do pelvic exams hurt?
Do pelvic exams hurt?
Regardless of whether or not this is something you have struggled with since your first pelvic exam with your gynecologist or it is something that has developed with time, just know that you are not the only one. Pain during pelvic exams is not something that just exclusively impacts people assigned female at birth (AFAB) or who identify as female and can also impact people assigned male at birth (AMAB) or who identify as male. While it is extremely common and affects anywhere between 11-60% (average of 35%) of people, it is not normal and not something that you have to deal with.
As a Board-Certified Pelvic Floor and Women’s Health Physical Therapist, I frequently work with clients who are experiencing pain with pelvic examinations who have a goal of being able to have pelvic exams pain-free (and spoiler alert: they usually do well with pelvic floor physical therapy treatment).
In this blog post, we will cover the purpose of pelvic exams, common reasons for discomfort during a pelvic exam, and things that you can do to help improve the pain you may be experiencing during pelvic exams.
do pelvic exams hurt: what is a pelvic exam?
A pelvic examination is an appointment that is typically completed by a gynecologist, urologist, or primary care physician (PCP) where they check the health of your reproductive and pelvic organs and happens when you turn 21 years old or first become sexually active, whichever comes first.
With this type of pelvic exam, your physician will usually complete:
A physical examination of the tissue at the outside surrounding your genitals (including the vulva, penis, scrotum, and testicles) and anal opening and may palpate or feel the genital tissue for any tenderness, irregularities, or hernias
A bimanual exam (one gloved hand is placed over the abdomen while the other gloved hand has one to two digits inserted vaginally and/or rectally) to assess your reproductive organs (like the uterus, ovaries, and prostate) for their size, shape, and position to help screen for cancer
An assessment of the fit of different types of birth control like a diaphragm or intrauterine device (IUD) or can insert a diaphragm or IUD
A Pap smear, which should typically occur every 3 years, is where a speculum is inserted into the vaginal canal and your physician will use a small brush or spatula to gently scrape cells from your cervix to screen for cervical cancer
Usually, for these types of exams, you will be asked to undress from the waist down (including your underwear or undergarments) and will provided with a hospital gown to drape yourself with. For people with vaginas or front pelvic openings, you will generally be asked to lay on your back and place your feet in stirrups with your buttocks at the edge of the table while people with penises or back pelvic openings only may be asked to complete the exam sitting, standing, or laying down.
Pelvic exams are a useful tool to help with screening for various diseases and infections, birth control, and overall health and wellness and are something that you should have completed regularly. But when it comes to having pain during pelvic exams: Common? Yes. Normal? No.
do pelvic exams hurt: what could be contributing to your pelvic exams hurting
There are many different reasons why pelvic exams may be painful for folks. Some of the main reasons include:
Pelvic floor muscle tension
We will go over things in a little more detail below, but essentially when tension is present in the muscles throughout the body we can start to develop pain in the muscles that are tense and tight. Similar to how we can have tension in the muscles throughout our body, like in the head and neck when we get stressed out, we can develop tension in the pelvic floor muscles. When the muscles get stretched or pressed on during pelvic exams it can cause pain and discomfort.
Different pelvic conditions
With different pelvic conditions such as endometriosis or fibroids, there is increased inflammation in the pelvic region and there can also be increased tension or activity of the pelvic floor muscles. With these types of conditions nodules, lesions, or scar tissue are incredibly common and if they become twisted, pressed against, or stretched, it can cause pressure and discomfort during pelvic exams with the insertion of a finger and/or speculum.
Another type of pelvic condition, called pelvic organ prolapse, is where the pelvic organs sit lower in the pelvic region than their original position and can cause feelings of pelvic pressure and heaviness. Sometimes with pelvic organ prolapse the pelvic floor muscles can start to increase their engagement to provide further support to hold the pelvic organs where they are supposed to be. This increase in pelvic floor muscle activity can cause pain with pelvic exams during speculum and/or digital insertion when the tense pelvic floor muscles are stretched.
Feeling stressed out or stressed during your exam
Stress and anxiety can cause an upregulation of your nervous system which is in direct control of the muscles throughout your body, specifically the muscles in the pelvic region. So with increased stress during or leading up to a pelvic exam, there can be an involuntary contraction of the pelvic floor muscles causing increased tension in these muscles. And, unfortunately, sometimes with increased tension there can be pain or discomfort which can contribute to discomfort during pelvic examinations.
