“Communication is to relationships what breath is to life” – Virginia Satir

Painful Intercourse

Painful intercourse is the second most prevalent problem I see in my practice, besides a lack of sexual desire or arousal. As many as one in five women has pain during intercourse. 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.

Sexual pain disorders like Vaginismus are however commonly misdiagnosed or left unaddressed. Women may need to be very courageous in persevering until their concerns are given due attention and a reliable medical diagnosis is reached.

Any pain during or after sexual intercourse is not normal, even though your doctor might have told you that on physical examination ‘there is nothing wrong.’ Painful intercourse (dyspareunia) can occur for a variety of reasons and the most important thing that you must know is that pain is painful– it is not in your head!

I work within a multi-professional team which specialises in the treatment of patients with painful intercourse and chronic pelvic pain. We have treated many patients who have never been able to have sex due to the severity of the pain as well as patients whose lives are affected by pelvic or perineal pain on a daily basis.

It is important to find the source of the pain and the right combination of treatment options for each person.

Women with sexual pain will often make some of the following comments:

• “It always felt tight and uncomfortable. I never realized it was Vaginismus.”
• “I experience burning pain upon penetration attempts.”
• “I’m still a virgin even though we’ve tried many times – it’s like he hits a wall.”
• “Sex used to be great, but now I close up – it burns and stings.”
• “Sex was fine until after the baby – now it always hurts.”
• “We can’t consummate our marriage – it’s impossible.”
• “The doctor says there’s nothing wrong with me. So why does it still hurt?”
• “When he starts to move, it feels uncomfortable and we have to stop.”
• “Ever since the operation I feel burning pain when I try to get him in.”
• “After menopause I began to feel soreness and now I tighten up.”
• “I don’t wear tampons because it is too hard to get them in.”
• “I seem to ‘tighten’ up down there even when I really want to have sex.”
• “There’s no way I’m doing a pelvic exam again – it’s unbearable.”
• “Sex has never been comfortable for me.”

Women with sexual pain dysfunctions often hear the following from healthcare providers or psychologists:

• “Just live with it. There’s nothing you can do”
• “It’s all in your mind”
• “Just drink some wine and the pain will all go away”
• “Just relax”
• “I don’t see anything physically wrong”
• “Just grind on your teeth – It will get better”
• “See a psychiatrist- it must be in your head”
• “Just think about a pain somewhere else in the body and it will go away”
• “Wish the pain away. Positive thoughts are the answer”
• “Since I can’t see anything that could be causing it, I’m sure it’s not that bad”
• “You are fine. You are just spending too much time thinking about it”
• “Your husband will appreciate it if you just don’t say anything”

You should not have to just “live with it”. Painful intercourse has an effect on you and can put a strain on a relationship. I understand talking about the problem and dealing with it can seem terrifying but as a team who spesialises in female sexual pain we deal with it on a daily basis and are therefore very understanding and empathetic.

Depending on the diagnosis, referral to a specialized pelvic floor dysfunction physiotherapists, and/or sexual medicine physician on the team (usually covered by medical aid) might be necessary with follow-ups until you have pain-free intercourse.

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 the woman 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. Depending on the intensity, Vaginismus symptoms range from minor burning sensations with tightness to total closure of the vaginal opening with impossible penetration.

Common Symptoms of Vaginismus
• Burning or stinging with tightness during sex
• Difficult or impossible penetration, entry pain, uncomfortable insertion of penis
• Unconsummated marriage
• Ongoing sexual discomfort or pain following childbirth, yeast/urinary infections, STDs, IC, hysterectomy, cancer and surgeries, rape, menopause, or other issues
• Ongoing sexual pain of unknown origin, with no apparent cause
• Difficulty inserting tampons or undergoing a pelvic/gynaecological exam
• Spasms in other body muscle groups (legs, lower back, etc.) and/or halted breathing during attempts at intercourse
• Avoidance of sex due to pain and/or failure

Examples of the effects of Vaginismus
• PC muscle group contracts and involuntarily tightens the vaginal entrance making intercourse painfully impossible ‘like bumping into a wall’. This type of Vaginismus makes penetration impossible.
• In other cases of Vaginismus, penetration may be possible, but the woman experiences periods of involuntary tightness causing burning, discomfort, or pain.
• 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 gynaecological 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’.

Vaginismus Symptom Severity Range
1. Minor discomfort or burning with tightness is experienced with vaginal entry or thrusting but may diminish.
2. More significant burning and tightness is experienced with vaginal entry or thrusting and tends to persist.
3. Involuntary tightness of the vaginal muscles makes entry and movement difficult and painful.
4. Partner is unable to penetrate due to tightly closed vaginal opening. If entry is forced significant pain results.

