Deep Pain During Sex - How Pelvic PT Helps
You are not alone.
Deep pain during sex is common and treatable with pelvic floor physical therapy.
What “deep pain” during sex actually means
Deep pain during sex can mean a few things. It is important to first distinguish deep pain vs superficial pain. Superficial pain will often feel raw, burning, or stingy more at the opening. This pain can also feel like it is at the urethra, or even feel like it creates a barrier to penetration. To learn more about this type of pain, read this blog here on why you feel like you are hitting a wall during sex.
For deep pain, this often feels like it is further back in the vaginal canal. Sometimes this type of pain can feel like it is at your cervix or even radiates to the lower abdomen. It often occurs during positions that allow for deeper penetration.
There can be many causes of this type of pain and sometimes more than one cause can co-exist. One reason you can feel deep pain is because there are certain muscles in the pelvic floor that are more in the back of your pelvis and they can get tight and painful. These muscles are called the levator ani muscles. If you are a chronic butt tucker, sit a lot for work, or have limited hip mobility you may develop tightness and tenderness in this part of your body.
If you have a history of falls on your tailbone or pain at your tailbone, this can also cause tightness at these muscles out of protection. Chronic constipation can also be associated with tightness at the deeper pelvic floor muscles.
If you have suspected or confirmed endometriosis, adenomyosis, pelvic adhesions, PCOS, or GI sensitivities/inflammation this can also cross sensitize the pelvic floor muscles as they will often tighten up in response to increased irritation and inflammation in the neighboring areas.
If you have had any surgeries to the abdominal wall, pelvis, or hips and did not have appropriate rehab and/or scar tissue mobility work this can also cause deep pain with penetration.
Lastly, hip pathologies such as impingement or FAI can also cause pelvic floor tightness and pain as there are a few hip rotators that are also part of the pelvic floor. This might be the case for you if you notice your pelvic pain increases with certain hip positions such as more extreme external or internal rotation.
All of these causes are treatable with pelvic floor PT alongside a team approach if multiple systems are involved.
Biomechanics: why hip mobility (internal rotation) matters for deep pain with sex
One of the reasons you may be experiencing deep pain with sex is because of the position. What we now know is that hip external rotation (think butterfly position) actually closes down the space between your sitz bones (butt bones) in the back of the pelvis. If you are in a position where you feel deep pain, try moving your hips into a more neutral position or even internal rotation (safely without forcing or knee pain) in order to see if creating more space and length in those muscles decreases your pain pattern. Positions such as sidelying and all fours will allow you to have better access to hip internal rotation.
If you cannot achieve hip internal rotation without pain, it is important to be assessed by a pelvic floor physical therapist. Hip range of motion can be worked on and improved with quality pelvic PT.
Ergonomics & positioning: simple, immediate strategies to reduce deep pain with sex
If deep pain with sex is consistent in certain positions, it might be worth considering other positions that can decrease this pain. One position that can help reduce deep pain with penetration is side lying. It can be helpful if your top leg is slightly flexed and potentially supported by a bolster or pillow. When the rest of your body is supported so you do not have to hold yourself up, your muscles can relax more, including your pelvic floor.
Ergonomic support with bolsters can also be helpful during positions where you want your hips elevated. If you are trying a position where you are on your back with your hips lifted, try placing a pillow, bolster, or even a yoga block under your sacrum so that you have more passive support.
If you are on your back with your legs in a butterfly position, consider placing a pillow or bolster (even a folded up blanket) under each thigh so that your legs can rest into the support. Inner thigh tension is also directly linked with pelvic tightness, so allowing your femurs to rest into gravity can decrease the activation of this muscle group.
If you are on your stomach, you can try pillows or blankets under your abdomen and waist so that you can get elevation at your hips without muscular effort.
Warm-up & cool-down: think of sex like exercise
Sex can and should be considered a form of exercise. And like an exercise routine, it is important you have a proper warm up and cool down, especially if you have deep pain with sex or symptoms.
It is understandable that sometimes sex is spontaneous and cannot always be planned for. However, it is possible to creatively include a warm up as part of sensual connection or foreplay. Something like diaphragmatic breathing can actually be quite sexy when done with a partner. Massaging muscles such as the inner thighs and glutes could be a way to increase arousal while also warming up the pelvic floor muscles and helping your nervous system relax as a whole. We also know that the vaginal canal elongates with arousal, so allowing for this to happen before penetration can be essential to decreasing deep pain with sex.
For a cool down, something connecting and bonding again such as deep breathing can be a simple way to integrate this in. If you have the time, something even more specific such as pelvic floor stretches or even fascial work which can be done (when taught correctly how to use by a pelvic PT) with tools such as the pelvic wand or cupping on external tissue can help with potential cramping and tightness after sex.
At Bodyful, we do pelvic PT sessions where partners are allowed to attend in order to learn breathing techniques and manual therapy techniques that can support you therapeutically so you do not have to hold all of this alone.
