Painful Sex (dyspareunia) and the Sacroiliac Joint

 

Dye being injected into the sacroiliac joint

Lucy just made an agonizing decision. She could no longer have sex with her husband due to increasing pain that was now too great to bear. It had started as an unpleasant physical annoyance but had become so severe it now caused her overwhelming anxiety in both the anticipation, and the unbearable pain during what had now become a frightening ordeal. She knew what was causing the pain; both her physical therapist and pain doctor had explained that it was her left sacroiliac joint. Lucy didn’t fully understand what this joint was, but she knew that everyone has two, and they were the two large joints holding the spine to the pelvis, the boney cradle in which Lucy’s babies, years ago, had developed and passed through during childbirth

Most women who suffer with dyspareunia don’t go around telling everyone about it. What gets talked about is how their sexual desires are diminishing, how they are misunderstood by their significant others, and the increasing friction occurring in their relationships. When looking at the lives of these individuals one sees deteriorating friendships, withdrawal from social activities, and a drifting toward family and financial insecurity. Most attempt to discuss this with their primary care doctors or their gynecologist, but after the usual “soft tissue” reasons are ruled out, they are either dismissed or thought to be psychologically off. Once this happens the gloom and doom of despair begins to set in and, for many, can quickly turn into a drastic downward spiraling disaster.  For the lay person suffering with this, not only do they not understand sacroiliac joint pain at all, but most have no idea where these joints even are in their bodies.  The only understanding they have is the severe pain they suffer with and the ramifications of it that slowly go about ruining their lives.

Two things I never learned in medical school and, I am told by many current students, are still not being taught are how severe and disabling chronic sacroiliac joint pain can be, and that sexual intercourse can make that pain worse. Even though it has been scientifically proven and subsequently published in prestigious medical journals that up to 22% of new low back pain patients have one or both sacroiliac joints as the cause, it still is not taught to new doctors and surgeons.  Obviously, if it is not taught to doctors, not only will it not be considered as a possible pain generator in these women, but it will not be treated as well.

It was only due to listening closely to patients who had successful surgeries for chronic sacroiliac joint pain that I began hearing how their severe pains during sexual intercourse were either gone or much improved. This was surprising to me as I had already published on results of sacroiliac joint fusion surgery but had never considered asking any patients about their sexual symptoms before or after surgery. After making this issue more transparent by asking new patients with chronic sacroiliac joint dysfunction about dyspareunia, I came to understand its prevalence in my sacroiliac joint pain patient population. On initial questionnaires involving 99 consecutive patients with chronic pain from this joint, 58% admitted to suffering with dyspareunia. Most of these were women, but there were a handful of men who suffered from this as well. The common scenario was that sexual activities had been either put on a unilateral indefinite hold or that it was an act that was anticipated with dread and then painfully endured.  These individuals related the feelings from the act of sexual intercourse as “being pounded over and over deep inside by a sledgehammer”.  For many of those having had children they stated the pains were equal to or greater than vaginally delivering a child.  Being a man, I can only imagine how that degree of pain leaves a woman feeling, both physically and emotionally, after what is supposed to be one of the most satisfying experiences there is between a man and woman.

There are two reasons why painful sacroiliac joints can result in severe pain during coitus.  The first is the strategic location of these joints inside the pelvis.  It is such that if the size of the perpetrator is large enough and the vagina is deep and flexible enough the anterior portions of the SIJoints can be directly impacted exacerbating pain that is already there. The second is that the act of pelvic thrusting, along with abduction or spreading of the legs in the woman, cause the SIJoints to be moved in such ways as to cause an intense escalation of the pain fig 1.

 

 

Figure 1. Looking from above down into the pelvis. The boney circle bordered by the sacrum, iliac bones and pubic bone is where a baby’s head would sit during pregnancy and pass through during birth.  

As I began to understand how misunderstood these patients were by not only society but frequently by those who loved them the most, I learned that not only their silence on this subject was a factor, but that the medical system in America itself, me included, was at fault. We had not been educated to properly understand and treat these people.  Those who treat painful SIJoints conservatively (manipulation, injections, exercise, etc.) have been all over this problem for decades.  It was the surgeons who knew nothing about it and maintained an attitude of ignorance and denial when it came to SIJoint pain in general. If it did not involve the lumbar spine they wanted nothing to do with it.  The irony of this is that it was almost a century ago that the first successful fusion surgeries for the painful SIJoint were published, in a very prominent orthopedic journal (1).  This resulted in patients with chronic SIJoint pain who were diagnosed and put in various types of conservative treatments, who weren’t improving, were literally caught in a “revolving door” of manipulations, injections and exercises. When critically assessing the potential size of this population of those in persistent SIJoint pain, it consisted of tens of thousands of individuals.  That’s a lot of people suffering.

My next step was to prospectively study this patient population when a minimally invasive type of SIJoint fusion was employed.  The surgery used took approximately 30 minutes to perform through a one-inch incision.  Two cages were inserted into the painful SIJoint Fig 2.

Figure 2. Two custom cages inserted directly from posterior into the sacroiliac joint. (this is an off-label procedure)

Patients were allowed to walk with full weight bearing on the affected side immediately after surgery.  Follow up averaged greater than two years.  The results showed statistical improvement in Low Back Pain (p = < 0.001); Leg Pain (p = < 0.013); and Dyspareunia (p = 0.0028).  This was the first study ever to prospectively prove that painful sex due to chronic SIJoint pain could be statistically improved by performing a minimally invasive SIJoint fusion (2).

Where are we today as a result of all this awareness of painful sexual intercourse because of chronically painful SIJoints and publications on how surgery can help in these cases?  The quick answer is we are not very far at all.  Tens of thousands of people, mainly women, continue to suffer with dyspareunia without a proper diagnosis and thus without a definitive cure.  The isolation and despair continue for these countless numbers of sufferers.  Why does this continue in the modern world of America today?  The best answer revolves solely around our system of Capitalistic Democracy.  The reasons for this are very complex so I wrote a book about it titled, “Sacroiliac Joint Pain: For Tens of Thousands the Pain Ends Here” (Amazon).

This is a problem that will require a “grass-roots” effort to understand and cause necessary change.  This book is written to those living in the grass-roots of our society who suffer with this chronic SIJoint pain and despite the current conservative treatments aren’t getting better.

References

  1. Smith-Peterson MN, Rogers WA, End-Result Study of Arthrodesis of the SacroIliac Joint for Arthritis-Traumatic and Non-Traumatic, J.Bone Joint Surg, AM, 1926; 118-136.
  2. Wise CL, Dall BE, Minimally Invasive Sacroiliac Arthrodesis, Outcomes of a New Technique, J Spinal Disord Tech; 2008, 21: 8; 579-584.

 

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