The Tissue-Muscle-Nerve Pain Map
Map painful sex across tissue, muscles, nerves, and internal causes
- Difficulty
- Moderate
- Time to result
- ~weeks to results
- Steps
- 6
- Confidence
- 95%
Rubin maps pain during sex across several possible systems instead of assuming one cause. Tissue may be affected by hormonal change, eczema, or autoimmune skin disease. Pelvic-floor muscles may be tight, painful, weak, or poorly coordinated. Nerves and spinal problems may refer pain to the vulva or penis. Internal conditions, including endometriosis and scar tissue, may also contribute. The method is a differential map: describe the pain, ask which system could generate it, and seek a clinician with an active interest in pelvic pain who can examine and distinguish among causes. Rubin says a patient may need more than one opinion. The framework does not determine a diagnosis; its value is preventing normalization and prompting cause-specific evaluation rather than generic reassurance.
Origin
Extracted from The Diary of a CEO
Core principles
- 01Pain deserves investigation rather than normalization
- 02Several biological systems can produce similar symptoms
- 03The location and character of pain can guide evaluation
- 04One opinion may not settle a complex pelvic-pain diagnosis
- 05Treatment should follow a cause rather than a generic label
How to run it
- 1
Describe the pain precisely
Record whether pain is at the opening, deeper inside, linked to touch, or associated with other symptoms. Note when it starts and what makes it better or worse.
Pro tip Bring a concise symptom timeline to the appointment.
Watch out Do not reproduce painful activity merely to collect more data.
- 2
Check the tissue lane
Ask the clinician whether skin, hormonal tissue change, irritation, or an inflammatory condition could explain the pain. This lane concerns visible or examinable tissue rather than assuming the cause is psychological.
Watch out Only a qualified professional can distinguish among similar-looking conditions.
- 3
Check the muscle lane
Ask whether pelvic-floor tension, weakness, or coordination could be involved. Rubin notes that pelvic muscles must relax for comfortable penetration and contract during orgasm.
Pro tip Seek a trained pelvic-floor physical therapist when an examining clinician recommends it.
Watch out More strengthening is not always the answer; some people need relaxation or coordination.
- 4
Check the nerve lane
Discuss whether nerve irritation or a spinal problem could refer pain to the genitals. This is especially relevant when symptoms extend beyond one local tissue area.
- 5
Check internal causes
Ask whether internal disease or scar tissue, including endometriosis where clinically relevant, belongs in the differential. The appropriate examination or referral depends on the presentation.
Watch out Do not infer endometriosis from pain alone.
- 6
Escalate to appropriate expertise
Seek a gynecologist, urologist, pelvic-pain clinician, or other specialist with demonstrated interest in the relevant problem. If the first explanation is incomplete, Rubin says it is reasonable to seek additional opinions.
Pro tip Ask directly about the clinician's pelvic-pain training and referral network.
In the wild
Illustrative example: a patient reports burning at the opening and pain when penetration begins. Instead of assuming low desire, a specialist assesses local tissue and pelvic-floor tension, then directs treatment toward the findings and refers to pelvic-floor physical therapy if muscle involvement is confirmed.
→ The complaint is investigated through plausible biological lanes rather than normalized or blamed on motivation.
Common mistakes
Assuming pain is normal
Rubin repeatedly says painful sex deserves an explanation and diagnosis.
Doing Kegels without assessment
The transcript distinguishes strengthening from relaxation and coordination, so generic exercise can miss the actual muscle problem.
Stopping after a dismissive opinion
Rubin recommends clinicians with an active interest in pelvic pain and says more than one opinion may be needed.
Is it for you?
Best for
It is best for someone preparing to seek qualified assessment for recurrent or persistent pain during sexual activity.
Not ideal for
It is not a self-diagnosis tool, and severe, sudden, infectious, bleeding, pregnancy-related, or emergency symptoms need appropriate urgent care.
From the transcript
“If sex is painful, you need to figure out why it's You deserve a diagnosis.”
“You could have a problem with the tissue.”
“It's okay to see a few different people for this problem.”
From the episode
Dr Rachel Rubin: "I'm Filled With Rage!" Your Doctor Was Never Taught About Women's Bodies!