Painful sex or Dyspareunia

Painful Sex or Dyspareunia

Introduction to Painful sex or Dyspareunia

Definition: This is pain during sexual intercourse or pain with sexual activity that involves penetration.

Dyspareunia can occur in men and women who are sexually active regardless of their age. The majority of dyspareunia or painful sex is seen in women but men also can be suffering with this diagnosis.

Physiology of Painful sex or Dyspareunia

When intercourse is painful (dyspareunia) our muscles naturally contract to protect from the pain. and in anticipation of pain. This anticipation of pain can lead your nervous system to react with a cascade of events leading to even tighter muscles, vaginal dryness and loss of lubrication. When this happens, intercourse becomes even less comfortable, resulting in more pain. Hence this becomes a viscous cycle that need to be broken and can be done with Pelvic Physical therapy.

Types of painful sex or dyspareunia ( in women)

1.Superficial Dyspareunia

2.Deep Dyspareunia

1. Superficial Dyspareunia :

Pain at the entrance of vagina during attempted penetration is superficial dyspareunia.

Causes of Dyspareunia

This type of dyspareunia can occur due to any of the following

Dryness of the vagina due to

Inadequate foreplay

Hormonal imbalance as in perimenopausal women and in women who are breastfeeding.

UTI

Injuries to the Genital area

Vaginismus

Vulvodynia – involuntary contraction of the vaginal muscles

Surgery : anything that narrows the vaginal opening such as episiotomy and it’s repair post child birth.

Congenital tight hymen

2.Deep Dyspareunia

Pain post penetration during the thrusting movement is Deep Dyspareunia

Causes :

Retroverted Uterus : Normally the uterus is tilted forward on the bladder, but it can be tilted back in retroverted uterus and this can cause dyspareunia.This can be surgically corrected if severe.

Vaginismus

P.I.D. ( Pelvic Inflammatory diseases) infection of cervix , uterus or vagina .

Endometriosis

Gynecological cancers : Ovarian, Uterine cancers and Fallopian tubes.

Scarring from radiation and Chemotherapy or surgical scars.

A through exam is the start to the solution of dyspareunia

Diagnosis for painful sex or dyspareunia

Subjective History:The diagnosis depends on the symptoms the patient reports such as when does the pain occur and where is the pain.For ex.

1.When do you have pain during intercourse ? Is it at the entrance of the vaginal opening or during thrusting?.

2. How long does the pain last ?

3.Was there ever a time when intercourse was not painful?

4. Any history of sexual abuse or genital trauma?

5.Any History of sexually transmitted diseases?

Pelvic Exam :This may be followed by a gentle but through pelvic exam to assess hypersensitivity to touch and any increased inflammation.The pelvic area may be touched by a cotton swab to assess the area of pain and sensitivity externally.The pelvic muscles may be assessed internally by gently inserting a gloved and lubricated finger through the vagina.

Pelvic Physical Therapy for painful sex or dyspareunia :

Physical Therapy: Intervention will include

Massage techniques/ Myofascial release.

Relaxation training , with Diaphragmatic breathing and Reverse Kegels.

Stretching.

Strengthening of weak muscles.

Postural training and coordination of the muscles that support your core.

I evaluate the back, hips and possibly the rib cage region to see if there are any imbalances in those regions contributing to your pain. I also be teach self-care techniques for you to utilize at home and possibly with your partner. PT is a process with which one has to have patience if you wonder about the duration of PT before you see results check this article I wrote on that subject matter.

Painful sex or Dyspareunia in Men

Painful sex or dyspareunia defined by ICS : It is Penile discomfort occurring during intercourse , may be caused by penile diseases ,altered vaginal anatomy( vaginal tightening and scarring) or various positions during intercourse, that causes impingement of the uterine cervix.

Chronic Dyspareunia : is recurrent or continuous pain that occurs in the pelvic and genital area that occurs during and after sexual intercourse, for 3 months or more pain may in the penis may be accompanied by a burning sensation.

Causes:

Psychological Causes:

Sexual Abuse

Anxiety

Stress

Fear

Medical Causes:

Phimosis : Tight foreskin

STD

Testicular Cancer

It can also be due to tears in the foreskin or Peyronie’s diseases.

Infections of bladder, UTI can cause painful ejaculation.

Conclusion

Painful sex is a common occurrence but not normal .

This is treatable and there is a solution to the problem.

