Sexual Pains & Physiotherapy

Sexual Pain (dyspareunia) can affect up to 75% of women at some stage in their life according to the American College of Obstetricians and Gynaecologists. At any given time, 7.5% of the female population are having painful intercourse. This may occur from an individual's first sexual experience or may develop at different stages throughout their life. It can occur in heterosexual and homosexual relationships. Understandably, it can have a significant effect on an individual's ability to engage in intercourse. Women report avoiding sexual activity, losing their desire to engage, struggling with arousal, enjoyment and climax. This can cause strain on relationships and further psychology stress, worry and negative body image.

Symptoms associated with painful intercourse include:

 - Pain with vaginal examinations/smear test
 - Pain with tampon usage
 - Bladder urgency/frequency or night time toileting
 - Urinary incontinence
 - Difficulty urinating
 - Constipation or urgency to pass a bowel motion
 - Pain with masturbation or foreplay
 - Lower back/pelvic pain
 - Pain sitting on a bike/horse riding

The pelvic floor is the muscular hammock to the body.

Its role is:
 - To hold your urine/faeces/wind
 - To let go of your urine/faeces/wind
 - To support your pelvic organs
 - To support your back and abdomen
 - Allow for penetration
 - Allow for orgasm

Generally, women who present to physiotherapy with the above complaints may have an overactive/uncoordinated pelvic floor. This is when the pelvic floor muscles have tightened or do not have enough length. This is how the body involuntarily tries to protect itself from pain.

Common causes of sexual pain include:

 - Lactation
 - Menopause
 - Child birth
 - History of infection eg. UTIs, thrush, STIs
 - Vulvodynia/vestibulodynia
 - Vaginismus
 - Skin conditions eg. Lichen schlerosis
 - Excessive high intensity exercise
 - Pelvic organ prolapse
 - Psychological conditions eg. Anxiety/depression
 - Chronic Pelvic Pain eg. Endometriosis/IBS/PCOS/adenomyosis/fibromyalgia
 - Previous surgeries including C-Section and laproscopic
 - Lower back/coccyx or hip pain/injuries
 - A history of trauma or pain
 - Neuralgia

There are two main types of sexual pain: deep and superficial. However, some individuals can have both and fluctuations between symptoms. Pain can occur prior to or during penetration, throughout intercourse or afterwards. It can even persist for up to 3 days. It can be sharp, burning, achy, tight or cutting in nature.

Sexual activity is an emotional, psychological and physical experience. Pelvic Health Physiotherapy can help you identify some of the primary causes and secondary complications of sexual pain.

Treatments include:

 - Pelvis/pelvic floor awareness education
 - Lubrication advice
 - Desensitisation/electrical stimulation therapies
 - Toileting advice
 - Bladder retraining
 - Biofeedback
 - Dilator therapy
 - Myofascial release
 - Scar massage
 - Pelvic floor relaxation
 - Mindfulness

As Pelvic Health Physiotherapists we work alongside Psychologists, Gynaecologists, GPs, Sexual Health Doctors and Sex Therapists.

Here at Auckland Physiotherapy, we have a Real-Time Ultrasound machine which can be used as an assessment tool as well as an adjunct in your therapy.

Prior to seeing your physiotherapist, we recommend you see your GP to rule out any potential pathology that may be causing your pain.

Patients are entitled to see their physiotherapist individually or you may bring a support person/partner with you if you wish.

Compiled by our Senior and Women's Health Physiotherapist Michelle Gall.


What is Stress Incontinence?

Stress incontinence is probably the most well-known of the pelvic floor disorders; it is defined by the International Continence Society as “involuntary loss of urine on effort or physical exertion, or on sneezing or coughing”. Many women may know it as leakage of urine when you laugh, cough, run, jump or even pick up your kids.  

What causes Stress Incontinence?

When you do any of these activities above there is an increase in the pressure inside your abdomen causing increased in force pressing on your bladder. To counteract the force on the bladder there needs to be enough ‘closing pressure’ at the urethra which is the exit tube from the bladder. Leakage occurs when the urethral closing pressure cannot stay high enough during increases in intra-abdominal pressure such as when you cough.

