2. Interstitial Cystitis (IC)
Unlike the kind of cystitis that can be treated with antibiotics, IC is a chronic inflammatory condition of the bladder wall. Some of the symptoms are an urge to urinate frequently, stinging the area surrounding the urethra, increased nighttime voiding (urinating), and a variety of pelvic and sexual pain symptoms.
3. Irritable Bowel (IBS)
Constipation and/or diarrhea are symptoms of this syndrome. Some women find that IBS flare ups correlate to an increase in vaginal irritation. Therefore foods that aggravate the bowel may also cause vaginal symptoms.
4. Lichen Sclerosis
This is an inflammatory chronic skin condition most common in the external genital area. Symptoms may range from none (for years) to mild or severe itching and irritation. Lichen Sclerosis does appear to be relatively prevalent in women with vulvodynia and sexual pain disorders. It can cause splitting and "paper cut" type tears in the region around the vaginal opening.
5. Myofascial Pain Syndrome
Myofascia are the muscles and connective tissue in the body. When in spasm, knots and "trigger points" develop that need to be released to eliminate pain and restore function. These trigger points in the pelvic myofascia can cause sexual pain.
6. Pelvic Endometriosis
Endometriosis occurs when endometrial cells, normally found only in the uterus, become imbedded in locations outside the uterus. These locations are usually within the pelvic cavity on reproductive organs, supportive ligaments, or structural systems like the bladder or bowel.
This misplaced tissue forms growths that look like dark spots. These growths respond to the menstrual cycle and break down and bleed each month, the same way the lining of the uterus does. This causes cyclical pain and inflammation - called dysmenorrhea. Additionally, the body’s immune response to this internal bleeding and breakdown of blood and tissues begins to cause scar tissue and adhesions (affected pelvic organs or structures adhering to one another) which can also cause ongoing pain.
Endometriosis affects millions of women but is often over diagnosed as the primary cause of pelvic and sexual pain. If the pain or deep sexual discomfort is intermittent and all month long, even though it may become worse leading up to the menstrual period, endometriosis may not be the primary reason for the pain. If you have been diagnosed and treated for endometriosis and you don't begin to get signifiant improvement either after medication or surgical treatment, insist on further evaluation for bladder, bowel, musculoskeletal, or nerve related causes of your pain.
7. Pelvic Floor Dysfunction
The pelvic floor encompasses all the muscles that surround and support the pelvic organs (uterus, bladder, and lower bowel). To function appropriately, these muscles must be toned. However, elevated tone in the pelvic floor muscles, making them too tight, tense, and "turned on" can result in painful sex and difficulty with bladder and bowel function. On the other hand, too little tone can lead to bladder and bowel incontinence (leakage) or prolapse (falling down, out of normal position). Pelvic floor dysfunction can refer to either too much or too little tone.
8. Previous life-long Pelvic Trauma
Events such as physical, emotional, and sexual abuse, surgeries, accidental injuries, and cumulative aggravating structural factors can play a role in sexual pain. Additional possibilities include years of various sports activities such as gymnastics, cheerleading, track & field, soccer, ballet dancing, horseback riding, skating, etc. More and more women have engaged heavily and competitively in these sports over the past few decades, making them extremely vulnerable to these types of bodily stresses. The nervous system bio-chemically "imprints" and "remembers" these accumulated traumas, and any or all of these may predispose a young woman to sexual and pelvic pain disorders even years later.
9. Generalized Vulvodynia
Generalized vulvodynia is a subset of vulvodynia, it is less common than vulvar vestibulodynia (see below) and often very difficult to successfully treat. It is a deeper, more generalized pain. Pain can occur spontaneously (unprovoked) or in response to touch or pressure (provoked, such as by intercourse). Pain emanating from the pudendal nerve and its distribution may be a significant contributor to this condition in some cases (pudendal neuralgia).
10. Vulvar Vestibulodynia (Vestibulitis)
This condition causes pain and inflammation at the vaginal opening. Women describe the pain as burning, itching, raw, sandpaper, ground glass, and stinging. It is commonly mistaken for vaginal yeast infections and is often treated incorrectly. Vestibulitis is the most common reason for entrance pain (painful sex) in reproductive-aged women.
"doing mode", you're operating almost exclusively in the sympathetic branch of your autonomic nervous system. This system is associated with the "fight or flight" response, shallow breathing patterns, muscle tension, and increased heart rate and blood pressure. These stress responses of the body not only negatively influence the pelvic floor muscles but also the overall pelvic region including bladder and bowel function, both common triggers of genital, sexual, and pelvic pain.
2. Pelvic Traumas, Injuries, or Surgeries
Injuries to the pelvic floor region caused by childbirth, previous pelvic surgeries, falls on the coccyx bone, and other accidental traumas to the region such as straddle injuries can all contribute to the development of chronic pain in the pelvis and genital area. Take for instance, the condition once known as "bikers syndrome" that affects long distance bike riders. Cumulative targeted pressure on the pudenal nerve overtime can cause damage to the nerve. This particular nerve branches out into the entire vulvar region and can therefore emit painful stimuli anywhere in the pelvic region, not just at the "sits bones".