Pelvic Physical Therapy can effectively treat this condition in most cases with success.

Please leave your questions and comments below .

References:

www.practo.com

July 7, 2020July 14, 2020

Guide to Pudendal Neuralgia and Physical Therapy

Introduction

Are you suffering with pain in the butt( pudendal neurlagia ) or is it siatica? How do you know? Pudendal Neuralgia is chronic pain in the innervation of the pudendal nerve, which is in the perineum( genital area). This can be found in men and women but 2/3rd of the patients are women. Pudendal nerve is the main nerve of the pelvis. it is formed in the low back in the pelvis near the tailbone, its travel in the pelvis is tortuous as it weaves its way in and out of the pelvis giving branches of nerves on its way to different pelvic floor muscles.

It is particularly vulnerable for compression in 2 anatomical areas 1. the Alcock’s canal and 2. in the “clamp” the nerve course between sacrotuberous and sacrospinous ligament.The cure of pudendal neuralgia will depend on targeting the cause of the symptoms, this is discussed more in the physical therapy section of this post.

Other names for Pudendal Neuralgia:

Pudendal canal syndrome
Cyclist’s Syndrome
AlCock’s Syndrome

Causes of Pudendal neuralgia

Nerve compression as in ligamentous or fascial entrapment (cyclist, childbirth injury and scarring)
Change of bony alignment as in sports injury.
Increased pelvic muscle tone ( fear or due to pain ) can compress the nerve.
Decreased pelvic and hip flexibility.
Any surgeries and resulting scars in the pelvic area.
Chronic Constipation ( lots of repetitive small trauma)
Recent loss of wt,decreasing the cushioning and causing compression of the nerve.

When nerves get irritated chronically pain is perceived at a lower level and the pain response is greater.

Is it Pudendal Neuralgia? If your answer is yes to the following it might be PN.

Do you have pain with sitting but reduced when sitting on the toilet?
Did your problems begin after biking for a long time?
Did your problems begin after a fall on your tailbone (coccyx)
Do you have incontinence of stool, gas or urine ?
Did you have pain during intercourse ?
Do you have pain after ejaculation?
Do you suffer from sexual impotency ?

Symptoms:

Pain is the main symptom, pain which progressively gets worse as the day goes on and pain with sitting but relieved by sitting on the toilet.
Symptoms may also be experienced as bladder. bowel and sexual dysfunction.
Symptoms may start suddenly or be of a gradual progression.
Symptoms may be on one side or both sides of the perineum.
Skin of the perineum may be sensitive to touch.

Location of pain: Perineum sometimes can be the hip and pelvis as well.

In the labia
Vulva
Clitoris ( Penis and Scrotum in men)
Urethra
Rectum and Anus

Diagnosis:

Pudendal nerve neuralgia is rare and is difficult to diagnose, it usually coexists with Pelvic floor dysfunction and is hard to diagnose.The most common misdiagnosis in men of PN is nonbacterial prostatitis. The Dr. who treat PN are Neurologists pain management Drs.. Some of the tests used to diagnose Pudendal neuropathy are as follows

Pudendal nerve motor latency test (PNMLT)
EMG ( Electromygraphy )
3T MRI
MRN ( Magnetic resonance neurography may give clear enough images to see nerve entrapment )
Diagnostic nerve blocks (CT guided)

To summarise the Conclusive diagnosis depends on the following

Symptoms consistent with PN.
An abnormal test, ( any of the above listed )
Pain along the pathway of the nerve.
Ruled out all other possible causes and diseases, such as infection , prostatitis (in men). Vaginal infections or STD’s to name a few .

Treatment for Pudendal Neuralgia:

PN is more likely to respond well to treatment when caught early .

The treatment can be divided into

Conservative Treatment
Surgical Treatment

Conservative Treatment:

A through Physical exam and understanding the symptoms
Ruling out all other causes of the pain, such as coccyxdynia ,interstitial cystitis and prostatitis
Tests to rule in Pudendal neuralgia
Physical Therapy
Pudendal nerve block
Medications,( Antidepressants )
Lifestyle modifications – Avoiding the prolonged pressure on the buttocks by limiting sitting, avoiding strenuous exercises
Perennial suspension pads to help relieve pressure when sitting.