What Causes Vaginismus?
Vaginismus is a unique condition in that it may result from a combination of either physical or non-physical causes or it may seem to have no cause at all

How does Vaginismus cause problems?

With Vaginismus, the mind and body have developed a conditioned response against penetration. The body has learned to expect or anticipate pain upon penetration, so that the powerful PC muscle ‘flinches’ or contracts to protect against the potential of intercourse pain. This can be equated to automatically blinking one’s eyes and wincing when an object is hurled toward us. It is not something a woman thinks about doing – it just happens.
The tightened PC muscles may cause burning or pain with sex or may completely block entry. Instead of preventing pain, the tightening of the PC muscle group ultimately causes pain; although acting as a defence mechanism against pain, the opposite effect results.
Vaginismus has a wide range of manifestations, from impossible penetration, to intercourse with discomfort, pain or burning, all resulting from involuntary pelvic tightness. When a woman has never been able to have pain-free sexual intercourse due to penetration difficulties, it is generally classified as primary Vaginismus. When a woman develops the Vaginismus condition after having previously enjoyed problem-free sex, it is generally classified as secondary Vaginismus. Depending upon the classification, there may be some minor differences in the way in which Vaginismus is treated.

Primary Vaginismus
When a woman has never at any time been able to have pain-free intercourse due to Vaginismus tightness, her condition is known as primary Vaginismus. Primary Vaginismus refers to the experience of Vaginismus with ‘first-time’ intercourse attempts. Typically, primary Vaginismus will be discovered when a woman attempts to have sex for the very first time. The spouse/partner is unable to achieve penetration and it is like he just bumps into a ‘wall’ where there should be the opening to the vagina. Entry is impossible or extremely difficult. Primary Vaginismus is the common cause of sexless, unconsummated marriages. Some women with primary Vaginismus will also experience problems with tampon insertion or gynaecological exams. The PC muscles constrict and tighten the vaginal opening making it uncomfortable or in many cases virtually impossible to have entry. When tightened, attempts to insert anything into the vagina produce pain or discomfort. Some women also experience related spasms in other body muscle groups or even halted breathing. Generally, when the attempt to put something in the vagina has ended, the muscles relax and return to normal. For this reason, medical examinations often fail to reveal any apparent problems unless the tightness occurs and is noted during the pelvic exam.
Most of the general public has never even heard of vaginismus, and indeed many gynecologists and sex therapists are also unfamiliar with the condition, but vaginismus is not that uncommon. Researchers estimate that from 1 to 7 percent of the female population worldwide suffer from vaginismus.

Contributing factors could include:
• Pelvic pain due to a medical condition, infection, physical trauma or assault, age-related changes, or painful physical events such as childbirth.
• Emotional distress, anxiety, fear, relational difficulties, or other similar emotions that relate to sex, intimacy, past trauma, or relationships.
• The anticipation pelvic pain due to some past or present condition or situation.
• Other causes.

Secondary Vaginismus sexual pain can affect women in all stages of life, even women who have had many years of pain-free intercourse. Secondary Vaginismus refers to the experience of tightness pain or penetration difficulties later in life, after previously being able to have normal, pain-free intercourse. It typically follows or is triggered by temporary pelvic pain or other related problems. It can be triggered by medical conditions, traumatic events, relationship issues, surgery, life-changes (e.g. Menopause), or for no apparent reason. Secondary Vaginismus is the common culprit where there is continued, ongoing sexual pain or penetration tightness where there had been no problem before. Most commonly, secondary Vaginismus strikes women experiencing temporary pelvic pain problems such as urinary or yeast infections, pain from delivering babies, menopause, or surgery. The initial pain problems are addressed medically, healed, and/or managed, yet women continue to experience ongoing sexual pain or penetration difficulties due to Vaginismus. While the initial temporary pain was experienced, their bodies developed a conditioned response resulting in ongoing, involuntary vaginal tightness with attempts at intercourse.
Left untreated, Vaginismus often worsens, because the experience of ongoing sexual pain further increases the duration and intensity of the involuntary PC muscle contraction. The severity of secondary Vaginismus may escalate so that sex or even penetration is no longer possible without great difficulty. Some women will also experience difficulty with gynaecological exams or tampon insertion. Vaginismus can also impede a woman’s ability to experience orgasm during intercourse, as any sudden pangs of pain will abruptly terminate the arousal build-up toward orgasm. Vaginismus is involuntary – not intentional. It is important to note that Vaginismus is not triggered deliberately or intentionally by women. It happens involuntarily without their intentional control and often without any awareness on their part. Vaginismus has a variety of causes, often in response to a combination of physical or emotional factors. The mystery of the problem can be very frustrating and distressing for both women and their partners. Despite the fact that Vaginismus is involuntary and can strike any woman, many women feel intense shame from being unable to have intercourse and keep their pain private, feeling uncomfortable sharing their secret with anyone.