Somatic strategies that actually change pelvic floor tone
The respiratory diaphragm and pelvic floor (diaphragm) are connected. The respiratory diaphragm is a domed shaped muscle underneath the ribcage that is meant to expand when you inhale and passively recoil when you exhale. It is meant to be your primary breathing muscle, it is part of your core, and it is not in the belly. Belly breathing is not true diaphragmatic breathing. In order to allow the diaphragm to expand, shifting focus to a gentle opening at the sides and the back of the ribcage can allow for this area to begin to open.
Biomechanically, the respiratory diaphragm and the pelvic floor are the top and bottom of a closed pressure system. This means that when the diaphragm expands and goes down, the pelvic floor will do the same to accommodate the pressure shift. This is one of the first and most effective ways to begin to regulate the pelvic floor.
Not only does this type of breathing help with pelvic floor relaxation directly through a mechanical mechanism, it also directly regulates the nervous system. The vagus nerve, which is a nerve that helps tell your body what state the nervous system should be in, runs through the diaphragm and gets mechanically stimulated with this type of breathing. This can help bring you more into the parasympathetic or rest and digest state. In this state, there is less tissue tension, cortisol, and even pain perception decreases. Breathing in this way can be a powerful somatic practice to help regulate and relax before, during, and after intercourse.
Special populations: endometriosis, postpartum recovery, and when to prioritize multi-disciplinary care
People with endometriosis or adenomyosis often report deep dyspareunia (deep pain with sex). This is often due to the underlying inflammation and resulting holding patterns in the pelvic floor muscles and fascia. It is important that people with endometriosis have a multidisciplinary approach to care in order to get to the root cause and have holistic management. The gold standard treatment for endometriosis is tissue ablation and must be performed by a specialist. However, surgery alone will not completely change symptoms as the nervous system and fascial holding patterns need to be addressed. This is where quality pelvic floor physical therapy can help, both before and after any surgery. At Bodyful, we are also trained in visceral fascial mobilization techniques that can really help with holding patterns in the deeper abdomen.
Pain with deep penetration can also be more common when you are postpartum. There can be many causes of this including scar tissue from potential tearing or c-sections, hormonal deficits due to decreased estrogen while breastfeeding, and pelvic floor tightness and/or sensitization in general as part of the recovery from being pregnant and giving birth. The pelvic floor often responds with tightness after birth and quality pelvic PT can help decrease this response to allow for less pain with penetration.
Partner Involvement & Co-regulation
When you are dealing with deep pain during intercourse, it is helpful to have your partner get involved in your healing strategies. Though part of healing penetration pain can be thought of as purely biomechanical, at the end of the day it is now known that nervous system states influence why muscles get tight or tender during certain activities.
There is a term called co-regulation which explores the idea that your nervous system can be regulated (or dysregulated) by the nervous systems of the people you are in relationship with. There is a wonderful opportunity with this concept to explore how your partner can hold a role of tending to their own sense of groundedness in order to contribute to a deeper sense of safety and presence during intimacy. This does not mean it is all on one person to create that environment, but rather that each person holds their own responsibility in tending to their sense of embodiment in order to contribute to the whole of the experience.
Some simple ways this can be explored is by offering the partner to also do deep diaphragmatic breathing with you either before or after the initial penetration. Another option is to explore the use of therapeutic tools such as dilators or the pelvic wand to warm up before penetration, and to have your partner present for this or even assisting. Rather than feeling like you have to do your physical therapy in isolation or on your own, you can invite your partner in to support and even have their own role which can often feel empowering for both parties.
It can also be supportive to have your partner learn therapeutic hands on techniques that are gentle and can be held in a sensual container rather than a sexual one. Oftentimes taking the pressure off of sexual expectation can allow for the pelvic floor and nervous system to more safely explore how sensual pleasure can first be received by the body.
At Bodyful, we allow for partners to be present during manual therapy techniques as well as learn techniques safely for home so you can work on your healing tools together as a team in a more independent way.
When pelvic floor PT can help
In order to successfully treat deep pain with sex, a pelvic floor physical therapist is recommended. At Bodyful Physical Therapy, you can expect a thorough intake process. We will not rush you as you tell your story. We are pelvic health experts trained to do a comprehensive assessment both with external functional movement screens as well as a potential internal assessment if you consent to it. You can read more about what an internal assessment consists of here.
As pelvic physical therapists, we are trained to competently assess hip range of motion, strength and coordination of your core and gluteal muscles, as well as posture and breathing patterns. We are also trained in manual therapy techniques including myofascial mobilization, visceral fascial mobilization, trigger point work, and biofeedback. We can teach you the correct mechanics of diaphragmatic breathing and pelvic floor relaxation and/or retraining.
Not only are we experts in manual therapy, but we can also prescribe an up to date and evidenced based exercise program that can help you sustain any changes. We focus on individualized programs that met your needs. We can also incorporate a more somatic approach to movement for those who are interested.
At Bodyful, we also offer opportunities to work with us in the framework of wellness or coaching. If you have done pelvic PT before but found you needed more support from a nervous system perspective or even needed support staying accountable with your exercises, we have options to work with us that support those goals. Learn more about what it is like to work with us here.
