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When Pleasure Turns to Pain

At some point in her life, a woman will experience painful intercourse, which can occur for reasons that range from structural problems to psychological concerns. Issues such as endometriosis, bacterial vaginosis, pelvic floor disorders, and more, can leave you feeling, well, deflated. If you are suffering from persistent or recurrent pain before, during or after intercourse, our expert team of urogynecology specialists, can help determine treatments that focus on the cause and can help eliminate or lessen this common problem.
When Pleasure Turns to Pain
Featured Speaker:
Costas Apostolis, MD
Costas Apostolis, MD is board-certified urogynecologist on the Medical Staff at Southwest General.

Costas Apostolis, MD: The first place to start is talk about it. You know, talk about your symptoms. You don't have to live with pelvic pain, painful intercourse, or any condition that affects you below the belt.

Caitlin Whyte: At some point in her life, a woman will experience painful intercourse, which can occur for a wide range of reasons. Joining us to tell us some more about these issues is Dr. Costas Apostolis, a board-certified urogynecologist on the medical staff at Southwest General.

This is Southwest General Health Talk. I am your host, Caitlin Whyte. So doctor, let's start with endometriosis. I feel like that's probably the most well-known issue when it comes to this topic. What is it?

Costas Apostolis, MD: So endometriosis is typically a disease state that affects a female's pelvic health. Potentially, endometriosis can happen at any point throughout a woman's menstrual cycle. And the way I like to describe it to patients is typically, when you have a period, obviously the menstrual blood comes out through the vaginal canal and onto a pad. Well, in endometriosis, some of that blood flow goes back through the fallopian tube and into the pelvis, into your belly.

And so sometimes, the way that I describe endometriosis to patients is, you know, when there is blood inside the belly, it's essentially glue. It's kind of like overcooking spaghetti, is my analogy for it. And when we overcook spaghetti, things kind of clump together. And so in endometriosis, that potentially can happen when we have menstrual blood inside the pelvis or inside the abdomen. It can cause certain organs inside the belly or the pelvis to kind of stick together. And that creates a sensation of pain or pressure or discomfort with intercourse. Irregular menstrual cycles are notorious for causing endometriosis-type symptoms.

So, you know, the first place to start would be to talk to your primary care or OB-GYN physician. These conditions are typically treated by a general OB-GYN doctor. And there's multiple treatment options available, it does not mean surgery.

The first step is to try to make the correct diagnosis and that can start with symptoms. But typically, in order to diagnose endometriosis, one may have to undergo a laparoscopy. And that is a surgical procedure where we place a camera through the belly button in order to actually visualize that menstrual blood inside the belly and to kind of see exactly what's going on.

Caitlin Whyte: Now, what are some other physical problems that could lead to painful intercourse besides endometriosis?

Costas Apostolis, MD: So when we talk about painful intercourse or dyspareunia is the medical term for it, there can be a number of different causes. So number one, endometriosis can definitely be a potential cause, but I would say it's somewhat lower on the potential risk for younger women. The most common potential for pain with intercourse would be a condition affecting the muscles of the pelvic floor called myofascial pelvic pain. And this is a condition where the pelvic floor musculature starts to tighten up and during intercourse can be a source of discomfort.

Other causes of pain can be vaginal infections, such as a yeast infection or bacterial vaginosis. It can be pelvic organ prolapse where the pelvic organs such as the bladder or the rectum or the uterus start to descend into the vaginal canal. And with that, patients would have discomfort with penetration or deep penetration with intercourse. All of these conditions should essentially be discussed with either a primary care OB-GYN or seeking out a urogynecology specialist for an exam, for a simple in-office evaluation to kind of tell you exactly what's going on.

Caitlin Whyte: So on those topics, let's dive into some of them a bit more. Tell us how urinary incontinence can affect intercourse.

Costas Apostolis, MD: Absolutely. Well, urinary incontinence first off affects approximately 30% to 40% of women in the United States. And the most common risk factor for urinary incontinence is having children. Having normal vaginal deliveries can put a female at risk for urinary incontinence.

Now, urinary incontinence comes essentially in two different types. So there's the leaking when you cough, sneeze, laugh, any exertional type leak, especially during intercourse. And so women that are sexually active and have urinary incontinence during intercourse may be experiencing what's called stress urinary incontinence. And oftentimes, I'll tell patients it's not the emotional type stress, but rather stress on the bladder, such as a cough or a sneeze or the act of intercourse putting pressure on the bladder, causing a leak.

And stress urinary incontinence is the most common type of incontinence affecting women across the United States of America. And it's very easily treatable. It starts out with an evaluation in the office where we'll kind of do a gentle pelvic exam, listen to your symptoms about urine incontinence to determine what is the next best step.

