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Understanding Sexual Pain – A Physical Therapist’s Perspective

Proper assessment and communication with this vulnerable patient population may improve potential outcomes. A PAINWeek 2018 highlight with Meryl Alappattu, DPT, PhD.


Meryl Alappattu, DPT, PhD, a research assistant professor in the Department of Physical Therapy at the University of Florida, spoke on “Fear and Loathing in the Bedroom: A Savage Journey into Sexual Pain” at PAINWeek 2018 in Las Vegas. As an introduction, she reviewed the current DSM terminology for sexual pain, including how vaginismus and dyspareunia are now grouped and referred to as genito-pelvic pain/penetration disorder (GPPPD). These distinct conditions were grouped due to clinical presentation overlap and a lack of consensus on assessment guidelines, she explained. The combined disorder includes difficulty with penetration during intercourse, genito-pelvic pain during intercourse or penetration, fear or anxiety associated with penetration, and tightness of the pelvic floor muscles during attempted penetration. In addition, one or more of these pain symptoms (whether lifelong or acquired) must have been experienced for 6 months or longer with no other potential diagnostic or medication sources of the pain.

Stats, Symptoms & Etiology

Looking at the statistics, Dr. Alappattu shared that dyspareunia prevalence varies from 3 to 25% of those in general population, 45% in older women, and 34% in younger women, while vaginismus affects 0.4 to 6.6%. GPPPD etiology encompasses a range of factors—biomedical, psychological, and physical—not to mention societal and other burdens placed on the patient. The pain may last for hours or days after intercourse and, in many cases, the patients do not feel comfortable discussing the condition with their partner or their friends. As a result, fear avoidance and pain catastrophizing may begin to build, leading many of these patients to avoid seeking treatment. Sexual pain is still considered a taboo subject, noted Dr. Alapattu, and not all providers are specifically asking about this type of pain when they see their patients. For these reasons, Dr. Alappattu advises using a multidisciplinary team to treat the patient, including but not limited to a physician, physical therapist, ARNP, and certified sex therapist.

It is important to note that men can experience sexual pain as well, although Dr. Alappattu’s talk primarily focused on women.

MSK Factors

Dr. Alappattu’s research focus is on the musculoskeletal factors that contribute to sexual pain. But, she clarified,  “It’s not just about kegel exercises and the pelvic floor—there is much more involved.” The iliac area, superficial and deep transverse perineal muscles, and more, all may play a role. “Sexual pain is also associated with a number of other conditions, such as vulvodynia,” she said, making the point that this type of pain is not always derived from a musculoskeletal area. Thus, asking the patient about whether any pain occurs outside the vagina, such as the hip, abdomen, sacroiliac joint area, lower back, and so forth, is key.

PT Assessment & Patient Communication

As a physical therapist, Dr. Alappattu spent some time describing a typical PT exam for a patient presenting with pelvic pain. In addition to an external pelvic exam and movement and strength testing, a PT’s initial subjective and self-report questionnaires may assess the patient’s relationship satisfaction, anxiety, depression, sexual function, and, of course, the specific areas where the pain is felt as noted above. Dr. Alappattu’s team at the University of Florida, in particular, has also developed a clinical questionnaire on fear avoidance which, she noted, they are planning to evaluate and validate in the near future.

Another major factor to consider when establishing a provider-patient relationship is to consider that a PT is likely the fourth, fifth, or sixth clinician that the patient is seeing after experiencing years of sexual pain. This means, patient expectations must be managed from the start, advised Dr. Alappattu. A physical therapist needs to explain upfront the standard examination procedures for assessing pelvic pain—which may be very different compared to, say, a primary care doctor or gynecologist. In addition, the PT should go over realistic treatments and outcomes with the patient before beginning therapy.

While Dr. Alappattu did not address specific treatment or manipulation approaches in her presentation, she did note that several questions still need to be addressed in terms of the interactions involved in sexual pain in order for practitioners to better tailor treatment.

She also encouraged physical therapists working in pelvic pain to coordinate with specialists when they refer a patient. “It’s important to ask the pain management specialist what their general approach may be so that you can share that with the patient in advance,” she said. This practice may prevent any potential lack of followup on the patient’s part and further strengthen multidisciplinary treatment.


Dr. Alappattu disclosed that she is the owner of the consultancy StylifyU.

Next summary: Video: Drs. Gudin & Fudin on PAINWeek 2018 and PPM's Future
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