Vaginismus

Not to be confused with Vaginitis.

Vaginismus
Specialty	Gynaecology

Vaginismus, sometimes anglicized vaginism is the German name for a condition which affects a woman's ability to engage in any form of vaginal penetration, including sexual intercourse, insertion of tampons, and the penetration involved in gynecological examinations. This is the result of a reflex of the pubococcygeus muscle, which is sometimes referred to as the "PC muscle". The reflex causes the muscles in the vagina to tense suddenly, which makes any kind of vaginal penetration—including sexual intercourse—painful or impossible.

A woman suffering from vaginismus does not consciously control the spasm. The vaginismic reflex can be compared to the response of the eye shutting when an object comes towards it. The severity of vaginismus and the pain during penetration, including sexual penetration, varies from woman to woman.

Primary vaginismus

A woman is said to have primary vaginismus when she has never been able to have penetrative sex or experience vaginal penetration without pain. It is commonly discovered in teenagers and women in their early twenties, as this is when many young women in the Western world attempt to use tampons, have penetrative sex, or undergo a Pap smear. Women with vaginismus may be unaware of the condition until they attempt vaginal penetration. It may be confusing for a woman to discover she has vaginismus. She may believe that vaginal penetration should naturally be easy, or may be unaware of the reasons for her condition.

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

• a condition called vaginal vestibulair syndrome more or less synonymous to focal vaginitis a so-called subclinical inflammation. No pain is perceived, until some form of penetration is tried.
• urinary tract infections or vaginal yeast infections.
• sexual abuse, rape, or attempted sexual abuse
• knowledge of (or witnessing) sexual or physical abuse of others, without being personally abused
• domestic violence or conflict in the early home environment
• having been taught that sex is immoral, vulgar, or demoralizing
• fear of pain associated with penetration, particularly the popular misconception of 'breaking' the hymen upon the first attempt at penetration, or the idea that vaginal penetration will inevitably hurt the first time it occurs
• being sexualized or told about sex in violent or inappropriately graphic terms before an age at which one is comfortable with such information
• any physically invasive trauma
• generalized anxiety
• stress

Occasionally, primary vaginismus is idiopathic.

Vaginismus has been classified by Lamont according to the severity of the condition. He describes four degrees of vaginismus: In first degree vaginismus, the patient has spasm of the pelvic floor which can be relieved with reassurance. In second degree, the spasm is present but maintained throughout the pelvis even with reassurance. In third degree, the patient elevates the buttocks to avoid being examined. In fourth degree vaginismus (also known as grade 4 vaginismus), the most severe form of vaginismus, the patient elevates the buttocks, retreats and tightly closes the thighs to avoid examination. Pacik expanded the Lamont classification to include a fifth degree in which the patient experiences a visceral reaction such as sweating, hyperventilation, palpitations, trembling, shaking, nausea, vomiting, going unconscious, wanting to jump off the table or attacking the doctor. The Lamont classification continues to be used to the present and allows for a common language among researchers and therapists. However, it does not allow for a language in which a woman might be able to verbalise her concerns, pain or problems. A woman with a lot of trust in the doctor might be classified as 1 but experience severe pain. A woman with less trust or a woman who is or has been subjected to harsh examination, might be classified as 4 or 5.

Though spasm of the pubococcygeus muscle is commonly thought to be the primary muscle involved in vaginismus, Pacik identified 2 additional involved spastic muscles in treated patients under sedation. These include the entry muscle (bulbocavernosum) and the mid vaginal muscle (puborectalis). This accounts for the common complaint that patients often say when trying to have intercourse "It's like hitting a brick wall".

Secondary vaginismus

Secondary vaginismus occurs when a woman 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, or it may be due to psychological 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.

Prevalence

The prevalence of vaginismus has been reported to be 6% in two widely divergent cultures, Morocco and Sweden. The prevalence of manifest dyspareunia has been reported as low as 2% in elderly British women, yet as high as 18–20% in British and Australian studies.

