By Emma McGowan

Have you ever had a UTI that just wouldn't go away? Or pain during sex that your doctor insisted was a UTI, even though the antibiotics didn't help? You're not alone. Many people with vaginas experience UTI-like symptoms, painful sex, or both at some point, and the causes aren't always straightforward. The truth is, UTIs aren't the only culprit, and the solution may have nothing to do with antibiotics.

Pelvic floor dysfunction, interstitial cystitis, endometriosis—these are just a few of the other possible issues that can make it feel like you have an infection that won't quit or turn intimacy into agony. 

But don't stress: We spoke with Dr. Sasha Davenport, MD, FACOG, IF, Director of Female Sexual Medicine at Wake Forest University School of Medicine, and sexual health nurse practitioner Rachel Murray about the relationship between UTIs, painful sex, and your pelvic floor health. Let's take a look.

The connection between UTIs and painful sex

Dr. Davenport tells The Pelvic People that "any time someone has a UTI, there are inflammatory factors in the area, so that inflammation inherently is going to be irritating and uncomfortable." In other words: If your vag and vulva are inflamed in a bad way, sex probably isn't going to feel so great!

So if you experience pain only during or after sex, it coooooould be a sign of a UTI. However, there are a bunch of other conditions that can mimic the symptoms of a UTI. Murray tells The Pelvic People she often sees patients who think they're having recurring UTIs, keep getting antibiotics, but nothing is helping. Then, when she runs a culture to check for an infection, it comes back negative. So what's the deal?

When UTI-like symptoms aren't actually a UTI

When you experience pain during sex or frequent urges to pee, it's easy to assume you have a UTI. But the truth is, UTI-like symptoms aren't always caused by an infection. And this might especially be true for people who believe they have recurring UTIs.

"People often are treated [for a UTI] when they don’t need to be treated," Murray says. "They have UTI symptoms and are given meds without culturing their urine. So people think they’re having UTIs for years and years, when that’s not what’s going on."

While it's easy to call up the doctor and say "Help! I need an antibiotic!" Murray recommends that anyone who's dealing with recurring UTIs go into an office, get a thorough workup looking at the tissue, and run a urinalysis. That way you and your health care provider can know for sure what's going on and treat it properly.

What else could it be?

There are a few main culprits when it comes to UTIs-that-aren't-really-UTIs: pelvic floor dysfunction, interstitial cystitis, and endometriosis. Let's take a look at all three.

Pelvic floor dysfunction

The pelvic floor muscles play a critical role in supporting your bladder, bowels, and uterus. Pelvic floor muscle dysfunction can manifest in various ways, and it's important to understand that the symptoms of too tight or weak pelvic floor muscles often overlap. When these muscles are not functioning optimally, whether due to being too tight or too weak (or a combination), it can lead to discomfort or pain in your daily life and during sex.

When pelvic floor muscles are too tight, they may struggle to relax or might spasm during penetration, causing a burning sensation. This tightness can also contribute to symptoms like frequent or painful urination, urgency to pee (even right after going), constipation, difficulty passing stools, and lower back and hip pain.

On the other hand, weak pelvic floor muscles can lead to a different set of challenges. These may include stress urinary incontinence (which is leaking urine during physical activities such as coughing, exercise, or sex), difficulty in reaching orgasm, and a sensation of your insides falling out.

The key to effectively addressing pelvic floor muscle dysfunction lies in a personalized approach. Pelvic floor physical therapy can be an excellent resource for this. Therapists specialize in targeted exercises and techniques to help relax, strengthen, and normalize the function of your pelvic floor muscles. Techniques may include diaphragmatic breathing, massage therapy, or a tailored exercise plan.

For anyone experiencing symptoms of pelvic floor dysfunction, it's crucial to consult with a healthcare provider or a pelvic floor physical therapist. They can help determine the underlying cause of your symptoms and guide you towards the most effective treatment options. Additionally, online resources like the pelvic floor assessment available on Pelvic Gym can provide valuable insights and guidance on managing pelvic floor health.

Interstitial cystitis (IC)

Also known as painful bladder syndrome, IC causes chronic pain in the bladder and pelvic area. Sex, stress, certain foods, and menstruation can trigger or worsen IC pain. Treatments focus on managing pain and symptoms. They include diet changes, physical therapy, medications, and counseling.

Endometriosis

If UTI-like symptoms are accompanied by severe menstrual cramps, heavy bleeding, painful sex or difficulty becoming pregnant, endometriosis could be the culprit. This condition occurs when tissue similar to endometrial tissue grows outside the uterus, often on the ovaries, fallopian tubes, and pelvic lining. Laparoscopic surgery to remove endometrial tissue and hormonal medications are common treatments.

The bottom line is that painful sex or symptoms that seem like a UTI could have a number of underlying causes. Talk to your doctor about other possible diagnoses and appropriate testing so you can find the best solution and get back to enjoying intimacy (and your bathroom breaks) without discomfort.

Getting the right diagnosis

Getting properly diagnosed is key to finding relief from painful sex and UTI-like symptoms. The cause could be a simple UTI, but other conditions can also lead to similar symptoms. "The big takeaway that I would hope people would know is that if they think there’s a long-term issue that they’re not getting answers to, what’s actually happening is they’re not being properly assessed," Murray says.

Dr. Davenport recommends going to someone who specializes in pelvic pain, if that's available in your area.

"Sometimes you've seen a provider for years and they're your go-to for these things, but really you need to see someone more specialized," Dr. Davenport says. "And that can be frustrating for patients because they don’t know how to look for a specialist.

For those whose primary care providers don't know how to help, Dr. Davenport suggests searching the ISSWSH website for a specialist in your area. You can also use these directories for finding care near you.