WHEN THINGS DON’T WORK IN THE BEDROOM
Life can feel a whole lot gloomier when things don’t work in the bedroom. A 2016 US study found that sexual health was a highly important aspect when measuring quality of life, even for those who had poor health. If you are suffering from Pelvic Floor Dysfunction (PFD), the likelihood that you are experiencing sexual dysfunction symptoms is extremely high. The women who seek treatment for sexual dysfunction symptoms tend to be those who experience pain, which can be due to high pelvic floor muscle tone (Non-Relaxing Pelvic Floor Dysfunction NR-PFD). You can read more about NR-PFD on the pelvic pain page. Even though they are less likely to seek treatment, those with pelvic floor dysfunction caused by low muscle tone also have a tendency to suffer sexual dysfunction in the form of loss of sensation.
Your pelvic floor, which provides the supportive foundation under your pelvic organs, has muscles that contract rhythmically to produce that wonderful peak of the sexual encounter – the orgasm. If your pelvic floor muscles are not functioning correctly, either due to hypertonicity (excessively tense/high tone) or hypotrophy (excessively weak/low tone), they will not contract with the same “umph”. Of course, sexual dysfunction is much more than just an issue with muscle tone. There are may factors at play that have the potential to negatively impact your sexual experiences. Let’s delve deeper.
MORE THAN JUST A MUSCLE THING
Although your pelvic floor muscle contractions play a role in orgasm, there is so much more at play than just the contraction of these muscles. Sexual function involves your whole body and mind. In the book we explore the connection between the brain and female genitals, and have a number of practices to strengthen this connection to help amplify the strength of orgasms. For the purpose of this page, we will focus on the recipe for climax and the female genitals from a sexual perspective.
WHAT IS THE RECIPE FOR CLIMAX?
The main ingredients in the recipe for climax are desire, arousal, and stimulation. Desire typically comes first, but not always. Maybe you can remember a time when you weren’t in the mood, but your partner did or said things to increased your desire creating arousal. Maybe your partner used stimulation to create arousal causing your desire to increase. Regardless of the route taken, if desire, arousal and stimulation are all present, you have the core ingredients to cook up an orgasm.
As the proceedings get underway, there are changes throughout the body. Heart rate and blood pressure increase. Pupils in the eyes dilate. Breasts swell up with the nipples becoming more sensitive and erect. The cheeks might flush. The blood supply to the vagina and cervix increases and the uterus can shift position, tipping downwards ready to welcome an inflow of sperm. Persistent stimulation of the clitoris (external) can in itself produce an orgasm, in fact, a 2018 US study into women’s experiences with genital touching, sexual pleasure and orgasm found that 36.6% of women reported clitoral stimulation was necessary for orgasm during intercourse. A further 36% reported having better orgasms if the clitoris was stimulated during intercourse.
The mechanism for touch, including location, pressure, pattern and rhythm is quite diverse between women. A wonderful website exploring the science behind orgasm was launched in 2016. OMGYes is an online tool to help you to increase the strength of your orgasms. Understanding what works for you is pivotal to successful orgasm. A 2016 study found that for women, “partnered sex of good quality seems to promote cardiovascular health, specifically reducing the risks of hypertension“. What better reason to find a nurturing relationship where you are sexually satisfied?!
HOW IS SEXUAL SATISFACTION MEASURED?
The quality of your sexual experience is very subjective. If you consistently fail to achieve orgasm during your encounters, you may report feeling unsatisfied. On the other hand, you may have really enjoyed the experience and feel no dissatisfaction on having failed to “cross the line”. Your thoughts are influenced by the hormones that radiate through your body. Hormones play a major role in the sexual response cycle, where you go through phases of arousal, plateau of excitement, orgasm and resolution (the return of everything to normal following climax). The relationship with your partner (or yourself if you are masturbating) also has an impact on your sexual satisfaction. Your thoughts in their subjectivity have the ability to make your experience positive or negative. This is something we explore at length in the book.
WHAT IS HAPPENING PHYSICALLY DURING SEX AND ORGASM?
