Pain with Penetration Even After Physiotherapy: Signs it Could be Sensitization
Lauren Rudko, PT, MSc PT
Pelvic Health Physiotherapist
Introduction
Pain with vaginal penetration can be frustrating and stressful, especially as it relates to intimate relationships. Pelvic health physiotherapy can be a first line of treatment and, often, pain responds well to interventions including pelvic floor muscle relaxation techniques, stretches, dilator therapy and breathwork.
However, in some cases, pain persists, even when the pelvic floor muscles are relaxed and appear to be “fine” on examination. This does not mean that the pain is not real, or should not be treated, but it could mean that the pain present in the tissues is not due to pelvic floor muscle dysfunction or tension but central nervous system sensitization. The good news is that sensitization can also be treated through pelvic health physiotherapy when it takes a bio-psycho-social approach.
What is Central Nervous System Sensitization?
Central nervous system sensitization is a process by which the brain and nervous system (spinal cord and nerves in the rest of the body) change and start interpreting sensations that should be slightly painful, neutral or pleasurable as painful. This change is real, and presents as chemical, structural and functional as it relates to the central nervous system. This can happen for many different reasons, including repeated exposure to pain and nervous system dysregulation (stress, anxiety, depression, fear). Often, pain that persists or routinely reoccurs for longer than three months can result in central nervous system sensitization.
Pain is an important physiological response, and is important for keeping you alive. However, sometimes, our pain responses can become altered in a way that is not helpful. You definitely want your pain system to alert you if you’ve stepped on something that has badly injured your foot so that you can take care of the wound, but you don’t need your pain system to go into high alert during intercourse or a routine pap test.
Often, a negative feedback cycle occurs in which the body is conditioned to have a greater response to pain each time it is felt, which leads to increased pain with each exposure and a worsened pain response each time. With central nervous system sensitization, an individual can also begin to fear movement or touch in a specific area, which can further increase anxiety and stress related to the pain, as well as increase how an individual holds tension in that area in an effort to protect themselves from future pain.
How do I Know if my Pain is Related to Sensitization?
If your pain is not responding to purely biological approaches, then your pain may be related to sensitization. Having a conversation with your pelvic health physiotherapist around your pain will also help determine what might be happening.
Pain that originated due to an injury (including childbirth) or surgical intervention and that persists past the normal timeframe of tissue healing (8-12 weeks) may also indicate that central sensitization could be a reason for the pain.
Your physiotherapist will likely ask questions about your pain history, perceptions around penetration and pain, as well as mental health to better understand what approaches might help support your nervous system. Standardized questionnaires related to all aspects of pain, stress, anxiety and depression, may also be used to help guide your treatment plan and better understand what may be affecting your nervous system.
How can Pelvic Health Physiotherapy Help with Sensitization?
Pelvic health physiotherapy can help with sensitization when it takes a bio-psycho-social approach to the pain. A bio-psycho-social approach considers not only the tissues in the painful area but also the psychological (stress, fear, anxiety, depression) and social factors that may be affecting the individual.
While physiotherapists are not psychotherapists, they do have tools that can help with nervous system regulation, provide pain science education and gradual return to activity that can support decreasing central sensitization. Research shows that the more a person who is experiencing pain understands pain, the less they fear pain and, as a result, their pain experience can actually alter and feel less amplified.
Conclusion
Individuals who are experiencing pain with penetration often benefit from exploring if central nervous system sensitization may be at play, in addition to any tissue restrictions. Working with a pelvic health physiotherapist who uses a bio-psycho-social approach is important in order to determine what role central nervous system sensitization is playing and what strategies might be best to address it. Connecting with a pelvic health physiotherapist at the Proactive Pelvic Health Physiotherapy Center can help support you further on your journey to decreased pain with penetration.