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  • Writer's pictureChantelle Morrissey

Dyspareunia- It hurts when I have sex


Dyspareunia is the medical term for pain during vaginal penetrative sex. This can occur for many reasons (some of which I will list below) but it can also occur with no known reason, which can make it a challenging condition for some women.


The DSM-5 (The most updated edition of the “Bible for Psychology” as I prefer to think of it as) defines a disorder called “Genito-Pelvic Pain / Penetration Disorder (GPPPD)”. This gives terminology and diagnosis to the many women who experience this condition.


Yong (2017) further clarified this diagnosis and outlined 4 subtypes of this condition, relating to the underlying pathology that might be linked to it. They are:


Type I- Caused by gynaecological conditions, such as endometriosis, adenomyosis, pelvic inflammatory disease and prolapse


Type II- Caused by other pelvic organs, such as interstitial cystitis (a painful bladder condition), recurrent UTI, IBS and inflammatory bowel disease


Type III- Caused by central sensitisation, where the nerves, spinal cord and brain develop a heightened pain response despite the absence of tissue damage


Type IV- Mix of sensitisation with an underlying condition. This is really common when you have had an underlying condition for a long time, as it’s common for the nerves to become sensitised when you’ve been experiencing pain for so long.


So why do we care what’s causing your pain?


It’s really important as health care providers when we are researching and treating conditions to help dyspareunia that we have some sort of conceptualisation of what’s causing it. If you have only Centralised Pain then of course surgery is not going to help you. It’s also important for you to know what is going on in your body. As Pelvic Physios, we work a lot in the space of addressing the sensitisation of pain as well as helping to manage some of the underlying conditions that may have caused it.


Why does it hurt?


Your brain is really, really good at protecting your body by paying attention and creating a pain signal. Our body has pain receptors (nociceptors) however we’ve known for a long time that you can experience pain without nociceptors firing at all (Butler & Moseley, 2013; Melzack & Wall, 1965), because pain is created in the brain. It can go the other way too- nociceptors can be firing without the experience of pain (think about the times you’ve noticed you’re bleeding but didn’t even feel it). The brain can also create the experience of pain if it believes that there is the potential for damage (Butler & Moseley, 2013).


We also know that the amount of Adverse childhood experiences (such as death or trauma) can increase your chances of developing pelvic pain (Krantz et al., 2020; Sachs-Ericsson et al., 2017). And we know that stress can increase pain (Greenwood‐Van Meerveld et al., 2016). It’s so important that when you are trying to get on top of pelvic pain, you do understand all of these mechanisms. We hear so often of women with Endometriosis having a sudden and intense increase in their pain when they are going through a period of stress (such as death in the family, relationship breakdown or loss of job). Although their actual condition is the same as it was, their pain is suddenly much worse.


It’s really important to get to the bottom of conditions that might have caused the pain in the first place. This is where your gynaecologist or doctor is so important. Thorough investigations are needed (in many cases, this may involve laparoscopic surgery to determine the presence of endometriosis or adenomyosis). But as well as this- it’s important to get on top of your pain and how this might have affected the way your pelvis is functioning.


So where does the pelvic floor come in?


Think about it. Let’s say you’re out in the yard and you twist the wrong way, and get a sudden pain shooting through your back. You might notice after a while that all the muscles around this area go into spasm. Then you’ve got a sore back AND a stiff back. That’s a protective response from your body to protect your back.


Your pelvic floor is similar. For many people who have had pelvic pain a long time, it’s really hard to relax their pelvic floor. You might have been told you have an “overactive” pelvic floor. The thing about this though is that a pelvic floor that’s always on can actually increase your pain (Aredo et al., 2017; Butrick, 2009). The other thing about a muscle that has increased tone is that it tends to be weak, because it rarely relaxes to its full rested position to complete a full and normal contraction. It’s like doing weights for biceps when your elbow is already bent most of the way.


How does Pelvic Physio help this?


We are in a unique position as therapists to look at your full history and try and nut out what factors are contributing to your pain. We might give you questionnaires so we can figure out how much of your pain is from an underlying condition and how much is coming from sensitised nerve pathways. This helps us work out a good treatment approach for you.


We can also assess your pelvic floor with an internal pelvic exam to figure out your strength and how well you can relax your pelvic floor. We can give you a program that’s unique for you to help you use your pelvic floor muscles better. Getting this under control has been shown to be helpful in decreasing pain in the pelvis (Naess & Bø, 2018).


The other thing we may do is help you with techniques to desensitise pain pathways. We can work out techniques that address the things that might be ramping up your nervous system so you can work on winding it down. Physiotherapy can sometimes involve massage therapy, EMG biofeedback devices and E-STIM devices (Klotz et al., 2019).


Take home message


Just know that there’s a lot to pain in the pelvis, and a lot of options in the toolkit of your healthcare providers. It’s so important you know there’s a lot of options out there for you and find a good team of providers around you who can help you manage this condition and get back to enjoying comfortable sex, without that pain.


References:


Aredo, J. V., Heyrana, K. J., Karp, B. I., Shah, J. P., & Stratton, P. (2017). Relating chronic pelvic pain and endometriosis to signs of sensitization and myofascial pain and dysfunction. Seminars in reproductive medicine,


Butler, D. S., & Moseley, G. L. (2013). Explain Pain 2nd Edn. Noigroup publications.


Butrick, C. W. (2009). Pathophysiology of pelvic floor hypertonic disorders. Obstetrics and Gynecology Clinics of North America, 36(3), 699-705.


Greenwood‐Van Meerveld, B., Moloney, R., Johnson, A., & Vicario, M. (2016). Mechanisms of stress‐induced visceral pain: implications in irritable Bowel syndrome. Journal of neuroendocrinology, 28(8).


Klotz, S. G. R., Schön, M., Ketels, G., Löwe, B., & Brünahl, C. A. (2019, 2019/06/03). Physiotherapy management of patients with chronic pelvic pain (CPP): A systematic review. Physiotherapy Theory and Practice, 35(6), 516-532. https://doi.org/10.1080/09593985.2018.1455251


Krantz, T. E., Andrews, N., Petersen, T. R., Dunivan, G. C., Montoya, M., Swanson, N., Wenzl, C. K., Zambrano, J. R., & Komesu, Y. M. (2020). Adverse Childhood Experiences Among Gynecology Patients With Chronic Pelvic Pain. Obstetrical & Gynecological Survey, 75(2), 99-100.


Melzack, R., & Wall, P. D. (1965). Pain mechanisms: a new theory. Science, 150(3699), 971-979.


Naess, I., & Bø, K. (2018). Can maximal voluntary pelvic floor muscle contraction reduce vaginal resting pressure and resting EMG activity? International urogynecology journal, 29(11), 1623-1627.


Sachs-Ericsson, N. J., Sheffler, J. L., Stanley, I. H., Piazza, J. R., & Preacher, K. J. (2017). When Emotional Pain Becomes Physical: Adverse Childhood Experiences, Pain, and the Role of Mood and Anxiety Disorders. Journal of clinical psychology, 73(10), 1403-1428. https://doi.org/10.1002/jclp.22444


Yong, P. J. (2017, 2017/10/01/). Deep Dyspareunia in Endometriosis: A Proposed Framework Based on Pain Mechanisms and Genito-Pelvic Pain Penetration Disorder. Sexual Medicine Reviews, 5(4), 495-507. https://doi.org/https://doi.org/10.1016/j.sxmr.2017.06.005



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