Aside from the obvious; stimulation, external, internal or both, and the reactions described above (dilated pupils, more blood to genitals etc), there are some other physical and chemical changes that are good to understand. The image below shows the external genitals (vulva) as well as the glands and muscles beneath the skin. When you experience arousal, the glands surrounding your vulva participate by adding lubrication. Your Bartolin’s glands at the bottom of each bulb of vestibule secrete fluid that lubricates the vagina making it wet to aide entry of the penis into the vagina.
The clitoris, as you can see from the image, is not just the small bean shaped organ that you feel beneath your fingers, but is a much larger wishbone-shaped structure that measures about 9cm in length by 6 cm in width. The vestibules are composed of erectile tissue that surround the walls of the vagina. The G-spot was objectively identified anatomically in a 2014 study. The 2014 study stated that it is an area “intimately fused with vessels, creating a complex” and concluded that the “G-spot presents as neurovascular tissues“. This was just one small study. Many other studies have failed to find the infamous g-spot. Regardless of its definitive anatomical identification, women consistently confirm the existence of an area of heightened sensitivity a few centimetres in on the front vaginal wall.
When climax is achieved, there is rhythmic contraction of the pelvic floor muscles whilst the brain releases a cocktail of dopamine and oxytocin. A portion of the front of the brain, that is responsible for self-evaluation, reasoning and control, is inactive during orgasm. This might explain in some way the release or “let-go” that is felt during climax. An inability to relax or let-go can inhibit your ability to orgasm. This is something you should consider if you suffer from Pelvic Pain.
WHAT IS SQUIRTING?
At the top of each bulb of vestibule, you have two small glands known as Skene’s glands which are the equivalent of the female prostate (paraurethral glands). The opening for these glands are very close to the urethral opening. These glands secrete liquid during sex and in some women, these glands can release fluid through female ejaculation. Female ejaculation happens in 10 to 54% of the female population. With female ejaculation, a few millimetres of thick milky fluid is expelled by the Skenes glands during orgasm. This is not the same as squirting.
Squirting is another phenomenon that is often combined with female ejaculation. In both cases, the secretions are from the Skene’s glands, however, in the case of squirting, the expulsion of tenths of millimetres of liquid comes from within the urethral opening. However, the liquid is not urine. It is defined as “a larger amount of diluted and changed urine”. Squirting is normally achieved by stimulating the g-spot (that infamous spot on the inside front wall of the vagina).
WHAT CAUSES SEXUAL DYSFUNCTION?
Sexual function is very complex and the causes cannot be simply explained. As mentioned already, those who suffer pain during sex are more likely to seek treatment for sexual dysfunction. The diagnosis from pain during sex is typically one of three things – Vulvodynia/Vestibulodynia, Vaginismus or Dyspareunia. However, painful sex can also be caused by non-relaxing pelvic floor dysfunction or by Surgery to treat incontinence or prolapse.
Both of these conditions relate to pain (odynia means pain) in the Vulva or Vestibule. This can be pain on intercourse or even pain when trying to insert a tampon. These conditions can be caused by medication, nerve issues or other medical conditions. If you have been diagnosed with Vulvodynia or Vestibulodynia, you can find out more on one of the many vulvar pain support groups.
Vaginismus is a condition where the vaginal muscles involuntarily spasm interfering with sexual intercourse. The spasming from vaginismus can also prevent you from using tampons or having gynaecological exams. It is considered to be a psychosexual dysfunction where the spasming is psychologically triggered. Spasming of pelvic floor muscle is considered to be a defensive mechanism and is a typical physical response to threatening situations, however, in the case of vaginismus, the spasming is dysfunctional as the triggers are not considered threatening. This condition can be so severe that even the touch of a feather can induce painful spasms.
Dyspareunia is a blanket name given to conditions that cause pain during intercourse that has not been associated with another condition (eg: Vaginismus or Vulvodynia). Giving your condition this name indicates that your specialist is unsure of the cause. There are many potential causes for pain during sex. The location of the pain can give some indication as to which muscles may be involved. Of course, there are many causes of pelvic pain that are not associated with your pelvic floor muscles. You can read more on the pelvic pain page where you will find links to other websites that have support groups associated with these other causes.
