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Painful Intercourse & Vaginismus: who to see and what helps

Painful Intercourse & Vaginismus · Kitchener, Waterloo & Cambridge

Painful intercourse (dyspareunia) is pain with sex that keeps happening, and vaginismus, in which the muscles around the vagina tighten on their own when anything is about to enter, is one cause. Infections, skin conditions and low estrogen are common causes too, so a physician or nurse practitioner should check for those first. In a Canadian trial in women with pain at the vaginal opening (provoked vestibulodynia), a course of pelvic floor physiotherapy reduced pain during sex more than a numbing ointment did. At CARESPACE the first visit is with a pelvic health physiotherapist, with counselling alongside where it fits.

What painful intercourse and vaginismus are

Dyspareunia is recurrent or persistent pain with sexual intercourse that causes distress. A US review puts it at roughly 10% to 20% of women in that country. The pain may be at the entrance to the vagina, deep inside, or both. This page is about pain with sex in women and people with a vagina, because that is who the research covers. A man with pain during or after sex should see a physician or nurse practitioner; our pages on prostate health and pudendal neuralgia describe two possible causes.

Vaginismus is an automatic tightening of the vaginal muscles when something is inserted. It is not something you are doing on purpose. It can start even if you have had painless sex before, and it does not necessarily affect arousal or the enjoyment of other sexual contact. It is most often seen from the late teens to the early thirties, which includes many students at the region’s universities and college. Vulvodynia is different again: pain of the vulva that has lasted at least three months with no cause found, either set off by touch or present without it.

Symptoms

  • Burning or stinging pain at the entrance when anything is inserted: a tampon, a finger, a penis, or the instrument used for cervical screening. This is the pattern of vaginismus.
  • Pain on touch at the opening of the vagina, the pattern of provoked vulvodynia.
  • Dryness and friction, when lubrication is low.
  • Deep pain with penetration.
  • Tender or tight pelvic floor muscles, sometimes with bladder or bowel symptoms.

What causes painful intercourse

  • Too little lubrication and thinning of the vaginal tissue, from low estrogen at menopause or while breastfeeding, from diabetes, or from certain medicines.
  • Infections, including thrush and sexually transmitted infections, which tend to bring discharge, burning or odour.
  • Skin conditions of the vulva, such as lichen sclerosus, lichen planus or contact dermatitis from a soap or other product.
  • Vaginismus. The cause is often unclear. Fear or anxiety about sex, an earlier painful experience, sexual assault or abuse, an unpleasant medical examination, a difficult birth, a belief that sex is shameful or wrong, and painful conditions such as thrush are all thought to contribute.
  • Vulvodynia, and tenderness or spasm of the pelvic floor muscles.
  • After childbirth. Tears, forceps or vacuum delivery and breastfeeding are linked with symptoms that last longer. See postpartum recovery.
  • Deeper causes: endometriosis, pelvic inflammatory disease or scar tissue from it or from surgery, interstitial cystitis, and ovarian masses.

How it is diagnosed

By a physician or nurse practitioner, from your history and an examination. Depending on where the pain is, that can include tests for infection, a look at the skin of the vulva, a cotton swab touched around the opening to map the pain, a single-finger check of the pelvic floor muscles, and an ultrasound for deep pain. You can ask for a female clinician and bring someone you trust. With vaginismus an examination may not be tolerable at first. Vulvodynia is diagnosed only after other causes are ruled out; itching is uncommon with it and points to a different diagnosis.

When to get medical help

See a physician or nurse practitioner about pain with sex that keeps happening. Bleeding after sex always needs a medical visit, and when it comes with pelvic pain it belongs on the same-day list below. The two lists that follow are the NHS’s signs for pain felt in the lower tummy or pelvis. They are separate from pain at the vaginal opening during sex or touch, which is what most of this page is about.

Call 911 or go to an emergency department if you have pelvic pain that is severe, getting worse, or hurts when you move or touch the area, or pelvic pain together with feeling faint, dizzy or lightheaded or passing out, pain in the tip of your shoulder, difficulty breathing, heavy bleeding from the vagina, or sudden confusion. Do not drive yourself. These are the signs the NHS, the UK’s health service, lists for emergency care.

