Assessment & diagnosis
- What symptoms you feel, and when
- Triggers that make it worse
- Things that help relieve symptoms
- External (and sometimes internal) examination
- Movement of the midsection, lower back, hips, and pelvic floor
Painful sex
Pain at the vaginal entrance, inside the vagina, or elsewhere in the pelvis in response to penetration (medically called dyspareunia). It is common, and it responds well to assessment and treatment.
Understanding painful sex
Painful vaginal sex (medically called dyspareunia) covers pain that occurs at the vaginal entrance, within the vagina itself, and pain that begins elsewhere in the pelvic region in response to penetration, whether from digital, oral or other penetrative intercourse, inserting a tampon or menstrual cup, or using a dilator. Because it can arise from a wide array of causes, the exact incidence is unknown, but an estimated 12 to 58% of women experience dyspareunia. Pain with anal intercourse in both men and women is covered on the painful anal sex page.
Dyspareunia can be a longstanding issue present since childhood or adolescence, with some genetic and environmental factors, while other cases develop later in life from trauma or other medical or biological processes, such as hormonal changes with puberty or menopause, or chemotherapy, among others.
What painful sex can feel like
Common signs and symptoms that suggest something is not quite right downstairs include:
- Painful sensations when touching the genitals or perineum (the area between the vagina and anus)
- Sharp, burning, or knife-like pain at the start of, during, or after intercourse that can linger for days
- Pain when wearing tight or fitted underwear or swimwear, particularly when sitting down
- Pain with pressure to the genital region, even sitting on a contoured chair or a bicycle
- Pain with insertion of hygiene products (tampons, menstrual cups, and similar)
- A sense of difficulty relaxing the pelvic floor, feeling constantly "on" or "tight"
- Many cases have a normal-appearing vulva and vagina (no redness, discharge, or other visual changes)
Note: vaginal bleeding after intercourse beyond light spotting, haemoserous (blood-tinged) discharge with deep, heavy sensations in the pelvis, or palpable masses in the lower abdomen, the vaginal walls, or the deep vagina near the cervix are medical emergencies. They warrant review by your GP, specialist, or emergency medical team to exclude conditions that are beyond the scope of physiotherapy.
Why sex can be painful
Painful sex is what it sounds like, pain with sex, and it includes all forms of sexual contact. It can show up as pain anywhere around or in the vagina with initial penetration that settles through sex, pain during or worse with longer sessions, pain after sex, or pain at the vulva, labia or vaginal entrance that can be irritated even by digital, oral, or assistive device (wand, vibrator, and similar) stimulation. Painful sex is an umbrella term for one of the primary symptoms people experience, and some of the conditions that can cause it are listed here.
Conditions that can cause it
- Vaginismus (muscle spasm of the muscles around and in the vaginal entrance)
- Referred pain from the joints of the lower back or the SI (sacroiliac) joint
- Referred pain from the back, hip, buttock, or pelvic floor muscles
- GPPPD (genito-pelvic pain / penetration disorder)
- Tactile vestibulodynia (sharp pain or burning at the vaginal entrance)
- Lichen sclerosus and other changes to the labia and vulval skin
- Deep pelvic pain conditions
- Pudendal neuralgia
- Endometriosis and adenomyosis
- Pubic symphysis or coccygeal (tailbone) pain
- Pelvic organ prolapse
How I treat painful sex
Treatment techniques
- Desensitisation techniques for skin and superficial tissue
- Trigger point and other muscle relaxation techniques
- Skin and mucous membrane optimisation strategies
- Pelvic floor muscle relaxation, strengthening, or co-ordination
- Progressive exposure to penetration using dilators
Your home program
- Exercises and strategies that extend the in-clinic treatment
- Breath work and pelvic floor co-ordination exercises
- Lower back, hip, and pelvis mobility or strength exercise
- Desensitisation strategies day-to-day and in the bedroom
- Modification of intercourse strategies and positions
Your first visit
During your first visit, I'll go through what has brought you in, the history and timeline, and the contributing factors that might be present, both lifestyle and medical or surgical, anything you have already tried that did or did not help, and what your main goals are. Where it is relevant, I'll also ask about your bladder and bowel habits if they are affected, your sexual habits if they are affected, and day-to-day habits that are affected (sitting, cycling, using tampons, pessaries, or other insertive hygiene products).
To diagnose accurately and build a treatment plan when there is pain in or around the pelvic floor or pelvic organs, I'll assess the pelvic floor. This is done externally for generally all presentations, and in many cases where there is pain with penetration, an internal (vaginal) assessment is recommended, as the muscles are most accurately examined about one knuckle's depth inside the vagina, along with checking the sensitivity of the vulva, labia, and the superficial pelvic floor muscles around the vaginal entrance. External examination only is an option if you are not comfortable with an internal one, along with ultrasound to view the deeper tissues and how they move and work in different positions and activities.
After the examination, treatment usually begins in the same session and often involves manual therapy in some form - sometimes soft tissue techniques to relax or desensitise muscle or tissue that is sensitive to touch or stretch, and sometimes relaxation or down-training, activation or co-ordination of the pelvic floor if the muscles are hard to feel working. Depending on the structures involved, there can be strategies to reduce sensitivity at the vaginal entrance (whether muscle, skin, or the stretchy tissue near the entrance), along with how to resume some activities at home and how to modify them to make them more tolerable as you recover. If I find other contributing factors during our initial discussion, I can talk you through exercises to continue at home, along with what to keep doing, what to modify, and what to temporarily avoid in the early stage of your recovery.
All of this is packaged into a plan to continue at home between sessions, where I continue or adapt the hands-on techniques as you improve, monitor your progress, and increase the intensity or complexity of the exercises as needed.
Consent is ongoing, specific, and yours to withdraw at any time.
Common questions about painful sex
What causes pain during sex?
Painful sex can come from a number of causes, and having an idea of the timeline or any contributing factors you have noticed helps identify the main reasons. Common causes include sensitivity of the labia or vaginal entrance, muscle tightness or irritability around the pelvic floor that does not tolerate the stretch of penetration, irritability of the nerves that supply sensation to the pelvic floor and genital region, and referred pain from the lower back, buttock, hip and pelvic regions. In some cases, position, lubrication, and the size of your partner can play a role in the onset and intensity, and there are remedies and work-arounds where those are contributing.
Can vaginismus be treated?
Vaginismus is one of the types of painful sex, and historically it was used as the umbrella term for pain with penetration. These days it sits within the GPPPD (genito-pelvic pain / penetration disorder) category, where there is muscle spasm or tightness around the vaginal entrance and superficial muscle groups that resist stretch and contribute to sharp or burning pain with penetration or insertion. Vaginismus can be treated with physiotherapy alongside a pain and trauma-informed approach to help desensitise and improve tolerance and comfort.
Will treatment involve internal work?
Because many of the symptoms of painful sex are located internally, assessment and treatment are best led with an internal examination, which can then guide treatment such as releasing (soft tissue techniques to relax or desensitise) the muscles inside the vagina or the soft, stretchy tissue at the vaginal entrance. This can be uncomfortable or painful at the start, since it is one of your primary symptoms, but the treatment is not designed to be painful ongoing. If you prefer, I can use pelvic models to demonstrate what to look and feel for, and you can give me real-time feedback on what and where you are experiencing symptoms. I can also use models to demonstrate treatment and home exercise techniques best performed internally, or give you techniques that can be performed externally if you need a slower, more gradual approach.
Book an assessment
Not sure if I'm who you need? Ask me and I'll let you know if physiotherapy is the right fit, or point you to who is.