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Melanie Cole, MS (Host): If you experience painful intercourse, you are not alone. Women may be too embarrassed or hesitant to discuss this with their physicians, but there are many treatment options available. My guest is Kim Snyder. She’s a physical therapist at the Pelvic Health and Wellness Center and Deaconess the Women’s Hospital. Kim, I'm so glad to have you on to discuss this very sensitive topic. As I said, women may be hesitant or too embarrassed to discuss it with their doctors. Tell us who’s most at risk and what age are you seeing this the most?

Kim Snyder PT (Guest): Thanks, Melanie, for having me on. Yes. This is a big problem. We see a lot of cases of women who are having pain with intercourse. The unfortunate part is that they're waiting so long to come in before they tell that practitioner. It’s just almost like they're just not discussing it as if its—I don’t want to say shameful, but that they feel like they're abnormal in some way. It is an abnormal problem. It’s not normal to have pain with intercourse, but many things can cause it. The causes vary mostly by the age that the dyspareunia starts. So if you are sexually active for the first time and you have pain with that initial onset of intercourse, and then the next time you attempt intercourse it’s painful again and then a third time you have intercourse again. You're basically starting a little file in your brain that says intercourse equals pain. The more that you have intercourse that is painful, the bigger that file is. That brain remembers that intercourse is pain.

Then all of a sudden even thinking about intercourse a woman can start to tense and tighten out of fear, the body trying to protect itself. So when her partner penetrates her and she’s fearing that pain, the body will want to close that opening. When her partner penetrates her, it is like putting a square peg into a round hole. It creates a little trauma. That trauma of the tissue causes a little bit of inflammation. That inflammation causes connective tissue to kind of lay down. It makes the tissues move less fluidly. The backside of the vaginal opening, there’s skin on the outside of the vagina that then becomes one with the vaginal canal. That skin should glide over the muscle wall as if the skin on your elbow moves. When you have pain with intercourse and you’ve had some inflammation and a little bit of adhesion or scar tissue development, that tissue no longer wants to move. So it kind of becomes sort of stuck to that muscle wall.

So then when I know I'm going to have intercourse and I know in my brain it’s going to hurt and I start to tense and I have a tight opening, then when he penetrates me, he’s tearing those underlying tissues. That hurts. Not only does it hurt, it creates inflammation again, which creates more connective tissue adhesion. So then the longer I wait in between having intercourse, the worse the problem gets.

Most of my patients who talk about pain with intercourse with me, the story is very similar. They’ll say well it was a little painful at first, and then it kept getting progressively worse. Often times by the time they get here they're not having intercourse at all. They can have absolutely no penetration. So we can also see it in postpartum women. Let’s say that you have delivered a baby vaginally and you had to have an episiotomy, which is a small cut that’s made to allow the opening to become a little larger to get the baby out a little easier. That, of course, when it heals heals by laying down scar tissue. It’s a similar effect to what we just discussed.

Then you have that woman who is menopausal. Let’s say she’s gone through menopause and one of the effects of menopause is that we’ll have drier tissues. We don’t have as much vaginal secretion, which helps intercourse of course. When you have dryness and you have penetration, then, of course, it can cause pain and then start that whole cycle over again. So that’s the populations that we’re typically seeing in. That new sexually active individual, the post-partum mom, and then of course anyone who is in that menopausal state. That can be a problem there too. Not to make this podcast any longer, but there’s a whole slue of other problems that can happen with your bladder than can also cause pain with intercourse. So we’re basically talking about just connective tissue issues here, but there can be a lot of other things that can cause it.

Host: Well that was what I was going to ask is how is it diagnosed if it is a connective tissue issue, or if it’s a deep pain that can be from fibroids or uterine cysts or any of these things. Is there a way to figure out the cause of the problem, and then deal with the treatment, whether it’s pelvis physical therapy or meds or whatever? Do we need to determine the cause of this pain?

