks the area where your hurt is in need of defense! If you’ve had a surgery and the pain persists, it may be less about what’s happening in the area and more about protecting it – this is all outside your conscious awareness, it’s a pretty cool system and we would die without the ability to feel pain. BUT – if you are stuck in pain, then you need to get to someone who can help you figure a path back to well being. It takes training the brain and the painful area both! There is hope.
Anything else you want to mention about sex?
Sex and intimacy are an important part of life. It helps us to feel connected, wanted, appreciated and it is great for your pelvic muscles. Orgasms are helpful for staying healthy!
Thanks so much, Sandy, for sharing your expertise. You can find Sandy on Twitter at @SandyHiltonPT.
Note from GGS: This interview was published on Prana-PT.com and is shared here with permission.
I had an uncomplicated vaginal birth in January. Things didn't feel great in my pelvic floor but I thought it was expected after growing and pushing a baby out! Two weeks postpartum, my midwife gave us the go-ahead to have sex, and at about three weeks postpartum we tried. It was excruciatingly painful, we weren’t even able to go through with it because everything was too tense and tender.
I asked some close friends who’d had babies, and none of them had this experience. We tried again and again, and continued to have the same result. Usually ended up with me crying in pain and disappointment. I got even more upset. No one ever told me this was possible. All you ever hear about is women getting 'loose' after having a baby, but for me it was like I was smaller!
At my six-week check up with my midwife, I finally shared with her how I was feeling. She couldn't explain it and told me it would just take time and practice, but she referred me to a pelvic floor physical therapist for some heaviness/weakness I was still experiencing.
Once I went to see the physical therapist, who did some manual release and gave me some exercises to work on, things started to improve, though they weren’t perfect. After months of some improvement, I had saw a pelvic floor physician, and she prescribed estrogen cream—that was the game-changer. I wasn’t tender anymore, which meant I wasn’t tensing up in fear of the pain. It took a lot of self-advocacy and insisting that things weren’t right to finally get back to a point where I look forward to enjoying sex again, at nine months postpartum!
At age 20, I started to experience dyspareunia due to pelvic floor dysfunction which accompanied the diagnosis of interstitial cystitis, a chronic bladder disorder. My then-boyfriend and I experienced difficulties with sex and all of the troubling intimacy problems that come with it.
Once I started to control my bladder symptoms, I put the pelvic floor problem off for a while, hoping it would somehow subside. When it didn’t, I concluded that it was something we would just have to live with. Of course, as supportive as he was, this only caused more distance between us, and with each passing day, I felt more and more inadequate. At this point, the symptoms had begun to trickle into other aspects of my life. It got to the point where I wouldn’t sit in chairs anymore because it was too painful.
I was lucky enough to find a gynecologist in my area who specializes in these issues, and she suggested a pelvic floor physical therapist. With some hesitance, I started seeing her twice weekly, and I noticed improvements almost immediately. Like anything else, it didn’t change overnight. But with compliance, sex became more comfortable within a couple of months. Eight years later, I still continue the exercises regularly, I no longer look towards sex with trepidation, and my now-husband and I are much more confident in our physical relationship. Without a doubt, choosing to see a physical therapist for these issues was one of the best healthcare decisions I’ve ever made.
I was experiencing discomfort during and after sex in early postpartum, after my C-section birth. This can take women by surprise after a Cesarean, but it really is more common than you think. For me, I was experiencing some pain around my incision during sex and a burning sensation afterwards.
I had began working with my pelvic floor physiotherapist at five weeks postpartum, so luckily I had a trusted source to talk with, even before I started having sex again.
After two or three sessions of internal release work done by my physio, all the pain and stinging gradually subsided. We also talked about certain positions during penetration that can be more comfortable for postpartum mamas. As always, pelvic floor physiotherapy is the #1 thing I recommend moms do after pregnancy!
I have been seeing a pelvic floor PT since June of this year. I was seven months postpartum at that point, and along with SUI and diastasis recti, sex with my husband was also painful. I knew something was wrong and I needed help when sex never got better, it always hurt, and I was always peeing during anything strenuous. I found out about a pelvic floor physical therapist through my own research, as the organization that I was following throughout my pregnancy and postpartum had no mention of it or why I would need to see one. Since being in physical therapy, sex is back to normal (when it happens), my diastasis is mostly closed, and my fascia has much tension when I'm working—and no more peeing my pants!
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