Gineclinic
Gynecology clinic in Sarrià-Sant Gervasi
C/ Lázaro Cárdenas, 4 · 08017 Barcelona
Area of expertise
Pelvic floor and perineal dysfunction
Pain during sex, vulvar pain, pudendal nerve entrapment or pelvic floor hypertonicity: common, very limiting problems that are rarely examined specifically.
Symptoms that raise suspicion
- Pain at the entrance of the vagina when attempting penetration (superficial dyspareunia)
- Deep pain with penetration or after sex
- Stinging, burning or constant vulvar pain, with or without contact (vulvodynia)
- Inability to have penetrative sex because of involuntary muscle contraction (vaginismus)
- Pain that gets worse when sitting and improves when standing or lying down
- Burning or electric-shock pain in the perineum, vulva or rectum
- A feeling of a bulge, pressure or a foreign body in the vagina
- Urinary urgency, difficulty emptying the bladder or constipation with straining
You don't need to have all the symptoms. If you have two or three that affect your life, it is worth looking into.
What is pelvic floor and perineal dysfunction
This term covers problems with the muscles, nerves and connective tissue of the pelvic floor and perineum: the platform of muscles that supports the bladder, uterus and rectum, and that plays a role in continence, bowel movements and sexual function.
Unlike conditions with a visible lesion, the problem here is usually functional: a muscle that is permanently contracted and cannot relax, a nerve compressed along its course, a scar that has altered the mechanics of the area, or a protective pattern the body has learned after childbirth, surgery or an episode of pain.
This is the field in which I trained specifically for two years in France, with the French school of pelvic pain and pelvic floor and perineal dysfunction, where careful clinical examination of the perineum is the cornerstone of diagnosis.
The most common conditions
Pelvic floor hypertonicity and myofascial pain
The pelvic floor muscles lose their ability to relax and stay tense. Trigger points develop in them: small hyperirritable spots within a taut band of muscle that hurt when pressed and can refer pain elsewhere, to the vulva, bladder, rectum, groin or lower back. It is a very common cause of pain during sex and of persistent pelvic pain with normal tests. It is diagnosed through examination and usually responds well to specialized physical therapy.
Vulvodynia and vulvar pain
Vulvar pain, often burning, lasting at least three months, with no lesion or infection to explain it. It can be generalized or localized to the vestibule (vestibulodynia), and spontaneous or provoked by contact. Dermatological, infectious and hormonal causes need to be ruled out, and both the neuropathic component and the associated muscular component need to be treated.
Pudendal neuralgia
The pudendal nerve carries sensation from the vulva, perineum and anal area. When it becomes irritated or entrapped along its course (typically between the sacrotuberous and sacrospinous ligaments, or in Alcock's canal), it causes a characteristic pain: burning in that area that gets worse when sitting and improves when standing up or lying down. It is a clinical diagnosis, based on defined criteria (the Nantes criteria) and, when appropriate, a diagnostic nerve block.
Vaginismus
An involuntary, reflex contraction of the muscles that prevents or hinders penetration. It is not a decision or a matter of willpower: it is a protective reflex. Treatment combines physical therapy, gradual desensitization work and, when needed, support from sex therapy.
After-effects of childbirth and surgery
Pain in an episiotomy or C-section scar, persistent perineal pain after childbirth, or pain related to pelvic surgery or mesh. There is often a very localized painful spot that can be treated.
Painful sex is not normal, it is not “a matter of relaxing,” and it is almost never solved with lubricant alone.
How it is diagnosed
The diagnosis is mainly clinical and depends entirely on the quality of the examination:
- Pain map: exact location, type of pain, which positions and activities change it, and its relationship with urination, bowel movements and sex.
- Perineal and pelvic floor examination: assessment of muscle tone layer by layer, search for trigger points, a pain reproduction test, examination of the nerve territories and a check for Tinel's sign (pain when pressing along the course of the pudendal nerve).
- Targeted vulvar examination, with the cotton swab test when there is vestibular pain, and assessment of the condition of the tissues.
- Ruling out what needs to be ruled out: infection, vulvar skin conditions (lichen), atrophy due to hormone deficiency, deep endometriosis.
- Diagnostic nerve blocks or imaging tests only when they change the treatment decision.
Treatment
- Specialized pelvic floor physical therapy: the cornerstone of treatment in most of these conditions. Manual therapy, trigger point release and relaxation and retraining exercises. It is not about doing Kegel exercises, which can make the problem worse in a hypertonic pelvic floor.
