What's Pelvic Pain and What Can I Do About It?
What is pelvic pain?
“Pelvic pain” is a catch-all term for any long-term pain or discomfort someone may experience in the genitals, pelvis, and surrounding areas. It can include sexual pain, but you don’t need to be sexually active in order to experience pelvic pain.
We’ve created this guide to let you know that if you are experiencing any kind of pelvic pain, we believe you, and to let you know that you are not alone.
If sexual activity is painful for you, you don’t need to “learn to relax” or just “deal with it.” In our culture, people with vulvas have usually been raised to believe that painful intercourse is normal and just how it is, but that’s totally false. While chronic pain (including pain with sex) is common, it is not “normal.” If it hurts, it’s usually because something is wrong. Pleasure is a human right and if you have decided that you are emotionally prepared for and enthusiastic about engaging in sexual activity, it should feel good.
Pelvic pain is a complex subject because the pelvic area is such a complex part of the human body!
This guide will specifically focus on people with vulvas who experience pelvic pain, but it’s important to remember that people with penises can experience it as well.
Pelvic pain can be a symptom of a chronic physical condition like endometriosis or pelvic floor dysfunction or it can be a physical manifestation of psychological trauma. Menstrual cramps can cause pelvic pain, or even a wonky sexual position. In these cases, the cause is temporary and/or easily fixed.
If you experience long-term pain, the root cause can be difficult to diagnose. It’s very common for medical professionals—including gynecologists—to not know how to handle pelvic pain because pain isn’t something that can be seen, and a lot times, the same goes for the root cause of chronic pain.
It can be even more difficult for people with penises to receive a proper diagnosis because while little time in medical school is spent studying the pelvic floor of people with vulvas, even less is spent learning about the pelvic floor in people with penises.
Some common causes of pelvic pain
- Menstrual pain, insufficient vaginal lubrication, uncomfortable sexual positions
- Vaginal infections like UTIs, yeast infections, or bacterial vaginosis. Pain from the organs (like the bladder, if you have a UTI) can be referred to surrounding tissue, like the pelvic floor muscles and nerves, resulting in pelvic floor pain, especially when these kinds of infections recur or become chronic.
- Diarrhea or constipation. Straining the muscles can cause muscle spasm in the pelvic floor, leading to more constipation, pain with intercourse, and generalized pelvic pain. Frequent diarrhea can also cause pelvic floor muscle strain.
- Endometriosis, polycystic ovarian syndrome (PCOS), interstitial cystitis, and other chronic gynecologic conditions.
- An injury like falling on the tailbone, pulling a muscle in the groin, or simply sitting on a hard surface for a long period of time.
- Sexual trauma or assault, which (in addition to any injuries sustained or acquired infections) can lead to vaginismus (tightening of the pelvic floor muscles that can make any kind of penetration painful or impossible) or vulvodynia (when any contact with the vulva—skin or even clothes—causes pain). The body stores its own memories, which is one common reason why assault survivors may develop pelvic pain as a response to trauma. Even consensual touch can unintentionally trigger negative body memories.
- Vaginoplasty, resulting in vaginal pain for post-op trans folks or others who have these procedures.
- Foreskin or frenulum pain for people with penises.
I don’t want this list to make you afraid of doing simple things like sitting on a hard surface for a long period of time—because something like that won’t cause pelvic pain for most people. I just want to give you an idea of the many, many ways that simple activities can create one symptom or another that can lead to pelvic pain. Frequently, pelvic pain ends up being a chain reaction of sorts.
My own experience with pelvic pain began with a yeast infection and multiple UTI diagnoses. After three rounds of antibiotics, I still had UTI symptoms: pain with urination, feeling the urge to urinate but not being able to, general pressure in the abdomen. Based on a lot of research I did while experiencing these terrible symptoms, I learned that pelvic floor dysfunction can mimic symptoms of a UTI. My urogynecologist (an OB-GYN who also specializes in urology) confirmed this belief after I tested negative for infections and a brief pelvic exam showed tightness in my pelvic floor muscles. Maybe I’d never even had a UTI at all; maybe the pain of a regular old yeast infection just kicked off a series symptoms that kept getting worse and worse. I will never know for sure!
