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| Vaginismus |
Involuntary painful contraction of perineal muscles prior to or during vaginal intercourse. The experience of or even the anticipation of pain on vaginal entry causes theses muscles to contract, occluding the vaginal opening and causing further pain when penetration is attempted.
Incidence/Prevalence in USA: 6-8% of women in some studies report complete vaginismus and up to 30% some degree of vaginismus
Predominant age: Postpubertal
Predominant sex: Female
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!
CAUSES:
•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 un-abused populations of women (studies show incidence of sexual abuse of women to be from 12-40%)
•Secondary
•New onset of infection
•Surgical or post delivery scarring
•Endometriosis
•Inadequate vaginal lubrication
RISK FACTORS:
•Previous sexual trauma, but rates appear to be similar in abused and non-abused women
•Often associated with other sexual dysfunctions
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS:
•Dyspareunia
PATHOLOGICAL FINDINGS:
Rarely found in primary vaginismus, but may be varied such as endometriosis or scarring in secondary vaginismus
SPECIAL TESTS:
Psychiatric consultation if not responsive to primary physician's therapy or if primary provider not comfortable with caring for sexual problems
DIAGNOSTIC PROCEDURES:
•General and sexual history
•At some point, a careful pelvic examination to rule out medical cause
TREATMENT
GENERAL MEASURES:
•Can often treat vaginismus successfully without defining/treating its etiologies!!
•No published controlled studies on success of psychotherapy for vaginismus
•Patient education as noted below on pelvic anatomy and sexual function
•Kegel's exercises to control perineal muscles
•Stepwise vaginal desensitization exercises:
•A) with vaginal dilators (patient inserts/controls), or
•B) 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
•A) Female superior at first; passive (non-thrusting); female directed
•B) Later, thrusting may be okay
SURGICAL MEASURES:
Contraindicated
ACTIVITY:
Simple techniques of gentle, progressive, patient-controlled vaginal dilation
DIET:
No special diet
PATIENT EDUCATION:
•Education about pelvic anatomy, nature of the vaginal spasms, normal adult sexual function
•Hand held mirror can help the woman visually learn to tighten and loosen perineal muscles
•Important to teach the partners that the spasms are not under conscious control and are not a reflection on the relationship or a woman's feelings about her partner
•Instruction in techniques for vaginal dilation
•Resources
•American College of Obstetricians & Gynecologists (ACOG), 409 12th St., SW, Washington, DC 20024-2188, (800)762-ACOG
•Valins L. When a Woman's Body Says No to Sex: Understanding and Overcoming Vaginismus. New York: Penguin, 1992.
Contraindications: Anxiolytics, especially benzodiazepines
Precautions: N/A
Significant possible interactions: N/A
ALTERNATIVE DRUGS:
N/A
POSSIBLE COMPLICATIONS:
Precipitation of memory of incest prior to patient's readiness to deal with it
EXPECTED COURSE AND PROGNOSIS:
•Some studies show high degrees of success (58-70%) with behavioral interventions
•History of sexual abuse does not predict outcome negatively or positively
ASSOCIATED CONDITIONS:
•Marital stress, family dysfunction
•Dyspareunia
AGE-RELATED FACTORS:
Vaginismus is generally primary, e.g. happens with first attempt at intercourse
Pediatric: N/A
Geriatric: N/A
Others: N/A
PREGNANCY:
Pregnancy can occur in patients with vaginismus via perineal ejaculation
REFERENCES
•Biswas A: Vaginismus and outcome of treatment: Human Sexuality and Sexual Dysfunction 1995;24:755-758
•Heiman JR: Evaluating sexual dysfunctions: Primary Care of Women. Norwalk, CT, Appleson and Lange, 1995
•Read S, King M, Watson J: Sexual dysfunction in primary medical care. Journal of Public Health Medicine, Oxford University Press 1997;19(4):387-391
•Sarwer D, Durlak J: A field trial of the effectiveness of behavioral treatment for sexual dysfunctions. Journal of Sex and Marital Therapy 1997;23(2):87-97 |
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