Intimate Issues

The true feeling of sex is that of a deep intimacy, but above all of a deep complicity.
                                                     - - - James Dickey

 Sex is a complex issue for all couples.  Having a chronic pelvic pain condition intensifies the complexity, and often limits the pleasurable aspect.  Face it;  much of our identity is wrapped up in sex.  Who we are as women (or men), who we are as a couple, or as an individual, all of these have our sexuality as part of the question.

I have posted about the importance of communication, and I strongly recommend seeing a certified sex therapist to help with the process.  And, before you start with "my partner is very understanding, we really don't have sex, but we are OK with that as a couple."  REALLY think about that.  Are you OK with it because you have accepted that this is the way it is - and you love each other, so you'll "get through?"  Do you ignore it so it is a "non issue?"  Just because you don't address a problem, doesn't mean it isn't there.  Just think about the possibility of improving intimacy.  This certainly doesn't require a sex therapist, but if it is an uncomfortable subject for you and your partner, think of the therapist as a guide.

Read the post "Sex, Lies, and Dyspar . . . who?" post for some tips and guidelines for what to do pre and post coitus to limit pain, and improve function.  

For a lot of people this information is not enough.  If vaginal intercourse is extremely painful, there are options.  Rectal intercourse is a little much for some people to get their heads around.  If it is not too "out there" for you, discuss it with your partner - they may not be as oppossed as you fear.   As a warning thought, if your pain is from the pelvic floor muscles, especially tightness or spasm, this option is not going to be less painful.  Be very careful when experimenting with new sexual concepts, both of your physical well being, and of your psychological limits.  Change takes time. 

If you are way outside of your box, allow for awkwardness (and fear),  and be very gentle with both yourself and your partner.   Allow a lot of emotional space.  Set up guidelines early.  Always, always, always have a way out.  You and your partner both need to be very comfortable with saying "no" or "stop."  No questions asked.  It doesn't matter if the block is physical, emotional or psychological, in an intimate situation, all limits must be honored.  Again - a certified sex therapist will help with working through the psycholgical and emotional blocks that come up.

There are also ways to mimic intercourse.  Well lubricated inner thighs can be a sexually satisfying alternative to vaginal intercourse.  And, before you do the "what's in it for the woman?" question, realize that sexual pleasure is more global for women than it is for men.  We really are wired for sex, personally I think more so than men.  Genital stimulation is not the biggest part of sexual arousal, or even orgasm, for most women.  Intimacy, closeness, passion, all the sounds and sensations surrounding sex.  For us it is a"whole body" process, and eliminating the worry and pain of trying for "penetration" can be surprisingly satisfying for both partners.

Oral sex is an option for some.  Many vestibulitis and vulvodynia sufferers cannot stand the stimulation of oral sex.  Again, proceed with caution.  Fellatio (oral intercourse with the male recipient) can be a problem for the woman because of positioning issues.  Most of the positioning options add a lot of abdominal pressure, which can increase bladder pain.  Play with positions, and until you are very comfortable, don't make orgasm a goal.  I also treat people with jaw, neck and headache issues, so if you are prone to these conditions, be VERY careful with oral intercourse.

Please add comments if you have postioning advice, or pre-post coitus tips. 

Sex, Lies, and Dyspar....WHO?

Dysapreunia, or painful sex, affects most, if not all sufferers of chronic pelvic pain. For some, it is the only symptom; for others, it is one of many aggravating factors. Vestibulitis is characterized by burning pain at or around the opening to the vagina, sometimes the entire labia minora is affected. Vulvodynia is often characterized as pain in the introitus (the muscular entrance to the vagina), or may encompass a larger area of pain. Interstitial Cystitis sufferers may have pain only with deep penetration that puts pressure on the bladder. Vaginismus is an involuntary spasm of the pelvic floor, which can be painful in itself, but contributes to other types of pain. Any combination of these symptoms is common.

Some women have pain at arousal, partially because of the blood flow to the area, which increases congestion of the tissues. Sometimes the pain is anticipatory, knowing it is going to hurt, causes tightness and pain. Sometimes the pain is only during penetration, and many women will tolerate very little. Some women cannot tolerate penetration of any kind. Sometimes the pain is during orgasm, when the pain of involuntary muscle contraction overrides the natural endorphins that make sex so pleasurable for most people. Sometimes the pain kicks in the next day, sometimes during sex, sometimes immediately after. Regardless of how or when the pain presents itself, the loss of a pleasurable sex life is an issue that should not be minimized.

Communication is key to having a fulfilling sex-life, regardless of limitations. Remember, the problem is in your body, not in your relationship. Talk to your partner. Open lines of communication, even if it is difficult and painful. Many women are more concerned with the effect that their pain has on the partner's sex life than their own. Chances are, your partner is just as concerned about you. You may need to modify how you define sex, at least when you are having an acute flare-up, or while you are seeking treatment. Sex isn't all about penetration, and it isn't all about direct stimulation. Be creative, and be gentle. If all of this sounds foreign, and maybe scary, consult an expert. Clinical Sexologists, or Sex Therapists, are available in every major city in the US. do your home work. Most states have very strict licensing laws about Sex Therapists. be sure whoever you talk to is appropriately certified.
Some things a Sex Therapist will NOT do:

• Ask you to have sex in front of them to "observe"
• Offer to "demonstrate" with you or your partner
• Belittle your concerns and fears

Sexology is a branch of psychotherapy. Sex Therapists are there to teach you and your partner how to communicate, and explore a fulfilling sex-life. They aren't scary, and they aren't weirdos. They are trained, compassionate professionals.

What else? Well, relaxation is huge. In physical therapy, we do alot of things to help you relax. We use biofeedback (surface emg), so you can tell when the muscles are tightening, even if you can't feel it. We do manual techniques to reduce the muscle spasm (see the Trigger Trauma post dated 1/30/2006). We recommend meditation and relaxation tapes.

Things you can do to help relax the pelvic floor before intercourse:

• Take a warm bath
• Use a moist heat pack on your back and lower abdomen
• Gently warm a safe device that can be placed inside the vagina for 5-10 minutes prior to intercourse. I often recommend the EZ-Fit.
• Apply topical Lidocaine, to numb the tissues. Be very careful with this recommendation, and consult your physician about safety for you. If the surrounding tissue is very fragile or sensitive, there may be tearing with intercourse that you won't be able to feel until it's too late. If the majority of the pain is from muscle spasm or interstitial cystitis, lidocaine will be less helpful. Be aware that for a man, the topical lidocaine that you use will limit his sensitivity, making it difficult for him to achieve orgasm.
• Use a lubricant, but be very particular about what you use. Many of the commercial lubricants irritate vestibulitis and vulvodynia. I have had very good luck with pure aloe vera gel, but even that has irritated at least one of my patients. Some of my patients prefer emu oil, but oils will break down the latex in condoms, making them less effective.

After intercourse try:

• Internal cold. Use a device that will hold the cold for 2-5 minutes. Again, the EZ-Fit works great. I have had patients try to fill a condom with water and freeze it, but they stretch to an enormous size. The finger of a rubber glove will work better for most patients. When using a frozen device remember that the vaginal wall is composed of very delicate tissue, and an ice-cold object may be damaging, so limit the time accordingly.
• Cold packs on the lower abdomen, low back, and/or between the legs to cover the external genitalia
• Another warm bath.

I hope some of these suggestions help. Please comment, with additional ideas, or e-mail me with questions.