When Love Hurts...It Could Be Muscular
The pelvic floor influences sexual function in a many ways. The pelvic floor muscles cross all three openings of the urethra, vagina and rectum. A dysfunction in the urinary, gastrointestinal or reproductive system can influence the muscular tension in the pelvic floor. The muscles can be tight or in a guarded position. This can create a problem with intimacy since the muscles need to be supple and relaxed enough to stretch for penetration. This altered tension can also influence sensation during intimacy, that can prevent pleasure and the ability to climax.
The vagina is made of smooth muscle, the same muscle in blood vessels, and is an involuntary muscle. The pelvic floor muscles are made of skeletal muscle and are under voluntary control by the brain. A vagina can stretch and return to its original shape by the nature of it being a smooth muscle! However, skeletal muscle is not very accommodating and does not stretch well, especially if it has a spasm or knot in it. For example, if a rope has a knot and is stretched or pulled apart from either end, the knot becomes tighter. The knot has to be untied first for the rope to lengthen and the same is true of our skeletal muscles. In addition, the pelvic floor muscles need to be stretched, just as other skeletal muscles in the body require stretching or massage.
It is estimated that 25% of women will suffer with pelvic floor dysfunction at some point in their life. The medical term for painful penetration is dyspareunia, which can occur upon exam, tampon insertion or during intimacy. Pain with penetration, or the inability to tolerate penetration, could be due to tight pelvic floor muscles. Other possible causes of dyspareunia include endometriosis, loss of estrogen (creating dryness and atrophy), or over proliferation of nerve endings inside the vaginal opening contributing to a diagnosis of vulvodynia. Medical attention may be necessary before beginning pelvic floor treatment. A specialist in vulvar pain or urogynecology can rule out medical causes.
One function of the pelvic floor muscles is to assist with orgasm. The clitoris is the female embryological equivalent to the penis, being essentially formed from the same tissue. In order to maintain an erection or engorgement, a healthy pelvic floor is required to contract the muscles that help blood flow into the penis or clitoris and stay there. In addition, orgasm is achieved through a series of muscle action potentials or contraction waves in the pelvic floor that increase in amplitude to result in tetany. Tetany is the peak of all the action potentials and results in contraction of muscles, locally and throughout the entire body. The end result is relaxation of all the skeletal muscles, which is also great for stress reduction. A healthy pelvic floor is required to achieve engorgement and orgasm for both male and female.
To further understand human sexuality, it helps to understand how human beings are created uniquely and have both body and soul. Our physical body represents our spiritual body and what we do with our body matters. Sex is a more than a physical experience; it engages mind, body and soul. There are many references to physical union in scripture. For example, the erotic love language in the book of Song of Songs, which is located exactly at the center of the bible. We learn how the body “sings” a language of divine love. This is a language of pure love. Sex is designed to be an expression of love, which must come first and sex must be consensual. In Song of Songs, the bride is described as a garden and her groom knocks on the door of the garden and awaits her response. She opens her garden to him with her “yes” willingly and in total freedom: “Awake, O north wind, and come, O south wind! Blow upon my garden that its perfumes may spread abroad. Let my lover come to his garden, and eat its choice fruits.” (Song of Songs 4:16). Sex should not be forced or coerced, but must be be mutual. It is also no coincidence that the book of Wisdom chronologically follows this erotic love language. We need to be open to wisdom since sex was created for a purpose.
Sex is for bonding! Human beings are the only animal that has intercourse face-to-face, making it relational and not just an animal instinct. As humans created with intellect and free will, we undermine our intelligence if we act only on instinct. In addition, if we understand the science of sex, it is the glue that bonds or holds a marriage together. Sex is not just for pleasure but for bonding, thanks to the bonding hormone, Oxytocin. This hormone is released in several ways, including nursing and hugging, and in large amounts during intercourse. Oxytocin is what helps us look at the other person with compassion and love. In some cases this bonding hormone can keep a person in a dysfunctional or abusive relationship, seeing the other only through the prism of rose-colored glasses. This is a good reason to abstain from sexual activity if you are in an abusive or new relationship. The benefits of sexual pleasure last long after the experience. Oxytocin is the glue that bonds a relationship and sex is what holds it together, especially during the hard times.
Sex is also for babies! The fruits of a couple’s love can result in one of the biggest blessings, new life. Sex is for the other as a true gift and is necessary for natural reproduction. It has been said that a person discovers themselves in a true gift of themselves. Parenthood is the most selfless vocation and allows a person to see themselves as they truly are. True love is what is best for the other person and not for our own benefit. When we shift the focus from ourselves to others, we can be more generous, giving and loving.