3. Present or Past Physical, Emotional, or Sexual Abuse
Memories from past (or current) abuses are stored in pathways along the central nervous system, and even in particular muscles, especially the psoas muscle. The psoas muscle has a direct and neurological connection to the pelvic floor muscles. These bad memories that are stored by the nervous system awaken when it is feeling threatened or when trying to protect itself. Even when attempting consented, pleasurable sex, the nervous system can interpret this environment as threatening. Protective measures include muscles tension and clenching (which leads to pain, which leads to the fear of pain, which leads to further clenching), and the over-sensitization of the pelvic nerves.
4. Participation in Competitive Sports
Many popular sporting activities require tight, clenched body positions and breathing from the chest in order to perform. If we are taught by these sports (or cultural influences) to suck in our stomach and breathe from the chest and clench our buttocks at all times as a matter of "good posture" this can, over time, be detrimental to the health and function of the pelvic floor. In addition, young women who participate in sports are more likely to experience sports-related injuries such as injuries to knees, ankles, legs, and hips. If a knee, for instance, is favored for a long enough period of time the opposite pelvic area takes on more stress and can contribute to pain due to compensatory patterns.
5. Genetic, Hormonal, & Dietary Influences
Structurally the body is not symmetrical and consequently curvatures of the spine, leg length difference, being left or right footed, all have a bearing on the long-term cumulative stress on one side of the pelvis or the other. Genetic and hormonal influences can also put us at risk for other triggers commonly associated with pelvic, genital, and sexual pain. For instance, endometriosis, irritable bowel syndrome, and interstitial cystitis (painful bladder syndrome or "IC"). The dietary decisions we make also influence how and when these triggers manifest in the body. Foods can promote the inflammatory responses contributing directly to pain, but also inhibit the immune system from functioning properly.
Chapter 31: Ongoing Treatment
Watch Chapter 31 of the Video Resource Series Healing the Pain 'Down There': A Guide for Females with Persistent Genital & Sexual Pain. Managing your ongoing treatment to maintain healthy pelvic function.
Now that you have the tools to treat the problem, decide what you need to continue in order to maintain healthy function and to manage your pelvic, genital, and sexual pain disorder. Many women experience painful sex for such a long period of time, they have no idea where the pain is coming from at first. But as you are able to map out your pain and understand where it is coming from (and why), you will begin to notice improvement. And you will begin to be confident that you have control over your pain. Should your pain return, you will begin to know why, and your confidence will build. Your learning curve about your own body will gradually increase and you will know how you can work to relieve it each time. With the techniques you have learned you can maintain proper function of the pelvic floor muscles and experience sexual intercourse with much less apprehension and discomfort.
Prior to this educational experience you may not have even heard of such conditions as Painful Bladder Syndrome or Interstitial Cystitis, Generalized Vulvodynia, Vulvar Vestibulodynia, Pudendal Neuralgia, and Pelvic Floor Dysfunction. These conditions and others just as common, such as Endometriosis and Irritable Bowel Syndrome all can be causes of and triggers for a variety of pelvic and sexual pain disorders. The more you know and the more you advocate for yourself and others with these conditions, the sooner the health care system will trend towards recognizing how common they are and how important it is to diagnose and treat them as early as possible. The quality of life of so many young people will depend on these issues being included in the routine evaluation of their health care into the future.
The long-awaited Video Guide Healing the Pain 'Down There': A Guide for Females with Persistent Genital & Sexual Pain is now available for purchase.
A woman with chronic pelvic pain brought together a team of multidisciplinary professionals to create this instructional and educational DVD guide for those suffering with “pain down there”. The team represents over 50 years of experience in women’s health related fields including OB/GYN, physical therapy, mindfulness techniques, and human sexuality with their focus being on the treatment of pelvic pain. This educational video is intended for women of all ages who are experiencing pain during intercourse who want to learn why they have their symptoms and learn strategies to improve them. This video is also for teens and young women who may be at risk for developing these symptoms, and for clinicians who are practicing in the field of women’s health.
“Groundbreaking … “
Jill Osborne, MA
ICN Founder & CEO
“A well designed comprehensive view of pelvic pain from a multidisciplinary perspective and clear options for returning to health and well being.”
Sandra Hilton, PT, DPT, MS
“A very important resource for many women...”
Frank Tu, M.D., MPH
" Respected pelvic practitioners create a road map to navigate the challenging path of healing pelvic pain."
Dustienne Miller PT, MS, WCS
Q: I now have “pain down there” for no apparent reason. The first time I had sex it was slightly painful but the pain faded away and felt good. On a few other occasions following that time, the same thing would occur: a little bit of pain but then fading away. But lately if we switch positions or he falls out he cannot insert again. If he does it’s excruciating pain for me. He can’t put it in again, it feels “too tight”. I experience burning pain during sex and afterwards it hurts to urinate (only right after we have sex though). I’d go to a doctor but I have no insurance so I’m unable to afford it. What’s going on?