The emergency departments in Waterloo Region are:

  • WRHN @ Midtown (formerly Grand River Hospital), 835 King St. W., Kitchener
  • WRHN @ Queen’s Blvd. (formerly St. Mary’s General Hospital), 911 Queen’s Blvd., Kitchener
  • Cambridge Memorial Hospital, 700 Coronation Blvd., Cambridge

If you cannot get there safely, call 911.

See a physician or nurse practitioner the same day, or go to an urgent care clinic or an emergency department, if you have pelvic pain and any of these: difficulty peeing or passing stool; blood in your urine or stool; unusual discharge, fluid or bleeding from the vagina; pain when you pee, or needing to pee more than usual; a very high temperature, or feeling hot, cold or shivery; vomiting and diarrhoea, or feeling sick; or you are or might be pregnant. If you are 20 weeks pregnant or more, contact your midwife or your hospital’s birthing unit.

If sexual assault or abuse is part of what you are carrying, the Sexual Assault Support Centre of Waterloo Region runs a 24-hour support line at 519-741-8633, for recent and historical survivors of all genders.

What the evidence says about treating painful intercourse

  • Treat the cause that is found. For pain from menopausal changes, vaginal estrogen is the most effective treatment; a US review rates the finding that tablets, creams and rings work similarly well at its highest level of evidence. Lubricants and vaginal moisturizers are the treatment for inadequate lubrication.
  • Pelvic floor physiotherapy beat a standard medical treatment in a Canadian trial. The trial randomized 212 women with provoked vestibulodynia, recruited from the community and four Canadian university hospitals. Ten weekly physiotherapy sessions (education, pelvic floor muscle exercises with biofeedback, manual therapy and dilation) were compared with lidocaine ointment applied overnight. Pain during intercourse fell 1.8 points further on a 0 to 10 scale with physiotherapy, a gap that held at six months, and 79% of the physiotherapy group against 39% of the lidocaine group rated themselves much or very much improved.
  • Across all the research, certainty is lower. A 2023 review of 19 studies of physiotherapy for painful intercourse, eight of them randomized, found improved pain and quality of life on low-certainty evidence, and no significant effect on sexual function.
  • Vaginismus is treated with a combination, and the trials are weak. Successful treatment may include cognitive behavioural therapy, psychotherapy, relationship and sexual counselling, lubricants and a graded set of vaginal trainers (dilators). A Cochrane review, with searches to 2012, found five studies, four of which (282 participants) gave usable data. It found no clear difference between graded desensitization and the comparison groups, rated every study at moderate or high risk of bias, and says conclusions should be drawn cautiously.
  • For vulvodynia, no single treatment is established. US gynaecologists note that few randomized trials exist and the best treatment remains unclear. They advise gentle care of the vulva, say pelvic floor physiotherapy and biofeedback can be used, and suggest treating the physical and emotional sides together.
  • Be wary of laser and other energy-based “vaginal rejuvenation”. The US regulator has warned that these devices are not approved for that use and may cause painful sex, scarring or burns.

What a doctor may offer

Treatment for an infection or a skin condition, vaginal estrogen, a numbing ointment such as lidocaine, medicines used for nerve pain, and botulinum toxin injection for vaginismus. Surgery to remove the painful tissue at the vaginal opening may be effective for vulvodynia confined to that area, only after other treatments have failed.

How each CARESPACE service treats painful intercourse

Pelvic Health Physiotherapy

Vaginismus is a muscle response, and women with vulvodynia should be assessed for pelvic floor problems too. A pelvic health physiotherapist can make that assessment. Treatment can draw on what the Canadian trial used: education about the pain, exercises to gain control of tensing and relaxing the pelvic floor, biofeedback, hands-on treatment of the muscles, and graded use of vaginal trainers. Nothing internal is done without your say-so.

About pelvic health physiotherapy →

Counselling & Psychotherapy

Treatment for vaginismus focuses partly on easing anxiety around penetration, so talking therapy is part of the usual combination. CARESPACE counsellors, who are Registered Psychotherapists and Registered Social Workers, offer cognitive behavioural therapy (CBT). Psychosexual therapy and sensate focus, a set of guided exercises for relaxing during sex, are also used; ask when you book for a counsellor trained in sex therapy. A first counselling visit is about understanding your concern and coming up with a plan. The NHS notes that involving a partner is your choice.

