In previous articles, I have discussed female sexual pain, some common diagnoses, and options for treatment via physical therapy. In this article, I’d like to describe a less common source of sexual pain that I encountered in a patient, and how we successfully treated it. I am describing her case with her permission, and we both hope that it is useful to other women who may be experiencing something similar.
Although it was assumed that her pain with sex was coming from an ovarian cyst, the source of her pain was actually elsewhere, and she is now essentially pain-free. When this woman arrived for treatment, she described a 30-year history of pain with vaginal penetration during sex (pain with penetration during sex is called “dyspareunia”). This pain was on the right side, deep and stabbing, and pierced from her front to her back and all the way up her abdomen. It occurred all the time, but she didn’t let it prevent her from having sex. In fact, she often didn’t tell her husband about the pain, because she knew that it was unavoidable and still wanted to have an intimate physical connection with him. Although some positions were better than others, the pain was always there.
She had made several attempts to evaluate and address the pain. In 1991 she was diagnosed with endometriosis and was told that the only cure would be to have children and then have a hysterectomy. Surgery for endometriosis didn’t improve her dyspareunia. When her doctor found a fibroid on the right side of her uterus, she had a partial hysterectomy (removing the uterus but leaving the cervix and ovaries). Unfortunately, the pain continued. From then on her and her doctors assumed the dyspareunia was related to chronic ovarian cysts. She came in for physical therapy treatment because she knew she had scar tissue from the endometriosis and surgeries. She believed that addressing this scar tissue could benefit her, and would hopefully improve her symptoms.
Pelvic Therapy For Dyspareunia
To understand what we were evaluating and treating, it is helpful to have some background information on what “pelvic health” physical therapy is and what treatment of the “pelvic floor” involves.
The pelvic floor is a group of muscles that are located in the area of the genitalia in both men and women. It functions to support the organs, to coordinate with the other “core” muscles for postural stability, to control urination and defecation, and to contribute to sexual function. Treatment of these muscles and pelvic structures can be done externally, vaginally, or rectally, and should only be done by a practitioner specifically trained in this area, such as a pelvic health physical therapist.
When she arrived for Pelvic Health physical therapy evaluation, this patient did have an ovarian cyst that was being actively monitored by her physician. The lateral location of her sexual pain, how it was triggered by deep penetration during sex, and the diagnosis of ovarian cysts, seemed consistent. I evaluated her with the initial presumption that her diagnosis was correct, and that her painful sex was indeed coming from the ovarian cyst.
However, during my evaluation, I found that I could reproduce her pain by palpating some of her deep pelvic floor muscles. I could also reproduce the pain by palpating around (but not on) the ovary externally. I found connective tissue restrictions in the area of her ovary, small intestines, and colon. Curious and encouraged, we started treating these areas, albeit very cautiously since she did have an active ovarian cyst that was being monitored. We didn’t want to risk irritating or even rupturing it.
By the end of her series of sessions (12 sessions spread out over 5 months), which were focused on treating the pelvic floor muscles, connective tissue restrictions, and visceral mobility, she had almost no pain with sex. Her ovarian cyst was still there, but she could have sex in almost any position without pain. This was an excellent outcome.
We will never know precisely, but I believe that due to endometriosis, surgeries, and chronic ovarian cysts, she had developed connective tissue restriction that limited her tissue mobility during sex. I believe that she also developed pelvic floor muscle dysfunction related to years of irritation and tension. While I do believe that the ovarian cysts probably contributed to her sexual pain, the major driver turned out to be connective tissue restriction and muscle dysfunction.
This was a good reminder for me as a practitioner to acknowledge the known issues, but also to stay curious and investigate further. This patient had suffered for 30 years, receiving multiple surgeries and even removed an organ (her uterus) to try to resolve her pain. Through specialized physical therapy, she finally found relief and is now able to have a pain-free sex life.
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