Kim: Absolutely. That’s where, as a physical therapist, I rely on their medical practitioner, such as their gynecologist or their family practice physician who is doing pelvic exams, doing pap smears to try to determine if there’s an underlying cause. When the patient comes to me, those underlying causes, for the most part, have been ruled out. So let’s say a patient has a history of endometriosis. They may want to further investigate that endometriosis as being one of the causes of the pain with intercourse. If they have something going on in the uterus or the ovaries, they have fibroids or cysts. That is pretty much ruled out by the time they get to us. On exam, the gynecologist, when they do their manual exam, they’ll assess that muscle wall and connective tissue. Often times when that patient is extremely tender at the vaginal opening and extremely tender over the muscle tissues, and they know that the other tests are negative, then they know that that is definitely a problem. Then they send them to us.

Host: So then what can you do for them? Tell us a little bit about pelvic physical therapy. Tell us about what lifestyle behaviors you would like women to try. What do you do for these women?

Kim: Okay. So we do an evaluation first to try to determine what tissues are involved. That evaluation involves us sitting down and talking. We get a lot of information that helps guide our practice through just simply talking to the patient and hearing her story. All the stories are different. When we hear that story, then that guides me on how and what I'm going to do for the evaluation. So then with the evaluation, I’ll do some testing to the muscle tissues outside the pelvis, but they actually connect to the pelvis. Like we’ll be looking at the belly muscles, strength and flexibility. We’ll be looking at hip muscles. All of these muscles feed into the pelvis and effect the pelvic floor. So we want to make sure that there’s no problems there first.

Then, the second part of the exam is a pelvic exam, which is very different than what they're receiving from the gynecologist. So the pelvic exam that the physical therapist will do is looking at the superficial tissues and then also looking at underlying tissues that are surrounding the muscles within the pelvic floor. The pelvic floor is a mass of muscle and tissue that basically runs from your pubic bone, which is that front pelvic bone, and goes all the way back to your tailbone. There’s five layers of muscle and connective tissue there that needs to be assessed. Some of that tissue we can get to from the outside, but the deeper layers we have to do an internal assessment to see that. So we do some testing to figure out their muscle strength, tender points, connective tissue restriction. All of those things are assessed.

Then on the most simple case, if it’s a connective tissue issue, we will talk to the patient about the issue. Then we typically will do manual therapy, which is us stretching and lengthening and improving that soft tissue mobility. It would be very similar to someone, let’s say, that had knee surgery. Let’s say you went and had knee surgery and you had that incision on the front of the knee. It would limit range of motion; it would be painful. As a physical therapist, we would address that scar tissue. We would cross-fiber massage it. We would stretch and lengthen over the knee, and we do kind of similar things to the pelvic floor. We stretch the tissue. We lengthen that connective tissue. Then because it’s difficult to stretch those tissues because they don’t cross a joint. So it’s not like we can take two bones and move them to create stretch on the muscle.

So if it’s at that vaginal opening where we’ve done the stretching, we’ll send them home with something called vaginal dilators. Vaginal dilators, the set that we usually use that I prefer—there’s a set of six of them and they're nesting. So if you line them all up, it would look like one long, slow, opening cone. They would start with the smallest, shortest, skinniest dilator. They would try to insert that like they're inserting a tampon. If they could put that in and remove it without pain, they would go to the second one. If they could put the second one in and remove it without pain, they go to the third. Let’s say they get to the third one and they put it in halfway and they start to feel that stretch or some discomfort. We would have them pull that out and stretch at that level until they could advance past that without pain. Our goal is to be able to get to a certain point with the vaginal dilators with no pain.

The dilators serve several purposes. One is they're going to stretch that tissue that we just lengthened because if they don’t stretch it, it’s going to tighten right back up. It also serves as a desensitizer. When that area is not touched or mobilized much, it becomes very sensitized and reactive. So we want to desensitize it. By doing that repetitive stretching and that repetitive movement, it desensitized. Thirdly, it gives them visual confidence. They see what is fitting in that opening and their body says, “You know? This doesn’t hurt.” Then they start to relax, and they start to have confidence that when something is penetrating their vaginal opening that it’s not going to be painful. We really encourage them early on to use the dilators just prior to intercourse to try to kind of further desensitize prior to the event.

