Vaginismus – Causes, Symptoms, Diagnosis, Treatment

Vaginismus is an involuntary contraction of the vaginal muscles which makes sexual intercourse difficult or impossible. It is one of the more common female psychosexual problems. Various therapeutic? strategies for vaginismus, such as sex therapy and desensitization, have been proposed, and uncontrolled case series appear promising.

Causes of Vaginismus 

Primary vaginismus

Vaginismus occurs when penetrative sex or other vaginal penetration cannot be experienced without pain. It is commonly discovered among teenage girls and women in their early twenties, as this is when many girls and young women first attempt to use tampons, have penetrative sex or undergo a Pap smear?. Awareness of vaginismus may not happen until vaginal penetration is attempted. Reasons for the condition may be unknown.^[rx]

A few of the main factors that may contribute to primary vaginismus include:

• chronic? pain conditions and harm-avoidance behavior ^[rx]
• the negative emotional reaction towards sexual stimulation, e.g. disgust both at a deliberate level and also at a more implicit level^[rx]
• strict conservative moral education, which also can elicit negative emotions^[rx]

Secondary vaginismus

Secondary vaginismus occurs when a person who has previously been able to achieve penetration develops vaginismus. This may be due to physical causes such as a yeast infection? or trauma? during childbirth, while in some cases it may be due to psychological causes, or to a combination of causes. The treatment for secondary vaginismus is the same as for primary vaginismus, although, in these cases, previous experience with successful penetration can assist in a more rapid resolution of the condition. Peri-menopausal and menopausal vaginismus, often due to drying of the vulvar and vaginal tissues as a result of reduced estrogen, may occur as a result of “micro-tears” first causing sexual pain then leading to vaginismus.^[rx]

Emotional triggers

These include:

• fear, for example, of pain or pregnancy
• anxiety, about performance or because of guilt
• relationship problems, for example, having an abusive partner or feelings of vulnerability
• traumatic life events, including rape or a history of abuse
• childhood experiences, such as the portrayal of sex while growing up or exposure to sexual images

Physical triggers

These include:

• infection, such as a urinary tract infection? (UTI?) or yeast infection
• health conditions, such as cancer or lichen sclerosis?
• childbirth
• menopause?
• pelvic surgery
• inadequate foreplay
• insufficient vaginal lubrication
• medication side effects

Sexual problems can affect both men and women. They are not anyone’s fault, and they are nothing to be ashamed of.

There are several possible causes of vaginismus.

These include physical and psychological factors, like

• trauma during childbirth
• medical conditions like recurrent? UTIs, yeast infections (thrush), chronic pain syndromes, endometriosis?
• rape, sexual abuse or assault in the past
• a painful examination in the past
• unpleasant sexual intercourse
• fear of getting pregnant
• fear the vagina may be too small for penetration

Symptoms of Vaginismus

The symptoms vary between individuals.

They may include:

• painful intercourse (dyspareunia), with tightness and pain that may be burning or stinging
• penetration being difficult or impossible
• long-term sexual pain with or without a known cause
• pain during tampon insertion
• pain during a gynecological examination
• generalized? muscle spasm or breathing cessation during attempted intercourse
• Difficult or impossible penetration, entry pain, uncomfortable insertion of penis
• Burning or stinging with tightness during sex
• Difficulty inserting tampons, even after repeated attempts
• Difficulty undergoing pelvic/gynecological exam with speculum
• Avoidance of intercourse due to fear, pain, or failure

Pain can range from mild? to severe? in nature and from discomfort to burning in sensation.

Diagnosis? of Vaginismus

Diagnosis of vaginismus usually begins with describing your symptoms. Your doctor will likely ask:

• when you first noticed a problem
• how often it occurs
• what seems to trigger it

Typically, your doctor will also ask about your sexual history, which may include questions about whether you’ve ever experienced sexual trauma or abuse.

