Sexual health

-- What is sexual pain?

Sexual pain, or pain in the pelvic region that occurs during vaginal penetration, can occur in women of any age. Some women have always had difficulty or discomfort with sexual activity and have never had an enjoyable sexual experience. For other women, sexual pain can start later in life after a period of relatively normal sexual function. This can be the result of childbirth, an injury to the pelvis or at the onset of menopause. Many suffer sexual pain in silence and don’t seek help for what is often a very treatable condition.

-- What are the symptoms and causes?

The symptoms of sexual pain vary and are unique to each woman. Some women may have pain with using tampons, during gynaecological examinations and also with sexual activity.

Some women have difficulty and pain with penetration, and the fear and anxiety that goes with this can cause increased tension of the pelvic floor muscles. Some women have described this as like “hitting a brick wall” and “feeling like a failure”, causing long lasting emotional impacts. The pain experienced may be superficial or deep inside the pelvis, and can be exacerbated by any movement within the vagina.

Around 40% of all women will experience sexual dysfunction during their lifetime, and about one in seven will experience some form of sexual pain. Women with a history of trauma and sexual abuse can have significant issues with pain and penetration, but some women will develop pain and discomfort without any prior trauma experience. In many cases other contributing psychological factors may play a part in this complex condition.

It may primarily be a pain disorder interfering with sexual function, for example, changes to the vaginal lining during menopause, overactive pelvic floor muscles, inadequate lubrication, or a disorder of the urethra or other structures nearby

--How do I know if I have a sexual pain disorder?

Besides physical symptoms, all of these common disorders below involve pain. Usually, these conditions have been present for longer than 3-6 months. This means the brain and nervous system have become extra sensitive and protective, which can feed into your experiences with pain:

• Vulvodynia is a condition where women have a burning pain in the vulva region (anywhere from your pubic bone to the tailbone where your underwear would sit). 10 to 20 per cent of women will experience this in their lifetime and it is often more common in younger women, as well as in women who have undergone treatment for breast cancer. Pain with sex (dyspareunia) and protective pelvic floor muscle spasm (vaginismus) can also be present. Other symptoms include pain, difficulty using tampons or having a PAP smear.
   
• Penodynia is a condition where men have pain in any area of the genitals, including along the shaft and tip of the penis and testicles. One-third of men attending urologists present with this problem and often there is a musculoskeletal reason, such as tight pelvic floor muscles, that physiotherapy can address.
   
• Pudendal neuralgia is a chronic pain problem related to the pudendal nerve. This nerve sits inside your pelvis on both sides and supplies the skin and some of the muscles between your anus and clitoris (in women) or penis (in men). There are many symptoms, such as pain when emptying your bladder, bowel movements and orgasm. Sometimes people feel pain when sitting or even wearing underwear. 7 to 8 per cent of long distance cyclists will experience this from sitting on their bike for long periods of time. Sometimes the nerve can get stuck in scar tissue after, or damaged during, childbirth or pelvic surgeries such as a hysterectomy or for urinary incontinence. There are other pelvic nerves close by that can also have similar symptoms just in a slightly different area.
   
• Peyronies Disease (curvature of the penis) affects up to 9 per cent of men. It is caused by the formation of fibrous plaques in the tissues of the penis. If detected early before the plaques calcify, therapy can be helpful. It is more common after surgery for prostate cancer.
   
• Erectile Dysfunction (ED) affects 1 in 5 Australian men over the age of 40. Previously known as impotence, ED is when a man has trouble getting and/or keeping an erection firm enough to have sex. Smoking, drinking, stress, reduced testosterone and diabetes have been linked to a higher risk of having ED, along with other underlying reasons such as weak pelvic floor muscles.
   
• Peristent Genital Arousal Disorder is an unwanted and unpleasant feeling of being aroused for long periods (hours to days or more) without wanting to have sex, and often does not go away after having an orgasm. Often the pelvic floor muscles are tense. This condition requires thorough assessment and diagnosis from your GP and then a multi-health team.

--What's the difference between a mental and physical sexual disorder?

Mental health plays a very important role in sexual health. Conditions such as depression, anxiety, stress and fear can all impact your physical wellbeing and experiences of pain. This can lead to more sensitive nervous systems, tight muscles, changes in heart rate and blood flow, poor sleeping and overall poor function in your daily life. Because mental and physical parts of sexual disorders often go together, sometimes people can feel like they are being told it is all in their head. This is true in that pain, stress, fear and anxiety can make your problem worse, but what you are physically experiencing is real and there are physical changes that also take place.

-- How do I know if my disorder requires physiotherapy or other medical attention?