The actual timing of when your pelvic exam happens
Depending on where you are in your menstrual cycle can have a huge impact on potential discomfort during a pelvic exam. This has to do with normal hormonal fluctuations when on your period, specifically estrogen levels declining. Estrogen has a protective effect when it comes to pelvic pain, so a reduction in estrogen during menstruation can cause increased pelvic discomfort with speculum and/or digital use with pelvic exams.
Another time when pelvic exams can feel sensitive or uncomfortable is in the immediate postpartum period. During the immediate postpartum phase, specifically, if you are chest feeding or nursing your baby, you can be in a state of low estrogen which can cause increased dryness and chafing in the vaginal and vulvar tissues which can contribute to any potential discomfort that may occur during the postpartum pelvic exam. In addition to hormones, if you had any form of perineal tearing during delivery this could also cause discomfort with a speculum and/or use of a finger during an external and internal pelvic exam.
do pelvic exams hurt: how the pelvic floor muscles can play a role
When it comes to the pelvic floor muscles it is important to start with the basics including where they are and what they do.
Where is the pelvic floor?
The pelvic floor muscles are a group of muscles located both outside the pelvis directly underneath your genital tissue (think at the vulva, scrotum/testicles, penis, clitoris, and anus) as well as inside your pelvis. The pelvic floor muscles are also a direct extension of your “core” or abdominal muscles and work in conjunction with the abdominal muscles throughout the day for various activities.
What do the pelvic floor muscles do?
The pelvic floor muscles are a group of skeletal muscles that are under your voluntary control (literally like any other muscle in your body) and…
Form a “hammock,” so to speak, to help to support your pelvic organs and keep them where they’re supposed to be (ahem, inside your pelvis)
Wrap around your pelvic openings (like the urethra where pee comes from, the vagina/front pelvic opening. and the anus or back pelvic opening) to help keep you continent so you don’t leak poop, gas, and urine throughout the day but also need to release so you can go to the bathroom when you want to
Work with your “core” or abdominal muscles to help give abdominal support and work throughout the day to help keep us standing upright
Are important for sexual functioning and comprise many of the muscles that allow us to have an orgasm as well as penetrative intercourse (vaginally, anally, or both!) pain-free
Serve as a natural “sump pump” in your body that helps with circulation of different fluids like lymphatic fluid
Frequently, but not always, when pelvic exams are painful the pelvic floor muscles may be to blame or could be a big underlying factor of experiencing pelvic pain during pelvic examinations.
What do I mean by this?
The muscles of the pelvic floor are susceptible to developing tension just like any other muscle in the body (think of when you are stressed and start to develop tightness in the muscles of the neck which lead to neck pain and headaches). When there is tension present in the muscles of the pelvic floor it can cause the muscles to become painful to the touch. This can be further exacerbated with digital and/or speculum insertion during pelvic examinations causing folks with pelvic pain to begin to get into a pain cycle where after one painful pelvic exam they start to anticipate that all pelvic exams will be painful which can cause even more tension to develop in the pelvic floor muscles causing more pelvic pain with future pelvic exams.
is it normal to have pain with pelvic exams?
Although pelvic pain during pelvic exams is incredibly common, it is not normal or something that you have to deal with. There are treatment options available to help improve your discomfort and to help you get to the point of having pelvic exams and pelvic screening pain-free if that is a goal for you.
do pelvic exams hurt: how pelvic floor physical therapy can help
So while pain with pelvic exams is common but normal, there are a lot of things that you can do to help improve discomfort that you may be experiencing when you go for a pelvic exam. I am a little biased as a pelvic floor physical therapist, but I strongly encourage you to find a pelvic floor therapist close to you who has experience working with clients with pelvic pain with pelvic exams. This is something that I commonly see and treat in my private practice and clients do really well with pelvic floor physical therapy treatment for this type of pelvic pain.
Some of the things that you can do with a pelvic floor physical therapist to help improve pain with pelvic exams include:
Pelvic floor muscle relaxation
A skilled pelvic floor physical therapist should complete a comprehensive screen of the muscles in your pelvic region both from the outside and on the inside (as long as it is something you consent to and are comfortable with completing). This assessment can give a full picture to test if there is tension and/or discomfort in the pelvic floor muscles which can cause pain with pelvic examinations.
