A SENSITIVE SUBJECT: HOW CAN PAIN AFFECT A RELATIONSHIP?

Written By Ingrid Harm-Ernandes

February is often associated with love and relationships because of Valentine’s Day. While for some people this is a time to appreciate and shower their loved ones with gifts, for others it can be a time of frustration and pain. As a pelvic physical therapist, I have seen so many people who have pain centered at their pelvic floor and over time it begins to impact their entire lives. Relationships suffer or sometimes are not even begun because of pain or the fear of that pain. There are many reasons for this, but unfortunately for some people not only can physical pain occur with intercourse it can also eventually progress to difficulty with relationships and emotional pain as well While sex is not always part of a relationship for many it is an important part

Pain with intercourse can occur for a number of reasons and it often goes by many different names

Vaginismus, genitopelvic pain/penetration disorder, and dyspareunia are a few names These terms generally mean that an individual has pain during sexual intercourse or other sexual activity that involves penetration and involuntary contraction of muscles around the opening of the vagina This will make intercourse painful and even impossible For those with a penis, pain can also impact sexual activity This can be during intercourse, at ejaculation, or after intercourse There are many potential causes of pain with intercourse for anyone These may include injuries to the pelvic region, pudendal neuralgia (compression of a nerve in the pelvis), vulvodynia, tissue changes that occur during menopause, post-pregnancy, and during cancer care, and response to physical or emotional trauma

There is a common connection with all of these cases.

That is the pelvic floor muscles (levator ani). They can tighten and/or have difficulty relaxing in day-to-day activities. When intercourse occurs these same muscles contract and make it difficult to have comfortable penetration during intercourse Imagine if you held your hand in a loose fist you could pass a finger from your other hand thru it easily and comfortably If you now tighten that fist it would be difficult and painful to get that finger through and if the fit is tight enough you could not fit your other finger through that fist at all If the tissue has less lubrication, as might occur during menopause or with cancer treatment, then this can be abrasive as well

This can lead to more pain Once the body knows that pain occurs with intercourse then the muscles will tighten more, making it more painful

You can imagine that if you know something is going to be painful you tense up, perhaps clench your fists or grit your teeth If you know intercourse is painful your body will automatically tighten the pelvic floor muscles to protect you. Unfortunately, this leads to tighter muscles and a tighter vaginal entry, and more pain. This cycle can continue until intercourse is no longer possible. This is not something that the individual is trying to make happen, it happens automatically.

Pain with sex is something that for years was treated as purely a psychological issue and the musculoskeletal system was not considered as a possible cause As a result, the muscles were ignored and people did not get proper treatment In fact, women were often dismissed when they did feel brave enough to ask their practitioner about pain with sex Many of my patients would come to me telling me that their practitioner told them to “Just go have a glass of wine and relax, honey!” This would often make the situation worse Stress and anxiety over the pain would worsen and the patient would often blame themselves for not getting better. This cycle would eventually become so strong that the patient stops having intercourse or just grit their teeth.

The good news is that people can get treatment and can find themselves starting or returning to their relationships. Their quality of life improves tremendously for both themselves and their partner.

Pelvic physical therapy is the answer to so many of these conditions Pelvic physical therapists work with patients to improve tissue health and muscle function at the pelvic floor as well as muscle health throughout the hips, pelvis, back, and abdominal regions They will guide the patient through various stretching techniques that might involve using dilators or wands at the pelvic floor Dilators are of various sizes starting at a width that is about pinky-sized and graduating up to help slowly stretch the vaginal or anal canal The wands are “S” shaped and help release trigger points anywhere at the pelvic floor internally and externally

Both devices can help slowly stretch the tissue and prepare the patient for starting or returning to comfortable intercourse Exercises for the entire body are often needed to help with flexibility and mobility that helps the patient with all activities as well as sex A pelvic physical therapist will determine the patient’s ability and guide them through the entire process at a rate that is specific to that patient’s needs Every patient is different and requires a program that is tailored to them In addition, a pelvic physical therapist may suggest working with other practitioners like urogynecologists, gynecologists, endocrinologists, sex therapists, acupuncturists, mental health practitioners, and more They may have you involve your significant other if it is appropriate It is important to have a team approach when working with such a delicate subject

It can be very difficult for a patient with pain from sexual activity to step forward and ask for help This can be out of embarrassment, because they have been told to live with it (“drink a glass of wine”), or because they are not aware that they can get help This needs to change There is so much misinformation on social media that can make learning about pain with sex and where to get treatment difficult It is important to reach out to your medical practitioner That can include a family medicine doctor practitioner, a urogynecologist, a gynecologist, and a pelvic physical therapist If you do not get answers to move on to another practitioner who will listen to you

Once you have started treatment with a pelvic physical therapist, they may recommend that you work with other practitioners to round out your team When you start seeing the progress you can see how your life can drastically change It may take a while but be patient and keep working at it There are some websites that help with learning about sexual health The Academy of Pelvic Health: https://aptapelvichealth.org/ and the American Association of Sexuality Educators, Counselors, and Therapists: https://www.aasect.org/about-us are some reputable sites to investigate My book “The Musculoskeletal Mystery: How to solve your pelvic floor symptoms” explains, in detail, the pelvic floor, pelvic physical therapy, members of your health care team, and some self-help tools to start your treatment https://www.linkedin.com/in/ingrid-harm-ernandes-5057773b/ https://www.facebook.com/ingrid.harmernandes.71/

With knowledge about our bodies and understanding that pain can happen at the pelvic floor and pelvis, and even better yet that there is treatment, we can move toward improving our pelvic health and our relationships. Partnership and teamwork guided by a pelvic physical therapist, and using the right tools, can be the answer to the question that some people don’t even know how to ask.

Hopefully, guided by good information as cited above, people with feel more confident to step out and ask for help and find the right treatment. Relationships that already exist will become less stressful and more fulfilled and some may even find they are ready to start a relationship. Pelvic physical therapy can make that happen.

Ms. Harm-Ernandes is a pelvic physical therapist. She was the Co-Director and a mentor for the Duke Women’s Health Physical Therapy Residency Program, a mentor for new pelvic PTs, and participated in PFDN research projects. She is board certified in Women’s Health (WCS) and Pelvic Bloor Biofeedback and served on committees for both the APTA and AUGS. She enjoys presenting the importance of recognizing and assessing the pelvic musculoskeletal system. She published “Assessment of the Pelvic Floor and Associated Musculoskeletal System”, in the FPMRS journal in December 2021. In 2021 she published her book, “The Musculoskeletal Mystery: How to solve your pelvic floor symptoms”. She has been a guest on national and international podcasts and webinars and is “The Pelvic Detective on YouTube. Her goal is to provide individuals with the knowledge they need to get proper pelvic care and for everyone to realize that pelvic conditions are common but not normal.