Pain with Sex: Conversations with a Pelvic PT
I was really wanting to dive further into common pelvic health issues that are either not talked about enough (i.e. pain with sex), due to embarrassment or the topic being considered “taboo”, or issue that are so common they are typically normalized when they shouldn’t be (i.e. incontinence). I had the pleasure of interviewing Dr. Victoria Mallow, PT, DPT (@restorepelvicrehab_boca on instagram) diving deeps into the topic of pain with sex. Usually I add a lot of narrative when posting an interview, however Dr. Mallow’s answers were so insightful and riveting that I wanted to plainly lay it all out for y’all. So enjoy:
1.) What is an area in pelvic PT you are passionate about addressing and why?
I love treating women with pelvic pain! Many times, women are dismissed or given an incorrect diagnosis when they present with pelvic pain, which can lead to years of suffering and self-doubt. In addition, many women are not comfortable talking about pelvic pain and many even think that their pain is normal. This is especially true when dealing with painful sex, or dyspareunia, as it is referred to. Physical therapy can make such a difference in the lives of women who suffer from pelvic pain and it feels very rewarding to see someone’s quality of life improve drastically after getting the right treatment.
2.) How do you find your patients who suffer from this (referred by other PT, referred by OB, etc.)?
Many women find me directly through searching on google for pelvic floor PTs near them. Others are referred from their physicians such as an OB/GYN, Urologist, Urogynecologist, Primary Care Physician, or Colorectal Surgeon. The nice thing about practicing in the state of Florida is that patients have direct access to physical therapy care and do not require a referral/prescription before starting!
3.)How common does someone come in with this complaint? What age do you usually see for this? Do you see females and males for this?
- Unfortunately, these complaints are very common. It is estimated that 15-25% of women suffer from chronic pelvic pain (www.pelvicpain.org) and 10-20% of women in the US suffer from pain with sex (Sorensen, 2018)
- Pelvic pain and pain with sex can occur at any age, however, I typically see this among women in their 20s-60s. I think a lot of this comes down to a generational difference in openness to speak about this topic. Many cultures still consider the pelvic area and the topic of sex to be taboo and something that is not readily discussed.
- I only treat women at the moment, however, male pelvic pain is a very prevalent and important topic to build awareness about and there are many pelvic PTs who treat male pelvic pain as well. The techniques we use are the same, regardless of anatomical sex, as every gender has a pelvic floor and much of the tissues are the same, from an embryological standpoint.
4.)What is the first thing you do when someone comes in with complaints of pain with sex?
- Sexual function is something that I discuss with patients during the initial part of the evaluation, when I gather a more detailed history and discuss their concerns. This is discussed with every patient, regardless of whether or not this is their primary complaint bringing them to see me. I describe how the pelvic floor muscles are directly involved in sexual function such as with arousal and orgasm. I try to make it clear that this region is no different from any other part of the body and that sexual function is just another part of our overall health that should not be shamed or ignored.
- During the examination, I am assessing for the specific areas that are problematic and determining how sensitive the areas are. Each examination is driven by the patient and performed in a way that is both comfortable and physically tolerable. For some, I am able to gauge muscle function internally, while for others the exam may include only external palpation, or no palpation at all. It is also critical to evaluate other contributing factors such as posture, the hip, the low back, breathing techniques, and the state of the nervous system.
5.) What are common causes for pain with sex?
There can be multiple different reasons why someone would experience pain with sex but some common causes include having an over-active pelvic floor, having an underlying medical condition such as Endometriosis or Interstitial Cystitis, having recently given birth, hormonal changes, and a history of abuse. This is why a thorough medical and social history is so important. Those who suffer from pain with sex may have pain with different stages of sexual activity, for instance only with initial penetration, deep penetration, orgasm, or a combination. Some may have always had pain with sex, while others may report a history of normal sexual function.
- I’ve seen you post about different sex “toys” like dilators and vibrators. List some of the toys you recommend and what they help with.
- Dilators and wands are tools we use and teach patients to use in order to achieve their goals. A dilator is a useful tool in relaxing the pelvic floor muscles and globally increasing flexibility and improving tone of the tissue in the vaginal canal. A wand is more specific to individual tender points in the pelvic floor. Each person would need to be evaluated to know if a tool would be helpful and they would then need to be educated on how to use it safely and most effectively to avoid pain or injury.
- Sex toys, such as vibrators, can be used as part of one’s treatment and would depend on the specific case. For those who are hypersensitive to touch and can’t necessarily tolerate internal work, a vibrator or similar sex toy can be useful to desensitize the area of interest. Vibration itself has been used successfully in other areas of physical therapy, as a way to reduce pain and elicit relaxation. Sex toys can also have the benefit of enabling one’s partner to be directly involved in their treatment and explore sexual activity together in a way that is pleasurable to both and avoids pain or fear. I often encourage my patients to consider involving their partner in treatment, if they are comfortable with it, regardless of whether or not I am recommending a toy or treatment device.
- Recommended “toys” really depend on the specific person as well as their complaints and goals. Toys that are made of glass or steel can be useful if friction is problematic and can also be heated or chilled for comfort. Silicone is a material that I commonly recommend, based on it’s non-porous properties which means it won’t harbor bacteria. Another benefit is that silicone can be boiled for sterilizing. Finally, silicone tends to have a nice balance of providing structure without being too rigid or hard.
7.) Let’s have a discussion about pain with sex post partum
Many women experience pain upon resuming sexual activity after giving birth. The tissues have just gone through a tremendous amount of stress and change during pregnancy and delivery. When a woman delivers vaginally, she may endure tearing of the perineum or have an episiotomy. When the perineum is torn or cut, it often develops some level of scar tissue during the healing process. This can leave the skin more rigid and inflexible, and thus cause pain when the tissue is asked to stretch out or be exposed to friction during sex. For women who are breastfeeding, we also must consider the associated decrease in Estrogen levels which can cause decreased lubrication and may lead to painful friction during sex. Many women also have a fear of sex after giving birth and this psychological factor can have a direct physical impact on the pelvic floor by increasing tension and guarding. If the pelvic floor cannot easily relax to allow for insertion of a finger, penis, toy, etc, the individual will almost certainly experience discomfort.
“What is especially concerning is when a medical provider tells a woman to “have a glass of wine” or “just relax” in order to deal with painful sexual activity. This is never okay and should never be the recommendation for anyone. Similarly, many patients and practitioners alike believe that once a mother is given the 6 week check-up, with no abnormal findings, she is ready to jump back into bed and have sex. This is simply not true, for all of the reasons stated above.”
Thank you for reading and I hope you learned something new with this month’s “What the Health”, be sure to give Dr. Victoria a follow on instagram @restorepelvicrehab_boca to learn more about pelvic health!
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