The pelvic floor muscles play a significant part in keeping the urethra closed at these times of increased pressure. It does this by providing a lifting action to the bladder and bracing the firm fascia that sits behind the urethra to keep it closed. A strong pelvic floor will cause the front of the urethra to be squeezed shut against the strong wall of pelvic floor behind it when the increased pressure hits.  Imagine stepping on a hose and the hose is squeezed closed against the firm ground underneath it and the water stream is stopped. A poor functioning pelvic floor would be like standing on a hose that was sitting on a trampoline…

How can physiotherapy help?

A full assessment of the pelvic floor can identify not only general muscle weakness (ie can you get a contraction at all), but also the co-ordination and timing ability of the muscles to contract when there is increased pressure (ie. during a cough or laugh). Research has shown that up to 50% of Women perform a pelvic floor contraction incorrectly if they are only given verbal cues. An internal pelvic floor examination is used so the therapist can ensure a correct and effective pelvic floor contraction can be achieved.
Following this assessment, an individualised pelvic floor retraining programme can be commenced. In the case of stress incontinence learning a technique called ‘The Knack’ is also an important component of the treatment; this is the ability to hold the contraction during times of increased pressure.
A review of relevant research in 2010 concluded that supervised pelvic floor muscle training is recommended as the first-line conservative management for urinary incontinence with many women reporting they were cured or improved and had better quality of life.

So if you have come to accept a bit of a leak when you lift your little one as just ‘one of those things that comes with having children then think again, it is very much one of those things that your physio can help with!

When you consider it takes up to 40 weeks or more to create a tiny human, you would think mothers would relax and give their bodies time to restore. Instead, according to a 2014 survey of 1,500 women in the United Kingdom, 40 per cent of new mums feel pressured into losing weight quickly. A 2015 study by the American journal Obstetrics & Gynecology found that 75 per cent of women don't achieve their pre-baby weight one year post-birth, while UK-based research revealed it takes an average of 19 months to get close to pre-pregnancy weight.

In my experience I see a huge number of women who have returned to exercise too soon, and too intensively - meaning they've come to see me with aches and strains on their pelvic floor function. Mothers must remember that you have just performed one of the most incredible things – developing and giving birth to a tiny human. Time and patience are vital.

Respect for the healing process is key. If you had an uncomplicated, natural delivery, you might feel tender for five weeks or more, and it is advisable to wait until your six-week, post-partum check-up before returning to gentle exercise. A caesarean section can require six to 12 weeks' recovery, depending on your body, and you should always wait for the green light from your doctor before starting any physical activity.

After six weeks for a natural delivery or eight to 10 weeks for caesarean section, you can start gentle low-impact exercise, such as cycling, cross trainer, Pilates, yoga and light weights. Avoid high-impact exercise such as running and aerobics until four to six months after giving birth. Exercise on your hands and knees or in bridge position should also wait until after six weeks.

Consider the first three months after birth as the 'fourth trimester' – a time of rest, recovery and irreplaceable moments with your newborn. Eat to nourish your body rather than trying to lose weight and under no circumstances try diet pills, liquid diets or other weight-loss products, which can be harmful to you and your baby if you are breastfeeding.

Blood lost during and after delivery can also lead to iron deficiency, which exacerbates the chronic fatigue that new mothers often experience. Fill up on iron-rich food such as free-range, grass-fed organic beef, dark green, leafy vegetables and dark beans such as kidney or aduki beans, and avoid too many raw foods (unless in easily digestible green juice or smoothie form) as these require more energy to process.

Breastfeeding mums who are tempted to cut calories to lose weight should also be aware that you need, in general, up to 500 more calories a day to support the process. Lactogenic foods can help with milk supply issues, try consuming things like moringa [add to smoothies to help mask the taste], oatmeal, brewer's yeast, salmon and fenugreek seeds.

I recommend booking in for a Women's Health physio appointment after your six week check-up. At this appointment we can check your pelvic floor function, discuss any developing aches and pains, discuss specific exercises for you to do/avoid, and give you some general piece of mind over your body changes.

We also have a number of specialty pre / post natal pilates classes. These group sessions are tailored for individual abilities and allow you to exercise safely and encourage movement through your body. To join a pregnancy, or mums & bubs class we do require you to have a 1-1 prep session first just to make sure you're not in any pain, and to identify any potential complications.

Our reception team is happy to discuss with you your best options and to assist with booking. 093664480 or admin@aucklandphysiotherapy.co.nz

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