WHEN LOVES HURTS
A healthy sex life is essential for the health of the pelvic floor. Unfortunately for millions of women, pain during or after penetration can result in partial or complete abstinence of intercourse, denying the couple the greatest benefit of the relationship. This is NOT NORMAL and it is necessary to temporarily abstain or stay away from activity that increases pain during the healing process. Think of the pelvic floor as a road under construction; the road might be bumpy or closed temporarily but eventually is paved and smooth. Avoiding sex during the healing process helps to prevent a conditioned response of clenching muscles further. Trauma can occur to the pelvic floor through sexual abuse, injury, falls to the tailbone or hip, pregnancy, childbirth, radiation, chemotherapy, straining and/or constipation. Healing is essential here. After the initial inflammation or injury is gone, the muscles remain in a protective spasm and scar tissue can proliferate. The pelvic floor muscles need to be retrained to relax, which can be accomplished through diaphragmatic breathing (reverse Kegels), pelvic floor stretching and manual release of the muscles and fascia. It is also crucial to avoid straining to urinate or defecate. Click here to read our blog on healthy bowel habits for the core.
“To reduce pain, we need to reduce credible evidence of danger and
increase credible evidence of safety.” (Lorimer Moseley).
Women with pelvic pain can feel isolated. It is important for a spouse or partner to be empowered in the healing process. They have something to gain; a closer relationship and the pleasure of intimacy. I have spouses or partners come in for at least one session if I am seeing a patient with painful penetration. I explain the anatomy, where to press and how much pressure and time it takes. I help them understand the emotional and fear component and encourage patience in this process. I also like to use the analogy of a slow cooker and a microwave. Women are more like slow cookers, requiring time to warm up and be aroused, while men are like microwaves and are quickly turned on, according to Gary Smalley in the book, Reignite Your Marriage in Two Days. Women who are afraid of pain will require additional time to warm up or might need to clear their mind before giving their body fully to the other person. Talking and good communication before sex can be great foreplay!
EXERCISE FOR THE PELVIC FLOOR
For pelvic floor tension, exercise should focus on lengthening the pelvic floor muscles, instead of strengthening. For example, doing Kegels can reinforce a tightened muscle pattern and should be avoided until normal length-tension is established in the muscles. Deep, diaphragm breathing (reverse Kegel) helps the muscles relax and lengthen through the piston effect of the two diaphragms. The pelvic floor relaxes during inhalation and contracts during exhalation. It is important to lengthen before you strengthen the pelvic floor while paying attention to the body’s signals and warning signs. As a general rule, if an exercise or activity causes pain, downward pressure or bladder leaking, it should be modified or avoided until the pelvic floor is functioning properly. Walking, using an elliptical and low impact exercise are good choices while your pelvic floor is healing.
This piston relationship of the respiratory and pelvic diaphragm is essential for a healthy pelvic floor. However, normal diaphragm mobility is altered if there are restrictions or adhesions in the abdomen. For example, if the diaphragm or renal fascia (fascia around the kidneys) is stuck, it will limit the ability to take a deep breath and therefore disrupt full relaxation of the pelvic floor. Someone who has had a C-section, laparoscopy or traumas, including falls, might require manual therapy to release the diaphragm and renal fascia in order to take a full, deep breath. A therapist trained in visceral mobilization can free up fascial restrictions around organs that interfere with deep breathing and teach you how to breathe properly. Diaphragm breathing must be practiced and mastered to become automatic with exercise and everyday tasks.
In addition, the pelvic floor muscles may need to be released and the knots untied with intravaginal trigger point release from an experienced and skilled women’s health physical therapist. Trust is essential here, and one of the reasons we have an outside-in approach with our patients. Working on muscles and fascia on the outside of the pelvis and hips prepares the internal pelvic floor muscles for further treatment. "Blasting past the foyer to get to the kitchen" only increases pelvic floor tension. The pelvic floor muscles are at a deeper layer and are part of an external myofascial system. Once proper breathing patterns have been established and pelvic floor length-tension is normalized, strengthening the pelvic floor can be initiated, unless contracting the muscles leads to an increase in symptoms or tightness. Individuals can experience this when they are instructed to do Kegels too soon or as a solution to all pelvic floor problems.
In addition to diaphragm breathing via Reverse Kegels, stretching other muscles that attach to the pelvic floor is also essential, and is more effective after the muscle knots have been untied by hands-on treatment. We recommend happy baby, goddess pose (full squat with heels on ground) and balancing pelvic floor tension with hip stretching exercises.
As always, exercise should never cause pain. You should STOP immediately and seek help from a qualified pelvic floor therapist if you experience pain during or after doing these exercises, or if you need guidance on how to exercise. You can restore your sex life! Intimacy is essential to a healthy marriage or lifelong relationship. Call us at 330-528-0034 to schedule an evaluation and get on the path to healing your pelvic pain.
West, Christopher (2008). Theology of the Body, Explained. Pauline Books and Media.
Smalley, Michael and Amy (2016). Reignite Your Marriage in Two Days. LuLu Publishing.