Who do I see for help?
Because there can be so many contributing factors to pelvic pain, and because if these symptoms go untreated, they can get worse or even take longer to heal, it’s important to see a professional. Depending on what body parts you have and where the pain is, the gynecologist can be a good place to start to rule out any vaginal infections. If you test negatively for yeast, BV or other common infections, your pain could be the result of some other condition, like interstitial cystitis (aka “painful bladder syndrome”) or pelvic floor dysfunction. If you’re having bladder/urinary tract symptoms, a urogynecologist may be able to help you. If you aren’t able to start with a specialist (some insurance plans require a referral from a general physician), see your family doctor.
If you can access this kind of care, a physical therapist can also be a good person to start with. How can a physical therapist help you with pelvic pain, you might ask? Actually, pelvic PTs are your best bet at getting a proper diagnosis if you have pelvic pain! Regular PTs get very little, if any, pelvic floor training, but pelvic PTs are highly trained in the complexities of the pelvic floor and surrounding musculoskeletal anatomy in addition to general physical therapy training.
Sometimes, it takes a village to heal pelvic pain, and a psychotherapist can also be extremely helpful, especially if your pain is the result of sexual assault and/or post traumatic stress disorder. A sex-positive therapist can help you work through issues that a physician or physical therapist can’t, like trauma cues (emotional triggers). More specifically, a somatic therapist is one that studies the mind-body connection and how past experiences affect both our minds and our bodies in present time. There is no shame in needing a therapist to help you through pelvic pain. There is no shame in needing a therapist at any time, period—but they can be especially helpful if you are coping with chronic pain.
What is pelvic floor dysfunction?
Pelvic floor dysfunction (PFD) is a common cause of pelvic pain in people of all body types. All that term means is that something isn’t right with the pelvic floor muscles, a group of muscles that everyone has in the shape of a hammock but that acts more like a trampoline (in other words, this muscle group shouldn’t sag like a hammock, but should have more flexibility like a trampoline).
The muscles of the pelvic floor are some of our hardest working muscles: they barely ever get a break. While you can sit down and rest your legs, your pelvic floor is still holding you upright and holding your organs in place, pretty much never fully at rest.
In younger people, PFD is usually the result of a hypertonic pelvic floor. “Hypertonic” means the muscles are too tight and in spasm and are working even harder than usual. It’s like flexing your bicep but then your bicep stays flexed and doesn’t relax. If that happened, your muscle would hurt, and would also become weak. This is why it can be tricky to treat a hypertonic pelvic floor—because the muscles are usually too tight, but there is an underlying weakness to them. They first need to be relaxed and lengthened before they can be re-strengthened.
The opposite of a hypertonic pelvic floor is a hypotonic one. While this is more commonly heard about in general, it's less common in young folks.
The reason we hear so much about hypotonic pelvic floor muscles (weak and/or sagging muscles) is because this is what can happen to the pelvic floor after a pregnancy and childbirth, so this kind happens to a lot of people. Because the muscles are so overworked during pregnancy and delivery, the muscles may start to sag and the organs aren’t held in place. Ever heard a joke about a woman who pees a little when she sneezes? It’s usually played for laughs, but it’s no laughing matter. A weak pelvic floor can lead not just to a little urine sometimes, but to organs like the uterus or bladder prolapsing (sagging into the pelvic floor). If your pelvic floor isn’t strong enough to hold your organs in place, it affects continence (the ability to control peeing and pooping).
You may have heard of Kegel exercises. This is something bound to come up whenever most people talk about the pelvic floor. A Kegel is a controlled way of tightening and releasing the pelvic floor. These exercises can be great for a weak pelvic floor, but can make a tight pelvic floor worse! If you experience pelvic pain, see a professional before attempting to do Kegels or assuming that they will help you.