A: First of all, let us assure you that you are not alone in experiencing these symptoms. There are countless individuals going through very similar situations right now, many of whom also are not getting helpful answers from the medical community. We often see "UTIs" and "yeast infections" overly diagnosed in cases like yours. Of course you need to rule these out. But this can easily be done by going to a nurse practitioner at a Planned Parenthood clinic (fees are usually reasonable even without insurance). If the tests are negative or the treatments don’t help you, don’t continue to accept antibiotics or creams that aren’t proving to be affective in treating your pain. Please also consider:
1. Be sure to always use a good vaginal lubricant, such as Astroglide Gel (not the liquid), another product actually named "Slippery Stuff" which you can find on-line, or even simple coconut oil. These products are generally tolerated by most women even if they have minor inflammation at the vaginal opening (Vestibule). Make sure to put these lubricants on yourself and your partner to eliminate any friction which can help to minimize the pain
2. You could also be experiencing muscular restriction at the vaginal opening (Pelvic Floor Dysfunction - a clenching response to increased sensitivity to touch or friction at the Vestibule). With initial penetration - these muscles (pubovaginalis) are stretched, which may be creating your initial burning pain which then subsides as sex continues. Any time re-entry needs to happen (switching positions or him falling out), your brain perceives this as a "dangerous" situation and your pubovaginalis "clenches" to protect the area of pain. There are certainly exercises that can be done to help to 1) stretch the vaginal opening and 2) retrain the brain that your vaginal opening is not a "danger zone" so that the red flags gradually fade and your gripping reflex is no longer present allowing your partner to enter with low to no pain.
3. Since you say you have "excruciating pain" with penetration, the simple suggestions above may not be helpful enough. If you have already tried these simpler solutions and they are not helpful and you continue with pain, you may have the early signs of vulvar vestibulitis as well as interstitial cystitis / painful bladder syndrome (IC) contributing to penetration pain. Early signs of both of these conditions are quite common in young women. (Usually deeper penetration pain is associated with IC as the tip of the penis "hits" the irritated bladder. Initial penetration pain can be associated with vulvar vestibulitis as the sensitive tissue of the irritated vestibule are stretched) Consider drinking more water and de-acidifying the body by lowering acids in the diet to lower the inflammation that can occur in the bladder, urethra and vestibule. To download our Vaginal Health Guide click here.
4. Our DVD Healing the Pain 'Down There’ can help educate you on why this all might be happening and will give you strategies to help make it better yourself and also to help find professionals who may know more about these issues.
Interstitial Cystitis: Also known as Painful Bladder Syndrome or IC. It is a very common disorder of the bladder, it is estimated that about one out of every six reproductive aged women have some degree of IC. This condition is caused by a loss of the “protective lining” of the inside of the bladder, allowing for an inflammatory reaction of the bladder wall. Since urine is ordinarily very acidic and with the protective lining already diminished, the acidic nature of the urine also causes an inflammatory response which in turn triggers off symptoms of urinary frequency, urgency, and pain, pressure or discomfort anywhere in the pelvic region.
Unfortunately, many pelvic practitioners do not mention or think about this disorder when diagnosing pelvic, sexual, or genital discomfort. However, cumulative research has shown that persistent pain in the pelvic region is triggered by the bladder and/or bowl function at least 80% of the time and by gynecological disorders alone only 20% of the time.
If you are being diagnosed with frequent urinary tract infections or "UTIs", always ask your practitioner for a urine culture before taking any antibiotics. Instant "dip sticks" of your urine can look the same with IC as in a UTI.
For more information we recommend:
Interstitial Cystitis Association
Paindownthere.com and the educational/instructional videos Healing the Pain ‘Down There’ intend to explain, as best as possible, that there are many reasons in the pelvis for pelvic floor dysfunction and for genital and pelvic pain. One of these reasons may be hypertonicity (as posted about last time). Virtually everyone with pain, caused by all sorts of injuries to the body, has reactive hypertonicity in and around that injured area. The muscles around a knee injury or shoulder injury, for instance, always tighten to guard that area and stabilize or “splint” that area. Same in the pelvis. The way that pain is processed in the brain along with fear and anxiety factors can also continue to cause hypertonicity even after the initial injury has healed. Mind/body aspects of care become so important in this instance.
Other reasons or “triggers" in the pelvis for pelvic floor dysfunction and for genital and pelvic pain besides the implications of hypertonicity include:
Somatic reasons: Current or previous injuries or stress on all of the surrounding structural entities. These structural entities include bone, muscle, fascia (connective tissue), ligaments, and nerves.
Visceral reasons: Organ dysfunction like IC (Interstitial Cystitis or Painful Bladder Syndrome), IBS (Irritable Bowel Syndrome), Endometriosis, Prostatitis and others.
We want to help “connect these dots” for all the potential and interconnected sources or “triggers” of chronic pain in the pelvic and genital area.
Stephanie Yeager: Passionate about spreading the word of hope and healing for those like her, influencing a paradigm shift in the medical community toward greater understanding of chronic pelvic pain disorders, and prevention initiatives that may protect young women before onset can occur.