• In general, diagnosis and treatment of vaginismus require a pelvic exam.It’s common for women with vaginismus to be nervous or fearful about pelvic exams. If your doctor recommends a pelvic exam, you can discuss ways to make the exam as comfortable as possible for you.
• Some women prefer not to use stirrups and to try different physical positions for the exam. You may feel more at ease if you can use a mirror to see what your doctor is doing. When a doctor suspects vaginismus, they’ll generally perform the exam as gently as they can.
• They may suggest that you help guide their hand or medical instruments into your vagina to make penetration easier. You can ask your doctor to explain every step of the exam to you as they go along.
• During the exam, your doctor will look for any sign of infection or scarring. In vaginismus, there’s no physical reason for the vaginal muscles to contract. That means, if you have vaginismus, your doctor won’t find another cause for your symptoms.

Treatment of Vaginismus 

A Cochrane review found little high-quality evidence regarding the treatment of vaginismus in 2012.^[rx] Specifically, it is unclear if systematic desensitization is better than other measures including nothing.^[rx]

Treatment usually includes a combination of the following:

• Pelvic floor control exercises –  These include muscle contraction and relaxation activities, or Kegel exercises, to improve control of the pelvic floor muscles.
• Education and counseling – Providing information about the sexual anatomy? and sexual response cycle can help the individual understand their pain and the processes their body is going through.
• Emotional exercises – This can help the person identify, express, and resolve any emotional factors that may be contributing to their vaginismus.
• Reducing sensitivity to insertion – A woman will be encouraged to touch the area as close as possible to the vaginal opening every day without causing pain, moving closer each day. When she is able to touch the area around the vagina, she will be encouraged to touch and open the vaginal lips, or labia. The next step will be to insert a finger.
• Vaginal Dilation Exercises – Vaginal dilation exercises use the patient’s own fingers or plastic instruments called dilators. The dilators are gradually increased in size and placed in the vagina over time. Patients may be asked to place the dilators themselves. The program is supervised by a healthcare provider. Women may be asked to practice Kegel exercises while the dilators are in the vagina. After patients have reached a level of comfort, sexual intercourse is attempted.
• Educational Treatment – Fear of sex is a large part of this disorder. Educating women is an important part of treatment. Women are taught about sex organs and how they work. The sexual response cycle and common sex myths are also discussed.
• Counseling – Depending on the cause, psychological counseling is often central to the treatment of vaginismus. It is particularly helpful to those with primary vaginismus due to sexual abuse or trauma.
• Insertion training – Once a woman can do this without pain, she will learn to use a plastic dilator or a cone-shaped insert. If she can insert this without pain, the next step will be to leave it in for 10 to 15 minutes, to let the muscles get used to the pressure. Next, she can use a larger insert, and then she can teach her partner how to apply the insert.
• Psychological – According to a 2011 study, those with vaginismus are twice as likely to have a history of childhood sexual interference and held less positive attitudes about their sexuality, whereas no correlation was noted for lack of sexual knowledge or (non-sexual) physical abuse.^[rx]
• Physical – Often, when faced with a person experiencing painful intercourse, a gynecologist will recommend Kegel exercises and provide some additional lubricants.^{[rx][trx][rx][rx]} Strengthening the muscles that unconsciously tighten during vaginismus may be extremely counter-intuitive for some people. Although vaginismus has not been shown to affect a person’s ability to produce lubrication, providing additional lubricant can be helpful in achieving successful penetration. This is due to the fact that women may not produce natural lubrication if anxious or in pain. Treatment of vaginismus may involve the use Hegar dilators (sometimes called vaginal trainers), progressively increasing the size of the dilator inserted into the vagina.^[rx][rx]
• Neuromodulators – Botulinum toxin A (Botox) has been considered as a treatment option, under the idea of temporarily reducing the hypertonicity of the pelvic floor muscles. Although no random controlled trials have been done with this treatment, experimental studies with small samples have shown it to be effective, with sustained positive results through 10 months.^[rx][rx] Similar in its mechanism of treatment, lidocaine has also been tried as an experimental option.^[rx][rx]

Anxiolytics and antidepressants are other pharmacotherapies that have been offered to people in conjunction with other psychotherapy modalities, or if these people’s experience high levels of anxiety from their condition.^[rx] Evidence for these medications; however, is limited.^[rx]

References