Surgical Treatment :

Surgery includes relasingthe entrapped pudendal nerve, which can be 3 approaches

Trans-perenial
Trans-rectal
Trans-ischiorectal

Physical therapy for Pudendal Neuralgia

Physical Therapy is a very important part of conservative treatment of the PN. Treatment is most effective in a team approach. PT, plan of care is going to depend on the findings during the Initial evaluation, after taking a thorough history and a physical exam, I prepare a custom tailored plan for the patient depending on the patients goals and the impairments I found.

When increased tone of the pelvic floor muscles and Trigger points are found (a trigger point is a hyperirritable spot in the muscle fibers which is painful with compression.)Trigger point release can be done manually when trigger points are identified. A more aggressive trigger point treatment would be trigger point injections ( injections are usually done by a Dr.)
When Pelvic floor dysfunction is noted, relaxing and lengthening the tight or shortened pelvic floor provides relief. Kegels is not appropriate to be done in this case.
Pudendal nerve gliding is done when abnormal neural tension is noted.
When Biomechanical and structural abnormalities are found in the SI joint, hips, low back, and joint hypermobility, exercises to improve stability and restore function are taught.

Dos	Don’ts
Do Stretching to lengthen the pelvic floor. Do seek myofascial release and trigger point release. Do Diaphragmatic breathing to coordinate relaxing the pelvic floor muscles	Don’t do pelvic floor strengthening exercises such as Kegels. Do not do Valsalva breathing

Conclusion:

1.Pudendal neuralgia is a rare peripheral nerve disorder, that can be very distressing .

2. Can be cured depending on the severity of nerve involvement

3.Most PN generally responds well to conservative treatment with Physical therapy.

References:

1. http://www.spuninfo.org

2. http://pudendalhope.org

3. http://www.tipna.org

4. http://www.pudendalhelp.com

5. http://www.pnfdn.org

May 8, 2020

Can deep breathing help pelvic pain?

Most of us probably heard of the diaphragm that lives under the lungs and helps us breath right? But have you heard of the pelvic diaphragm ? The 2nd layer of the pelvic floor muscles is referred to as the pelvic diaphragm. Both these structures are anatomically positioned to be parallel to each other .

Now let me talk a little bit about pelvic pain. Pelvic pain can be due to many reasons. Irrespective of the underlying pathology the common finding as a response to pathology is a tight or shortened pelvic floor. When PFM (pelvic floor muscles ) are tight the functions of the pelvic floor are hampered so the person may have complaints of

constipation ( can include men )
difficulty with initiating urination
pain with intercourse

Now let’s connect breathing and pelvic pain ! Yes deep breathing can help pelvic pain and here’s what happens when you take a diaphragmatic ( deep belly breath ) breath , the abdominal diaphragm contracts and pelvic diaphragm relaxes .The two diaphragms are positioned in such a manner that when doing deep breathing the abdominal diaphragm contracts and causes the abdominal contents ( intestine and stomach) to descend into the pelvis and in turn will cause the pelvic diaphragm/ the muscles in the pelvis to lengthen/ relax .The opposite happens when we exhale , the diaphragm relaxes and the abdominal organs move up and away from the pelvic floor and the pelvic floor contracts.

Repeating this as an exercise for 5 to 10 minutes for about 1-2 x /day is a good start to start learning to relax the pelvic floor. This is excellent to relax your mind as well, prior to mediation or in conjunction with mediation .

In my experience I see people who carry their stress and tension in two places. In their shoulder ( upper trapezius muscles) and in the pelvic floor! Yes ! you read that right ! in the Pelvic floor !. This is my finding in my practice ,when I teach patients to correct their posture and relax their shoulders this helps with the pelvic pain as well over time.

Sit comfortably with hands positioned as in the pic.

So how is this Diaphragmatic breathing done ?

Start by laying down ( with knees bent ) or sitting down comfortably .
Place one hand on the chest .
Place the 2nd hand on the abdomen around the belly button .
Take a nice deep breath in through your nose, your hand on the chest should not feel much movement but the hand on your belly should rise up slightly .
Do not forcefully push your belly out .
Gently breath out through pursed lips.
Wait for about 1 min and repeat slowly for about 5 min.

Some final thoughts This kind of breathing might feel awkward if you are used to shallow breathing using the upper chest , it will take some time to retraining .

This is also a good exercise for people with COPD ( chronic obstructive pulmonary diseases) and can help lung function .If you experience lightheadedness , discontinue the deep breathing consult your PT to be trained to do the exercises appropriately .