Excessively tense or lax muscles in the pelvic floor can produce pain or loss of sensation. It is for this reason that women who suffer from PFD or NR-PFD often report sexual dysfunction as one of their symptoms. This also means that the causes of PFD can cause sexual dysfunction (eg: childbirth). It is important to address sexual dysfunction as early as possible, regardless of the cause, as quality of life can be negatively impacted by sexual dysfunction.
Although surgery can sometimes help to restore sexual function (for example, perineal repair that reattaches detached muscles), it also has the potential to cause sexual dysfunction. Any surgery in this delicate area can damage muscles and nerves while introducing scar tissue. This can result in loss of sensation and/or pain. In cases where synthetic mesh or other materials are implanted or injected into the vaginal area, there is an increased risk of developing sexual dysfunction. Particularly with synthetic mesh which has the potential to erode through the vaginal wall causing pain and in some cases, injuring the male penis.
Of the mesh implantation surgeries, the mid-urethral strings pose one of the greatest risks to sexual function due to the placement in close proximity to the dorsal nerve of the clitoris while also being close to the crus of the clitoris. A 2015 study into the clitoris and its role in female sexual function highlighted these dangers associated with mid urethral slings while also highlighting that these are not the only concerns with this type of surgery. They stated that “The presence of a foreign body, such as with synthetic midurethral slings, can result in tissue reaction that may impact the nerovasculature of the vaginal wall and clitoris”. This is an important consideration if you are planning to have surgery with synthetic mesh.
HOW IS SEXUAL DYSFUNCTION CONNECTED TO PELVIC FLOOR DYSFUNCTION TREATED?
Whether you are suffering from PFD or NR-PFD, your treatment should include both physical therapy and some type of psychological or sex therapy. The psychological aspect of PFD can pull your self-esteem down so low that any potential desire is drowned by your tears. Body image is often reported as being negative in women who suffer from PFD. Fear of having a “leak” either urinary or fecaly can force you to abstain from sex. You have to work on your relationship to your vagina and your body, which is a big part of the relationship you have with yourself. This work forms a pivotal aspect of the whole life, whole mind, whole body approach in the book.
There are a number of products that can be used to treat some of the conditions related to sexual dysfunction, mostly focusing on the pain elements. With Vaginismus, you may be advised to use pelvic dilators, which come in a range of sizes from very small to normal penis size. The idea is that you gradually train your vagina to relax to a sufficient size to accept a penis. You can also treat pain using TENS. Learning to relax your pelvic floor over a massage ball is a very useful exercise, but should not be done by someone with a lax pelvic floor.
For those suffering from conditions where the pelvic floor is weak, electronic muscle stimulation can help to increase strength and tone. You should speak with your pelvic health physical therapist before using one of these devices. Reviews of these products will be covered on our YouTube channel. If there is a specific product that you would like to see reviewed, just contact us and we will review. The images below link to the products on in your local amazon store.*
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CONSERVATIVE TREATMENTS HAVE NOT WORKED FOR ME, WHAT NEXT?
You should give conservative treatments time to take effect. It takes time for physiotherapy to work, the amount of time is dependent on your own unique body. Consistency is key with any rehabilitation. Your pelvic floor physical therapist will refer you to a different type of specialist if needed. With psychotherapy or sexological therapy, you also need to give it time.
WHAT OTHER TREATMENT OPTIONS DO I HAVE?
Aside from treating the underlying pelvic floor dysfunction and the psychological/sexological therapies, there are not so many other options. In cases of pain, medication or botox injections can be offered.
Medication is often the first thing we reach for when in pain, but it is not a typical treatment for painful sex. In the US, there is currently an opioid epidemic. Popping a pill is easy but it only masks the pain. Addressing the root cause of pain should be your goal. Your pelvic health physiotherapist can help with this. In the meantime, your doctor can advise on which medications to use for your type of pain with the least chance of developing addiction.
If spasms or hypotonic pelvic floor muscles are causing your sexual dysfunction, botox injections may help. There have been some very small studies into the efficacy of using Botox in treating pelvic pain. Botox works by blocking signals from the nerves to the muscles. These studies have shown to be effective with few adverse side effects. Long term studies are not available. Your pelvic health physiotherapist can advise if this procedure is right for you.