Pelvic Pain and Dyspareunia

Jun 16

Written By

Reviewed by Cheryl Long, AHPC-registered physiotherapist, Goji Physio

Pelvic pain — pain felt in the lower abdomen, pelvis, or perineum — affects a significant number of women and is frequently under-investigated and under-treated. Dyspareunia (pain with intercourse) is among its most common presentations. Both are real, physical conditions. Physiotherapy addresses the musculoskeletal and neuromuscular drivers of pelvic pain, and is often a central part of the management pathway alongside medical assessment.

What causes chronic pelvic pain?

Pelvic pain has many possible contributors, and in most cases, several factors are present simultaneously. Common drivers include:

Pelvic floor overactivity (hypertonia): excessive or persistent tension in the pelvic floor muscles, which can cause pain at rest, with movement, or with penetration
Musculoskeletal dysfunction: problems in the lumbar spine, SI joints, hip, or coccyx that refer pain into the pelvic region
Nerve sensitivity: sensitisation of the pudendal or other pelvic nerves, often following surgery, birth trauma, or persistent pain
Connective tissue sensitivity: particularly at scars (perineal, episiotomy, Caesarean, endometriosis-related)
Hormonal factors: low oestrogen (postnatal, during breastfeeding, or peri/postmenopausal) causes atrophy and reduced elasticity of vaginal and pelvic floor tissue, which can contribute to pain

Other associated medical conditions including endometriosis, interstitial cystitis, vulvodynia, and vaginismus can also contribute to pelvic pain and require specialist review alongside physiotherapy. Goji will refer you to the appropriate specialist when indicated.

What is dyspareunia and why does it happen?

Dyspareunia is pain associated with intercourse — it can be superficial (at the vaginal entrance) or deep (felt in the pelvis or abdomen). Physiotherapy is highly effective for the musculoskeletal and neuromuscular contributors to dyspareunia, particularly pelvic floor overactivity, scar tissue, and oestrogen-related tissue changes.

What does a session at Goji involve?

Your first session is largely conversational so that we can understand your condition and concerns in depth. You are welcome to share as much or as little as you are comfortable with initially.

A physical assessment, when you are ready for it, may include:

External pelvic floor and perineal assessment: observing resting tone, reflexes, and tissue quality without internal examination
Internal pelvic floor assessment: offered when clinically appropriate, explained clearly, and entirely optional at each stage
Musculoskeletal screen: lumbar spine, hip, SI joint, and coccyx, as pain in these regions can refer into the pelvis

Treatment will depend on what the assessment reveals, and is always tailored to your presentation. It may include manual therapy, pelvic floor relaxation techniques, neurosensory retraining, and progressive load management. There is no expectation of rapid progress — pelvic pain often responds gradually, and the plan will be adjusted accordingly.

Is pelvic pain "in my head"?

No. Pelvic pain is a physical condition with physical drivers. However, it is also true that persistent pain changes how the nervous system processes signals — a well-established phenomenon called central sensitisation — which means that pain experienced can exist in larger proportions than the state of actual tissue injury. Understanding this is part of management, not a suggestion that the pain is imagined. A physiotherapist experienced in pelvic pain will address both the peripheral (tissue/muscle) and central (nervous system) contributors to your symptoms.

Frequently asked questions

How long does it take to see improvement in pelvic pain?

This varies considerably based on the cause, duration, and contributing factors. Pain that is primarily musculoskeletal may improve within a few sessions. Longer-standing pain with a central sensitisation component typically takes more time. Our physiotherapist will give you a realistic estimate based on your assessment findings.

Should I see a gynaecologist before seeing a physio?

For new-onset pelvic pain — particularly if accompanied by abnormal bleeding, discharge, or fever — a GP or gynaecologist review is the appropriate first step to rule out gynaecological causes. Once medical causes have been assessed, physiotherapy addresses the musculoskeletal and neuromuscular contributors. In many cases, physiotherapy and medical management run in parallel.

I was told my pelvic floor is "too tight". What does that mean?

Pelvic floor overactivity (hypertonia) means the muscles are in a persistently elevated state of tension, rather than resting at a relaxed baseline. This is different from the weakness commonly associated with leaking, although it can cause symptoms similar to pelvic floor weakness. Overactive pelvic floor muscles cannot relax effectively, which may cause pain, difficulty with penetration, and sometimes bladder and bowel symptoms. Treatment focuses on downtraining — learning to release, relax, and coordinate the pelvic floor, rather than simply strengthening it.

Can physiotherapy help with vaginismus or vulvodynia?

Physiotherapy is part of the management pathway for both conditions. Vaginismus involves discomfort and involuntary pelvic floor muscle contraction with anticipated or attempted penetration; vulvodynia is chronic vulval pain without a clearly identifiable cause, though there are many associated pelvic health factors. Both respond to a combination of physiotherapy (pelvic floor rehabilitation, desensitisation, progressive loading) and psychological support. Goji works alongside psychologists and gynaecologists as part of a coordinated approach.

Is pelvic pain common after menopause?

Yes. The decline in oestrogen during and after menopause causes changes in vaginal and pelvic tissue — reduced lubrication, thinning of the tissue, and decreased elasticity. This can result in pain, discomfort, and increased susceptibility to irritation. Physiotherapy can address the tissue and muscle components; topical oestrogen (prescribed by a GP or gynaecologist) often works alongside it.

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Tell us about where you are feeling pain and how long it has been going on — we'll help you understand what is happening and what physiotherapy can offer.

Reviewed by Cheryl Long, BSc (Hons) Physiotherapy, AHPC-registered
Clinical Director, Goji Physio — Women's and Family Physiotherapy, Lentor, Singapore