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Pelvic + Sexual Health

Physical Therapy for Painful Sex: Here's What to Expect

Sep 01, 2022Alexandra Bertucci, PT, DPT3 MIN
a woman lifting her tank to reveal her swim suit bottoms to represent pelvic pain and pain with sex

As a pelvic floor physical therapist and AASECT certified sex counselor, I’ve always felt particularly connected to my patients who experience pain with sex. Being unable to have the sex you want, either with a partner or with yourself, can feel demoralizing, frustrating, embarrassing — and even shameful. I can see difficult emotions like these in my patients’ faces before they even began to tell me their stories. And I’m always so glad that they decided to come to Origin for help.

If you’re currently experiencing pain with sex and are reluctant to start working with a pelvic floor PT, you’re in the right place. I want to explain what to expect from this kind of care, why treatment goes beyond “physical” therapy, and how to get the help you need to feel good in your body and have the best possible sex life.

Talking to Your PT About Pain with Sex

While some patients are perfectly comfortable describing when and where they experience pain with vaginal penetration, others dread getting into the details. If you’re in the latter group, you’re not alone — and it’s important not to let that stop you from trying physical therapy.

A big part of any pelvic floor PT’s job is helping patients to feel comfortable talking about intimate issues, ranging from pee and poop to sexual functioning. That means you can come to PT feeling nervous, awkward, mortified, or however you might be feeling.

You can come to PT feeling nervous, awkward, mortified, or however you might be feeling.

Building trust and putting you at ease is our first goal. Every PT will do this slightly differently. The first thing I do is give my patients permission to ask any and all questions. I open with “This is your space to openly ask me anything having to do with sex, sexuality, or sexual function — no matter how big or small or strange it might sound.” Then I respond to all questions with enthusiasm and without judgment.

Once you’re comfortable, we’ll start discussing how sex is impacting you, both physically and mentally. We’ll also talk about how sexual dysfunction can be affected by a long list of factors, including your sexual upbringing, your relationship with your body, your relationship with your current partner if you have one, and any traumatic experiences that may have contributed to stored tension in your pelvic floor.

It’s a lot. Rest assured, you won’t be expected to go over everything all at once. Whatever you’re ready to share and discuss at each visit is okay. Physical therapy for painful sex typically takes up to 20 weeks — which gives you and your PT plenty of time. And I can’t say this enough: There is no such thing as too much information. The more you share with your PT, the better we can help you.

Treating Pelvic Floor Dysfunction

As you’d imagine, pelvic floor physical therapy includes learning about your pelvic floor muscles — how they impact sexual function, how to contract and release them, how to stretch them, maybe even how to use a dilator set to increase your comfort with penetration. (For a preview, check out this introduction to pelvic floor functioning and anatomy.)

PT for painful sex is highly personalized because everyone's experiences with sex are different and unique. This is why we start with some counseling to better understand how your past experiences and ideas about sex may be impacting you now.

PT for painful sex is highly personalized because everyone's experiences with sex are different and unique.

We can then assess your pelvic floor function in a number of ways. We know patients can be anxious about doing any kind of intra-vaginal work, but this type of work only happens if you are ready. At Origin, we also offer virtual treatment for painful sex which can involve self-guided assessments that you do between visits, while safe in your own space. Many patients find this to be an especially comfortable way to do pelvic floor PT.

All internal techniques aside, sometimes the most powerful thing for working through pain with sex is helping you to understand the control that you have over your pelvic floor muscles. In PT we use gentle exercises paired with mindfulness techniques to bring awareness to the control you have — and to increase it. So many patients have said to me "as soon as I remember how to control my muscles and release the tension that I feel building, I feel the rest of my body relax."

Your PT will work with you to ensure that you make progress at a pace that feels right for you and that gets results. I’ve seen many patients get positive results as soon as their muscles softened and they were able to relax and release tension in their pelvic floor. For others, even if their muscles were able to relax completely, having penetrative sex with their partner remained just as impossible as when they started PT. For these patients, there’s another very important part of treatment.