From there pelvic floor physical therapists who are trained in working with clients with pelvic pain can complete hands-on manual therapy to the pelvic floor muscles to help treat and resolve pain with pelvic exams. We can also even practice using a speculum during appointments to mimic what happens during an examination to help improve the relaxation of the pelvic floor muscles when you go in for your pelvic exam.
Pelvic floor education
A big part of pelvic floor physical therapy treatment is spent educating clients about their anatomy including what the pelvic floor muscles are, what they do, and how they can contribute to ongoing pelvic pain with pelvic exams. Research shows that a medical provider simply providing clients with pain education and neuroscience surrounding how the brain can impact pain can significantly improve the pain that we feel.
By incorporating education to clients during pelvic floor physical therapy appointments we can also help to improve a client’s pain by calming down the nervous system, which plays a huge role in the reflexive tightening or contraction of the pelvic floor muscles and can impact the pain that we feel. When we feel stressed or perceive something as potentially painful it can further feed into the pain feedback loop and increase the pain experience, and inversely, when we better understand pain and its purpose we can help to reduce the pain that we feel.
Preparation before a pelvic exam
As a pelvic floor physical therapist, I spend a lot of time helping clients with pelvic pain during pelvic exams prepare for upcoming pelvic exams to ensure that they don’t have future painful experiences. We do this through different relaxation techniques, including diaphragmatic breathing, which helps to calm down the nervous system and decrease any tension in the pelvic floor muscles which can create discomfort during pelvic exams. I also do a lot of pelvic floor exercises with clients specifically focusing on muscle coordination and down training to get muscles to lengthen and release.
I mentioned this before, but one of my favorite things to do with clients who experience pain with pelvic exams and speculum use is to practice using a speculum during appointments. This helps to mimic what happens during an examination and can help clients practice how to improve the relaxation of their pelvic floor muscles when they go in for their pelvic exams.
Desensitization techniques
Another common thing that a skilled pelvic floor physical therapist will do for clients who are struggling with pelvic pain is incorporate different types of desensitization exercises including dilator therapy and internal release techniques over the pelvic floor muscles. Provide information on how pelvic floor therapy may incorporate gradual desensitization exercises, such as self-massage or dilator therapy, to make internal exams less uncomfortable.
Most clients who I work with who are struggling with or have struggled with pelvic pain during or following pelvic exams see big improvements when using dilators to address their symptoms. The research proves that dilator therapy (in conjunction with working with a pelvic floor physical therapist) is one of the most effective ways to address pelvic pain with pelvic examinations.
Think of dilators as a form of graded exposure where they gradually increase in size and length (starting as small as your pinky finger and gradually increasing up to the size of a large dildo). These tools help to desensitize, stretch, and lengthen your pelvic floor muscles to help improve the discomfort that you feel during and following pelvic exams.
Some of my go-to dilators that I recommend to clients are from the following companies:
Intimate Rose Vaginal Dilators and Rectal Dilators
do pelvic exams hurt: how to advocate for yourself
If your pelvic pain during or following pelvic exams is not a one-time experience for you, you are your best advocate when it comes to treatment and seeing improvements. Here are some of the things that I recommend to folks who are struggling with pelvic pain during or following pelvic exams:
Tell your provider if pelvic exams hurt: your provider should 1000% know if the pelvic exam they are providing to you is painful so that they can do further screening and make modifications to help make you more comfortable. While pain during or following pelvic exams is common, it is not normal and can indicate that you have an underlying medical condition like pelvic floor muscle tension or dysfunction, vulvodynia, or endometriosis which would be indicative of a referral to a provider for more specialized treatment.