See our counselling team →

Nurse Practitioner

A Nurse Practitioner can do the medical work-up: examine you, test for infection, look for skin conditions, prescribe treatment such as vaginal estrogen, and refer you to a gynaecologist.

See our Nurse Practitioners →

Other services people ask about

Naturopathic medicine. We found no trial or guideline position on naturopathic care for painful intercourse or vaginismus. Hormone treatment and other medicines are prescribed by a physician or nurse practitioner.

Where most people start

If nobody has examined you yet, see a physician or nurse practitioner: infection, skin conditions and low estrogen are treated medically. For the muscles and the pain, book with a pelvic health physiotherapist, who assesses and treats at the first visit.

How your team works together

A pelvic health physiotherapist works on the muscles and on getting used to insertion, a counsellor on the feelings around it, and a nurse practitioner or physician on the medical causes.

Browse by service: physiotherapists, counsellors and nurse practitioners.

What to expect at your first visit

  1. Talking first. When the pain happens, where you feel it, and what has been checked so far, in as much detail as you want to give.
  2. An assessment on your terms. Nothing internal happens unless you choose it.
  3. A first treatment, and a plan that moves at your pace.

What you can do at home

  • Use a lubricant during sex and, for dryness, a vaginal moisturizer several times a week.
  • Be gentle with the vulva: cotton underwear, water only for washing, and no products that irritate.
  • Explore sex that does not involve penetration.
  • Practise relaxation: breathing, mindfulness and gentle touch are part of vaginismus treatment.
  • Start vaginal trainers with a practitioner’s guidance, then continue at home.

Outlook

Vaginismus can be treated, although the trials do not show which approach works best or how long it takes. In the Canadian trial the gains from ten weeks of physiotherapy were still there six months later. Pain after childbirth becomes less common over the first six months.

Painful intercourse treatment in Kitchener, Waterloo and Cambridge

Kitchener. Physiotherapy in Kitchener and Counselling in Kitchener. Locations: Victoria North, Fischer-Hallman, Westmount East and Deer Ridge.

Waterloo. Physiotherapy in Waterloo, Counselling in Waterloo and Nurse Practitioner in Waterloo. Locations: Weber North, Uptown Waterloo and Waterloo GoodLife.

Cambridge. Physiotherapy in Cambridge and Counselling in Cambridge. Location: Hespeler Road.

The city pages linked above show the locations and practitioners for each service, with their next availability.

Common questions

What is the difference between vaginismus and vulvodynia?

Vaginismus is the vaginal muscles tightening automatically when something is inserted. Vulvodynia is pain of the vulva lasting three months or more with no cause found.

Is painful sex normal after having a baby?

It is common. A US review reports painful sex in approximately 40% of women three months after a first vaginal birth, and 20% at six months. Tell your physician, midwife or nurse practitioner about it.

Why has sex become painful around menopause?

Low estrogen leads to dryness and thinning of the vaginal tissue. Vaginal estrogen, prescribed by a physician or nurse practitioner, is the most effective treatment. See menopause.

What if I cannot manage an internal examination?

Then it does not happen. At CARESPACE an internal examination is always the client’s choice, and with vaginismus one may not be tolerable at first.

Where can I get help with painful intercourse in Kitchener, Waterloo or Cambridge?

Both physiotherapy and counselling are offered in Kitchener, Waterloo and Cambridge. The pelvic health physiotherapy page lists who provides that service. Book online or call 519-208-2273 and our Central Reception Team will find the closest location with an opening.

Do I need a referral?

No. Book online or call 519-208-2273. You pay at each visit and receive a receipt for your extended health plan. More on fees and insurance →

Sources

Related conditions

Pelvic Pain · Endometriosis · Menopause · Postpartum Recovery · Interstitial Cystitis

The CARESPACE Central Reception Team

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Book online with a pelvic health physiotherapist, or call 519-208-2273 and our Central Reception Team will match you with the right person and the closest location.

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