About the Author
Josh Spurlock, MA, LPC, CST is a Licensed Professional Counselor and Certified Sex Therapists with over 10,000 hours of clinical experience. Josh specializes in Marriage Counseling and Sex Therapy. Click here to schedule an online counseling appointment with Josh.
Really Painful Sex is NO Fun
Does anybody desire physical pain? If you do, you should probably see a counselor about that, it’s not healthy. If sex hurts, I mean really hurts not just a little rough in a playful way, you’re not ever going to desire it. Nor should you. In fact, if you “play through the pain” you can do serious long-term damage to your sexual relationship by pairing pain with all things sexual and romantic in your brain. That pairing can even bleed into an association with your spouse in general, which can lead to resentment and loss of respect for your spouse.
Types of Sexual Pain / Where does it hurt?
Sexual pain can range from mild to excruciating; burning, stinging, sharpness, or extreme tenderness. Depending on its cause, the pain may be located in the outer genitals (vulva), within the vagina, or deep in the pelvis. Dyspareunia, painful intercourse, can start suddenly or develop gradually. Pain may occur every time with sex, or only occasionally. For some women, simply thinking about intercourse can start a cycle of tightness, pain, and avoidance of sex.
When troubleshooting dyspareunia very specific information about where pain is felt must be gathered. Treating sexual pain is often a multi-disciplinary strategy involving a sex therapist, physician, and possibly a pelvic floor physical therapist. Having good terminology to describe your experience will help with accurate diagnosis and treatment.
Pain from the Outer Genitals (Vulva)
If the pain originates from the surface of the delicate skin around the opening to the vagina it could be a dermatological condition. These conditions are highly treatable, but treatment varies depending on the diagnosis.
Anatomy of the Vulva
To aid in identifying where your pain comes from, it will help to have some terminology for understanding your girl parts.
The vulva consists of several layers that cover and protect your sex organs. The plush outer lips of the vulva — the labia majora — are covered with pubic hair and contain fat that helps cushion the area. Inside the labia majora are the thinner, more pigmented and delicate flaps of skin called the labia minora. The labia minora join at the top to enclose the clitoris.
The labia majora, labia minora, and clitoris become engorged with blood during arousal. The area between the labia minora, the vestibule, contains the openings to the urethra (from which you urinate) and the vagina, as well as the Bartholin’s glands, which are located on either side of the vaginal opening and produce lubricant for the vestibule.
The skin between the vaginal opening and the anus, the perineum, is not part of the vulva but often involved in vulvar skin problems. This is where the incision called an episiotomy is sometimes made during childbirth.
Vulvar Skin Conditions and their Treatment
Several vulvar skin conditions are found else where on the body but may be difficult to recognize when they appear on the vulva.
This inflammation of the vulva skin causes a cycle of itching and scratching that leads to thickened and intensely itchy skin. If eczema affects the vestibule, it may cause stinging and burning. Often, it begins with exposure to an irritant or allergen.
Many things can cause an allergic reaction or irritate your vulva. Here are some of the leading suspects:
Irritants (on exposure, can cause immediate stinging or burning)
• Soap, bubble baths and salts, detergent, shampoo, conditioner
• Adult or baby wipes
• Panty liners and their adhesives
• Nylon underwear, chemically treated clothing
• Vaginal secretions, sweat, and urine
• Douches, yogurt
• Spermicides, lubricants
• Perfume, talcum powder, deodorants
• Alcohol and astringents
Allergens (symptoms may not appear until several days after exposure)
• Chlorhexidine (in K-Y Jelly)
• Imidazole antifungal
• Propylene glycol (a preservative used in many products)
• Tea tree oil
• Latex (in condoms and diaphragms)
Another culprit to sexual pain is vulvodynia, unexplained and persistent pain in the vulvar area. Vestibulodynia is a type of vulvodynia characterized by chronic pain affecting the vestibule. Any kind of touch or pressure—not only from sex, but even from a tampon, cotton swab, tight jeans, or toilet tissue—can trigger discomfort.
Pain From Within the Vagina
Vaginismus is vaginal tightness causing discomfort, burning, pain, penetration problems, or complete inability to have intercourse. The vaginal tightness results from the involuntary tightening of the pelvic floor, especially the pubococcygeus (PC) muscle group, although you may not be aware that this is the cause of her penetration or pain difficulties.
Vaginismus is a common cause of ongoing sexual pain and is also the primary female cause of sexless (unconsummated) marriages. Sexual pain can affect women in all stages of life; even women who have had years of comfortable sex.
While temporarily experiencing discomfort during sexual intercourse is not unusual, ongoing problems should be diagnosed and treated.Vaginismus can be triggered in both younger and older women, in those with no sexual experience and those with years of experience.
