Down There 

On vaginal/vulval pain.

I am a cis woman in my mid twenties. I get a pang or a spasm of pain in a place deep in my clit/urethra area. I can't pinpoint which part exactly. It takes me by surprise every time it happens, so I jerk around and press my crotch for a hot second — which doesn't help, but it's about the only thing I can do. This obviously does not look cool in public, and regardless of when it happens, the episode irritates me. Around four or five convulsions happen and then quickly it's over. There's no pattern — it happens at random times and anywhere from one to four times daily. It started about a week ago. It doesn't hurt when I pee, apply pressure to the area, work out, masturbate, or orgasm. I wonder if my lady spasms are associated with stress. I started a new job in September that I love, but it's very demanding of my time, which has taken a toll on my mental and physical health (i.e., doing work things all fucking day, having no "me" time). What's going on down there? What's the solution? Will doing Kegels help me manage these spasms? (P.S. I'm a lesbian if that detail is helpful.)

Super Perplexed About Spasms Mostly

I shared your letter with Dr. Lori Brotto, an associate professor in the Department of Gynecology at the University of British Columbia. Dr. Brotto has done extensive research on vaginal/vulval pain and is a recognized expert on this subject and lot of others. Brotto shared your letter with Dr. Jonathan Huber, an Ottawa-based gynecologist with expertise in treating genital pain. "SPASM definitely needs to see a physician as soon as possible to have her vulva and vagina examined," Dr. Brotto and Dr. Huber wrote in their joint response. "The collection of symptoms she describes does not map perfectly onto any single diagnosis, so these ideas below are best guesses."

Before we get to those best guesses, a word of warning for the hypochondriacs in my readership: If you're the kind of person who can't read about mysterious symptoms and their possible causes without immediately developing those symptoms — particularly vagina-having hypochondriacs — you might want to skip the rest of this response. Okay, back to the good doctors...

"Sudden onset, intermittent genital pain can be caused by a number of simple things, such as abrasions, an infection, an allergic reaction, buildup of smegma, dermatosis, etc.," Dr. Brotto and Dr. Huber continued. "Although these things are unlikely to be the cause of her pain, they're easy to rule out and treat, if necessary." ("Wait just a minute," I hear some of you crying. "Women don't have problems with smegma — that's just a dudes-with-foreskins* problem." Dr. Brotto responds: "Women get smegma, too. We don't hear about smegma in women because yeast infections get a lot more attention. But smegma in women is the same as smegma in men: a harmless buildup of skin cells and oils.")

"SPASM's symptoms most closely map onto a condition called 'interstitial cystitis' (IC) or bladder pain syndrome," Dr. Brotto and Dr. Huber explained. "IC is diagnosed when there is chronic bladder or urethral pain in the absence of a known cause. It's typically described as having the symptoms or sensations of a bladder infection, without actually having an infection. Although IC usually has a gradual onset and presents with pressure more often than pain, some women do describe a sudden onset, with pain as the most prominent symptom as opposed to pressure. Since IC often coexists with vulvodynia (vulval pain), dysmenorrhea (painful periods), and endometriosis (when endometrial tissue grows outside the uterus), if this individual has any of these other diagnoses, then IC may be more likely to account for her pain."

How can you determine if it's IC? "IC is best assessed by a urologist, who may choose to do further urine tests, like examination of urine under a microscope, and even a cystoscopy — putting a narrow camera through the urethra into the bladder to take a look."

Another possible cause: a urethral diverticulum. "It's like an outpouching along the tube of the urethra," Dr. Brotto and Dr. Huber wrote. "This is kind of like a dead-ended cave where urine and other debris can collect, which can possibly lead to infection and pain." A gynecologist might be able to diagnose a diverticulum during a normal exam — just by feeling around — but you'll most likely need to have a tiny camera stuffed up your urethra to diagnose this one too, SPASM. Moving on...

"Some of her symptoms also sound like the beginnings of 'persistent genital arousal disorder' (PGAD), a condition of unwanted genital sensations and arousal in the absence of sexual desire. PGAD can be triggered by stress and temporarily relieved with orgasms. For some women with PGAD, it is related to starting or stopping a medication (especially antidepressants)." The good news: You don't need to cram a selfie stick up your urethra to determine whether you've recently stopped taking antidepressants. More good news: There are treatments for all of these conditions.

"In sum, we feel she should see a gynecologist first and possibly get a referral to a urologist," Dr. Brotto and Dr. Huber concluded. "She also asks about whether Kegel exercises will help. Sometimes pelvic floor dysfunction can contribute to vaginal/vulval pain, and seeing a pelvic floor physiotherapist to learn proper pelvic floor exercises (including, but not limited to, Kegels) can help. A good gynecologist will be able to test her pelvic floor strength and control, and advise whether she should be seeing a pelvic floor physiotherapist."

Follow Dr. Brotto on Twitter @DrLoriBrotto, and follow Dr. Huber @DrJonathanHuber.

(P.S. Lesbians, in my experience, are always helpful.)

I am a 23-year-old Italian girl and I have been in a long-distance relationship for one year. We love to have sex, and when we are far away, we send each other hot pictures and videos. At least two times per week, we masturbate on Skype. There is something that confuses me about the way I masturbate when I am alone. My boyfriend watches pornos daily when we are far away. This is something I don't like, but I have not asked him to give up watching pornos. I think there is nothing wrong in pornos by themselves: Sometimes I watch them, and when we are together, it's me who suggests to watch them together or I let him watch them while I'm giving something to him. However, I'm not a fan of him watching pornos when he is alone. But when I masturbate, I think only about him watching porno alone. What's wrong with my sexual fantasies?

Confused Italian Asking Obviously

There's nothing wrong with your sexual fantasies, CIAO, you're just experiencing a little cognitive dissonance and residual sex-negativity — and that particular tension can both distress and arouse. But seeing as your boyfriend is going to look at porn (and other women) whether you want him to or not (just as you look at porn and other men), and since you enjoy porn together, I would advise you to err on the side of embracing your fantasies. And don't feel like you have to overcome the cognitive dissonance. The naughtiness of it, the transgression, and the symbolic betrayal — all of that turns you on. So live with it, lean into it, and enjoy it.

* For the record, quickly, before Tumblr explodes: Some women have penises! Some women with penises are uncut! A tiny percentage of uncut-penis-having women have poor personal hygiene practices and consequently have smegma under their foreskins! #TheMoreYouKnow

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