Difficulty With Intercourse

Types of difficulty with intercourse

Sexual difficulties fall into four broad groups, and many people have more than one:

Causes in women

Pain with penetration

Dyspareunia means painful intercourse. Where it hurts helps point to the cause:

• Pain at the entrance: dryness, not enough arousal, infections (yeast, herpes), skin conditions (lichen sclerosus), vulvodynia, scarring after childbirth
• Deep pain: endometriosis, pelvic infection, ovarian cysts, fibroids, an irritable bowel, or a tilted womb

Vaginismus

Vaginismus is involuntary tightening of the muscles around the vagina when penetration is attempted, making intercourse painful or impossible. It can follow painful experiences, fear of pain, or anxiety, and often responds well to pelvic floor therapy and gradual dilator training.

Menopause and hormone changes

Falling estrogen after menopause, while breastfeeding, or with some cancer treatments thins and dries the vaginal tissues. This is called genitourinary syndrome of menopause or atrophic vaginitis. It causes dryness, burning, tearing and pain, and affects about half of postmenopausal women.

Causes in men

Erectile dysfunction

Difficulty getting or keeping an erection firm enough for sex. It becomes more common with age and is often linked to:

• blood vessel disease: high blood pressure, high cholesterol, smoking, diabetes and heart disease
• nerve damage: diabetes, prostate surgery, spinal problems
• low testosterone
• medicines and alcohol
• anxiety, especially performance anxiety

ED can be an early warning sign of heart disease, often appearing 2 to 5 years before heart symptoms.

Ejaculation problems

Premature ejaculation (consistently within about 1 minute of penetration and causing distress) is the most common male sexual problem. Delayed ejaculation is often caused by antidepressants (SSRIs), nerve damage or alcohol.

Penile problems

• Peyronie's disease: scar tissue in the penis causes a bend, indentation or pain on erection, sometimes making penetration difficult.
• Phimosis: a tight foreskin that hurts during erection.
• Infections such as balanitis or STIs.

Causes in anyone

• Medicines: antidepressants, blood pressure medicines (especially beta blockers and diuretics), antipsychotics, opioids, hormonal birth control, and prostate drugs
• Long-term conditions: diabetes, heart disease, multiple sclerosis, kidney disease, thyroid problems
• Mental health: depression, anxiety, past sexual trauma, body image concerns
• Relationship factors: conflict, poor communication, a partner's sexual problem
• Lifestyle: heavy drinking, smoking, recreational drugs, tiredness and stress
• After childbirth: tears, scarring, dryness from breastfeeding and exhaustion

How doctors assess the problem

Talking about sex can feel awkward, but doctors are used to it. Expect questions about when the problem started, whether it happens every time or only sometimes, morning erections (in men), where pain is felt (in women), medicines, alcohol and relationship factors.

Depending on the problem, an exam and tests may include:

• a pelvic exam, done gently and at your pace, or a genital exam
• swabs for infections
• blood tests: blood sugar, cholesterol, testosterone (morning sample), thyroid, prolactin
• pelvic ultrasound for deep pain
• penile ultrasound for Peyronie's disease

Treatments that help

For women

• Lubricants during sex and vaginal moisturizers used regularly
• Low-dose vaginal estrogen for menopause-related dryness and pain. It is safe for most women
• Pelvic floor physical therapy and vaginal dilators for vaginismus and pain
• Treating infections, skin conditions and endometriosis
• More time for foreplay and arousal

For men

• PDE5 inhibitor tablets (such as sildenafil or tadalafil) for erectile dysfunction. Do not take them with nitrate medicines for chest pain.
• Vacuum devices, penile injections, and penile implants if tablets do not work
• Behavioral techniques, topical numbing sprays or certain medicines for premature ejaculation
• Testosterone replacement only when levels are confirmed low on repeated tests
• Treatments for Peyronie's disease, from traction devices to injections or surgery

For everyone

• Reviewing medicines with your doctor (do not stop prescribed medicines on your own)
• Managing diabetes, blood pressure and weight, stopping smoking, and cutting down alcohol
• Treating depression and anxiety
• Sex therapy or couples therapy, which is effective for many problems, especially when anxiety, avoidance or relationship issues play a part

Frequently asked questions

Why is it difficult to have intercourse?

Common reasons include pain from dryness or infection, vaginismus, menopause changes, erection problems, early ejaculation, and anxiety or relationship stress. Medicines and conditions such as diabetes often contribute. A doctor can help identify the cause and the right treatment.

Why does it hurt when I try to have sex?

Pain at the entrance is often due to dryness, infection, skin conditions or involuntary muscle tightening (vaginismus). Deep pain can come from endometriosis, pelvic infection or ovarian cysts. Persistent pain is not normal and is treatable.

Can stress cause problems with intercourse?

Yes. Stress, anxiety and depression reduce desire and arousal, can cause erection problems and early ejaculation in men, and contribute to pain and muscle tightening in women. Addressing stress often improves sexual function.

Is erectile dysfunction a sign of heart disease?

It can be. ED often shares causes with heart disease, such as narrowed arteries from high blood pressure, high cholesterol, smoking and diabetes. Men with new ED should have their heart risk factors checked.

Who should I see for difficulty with intercourse?

Start with your primary care doctor, gynecologist or urologist. They may refer you to a pelvic floor physical therapist, a sex therapist, or a specialist in sexual medicine depending on the cause.