Pain during intercourse – a common yet treatable problem – Part I

Dyspareunia is pain during sexual activity or intercourse.  It’s a problem estimated to affect 10 to 15 % of North American women who often describe the pain as a burning, stinging or ripping pain.  It can be so excruciating that often intercourse is not only unbearable, but impossible.

As you can imagine, dyspareunia can have a devastating impact on a woman’s sex life, her relationships and her social and emotional well being, in particular if you are trying to have a baby!  The most frustrating thing about this condition is that it remains appallingly undiagnosed, is rarely treated quickly and is often misdiagnosed or labeled as something psychological.  Because there is a lack of awareness surrounding this pain, women often suffer behind closed doors, refrain from disclosing their problem and, unfortunately, never get properly diagnosed and treated.

One of the most common causes of pain during intercourse is called vestibulodynia, also termed provoked local vulvodynia (pain only when touched) – PVD, or commonly known in the past as Vulvar Vestibulitis Syndrome (VVS).

Vestibulodynia is probably the most common cause of dyspareunia in pre-menopausal women.  This syndrome is characterized by an acute burning pain localized and limited to the vaginal vestibule (the region at the entrance of the vagina) and pain that is elicited by any pressure applied to this area.   This syndrome is usually accompanied by hypertonicity (increased tone or abnormal tightness) of the pelvic floor musculature and an increase in protective muscular reactions.

Secondary vestibulodynia pain can also develop post-partum as a result of any degrees of stretching and stress of the pelvic floor muscles and surrounding tissues during the birthing process.  The initial onset is usually mild compared to typical vestibulodynia and often only requires a few treatment sessions to resolve.  However if it is left ignored and untreated, this pain can also become equally as severe.

The pain/spasm cycle:

The pain associated with vestibulodynia results in a protective muscle contraction or spasm of the pelvic floor muscles.   Paradoxically, this protective response intensifies the pain: as the tension of the pelvic floor increases, the diameter of the vaginal opening decreases, increasing the pressure exerted by the penis during penetration.  The intensified pain creates more anxiety, and can exacerbate the tension and pain.  This vicious pain/spasm cycle continues to perpetuate unless it is appropriately treated.  Typically, patients will eventually limit their frequency of sexual activity and many will eventually abstain from intercourse altogether.

 

 

Etiology of Vestibulodynia:

Vestibulodynia was first identified as VVS (Vulvar Vestibulitis Syndrome) over 100 years ago; however, the etiology or cause remains unclear.  It is speculated that it may be caused by many factors:  infections (e.g. yeast); altered pH of the vaginal secretions; irritants; trauma; hormonal imbalance; chemical therapeutic agents (e.g. creams and antiseptics) and destructive agents (e.g. laser or cryosurgery).  From my clinical experiences and those of my colleagues, some patients who have vestibulodynia do not report any of the above causes.  There does, however, seem to be something in their past experience that links pain with vaginal penetration (e.g.  an emotional trigger, such as a traumatic relationship or a painful internal examination).

Secondary vestibulodynia pain post-partum is typically due to the varying degrees of pelvic floor trauma as the baby stretches through the birth canal.  This can occur even if the baby is not born vaginally.  With a successful vaginal birth, the perineum and pelvic floor muscles have undergone some degree of stretching and stress (i.e. trauma).    Consequently scar tissue is formed as they repair.  Often this scar tissue lacks extensibility (elasticity) and requires specific stretching.  The pelvic floor muscles may also need some stretching and other techniques to ensure that the tissue mobility and tone is normal and to work out any tightness or trigger points that can refer pain.  This is even more apparent with interventions such as forceps, manual manipulations or ventouse (suction).

Symptoms of Vestibulodynia:

Patients often describe the pain with vestibulodynia as a burning, stinging, and even ripping pain.  This is caused by a change in the neuromuscular pain mechanisms (i.e. the route of pain transmission or nerve pathway, from the pelvic region to brain and back), which leads to a hypersensitivity to the pain.  The pain perceived with normal touch can also become abnormal in sensation and intensified.

Other less common symptoms can include:

• erythema (inflammation or redness) at the opening of the vagina
• bladder symptoms (urgency and frequency) and bowel problems (i.e. irritable bowel syndrome)
• pain around the urethral opening, urethra and anal region.
• pain or discomfort during ordinary activities of normal living such as sitting and exercising
• decreased tolerance to tampon usage
• decreased tolerance to tight pants, in particular pants with a thicker inseam (i.e. jeans) or pantyhose
• pain during post-coital urination lasting for 1-24 hours

Because vestibulodynia is such a private pain, women find it extremely difficult to disclose their problem and therefore refrain from seeking immediate help or treatment.  They suffer quietly, unaware that this is a condition that can be treated effectively.  When these patients finally seek advice from their family physician, they are often sent into a loophole of consultations with different doctors and specialists before being diagnosed with an actual condition.   Various ineffectual treatments are subsequently prescribed, often leaving the patient grasping at loose ends.

When a referral is finally made for treatment, such as pelvic floor physiotherapy, the patients’ lives have already been greatly impacted.   You can imagine the gratitude and relief these women feel knowing that their problem is not only very real but treatable!

Treatment:

Women with vestibulodynia naturally hope that abstaining from intercourse or other activities that provoke this pain will eventually lead to a decrease in their symptoms. Occasionally there may be spontaneous remission of symptoms, but more often there is not.  Typically, there is no change in their symptoms and the “time heals all wounds” rule really doesn’t seem to apply.

The good news is that effective treatment does exist for vestibulodynia or dyspareunia called Pelvic Floor Physiotherapy or Rehabilitation.

Pelvic Floor Physiotherapy:

With pelvic floor physiotherapy or rehabilitation, patients learn to limit the magnitude of the protective response to vestibular pressure, and to consciously relax the muscles of the pelvic floor for penetration.  As the patient realizes the role that she an play in pain control, her anxiety to penetration decreases, and this in turn, further decreases the pain (the pain/spasm cycle is broken!). Pelvic floor physiotherapy is very effective in treating vestibulodynia and often full recovery is established where the patient has normal sexual intimacy and pain free intercourse!

Pelvic floor physiotherapy also assists in releasing trigger points, tightness or scar tissue often found in the pelvic floor muscles resulting in decreased pain.  Desensitization of the tissues in the vestibule also assists in normalizing the neuromuscular pain mechanism which decreases the intensity of the pain and abnormal sensations. As the pain continues to subside and the patient learns to further relax the pelvic floor muscles, comfortable sexual intimacy becomes possible once again!

A large role of the physiotherapist specializing in pelvic floor physiotherapy is to educate and provide techniques on how to relax the pelvic floor muscles, thereby stopping the pain/spasm cycle.   She will reassure the patient that this problem is very prevalent and will explain the expected course of treatment before the physical examination and assessment.  During the treatment sessions, the physiotherapist keeps the patient fully informed of any procedures that will be performed and explains the advantages and benefits of treatment.  The patient remains comfortable and relaxed during the treatment sessions.

Please stay tuned for Part II of Pain During Intercourse, where various assessment and treatment techniques of pelvic floor physiotherapy are further described and discussed in detail.