We have great success with it. Some of the younger patients who are highly estrogenized, they will come in and after one treatment, within a couple of days they're having pain free intercourse. Other folks who have other issues, it may take us four to six weeks, but also can attain intercourse without pain. Once we get intercourse pain-free, then we start working with the other muscle dysfunctions because often times we’ll find muscle weakness as a result of what they’ve gone through. So we’ll go through and start a strengthening program. That’s a little bit different, but it’s very necessary in order to keep those muscles healthy. Then we educate them. We educate their partners; we educate the patient on what is healthy intercourse. Meaning, when is a good time and not so good time to have my pelvic floor penetrated.

So let’s say that I'm a woman that has three kids and my husband wants to have intercourse. I'm not really in the mood, but I'm going to have intercourse anyway. If I'm not in the mood mentally, then physically I'm going to have a challenge. If I'm not mentally into it, I'm going to have a little hard time getting appropriate lubrication. I'm going to have a hard time getting good blow to those tissues and having those tissues be able to be nice and stretchy. So then the chances are that I could cause dyspareunia again. So we educate them on some of the causes and how to prevent that.

Unfortunately, our mamas don’t always talk to us about good, healthy intercourse. It’s so important on how to read the body, when the body’s ready for penetration, when it’s not. I think gosh. Those spouses, we’ve had some wonderful spouses and partners who’ve come in who want to be educated. They're just soaking it all in. That they have no idea that it’s important for their partner to be well lubricated before penetration. So even giving those little tips, it goes a long way in further prevention of dyspareunia.

Host: What a great explanation of all of the treatment options. It’s really like strength training with that gradual progression to make a woman much more comfortable. Tell me as we wrap up, Kim, how comfortable are women getting this type of treatment? Tell us about your team and how you can work in a caring, compassionate, private, confidential way. Because as we said at the beginning, this is a very sensitive topic. Some women might not be comfortable with this type of physical therapy. They don’t even think of a physical therapist of doing this type of therapy. So give us your best advice on how a woman can feel very comfortable discussing this with their physician and getting these types of treatments.

Kim: I think being open to your physician is the number one most important thing because there can be other underlying conditions that they will be able to diagnose by knowing that symptom. So I think number one, open up to your physician. Number two, if it is a muscular dysfunction, most women tell us they're very nervous about being here. Then after all is said and done and the treatment is over, they're completely thankful. They tell us, “I couldn’t be in a more comfortable environment.” We hand out surveys after our treatments and we constantly get feedback that states, “I am so glad that I talked about this problem. They made it feel like it’s just a normal body function. They made me feel comfortable. They made me at ease. I was able to talk freely and not feel judged. I think many of us worry that we’re going to be judged in some way. That we’re abnormal in some way. It’s so not like.

We have all women that work here. So we have a female team. We have private treatment rooms. So everything is kept very confidential. It’s just a warm and easy environment. We’re all women. We have intercourse. We understand. We talk about this all day long. So it is… We are surprised by nothing. We ask our patients to be very honest and open and we tell them why. They appreciate that. I think in the end they just love to be empowered with the ability to, number one, treat this condition. It’s so important and we tell them that. This is a God-given gift to have healthy, pleasurable intercourse. It’s very important that we get that part of our bodies. It’s healthy for our relationships and they appreciate that information.

We really treat them as a whole person. We are not just treating their vagina. It goes way beyond that. The vagina and the brain are so tied. There’s so much hurt, but there’s also so much good that can happen out of that. So we want to give that quality of their life back to them. I think they appreciate that. They see our passion for it, and it makes them complete treatment. They want to come back. We get a lot of word of mouth referrals because once they’ve been treated, they think, “Oh my gosh. This was nothing what I thought it would be. It helped so much that I want to spread the word.” So, yeah. It’s pretty comfortable here.

Host: What a great segment this was Kim. I can hear your passion as well for helping women with this condition. Again, it can effect their quality of life so much. Thank you for all of that great information on the treatment options. That wraps up this episode of the Women’s Hospital, a place for all your life. To schedule an appointment, please call 812-858-5950 or head on over to our website at deaconess.com/pelvichealth for more information and to get connected with one of our providers. If you found this podcast informative, please share with other women on your social media and be sure to check out all the other fascinating podcasts in our library. I'm Melanie Cole.