Ask for necessary accommodations: don’t feel weird asking your provider to use a smaller speculum size, having additional providers in the room or use bolsters or pillows under your legs to help with positional modifications to help improve pelvic floor muscle relaxation, slowing down the pelvic exam, or even using more lubrication to make sure that there isn’t any dryness that could be contributing to discomfort during pelvic exams
Have providers on your team who are willing to collaborate with each other: if it is something that you provide informed consent to often times providers like gynecologists, urogynecologists, urologists, and pelvic floor physical therapists are happy to work with each other when it comes to you and the pelvic pain you are experiencing during pelvic exams to help make things more comfortable. We are able to bounce ideas off of each other and to share any information that we may learn while working with you that can help to make things more comfortable in the future.
quick tips to improve pelvic pain during and following pelvic exams
As a Board-Certified Pelvic Floor Physical Therapist, there are SO many things that we can do during pelvic floor physical therapy to help improve symptoms of pelvic pain during and following pelvic exams. Here are some general recommendations for some symptom relief for pelvic pain with pelvic exams:
Schedule your exam at an ideal time for you
Make sure that you schedule your pelvic exam at a day and time that doesn't feel stressful for you (for example, not immediately before or following a stressful meeting with your boss) to ensure that you’re not walking into the pelvic exam with muscles that are already tense from extenuating circumstances which could contribute to feeling pain during the exam. I also would recommend avoiding scheduling a pelvic exam the week before you are menstruating because hormonal fluctuations could also contribute to feelings of discomfort during or after a pelvic exam.
Relaxation techniques can be incredibly helpful
I usually recommend that clients who are experiencing discomfort during or following pelvic exams to make sure they are practicing “diaphragmatic breathing” during their examination. This means breathing in through your nose, carrying your breath from your upper chest down into your abdomen to help stimulate the diaphragm (which separates your upper chest from your belly), and then breathing out through your mouth. You want your breath out to be twice as long as your breath in and you can even pause at the top of the inhale to get a little more benefit. This breathing technique helps to stimulate the vagus nerve which has a calming effect on the nervous system and can help to improve pelvic floor muscle tension and discomfort.
You can also try other techniques to help calm down your nervous system which will help to improve pelvic floor muscle tension and discomfort such as positive imagery and progressive muscle relaxation.
Dilator therapy is a great tool
Using dilators can help to improve pelvic floor muscle tension with pelvic exams. Something I commonly do with clients I am working with who have a goal of pain-free pelvic exams is regular dilator therapy where we progress dilator size up to the size of a speculum and/or finger to help improve any discomfort that a client may feel during or following the exam. Another thing I recommend to clients is to use their dilators immediately before a pelvic exam to help lengthen the pelvic floor muscles and reduce any potential for discomfort that may occur.
See a pelvic floor physical therapist who specializes in treating pelvic pain!
If you are struggling with pelvic pain during or following pelvic exams, just know that it’s common but not normal and not something that you have to deal with.
During a pelvic floor physical therapy examination and treatment, we will go through your medical history to learn more about what you are struggling with and what your goals are for therapy and then complete a comprehensive screen of the muscles in the pelvic region both outside of the pelvis and internally (if you consent to complete a pelvic exam), so that we can figure out if you have any tension of the pelvic floor muscles that could be causing the pain you are experiencing. Then from there we can identify the underlying cause of your issues and come up with a treatment plan tailor-made for you to help improve your pain.
So, if this sounds like you and you are located in Durham, NC, I would love to hear from you. Please don’t hesitate to reach out using the link below!
Have questions or feeling on the fence about whether or not pelvic floor physical therapy is for you? If you are looking for treatment for pelvic pain during pelvic examinations and you’re located in Durham, North Carolina I would love to work with you! Reach out to me using the link below to tell me a little more about what is going on so we can chat more and get the process started.
Live outside of the state of North Carolina? I also offer virtual appointment options to provide more accessible care to those seeking out pelvic floor physical therapy treatment.
Struggling with pelvic pain during pelvic exams or other pelvic floor conditions and having a hard time finding a knowledgeable pelvic floor physical therapist?
Check out my website here to see what other conditions I treat as a pelvic floor physical therapist.
Dr. Brook Orvis (she/her) is a Board-Certified Women’s Health and Pelvic Floor Physical Therapist, Duke Residency-Trained in Women’s Health, and the owner of Flora Physical Therapy. As a momma to a spirited toddler, she understands the difficulty of being a parent while prioritizing self-care, including caring for your body and pelvic floor. She believes that pelvic floor therapy is for everyone and is passionate about providing accessible treatment options for birthing people, men, women, kids, and the LGBTQIA+ community so that they can take better care of themselves and receive equitable care. She loves educating and empowering clients to take charge of their body and health and to not accept leaking of urine, prolapse, pelvic pain, pain during sex, and core weakness as a normal part of being a human.