Not all women experience vaginismus the same way, and the extensiveness of vaginismus varies:
• Some women are unable to insert anything at all.
• Some women are able to insert a tampon and complete a gynecological exam, yet are unable to insert a penis.
• Others are able to partially insert a penis, although the process is very painful.
• Some are able to fully insert a penis, but tightness and discomfort interrupt the normal progression from arousal through to orgasm and bring pain instead.
• Some women are able to tolerate years of uncomfortable intercourse with gradually increasing pain and discomfort that eventually interrupts the sexual experience.
• Women may also experience years of intermittent difficulty with entry or movement and have to constantly be on their guard to control and relax their pelvic area when it suddenly ‘acts up’.
The deterioration of vaginal tissue caused by estrogen loss associated with menopause is a major source of painful intercourse for women at midlife. When ovarian production of estrogen declines at menopause, vaginal tissue may become thinner, less lubricated, and less elastic. Eventually, these changes can result in vaginal dryness, burning, itching, and pain. Reduced sexual activity, as well as medications such as antihistamines, can also contribute to vaginal dryness.
Pain Deep in the Pelvis
The pelvic floor is a melon-size web of muscles, ligaments, and sensitive nerves at the bottom of the pelvic region, where it supports the uterus, bladder, colon, and rectum; stabilizes the pelvis, trunk, and hip joints; and plays a role in everything from orgasm to continence.
There’s a lot that can happen to the intricate components of the pelvic organs, nerves, ligaments and muscles.
• pelvic inflammatory disease,
• bladder prolapse,
• infections of the urinary tract, vagina, or reproductive organs;
• injury to the pelvic area from childbirth;
• damage to the pudendal nerve, which supplies the vaginal area;
• musculoskeletal complaints, such as arthritis or tight hip or pelvic muscles
Any of these and more not listed can create pain deep in the pelvis that may make sex uncomfortable or even extremely painful.
Treating Sexual Pain
Treating dyspareunia often requires a multifaceted approach that includes medications, other therapies, and self-care. Frequently prescribed strategies for managing dyspareunia include the following:
Emotional and psychological issues, from anxiety to poor communication in a relationship, can contribute to painful sex, and painful sex can put stress on a relationship. Talking with a professional counselor or sex therapist can help.
Local low-dose estrogen helps most women with vaginal atrophy; it’s also recommended in some cases of vestibulodynia and vulvar skin problems. It comes in a cream (applied to the vulva or in the vagina), a small tablet inserted into the vagina, and a flexible vaginal ring is worn continuously and replaced every three months.
Women with stubborn and severe vestibulodynia may want to consider an outpatient procedure called vulvar vestibulectomy, which removes some vestibular tissue. This surgery is usually offered only after other medical approaches have failed.
Nonhormonal vaginal lubricants and moisturizers may help reduce friction and pain during intercourse. (Lubricants are applied just before sex; moisturizers are applied more regularly, for longer-term relief.) There are many brands with different ingredients, and finding the products that work for you can take time. Vegetable oil is an inexpensive option; however, like other oil-based lubricants, it can weaken latex and shouldn’t be used with condoms.
Extend foreplay to increase moisture in the vaginal tissues before intercourse. Try switching positions. Experiment with different ways of being intimate. And communicate with your spouse; speak up about what does and doesn’t feel good.
“Use it or lose it.”
Frequent sexual activity can help stretch and strengthen muscles and increase blood flow and lubrication. But if intercourse hurts, practice different ways of being sexually intimate that don’t involve penetration.
Gentle Vulvar Care
Whether you have a vulvar skin problem or are just prone to irritation, gentle care of your vulva is a must. Wear loose clothing. Choose cotton underwear (and go without when at home). To wash the area, use your fingers instead of a washcloth and an unscented, non-alkaline cleanser such as Cetaphil or Basis. Avoid perfumed, multi-ingredient products such as bubble bath, douches, and some panty liners.
Pelvic Floor Physical Therapy
Pelvic floor physical therapy is relatively new, and there isn’t much hard data on it yet, but experts consider it safe and effective. Many women with vulvar pain have tight or weakened vaginal and pelvic floor muscles. These muscles can weaken as a result of aging, childbirth, excess weight, hormonal changes, and certain physical strains. They can also tighten in response to genital pain. Physical therapy can help reduce tightness and improve muscle function.
Sexual Pain is Treatable
The bottom line is: Sexual pain is treatable, don’t let it ruin your sex life.
- The V Book, by Elizabeth G. Stewart, M.D., and Paula Spencer (Bantam Books, 2002)
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