Examples of Non-physical Causes

Fear or anticipation of intercourse pain, fear of not being completely physically healed following pelvic trauma, fear of tissue damage (ie. “being torn”), fear of getting pregnant, concern that a pelvic medical problem may reoccur, etc.

Anxiety or stress

General anxiety, performance pressures, previous unpleasant sexual experiences, negativity toward sex, guilt, emotional traumas, or other unhealthy sexual emotions

Partner issues

Abuse, emotional detachment, fear of commitment, distrust, anxiety about being vulnerable, losing control, etc.

Traumatic events

Past emotional/sexual abuse, witness of violence or abuse, repressed memories

Childhood experiences

Overly rigid parenting, unbalanced religious teaching (ie.”Sex is BAD”), exposure to shocking sexual imagery, inadequate sex education

No cause

Sometimes there is no identifiable cause (physical or non-physical)

Addressing Vaginismus Causes

Vaginismus does not always have an obvious cause. Sometimes women with near perfect childhoods, great relationships, strong education, and few anxieties, have trouble finding any plausible explanation for what caused their Vaginismus.
Understanding why they had Vaginismus may remain a mystery even after it is fully resolved. Fortunately, though it is helpful to know the causes, full knowledge is not necessary to complete successful treatment.

Examples of Physical Causes

Medical conditions

Urinary tract infections or urination problems, yeast infections, sexually transmitted disease,
endometriosis, genital or pelvic tumors, cysts, cancer, vulvodynia / vestibulodynia, pelvic
inflammatory disease, lichen planus, lichen sclerosus, eczema, psoriasis, vaginal prolapse, etc.
Childbirth Pain from normal or difficult vaginal deliveries and complications, C-sections, miscarriages, etc. Age-related changes Menopause and hormonal changes, vaginal dryness / inadequate lubrication, vaginal atrophy. Temporary pain or discomfort resulting from insufficient foreplay, inadequate vaginal lubrication, etc.

Pelvic trauma: Any type of pelvic surgery, difficult pelvic examinations, or other pelvic trauma

Abuse Physical attack, rape, sexual/physical abuse or assault

Medications Side-effects may cause pelvic pain
Since Vaginismus can be triggered by physical events as simple as having inadequate foreplay or lubrication, or non-physical emotions as simple as general anxiety, it is important that it be understood that Vaginismus is not the woman’s fault. Once triggered, the involuntary muscle tightness occurs without conscious direction; the woman has not intentionally ’caused’ or directed her body to tighten and cannot simply make it stop. Women with Vaginismus may initially be sexually responsive and deeply desire to make love but over time this desire may diminish due to pain and feelings of failure and discouragement. It is extremely frustrating to be unable to physically engage in pleasurable sexual intercourse.
Life experiences vary dramatically from person to person. Some women’s bodies react with Vaginismus, while others with nearly identical experiences do not. The anticipation of pain, emotional anxieties, or unhealthy sexual messages can contribute to and reinforce the symptoms of Vaginismus. Frequently, but not always, there are deep-seated underlying negative feelings of anxiety associated with vaginal penetration. Emotional triggers that result in Vaginismus symptoms are not always readily apparent and require some exploration. It is important that effective treatment processes include addressing any emotional triggers so a full pain-free and pleasurable sexual relationship can be enjoyed upon resolution.
Vaginismus is often a complicating factor in the recovery from other pelvic pain conditions. Vaginismus may co-exist with other medical conditions, possibly triggered by temporary pelvic pain resulting from those conditions. Or, it can be the sole cause of sexual pain remaining after the original medical problems are addressed. When the underlying cause has been resolved or managed and ongoing pain, discomfort or penetration difficulties continue to remain, this is typically due to Vaginismus. In cases where there is clearly both Vaginismus and another pelvic medical problem existing simultaneously, both problems will need to be treated to ensure full resolution. Without addressing the other medical condition, it will be difficult to resolve the Vaginismus as it may continue to be triggered by pain from the other problem.