Up until recently, we’ve mistakenly associated most, if not all, pelvic pain and its symptoms with people who have just given birth or who are menopausal. But the truth is that anyone of any age or genital makeup can experience pelvic pain. Some studies state that up to 75% of people with vulvas experience pain with sex at some point in their lives, but it could really be anywhere from 25 to 75 percent.
Can I still have sex?
Chronic pelvic pain, like any other chronic pain, can have a negative impact on your quality of life. Not only is the pelvis a private and little talked-about area of the body, but it can be especially frustrating when a part of the body we strongly associate with and expect to give us pleasure ends up causing us chronic pain.
Dealing with pelvic pain can be extra tough if you’re unable to have the kind of sex you want to have, whether that’s sex with a partner or with yourself. Masturbation can actually be a great way to help recover from pelvic pain if one of your goals is to be able to have pain-free sex (this isn’t always a goal of someone who experiences pelvic pain and that’s okay, too!). Remember how we said the body remembers? A common cause of lingering pelvic pain is an anticipation of pain. Even if your body is physically healing, it may still associate sex with pain. The body needs to re-learn that sex can be pleasurable—and that other things that may have been painful recently can be pain-free.
Of course, for some folks, masturbation or orgasm aren’t sexual—they can just be a great way to relieve stress or even temporarily relieve pain (the endorphins and chemicals that the brain releases during orgasm, like oxytocin, really can offer short-term pain relief!). For others, still, masturbation and orgasm aren’t of any interest at all—and that’s okay, too!
Remember, sex doesn’t have to involve vaginal (or other) entry of any kind. Oral sex and manual (hand) sex are also intimate sexual activities people commonly find satisfying. If you find that your body isn’t up to any kind of sex, though, that’s still okay! An understanding and supportive partner will meet you wherever you are.
How do I communicate my pain with others?
It can be incredibly difficult to explain something like pelvic pain to other people. Chronic pain is hard enough to understand when you’re experiencing it yourself, let alone if you haven’t ever experienced it. You may also feel embarrassed about pelvic pain because we don’t tend to talk openly about pelvic issues. But guess what? Everyone has a pelvis and, as we’ve learned, pelvic pain is actually very common.
A good doctor will not act awkward or make you feel uncomfortable if you bring up pelvic pain. If they do, consider seeing someone else if that is an option. If not, something as simple as taking an article like this with you can be helpful in explaining your situation. This is also a good way to start a conversation with a parent or trusted adult if you are young enough to need a parent or guardian to take you to the doctor.
A good sexual partner will listen to you and try to understand what you are going through. There are countless ways to be intimate without even taking your clothes off! During the worst of my own pelvic pain, I kept my underwear on during sex so my partner didn’t have to worry about hurting me and so I could fully relax.
Pelvic pain can impact more than sex, though. Depending on the kind of pain and where it manifests itself, just standing or sitting for long periods of time can be difficult. Leaving your house can be a challenge. It may even affect how you sleep and what you eat. These are all things it’s really helpful for loved ones to understand.
Books can help, too! A really wonderful and accessible resource is a little book called Why Pelvic Pain Hurts by Adriaan Louw, Sandra Hilton, and Carolyn Vandyken. If you are interested in a much more in depth study of pelvic pain, I love Pelvic Pain Explained by Stephanie A. Prendergast and Elizabeth H. Akincilar. Healing Painful Sex by Deborah Coady and Nancy Fish is about all different sorts of pelvic pain and how it affects sexual functioning—this book in particular can be a great way to feel less alone. It’s worth noting that these books (and most resources about pelvic pain) are cis- and sometimes heteronormative. Pelvic pain professionals are starting to understand the needs of trans and gender non-conforming patients—which is great!—but really inclusive resources are still currently lacking.
Pelvic pain can be difficult to navigate, but more and more medical professionals are beginning to study and understand it. The pelvic floor physical therapy field is growing very quickly! While pelvic pain is a common medical issue, everyone’s experience of it is individual. It’s important to remember that what helps one person may not help another— sometimes it takes a little trial and error to find out what works for us. Sometimes pelvic pain goes as quickly as it comes, sometimes it takes some work to find your new “normal.” But at least remember that you are not alone—and that you are not your pain.