What is pain with sex? 

painful sex is not normal.
One of the questions you can expect to be asked during a pelvic floor physical therapy evaluation can be the following: do you have pain with sex?
Now, let’s get into it; what does this mean? When I ask this question to my patients, more often than not, I get told no almost immediately. As a physical therapist, it is my job to be very thorough in the way I ask things. With that being said, I almost always then go into a subset of questions. I ask if there is any discomfort at the entrance upon initial penetration, if there are some positions that might be more uncomfortable than others, if there is occasional deeper pain or if there is just a general discomfort feeling that a patient does not necessarily classify as “pain.”
After asking those more intimate questions, that is when the patient and I can really get into this topic and start to understand what is really happening at the pelvic floor. Whether it is due to society, what we were exposed to growing up, or simply not wanting to speak up in intimate situations, a lot of the people I treat have pain or “discomfort” with penetrative intercourse, and they might not even know it until I ask. I always try to thoroughly explain to my patients that not even a slight discomfort is normal throughout intercourse, and countless individuals experience pain with initial penetration that gets better as it goes. However, this is still not normal. This symptom is signaling to both me and the patient that their pelvic floor is irritated/over-activated/too tight, and the possible reason it gets better as time goes on is because of increased blood flow to the tissues, muscle tissue accommodation to penis size, etc. Even still, there should NOT be discomfort/pain initially. The pelvic floor muscles should be at a normal resting position that allows for proper lengthening when initiating penetrative intercourse without pain.
When a patient lets me know that some positions are more uncomfortable than others, this also signals to me that the pelvic floor is not within its “normal limits”/dysfunction is more than likely occurring throughout the pelvic floor muscles. The most common position that people report is uncomfortable at the deeper pelvis is doggy style/on all fours/quadruped. Because of this, a lot of my patients will avoid this position and tell me, “but everything else isn’t painful so I don’t consider it pain with sex.” Now, realistically, I do want to shine light on the fact that a vaginal canal is only so long, and it can tolerate more stretch when participating in intercourse. However, it still shouldn’t be painful. Discomfort due to lack of room is one thing (which there are tools to compensate for this issue), whereas a dull/ache/sharp sensation is not normal and can be an indicator of pelvic floor dysfunction.
These are just a few reasons as to why I ask questions in a certain way to be able to further discuss and educate patients on what is or is not normal, as this is not necessarily made known to us. And this is only one subset of questions regarding pain with intercourse… There are so many others I go into for other impairments. I digress, as those will be saved for another blog post. It is so important to understand what is normal vs what is common, and shed light on the fact that many things we experience as a whole are common, but they are NOT normal!

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