- Medication for neuropathic pain: oral pain modulators and topical treatments.
- Injections and nerve blocks: of trigger points, the pudendal nerve or other nerves involved, for diagnostic and therapeutic purposes.
- Botulinum toxin in the pelvic muscles in selected cases of resistant hypertonicity.
- Local hormone treatment when atrophy or estrogen deficiency contributes to the pain.
- Sex therapy and psychological support when the pain has affected your sex life and relationship, which is common when it has lasted a long time.
- Decompression surgery of the pudendal nerve: reserved for very carefully selected, well-documented cases after conservative treatment has failed.
Most of these conditions improve, but they require persistence: the results of pelvic floor physical therapy are measured in months, not weeks.
Frequently asked questions about pelvic floor and perineal dysfunction
Sex is painful for me and I was told there's nothing wrong. What should I do?
Ask for a specific pelvic floor examination. One of the most common causes of pain during sex with a “normal” gynecological exam is hypertonicity with myofascial pain of the pelvic muscles, which is only detected if the muscles are palpated in a targeted way.
Will Kegel exercises help me?
If your pelvic floor is hypertonic, they will most likely not help and may even make the pain worse. Kegel exercises strengthen a muscle that in these cases is already permanently tense: what you need is to learn to relax it. That is why it is important to know what type of dysfunction you have before starting any exercise.
Can vulvodynia be cured?
It improves significantly in many patients with combined, sustained treatment, although it can take months and requires adjustments. What does not work is trying one cream after another without a diagnosis of the pain mechanism.
How do I know if it is the pudendal nerve?
The most characteristic clue is burning pain in the nerve's territory that clearly gets worse when sitting and improves when standing up or lying down. The diagnosis is based on a targeted examination and defined clinical criteria, not on an MRI.
I have had perineal pain since giving birth, years ago. Is it too late?
No. The time that has passed does not prevent treatment. It is true that pain that has lasted for years usually adds muscular and sensitization components, so the approach has to be more comprehensive, but the pain can improve a great deal.
References
- Lamvu G, Carrillo J, Ouyang C, Rapkin A. Chronic pelvic pain in women: a review. JAMA. 2021;325(23):2381-91. doi:10.1001/jama.2021.2631 · PubMed
- Labat JJ, Riant T, Robert R, et al. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn. 2008;27(4):306-10. doi:10.1002/nau.20505 · PubMed
- Bornstein J, Goldstein AT, Stockdale CK, et al. 2015 ISSVD, ISSWSH and IPPS consensus terminology and classification of persistent vulvar pain and vulvodynia. Obstet Gynecol. 2016;127(4):745-51. doi:10.1097/AOG.0000000000001359 · PubMed
- Luo FY, Nasr-Esfahani M, Jarrell J, Robert M. Botulinum toxin injection for chronic pelvic pain: a systematic review. Acta Obstet Gynecol Scand. 2020;99(12):1595-602. doi:10.1111/aogs.13946 · PubMed
- Quintas-Marquès L, Valdés-Bango M, Box C, et al. Multidimensional evaluation of myofascial pelvic pain and other comorbidities in endometriosis patients. J Clin Med. 2025;14(10):3455. doi:10.3390/jcm14103455 · PubMed
Related areas
Where I practice
Private practice and public hospital practice
I have a private practice at two centers in Barcelona and continue my public hospital practice at Hospital Clínic. They are two different routes: for the private practice you can book an appointment directly; the public hospital is accessed by referral.
Private practice Book an appointment directly
Women's Clínica Ginecológica
Women's health specialty center
Vía Augusta, 257 · corner of Ronda General Mitre · 08017 Barcelona
Monday to Thursday, 8:30 a.m. to 8:30 p.m. · Friday, 8:30 a.m. to 3:00 p.m.
Public hospital practice Public health system
Hospital Clínic de Barcelona
Endometriosis Unit
Senior Consultant Gynecologist and Lead, Chronic Pelvic Pain Clinic · Institut Clínic de Ginecologia, Obstetrícia i Neonatologia
C/ Villarroel, 170 · 08036 Barcelona
My practice at Hospital Clínic de Barcelona is part of the public health system and does not accept direct appointment requests: patients are seen through the usual channels of the health system, by referral from your primary care physician or from another specialist.
This website does not handle emergencies
If you have sudden, severe pain, a fever, heavy bleeding, or you are pregnant and something is not right, do not wait for an appointment: go to an emergency room or call 112.