The Role of the PC muscle group

The pelvic floor muscles predominant in Vaginismus are called the pubococcygeus (PC) muscle group. The PC muscle group plays a key role in the function of a woman’s reproductive system, urinary tract, and bowels. The muscles enable a woman to urinate, have intercourse, orgasm, complete bowel movements, and deliver babies. Hence, they are also referred to as pelvic floor muscles, vaginal muscles, and love muscles. With Vaginismus, the mind and body have developed a muscle memory or conditioned response against penetration. The body has learned to expect or anticipate pain upon penetration, so that the powerful PC muscle ‘flinches’ or contracts to protect against the potential of intercourse pain. This can be equated to automatically blinking one’s eyes and wincing when an object is hurled toward us. It is not something a woman thinks about doing – it just happens. Unfortunately, instead of preventing pain, the tightening of the PC muscle group ultimately causes pain; although acting as a defence mechanism against pain, the opposite effect results. The spasms cause burning or pain upon penetration or movement and may even completely block entry. The PC muscle group is large and very powerful. It encircles the urinary opening, vagina, and anus in a figure-eight pattern with one loop of muscles surrounding the vaginal area and the other loop surrounding the anal area. On each end, the muscles are attached to the skeleton and support and hold in place the abdominal and pelvic organs like a net, forming the pelvic floor.

There are many dangers in being given an improper diagnosis from an uninformed professional. Unnecessary, invasive and potentially harmful surgeries and medications have been suggested for women with Vaginismus who have not been properly diagnosed.

Misdiagnosis and the promotion of invasive or unhelpful surgeries are sometimes the unfortunate result of all this confusion. There is no surgery to cure Vaginismus. It is very important to seek a second opinion if surgery to ‘widen’ the vaginal opening has been recommended as this does not normally resolve the penetration problem, but instead may further complicate the problem.

Fortunately Vaginismus is highly treatable with full restoration of sexual intercourse. And the treatment does not require any invasive procedures. Couples completing treatment fully consummate and enjoy normal penetrative sex.

Localised provoked vulvar pain (vestibulodynia) is a term used to describe pain upon penetration of the vagina. There is also tenderness to touch around the vaginal opening (vestibule) during physical examination. It occurs in women of all ages. It is estimated that approximately 15% of women will experience this type of vulvar pain sometime in their lifetime. Other names used in the past to describe this pain included vulvar vestibulitis syndrome, superficial dyspareunia and vulvodynia.
What causes it?
Researchers are studying vestibulodynia to learn more about the cause of the pain. In the last two decades they have shown that the painful tissue of the vestibule has increased nerve endings and inflammation. Although the cause is unknown at this time, there are theories that chronic inflammation from frequent yeast infections, hormonal changes, poor sexual
arousal or chronic skin conditions may trigger the pain. It is likely that there is a combination of factors involved in the cause of vestibulodynia.
What are the symptoms?
Pain with vaginal penetration during sexual activity is the most common symptom experienced by most women with vestibulodynia. The pain can be described many different ways including burning, stinging, tearing, throbbing, searing and occasionally itchy. Some women may experience pain for several hours or days after intercourse. Some women may also have pain with tampon insertion or speculum exam during a routine gynaecologic exam. Most women have pain only with touch to the vestibule and are otherwise not bothered by pain.
What do I see?
The appearance of the vulva can vary with each woman. Some women will have redness at the vaginal opening but some will not. For many, the vulva and vestibule look entirely normal.
How is it diagnosed?
Many different treatment options have been tried for vestibulodynia. Some women experience a great sense of relief just knowing that the pain they are experiencing is real and has a name. With a supportive team that may include a spouse or partner, physiotherapist, sexologist, pain specialist, and psychologist most women will have improvement of their pain. Often, different treatment options are combined to maximize therapy.

Elmari specialises in the following:
  • Sexology
  • Individual Psychotherapy
  • Clinical Hypnotherapy
  • Sex therapy
  • Couples Therapy
  • Relationship/Marital Enrichment
  • Pre-marital Counselling
  • Conflict Resolution and Effective Communication Skills
  • Divorce Counselling
  • Trauma Counselling

The diagnoses and treatment of male and female sexual dysfunction, eg
  • Loss of sexual desire
  • Libido differences
  • Sexual Pain Disorders:
    Vulvadinia ext
  • Inability to reach orgasm
  • Erectile dysfunction
  • Ejaculation control and timing
  • Sexual behaviour disorders
  • General Sexual Problems
  • Sexual Enrichment