VAGINISMUS

VAGINISMUS - Leena Nathan, MD; Wendy Satmary, MD, FACOG
BASICS
DESCRIPTION
• Involuntary painful contraction of perineal muscles and levator ani prior to or during vaginal intercourse. The experience of or even the anticipation of pain on vaginal entry causes these muscles to contract, occluding the vaginal opening and causing further pain when penetration is attempted. Repeated dyspareunia (pain with intercourse) can cause vaginismus and vaginismus can cause dyspareunia.
• System(s) Affected: Reproductive
ALERT
Pregnancy Considerations
Pregnancy can occur in patients with vaginismus, via perineal ejaculation.
EPIDEMIOLOGY
Predominant age
• Postpubertal
Prevalence
In the US: 5.1-17% in females presenting to sexual dysfunction clinics. No incidence or prevalence data available for occurrence in general population.
RISK FACTORS
• Previous sexual trauma, but rates appear to be similar in abused and nonabused women
• Often associated with other sexual dysfunctions
ETIOLOGY
• Primary: Often multifactorial
- Negative messages about sex and sexual relations in upbringing may cause phobic reaction
- Poor body image of genital area
- History of sexual trauma, although rates of vaginismus appear to be similar in sexually abused and nonabused populations of women (studies show incidence of sexual abuse of women to be 12-40%)
• Secondary
- New onset of infection
- Surgical or postdelivery scarring
- Endometriosis
- Inadequate vaginal lubrication
• Can be complete (perineal spasm with attempts to insert anything into vagina) or situational (tampons or pelvic exams permitted)
ASSOCIATED CONDITIONS
• Marital stress, family dysfunction
• Dyspareunia


DIAGNOSIS
SIGNS AND SYMPTOMS
• Inability to allow entry for vaginal sexual intercourse secondary to involuntary muscle spasms
• Reluctance or avoidance of pelvic examination
• Relationship discord or difficulty
• Infertility
• Sexual satisfaction may be independent of sexual function.
History
General and sexual history
Physical Exam
• At some point, a careful pelvic examination to rule out medical cause
• Lamont classification of degree
- 1st degree: Perineal and levator spasm relieved with reassurance
- 2nd degree: Perineal spasm maintained throughout the pelvic exam
- 3rd degree: Levator spasm and elevation of buttocks
- 4th degree: Levator and perineal spasm and elevation with adduction and retreat
TESTS
Psychiatric consultation if not responsive to primary physician's therapy or if primary provider not comfortable with caring for sexual problems
Pathological Findings
Rarely found in primary vaginismus, but may be varied, such as endometriosis or scarring, in secondary vaginismus
DIFFERENTIAL DIAGNOSIS
Dyspareunia
TREATMENT
GENERAL MEASURES
• Outpatient care
• Can often treat vaginismus successfully without defining/treating its etiologies
• No published controlled studies on success of psychotherapy for vaginismus
• Patient education as noted on pelvic anatomy and sexual function
• Sexual cognitive behavioral therapy has been found to be very effective
• Kegel exercises to control perineal muscles
• Stepwise vaginal desensitization exercises
- With vaginal dilators (patient inserts/controls)
- With woman's own finger(s) (promotes sexual self-awareness)
• Valsalva can help with vaginal entry
• Advance to husband's fingers with patient's control
• Coitus after achieving largest vaginal dilator or 3 fingers; important to begin with sensate-focused exercises/sensual caressing without necessarily a demand for coitus
- Female superior at 1st; passive (nonthrusting); female directed
- Later, thrusting may be allowed
Diet
No special diet
Activity
Simple techniques of gentle, progressive, patient-controlled vaginal dilation
SPECIAL THERAPY
Complementary and Alternative Medicine
• Biofeedback
• Functional electrical stimulation
MEDICATION (DRUGS)
• Botulism toxin: 150-400 U of botulism toxin type A injected in the levator ani at 3 points on each side with 23-gauge needle is effective for 3rd- and 4th-degree disease but still experimental.
• Contraindications: Anxiolytics, especially benzodiazepines
SURGERY
Contraindicated
FOLLOW-UP
PROGNOSIS
• Some studies show high degrees of success (58-70%) with behavioral interventions.
• History of sexual abuse does not predict outcome negatively or positively.
PATIENT MONITORING
General preventive health care
REFERENCES
1. Lamont J. Vaginismus. Am J Obstet Gynecol 1978;131:632-636.
2. Spector IP, Carey MP. Incidence and prevalence of the sexual dysfunctions: A critical review of the empirical literature. Arch Sexual Behavior 1990;19:389-405.
3. Biswas A. Vaginismus and outcome of treatment. Ann Acad Med Singapore 1995;24:755-758.
4. Heiman JR. Evaluating sexual dysfunctions: Primary care of women. Norwalk, CT: Appleton  Lange, 1995.
5. Read S, King M, Watson J. Sexual dysfunction in primary medical care. J Public Health Med 1997;19(4):387-391.
6. Sarwer D, Durlak J. A field trial of the effectiveness of behavioral treatment for sexual dysfunctions. J Sex Marital Ther 1997;23(2):87-97.
7. Ghazizadeh S, Nikzad M. Botulism toxin in the treatment of refractory vaginismus. Obstet Gynecol 2004;104:922-925.
MISCELLANEOUS
See also: Dyspareunia; Sexual Dysfunction in Women