We do offer a specialized form of bladder testing called urodynamics, which is a 30-minute test in the office and it helps us understand potentially the type of urinary leakage that a patient might face. Part of the workup may also involve a cystoscopy, which is a little camera. It takes about two minutes to do in the office to make sure that there aren't any stones or masses or, God forbid, anything in the bladder or urethra that can be a potential cause for the urinary incontinence.

But again, women who suffer with urinary incontinence, there's a major psychological component to it as it keeps people at home, very high rates of depression, they don't know where to turn or what they can do about it. Big stigma amongst women is that, you know, "My mother leaked, my grandmother leaked. This is probably normal for me as well." And the answer is no amount of leaking is normal. Not during intercourse, not during exercise, not during any of your daily routines. And there is help. There are things you can do to help with urinary incontinence. And it does not always mean surgery. So I would urge all women who suffer with urinary incontinence to please talk to your primary care or your OB-GYN. Seek out a urogynecologist in your area that can take you through the workup to determine how you can get a better handle on your urinary incontinence.

Caitlin Whyte: You also mentioned prolapse earlier in this episode. How does that lead to painful intercourse?

Costas Apostolis, MD: So pelvic organ prolapse is a condition that affects women's organs in the pelvis, essentially the bladder, the uterus, and or the rectum. And pelvic organ prolapse affects about 20 to 30% of women across the country. The most common risk factor again, being those vaginal deliveries and by no means am I advocating against vaginal deliveries. That's the way God made it and intended it, so we want women to deliver vaginally. Absolutely. But we just want women to know that there are potential risks that come with that. And one of those is pelvic organ prolapse.

When there is a descent or a drop from the normal level of where the bladder or the uterus or the rectum are suspended, that's considered prolapse. Now, all prolapse is not symptomatic, meaning it doesn't cause any problems. And typically, we will follow women who have prolapse to make sure that they are comfortable. So the act of intercourse, when a pelvic organ has dropped, can kind of get in the way. And so when patients are being intimate and feel pressure, pain, discomfort, the feeling that, you know, their partner is hitting something inside their pelvis, that could be a potential sign of prolapse and pain.

Caitlin Whyte: So when it comes to treatments, what are some ways that we can get women back to having comfortable sex with their partners?

Costas Apostolis, MD: Absolutely. Great question. And you know, there's a number of different things that go into an evaluation, not only looking at are there infections or is there incontinence, or is there masses or is there prolapse, but again, we also look at the quality of patients' vaginal skin to make sure that hormonally they are where they need to be, and that will help with intimacy, making things more comfortable.

I would urge all women who suffer with any of these conditions, especially with pain during intercourse to seek out your gynecologist or urogynecologist. Come in, describe your symptoms. You'll undergo a gentle pelvic exam to make sure that the anatomy is where it needs to be, that there isn't some underlying cause for the painful intercourse. Just get in with somebody that you can trust and can help guide you and counsel you to a more healthy pelvic life

Caitlin Whyte: And wrapping up here, is there anything else you'd like to add when it comes to just coming into the office? I imagine some people may be embarrassed or don't want to bring up their sex life at the doctor's office.

Costas Apostolis, MD: Absolutely. And historically with these conditions, women have a tendency to just keep it in for, you know, fear of being judged or being depressed about it, or just considering it normal. Or even more importantly, afraid of what their options might be. Surgery, you know, that evil word surgery. Well, you know, I'm here to tell you that, you know, all conditions do not require surgery.

The first step in getting better is to have a conversation with your medical professional, really. Talk about your symptoms. Get the help you need. Learn about your options. I'm a very big advocate of second opinions. I think that it helps patients feel more comfortable with what they're being told, you know, about the conditions they're facing. I think second opinions are awesome in getting people to understand. Because again, physicians, we're all different and we all may have a different way of delivering that information to potential patients, to get them more comfortable. So I think the first place to start is talk about it. You know, talk about your symptoms. You don't have to live with pelvic pain, painful intercourse, or any condition that affects you below the belt.

So we at Southwest General, myself and my nurse practitioner, Amy Skabar. We are at Southwest general hospital. We offer state-of-the-art testing. We are available five days a week to see patients, evaluate patients and help them achieve a more comfortable way of life.

Well, thanks, doctor, for joining us. It's an intimate subject, but I hope we can get some people on the road to more comfortable, pleasurable sex with their partners. To learn more about Southwest General's urogynecology services, visit This is Southwest General Health Talk. I'm Caitlin Whyte. We'll see you next time.