Don't wait to get relief from vaginismus or dyspareunia. Start working with a pelvic floor PT today.
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Addressing Emotional Aspects of Sex

Given that sex is a highly emotional activity, it’s not surprising that resolving pelvic muscle tension doesn’t always lead to pain-free sex and a completely restored sex drive. “My pelvic floor is finally getting better, so why don't I want to have sex?” is something I hear a lot.

When I talk to patients about their experiences, I often discover that sex was introduced to them early on as something shameful or wrong, or that they’ve had significant negative sexual experiences in the past. This can set them up for sexual dysfunction and low sex drive. In these instances, I go over the many factors that can impact a person’s sex drive and ability to get physically aroused to the point where penetration is both possible and pleasurable.

To put it simply, you’re much more likely to seek out sex and become aroused when you’ve had many positive experiences with sex in the past. And that doesn’t just have to be a positive physical experience like an orgasm — it can be feeling good about your body, feeling more emotionally connected with your partner, and other feel-good feelings that come with being a sexual being.

You’re much more likely to seek out sex and become aroused when you’ve had many positive experiences with sex in the past.

If you lack that positive feedback loop —  because you’ve had sexual experiences that caused pain, shame, or any other negative emotion — your body basically can’t find a reason why it would want to seek out this activity. The result: low or no sex drive.

One of the things we can do in pelvic floor PT is to help guide you in creating safe, positive experiences around sexual touch and vaginal penetration. As these positive experiences add up, your sex drive — and your ability to have penetrative sex — often increases.

Staying Aware of Stress

During treatment for painful sex, many patients underestimate how the body’s “fight or flight” system can impact their libido and tolerance for penetration. When stress ramps up in any part of your life — stress related to school or work, moving, the argument you had a few weeks ago with a friend, the airline tickets you still have to buy that keep rising in price — your body thinks that it’s under attack and gets ready to battle or run from a threat.

If these fight-or-flight signals are present when you’re trying to have sex, they block the physical changes that help to make sex pain-free. In women and individuals with vaginal anatomy, these blocked changes include natural vaginal lubrication, vaginal canal lengthening, and pelvic floor muscle contractions.

Fight-or-flight signals block the physical changes that help to make sex pain-free.

If you were already worried that sex could be difficult or painful, or concerned that your partner may be frustrated or hurt, this stress can snowball and make it even harder for you to become aroused and have penetrative sex.

When you’re caught in this cycle, your pelvic floor PT can help you adopt stress management strategies like diaphragmatic breathing that can wind down your flight-or-fight response. They may also recommend that you work with a mental health provider to reduce stress more holistically.

Getting Help for Painful Sex

If you have any kind of pain with sex, I hope you’ll seek out a pelvic floor therapist who can help you understand where to start. For many, being able to learn how to control the pelvic floor muscles and understanding what’s happening is therapeutic enough to return to pain-free sex.

For others, seeing a sex counselor and/or or a mental health therapist at the same time that you do pelvic floor PT will be the best approach. The time and effort is very much worth it. Research shows that people with satisfying sex lives report better mental health and have a lower risk of developing depression.

Not enough of us are told that pain with sex isn't normal. So if this is something that is affecting you, know that it can get better and pelvic floor physical therapists are here to help.

Origin Pelvic Floor Physical Therapist Dr. Alex Bertucci PT, DPT
Alexandra Bertucci, PT, DPT

Alex is a physical therapist and pelvic floor specialist. After a few years of clinical practice, Alex realized the importance of focusing on the psychosocial aspects of a patient's health, especially for patients experiencing pain with sex. This compelled her to become 1 of just 5 physical therapists in the world to be certified through AASECT as a sex counselor. With these skills, she also began working closely with the LGBTQ+ population as an ally and provider to help patients understand how gender identity and/or varieties of sexual expression can impact — and be impacted by — pelvic floor dysfunction. She enjoys providing meaningful and effective physical therapy via telehealth, and continues to focus her practice on patient empowerment and education.

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