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Overcoming Sexual Pain: The Role of Physical Therapy in Healing

Sexual dysfunction is a broad umbrella term that encompasses a variety of diagnoses and disorders. It is typically divided into four main categories:

1) decreased sexual desire (libido)

2) inability to get aroused

3) difficulty achieving orgasm

4) pain with sex (dyspareunia).

Due to the complexity of arousal and sex, sexual dysfunction is often multifactorial. 

Systemic Factors

Systemic factors are those that affect the body as a whole rather than a single localized area. In terms of sexual dysfunction, systemic factors are generally related to mental/emotional wellbeing, hormone balance, medications, and overall physical health.

A person’s mental and emotional status are particularly important for libido - sex isn’t usually a top priority when someone is chronically stressed or sleep deprived (i.e. moms with newborns!). A history of sexual abuse or PTSD can also lead to significantly increased or decreased sex drive. An imbalance in sex hormones (like testosterone) or thyroid hormones also alter sexual desire. Medications, especially the SSRI class of antidepressants, are notorious for decreasing arousal and delaying orgasm. Physical ailments such as high blood pressure, diabetes, high blood pressure, and others can also affect sexual function.

In order to normalize sexual function, any contributing factors should be addressed appropriately. This may involve medication changes, lifestyle changes (nutrition, exercise, stress management, etc). A licensed counselor or a sex therapist can be exceptionally helpful in addressing any mental/emotional barriers to sex.

"Sex isn't usually a top priority when someone is chronically stressed or sleep deprived."

Local Factors

Local factors are those that are relatively confined to a specific area. For sexual dysfunction, local factors are usually in the pelvic region and sometimes in the abdomen or spine. The most common local factors are usually related to pelvic floor muscle function, scar tissue, or clitoral hood mobility. 

In order to achieve orgasm, the pelvic floor muscles (and abdominal muscles) must go through a series of pelvic floor contractions. If the pelvic floor muscles are weak or extremely tense (tight), this can impede normal neurovascular dynamics and sensation and thus prevent or reduce orgasm. Entrapment or irritation of certain nerves, such as the pudendal, hypogastric, genitofemoral, or vagus nerves can also impact ability to climax. For most women, orgasm is achieved via clitoral stimulation rather than G-spot stimulation alone. The clitoral hood, which is a mobile tissue that moves out of the way and exposes the clitoris when aroused, can sometimes become “stuck” and not retract enough, causing diminished clitoral sensation and therefore reduced ability to climax. 

Pain with sex (Dyspareunia) is often due to tight pelvic floor muscles, scar tissue, or vaginal dryness. These changes can be due to childbirth, stress, or hormone changes, especially in the postpartum period or with menopause. Painful sex is also a common symptom of endometriosis, where endometrial tissue lesions are anywhere outside the lining of the uterus. This causes chronic inflammation, scarring, and irritation, resulting in pain. Anatomical abnormalities can also cause pain with sex, such as an imperforate hymen or excessive hymenal tissue remnants. 

How Pelvic Floor PT Can Help

If you are experiencing symptoms of sexual dysfunction, your physical therapist will do a head-to-toe assessment, including a pelvic floor muscle exam, to determine the root of the issue and address it accordingly. Common treatments include normalizing pelvic floor muscle tone and mobility, scar tissue mobility and desensitization, and pain management techniques. In the case of systemic issues such as hormone imbalance, endometriosis, depression, etc., your physical therapist may also recommend adjunct treatment such progesterone, vaginal estrogen, sex therapy, counseling, or functional medicine intervention through other providers.

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