As a pelvic health physiotherapist, I see numerous women in my clinic devastated by pain during intercourse (dyspareunia) and the emotional repercussions it can cause. For some, they have been to various practitioners prior to finding me and many hold the belief that there is little hope of resolution. Of course, this is not the case. There IS hope. And for many women, a cure!

Sexual pain is a sensitive and emotional subject, and it takes a lot of courage to seek help. To all the women that come forward to seek help I see you and recognise that it has not been an easy journey to lead you to this point. Therefore, it is so important to find a medical practitioner that is empathetic, listens to your concerns, and refers you to the necessary practitioners that will help you on your journey to recovery. More on this to come.

How Common Is Sexual Pain?

Sexual well-being is an integral part of a person’s overall well-being. Sexual difficulties can be taboo and hard for a woman to discuss and seek help for – and therefore, sadly often go untreated. Painful sex is also a common condition with prevalence globally varying from 10% to 18% and affecting up to 28% of the female population during their lifetime. 

What Is Dyspareunia/Sexual Pain?

The medical terminology is constantly changing, and dyspareunia (painful sex) is sometimes replaced with genito-pelvic pain/penetration disorder. The pain can be superficial (pain in the vulva or entrance to the vagina) or deep (deep within the vagina), primary (pain initiated when first began sexual activity) or secondary (pain develops sometime after a period of pain-free intercourse).

Dyspareunia can lead to a multitude of issues, both physical and mental, and can have a serious impact on emotional well-being. It can lead to a lack of sexual arousal and desire, pelvic floor dysfunction, pelvic/low back/hip pain, anxiety, depression, difficulties in relationships, lack of self-worth and self-esteem, hypervigilance of pain, and negative self-image. Whoa! That’s a lot. Of course, not all women will experience each of these symptoms. 

What Is the Cause?

The cause of dyspareunia can be multifactorial and include structural, inflammatory, hormonal, traumatic, neoplastic (abnormal growth of tissue), and psychosocial factors. Therefore, it is of utmost importance to first seek help from a specialised, empathetic gynaecologist to obtain a correct diagnosis and referral to a pelvic health physiotherapist. 

While dyspareunia is a physical condition, it is important to note that it can be further compounded by social conditioning, cultural and religious belief systems, past experiences, and trauma – and these also need exploring when treating this condition.

Where to Start on Your Healing Journey?

Pain with intercourse can be very overwhelming and stressful for many women. Thankfully, there is no need to suffer in silence. As mentioned above, sexual pain is multifaceted and can be due to an underlying medical condition such as endometriosis, pelvic inflammatory disease, or vaginal prolapse for example.

Therefore, it is important to see a gynaecologist as the first point of call when experiencing pain for medical treatment of the condition. A referral to pelvic floor physiotherapy is a must, and we can help in many ways. Research has shown that physiotherapy is an underused and untapped resource when treating this condition, and experts conclude that it should be an integral part of the multidisciplinary approach to healing sexual pain.

My Approach

I believe in an intuitive and holistic approach to treating clients who experience painful intercourse. I look at the whole person – body, mind, and soul. I also have a great network of professionals that I work with and refer to. This may include psychologists, sex therapists, intimacy coaches, gynaecologists specialised in this area, pain management experts, and alternative therapists.

Physiotherapy Healing Journey

Physiotherapy treatment will firstly include pain education. Pain is a complex, multilayered perceptual experience that requires an explanation. As a sufferer, an inability to make sense of the often worrying and persisting uncertainties of pain, can cause increased sensitivity to pain and exacerbate the condition.

Knowledge is key, so it is proposed that pain education and training be provided about the nature and effects of pain and strategies on how to address the pain. The goal is to empower people to self-manage. However, pain education should be part of a larger holistic treatment approach, not a standalone treatment. 

The pelvic floor muscles will also be addressed by your physiotherapist. Pelvic floor muscles refer to incredibly important muscles that sit at the base of your pelvis and run from the pubic bone to the tailbone and the sitz bones. They wrap around and have openings for the vagina, urethra (tube for urination), and anus. They support your pelvic organs, have many functions (including supporting your pelvic organs), and are extremely important for sexual function and sensation. 

An internal vaginal assessment by your pelvic health physiotherapist is advisable, but not required. This allows the physiotherapist to assess fully the vulva, vagina, pelvic floor muscles, connective tissue, nerves, and position of the organs (bladder, rectum, and cervix). This assessment is very discreet, performed in a private room and completely at your own pace and control. I understand that this is extremely daunting for many women and guarantee my clients complete control and autonomy. I ensure the full trust between the patient/therapist before any assessment or treatment and often engage the patient in breathwork, meditation, body scan, and/or energetic settling techniques before any internal vaginal assessment and treatment.  

Research has shown that most dyspareunia clients will have both weak and overactive/tight pelvic floor muscles. This will be addressed by the physiotherapist through gentle muscle-release techniques, biofeedback, graded touch, mirror use, and strengthening as required. Vaginal dilators are also very useful tools for overactive muscles. These are graded plastic or silicone cylinders that are gently inserted into the vagina to help stretch the tissue and prepare for intercourse. I teach the client how to use the dilator in the clinic, again empowering the client toward self-management.

I am also a qualified biodynamic craniosacral therapist and use this modality in my approach. This is a gentle hands-on technique that believes in the intelligence of the body to heal itself. Through craniosacral therapy, we can address the whole person – trauma, nerves, muscles, emotions, and connective tissue included – and help the body to integrate and settle. Sexual intercourse is a serious issue that needs addressing – do not suffer in silence! We are sexual beings and should be able to enjoy sex and the potent energy it illuminates within us.

Sexual pain is multifaceted and therefore requires a multilayered, multidisciplinary approach. Both the physical and mental aspects should hold equal priority. Firstly, make an appointment to see a gynaecologist to address the medical aspects. Pelvic floor physiotherapy is also a must. Addressing the emotional and energetic aspects, conditioning, belief systems, and trauma (if any) are of importance, too. Psychologists, sex therapists, alternative therapists, and intimacy coaches are just some of the wonderful disciplines I call on to support women on their healing journey.

Neasa Barry is a Pelvic Health Physiotherapist at Heal Hub Rehabilitation Centre. Visit @herphysio and @healhub_rehab for more information.