You should not have to live with pain in the genitals, bladder, bowel or put up with pain or difficulty having sex or using tampons. It is always good to speak with your GP regarding the symptoms above or any other concerns you have with your sexual health, including low sex drive. Sometimes there are other reasons for your problems like an infection or hormonal imbalances. Your GP will often refer you to a gynaecologist or urologist. Sometimes there are specific tests they can do, such as blood tests or nerve testing, but some problems are diagnosed based on your symptoms, your history and the exclusion of other conditions.

-- How can physiotherapy help with sexual pain disorders?

Physiotherapy can help with sexual pain disorders in many ways:

Education and advice – Your physiotherapist will explain why these things are happening and how chronic pain works in the body and the brain. Education and emotional support can be extremely helpful in allowing your nervous system to calm down, as well as help with fears or worries you may have. This may be with a psychologist or sex therapist.

Physiotherapists also give advice on sex, including how long to have a break from it, how to stay close to your partner (if you have one), and how to slowly get back into it. They can recommend what products you can use to help or when and who to see if you need to speak to a sexual or intimacy counsellor.

Exercise and relaxation – Often you will be given relaxation exercises to help you breathe and relax your pelvic floor muscles or other muscles in your body that may be tight and over protecting you. These relaxation exercises can help lower sensitivity in your genital area and help with stretching in the vagina for women, often with tools such as vaginal dilators. Physical activity in general is really important to help your body recover. Mindfulness exercises may also be helpful to treat chronic pain.

Massage - Because everything is connected, often your back, hips and pelvis will be assessed and may need some specific massage or mobilisation techniques. For women, specific trigger point therapy massage inside the vagina may help for some conditions and for men, through the anus. However, it should never hurt. Your physiotherapist can teach you how to do this yourself if you find it to be helpful.

-- How effective is physiotherapy for sexual pain disorders?

Educating people about their pain, no matter what kind of pain or where it is in the body, has been shown to help recovery and give patients a feeling of being in control of their journey. Most of these studies have been done on chronic low back pain over the last 10 years, which still apply to the pelvis, however more studies are now looking at the positive role of education in sexual dysfunctions.

Research also supports different types of exercise such as cardiovascular, relaxation and mindfulness in helping to decrease the sensitivity of the nervous system, lower stress, help with anxiety, and decrease pain. Combined with massage and pelvic floor relaxation exercises, people with persistent pelvic pain conditions have great improvements in their symptoms.

It is important to remember that a women’s health physiotherapist should assess, diagnose, and manage your chronic pelvic pain. In most cases, this requires you to be reviewed by a gynaecologist and possibly a psychologist. They will formulate a management plan and guide you through treatment.

-- What can I do at home to help my sexual pain disorder?

Some home exercises to try for sexual pain disorders:

• Find a good comfortable position – sometimes this can be lying on your back with your feet up onto a couch, or even just lying down on your side. This is a great place to practice your breathing exercises.
   
• Breathing exercises — great for calming your nervous system and can help with mobility of other muscles around your trunk and pelvis. Try them lying down on your back or sitting or standing (wherever you are comfortable and can relax). Put one hand on your belly and the other on your chest. Slowly take a breath in through your nose for about 3-4 seconds. You should feel more movement of your belly outwards than your chest. Hold your breath for one second if you can, then slowly breathe out for 3-4 seconds (or longer) through you nose if possible or through pursed lips. Repeat 10 times, every couple of hours during the day if you can.
   
• Walking – try getting outside for 10 minutes a day. If you cannot do this much, start with less. Even if it is just to the end of your driveway and back.
   
• Re-writing your story – think about movements or activities that make your pain worse, but now imagine them in your mind without pain. For example, if you know it hurts every time you sit down, imagine sitting down in your mind without any pain. This can be a useful method for sex—start to imagine having sex without pain. Sometimes your brain doesn’t know the difference between imagining things and actually doing them.

-- How can I talk about my disorder with my partner?

There are great sexual and intimacy psychologists and counsellors that you can see privately. They will give you the best strategies to start the conversation with your partner, and to help you overcome some of the barriers and fears you may be feeling about yourself and closeness with your partner. They will often have you in as a couple to talk about your concerns, how to support each other and strategies to work on together.

-- How long until I feel normal again?

Every person is different. You need to be patient and kind to yourself, as well as consistent and persistent. If you have any symptoms consistent with chronic pelvic pain such as painful intercourse, general pelvic pain, or pain with empting your bladder or bowel, see your GP, women’s health physiotherapist or continence physiotherapist. Helping overcome pain, especially if you have had these issues for more than 6 to 12 months will take time. Know that you will have ups and downs over your recovery, which is why physiotherapists will give you a toolkit to help you during those flare-up times.

-- What next?

Find your nearest women’s, men’s and pelvic health physiotherapist by choosing the ‘Women’s, Men’s and Pelvic Health’ option under the special interest area in the ‘refine your search’ drop-down box at www.choose.physio/find-a-physio