By another study vaginismus rates of between 12% and 17% have been reported in women presenting to sex therapy clinics (Spector and Carey 1990). National Health and Sexual Life Survey, which used random sampling and structured interviewing, found that between 10% and 15% of women reported having experienced pain during intercourse during the last 6 months (Laumann et al. 1994).

The most recent study-based estimates of vaginismus range from 5% to 47% of people presenting for sex therapy or complaining of sexual problems, with significant differences across cultures (see Reissing et al. 1999; Nusbaum 2000; Oktay 2003). It seems likely that society's expectations of women's sexuality may particularly impact on these sufferers.

Treatment

There are a variety of factors that can contribute to vaginismus. These may be psychological or physiological, and the treatment required can depend on the reason that the woman has developed the condition. As each case is different, an individualized approach to treatment is useful. The condition will not necessarily become more severe if left untreated, unless the woman is continuing to attempt penetration, despite feeling pain. Some women may choose to refrain from seeking treatment for their condition.

According to the Cochrane Collaboration review of the scientific literature, "In spite of encouraging results reported from uncontrolled case series there is very limited evidence from controlled trials concerning the effectiveness of treatments for vaginismus. Further trials are needed to compare therapies with waiting list control and with other therapies." Although few controlled trials have been carried out, many serious scientific studies have tested and supported the efficacy of the treatment of vaginismus. In all cases where the systematic desensitization method was used, success rates were close to 90–95% and even 100%. For an example of one of these studies, see Nasab, M., & Farnoosh, Z., or for a basic review, see Reissing's literature review (links below). A Dutch study showed that many women were subsequently able to be penetrated, but far fewer women actually enjoyed being penetrated.

One treatment that is employed is that of vaginal probes. Vaginal probes are graduated or tapered blunt ended probes. They come in different sizes, usually no larger than the size in length and diameter of a tampon. Here, the woman can work with a trusted nurse practitioner, doctor or other person trained in sexual dysfunction and disorder; to help her organize a therapeutic program to (slowly and gradually) assist her in overcoming her fear of penetration. Vaginal probes are introduced into the woman's vagina, and usually with her own hand so that she can maintain control physically and psychologically over the rate of insertion. This procedure requires a great amount of trust and compassion to take place between the patient and the practitioner for the outcome to be successful.

Psychological treatment

According to Ward and Ogden's qualitative study on the experience of vaginismus for women (1994), the three most common contributing factors to vaginismus are fear of painful sex; the belief that sex is wrong or shameful (often the case with patients who had a strict religious upbringing); and traumatic early childhood experiences (not necessarily sexual in nature).

Vaginismus patients 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 physical abuse.

For some women, especially those with primary vaginismus, it is important to address the psychological aspects of the problem as well as the actual muscle spasm. A woman may choose to address the issue on her own terms, or she may avail the help of a therapist. Some women, especially those with secondary vaginismus, may rely on a physical rather than psychological treatment and also be successful. There are emotional difficulties associated with vaginismus, which can include low self-esteem, relationship issues, continued fear of penetration, and depression.

Physical treatment

Dilators for Treating Vaginismus

Physical treatment of the internal spasms may include sensate focus exercises, exploring the vagina through touch, and desensitization with vaginal dilators. Dilating involves inserting objects, usually phallic in shape, into the vagina. In treating the spasms through dilation, the objects used gradually increase in size as the woman progresses.

Botox Vaginismus Treatment

In cases of vaginismus where more traditional treatments have not been successful, Botox is now used. Botox offers an option that allows women who deeply fear penetration to the point where dilators are "too scary" to move ahead despite this fear. The use of Botox relaxes the muscle spasm for about four months. After the procedure, the patient awakens having already achieved that which is usually the hardest first step, the insertion a large dilator. The anesthesia works to ensure that her first experience with the dilator is not painful.

Sexuality

If a woman suspects she has vaginismus, sexual penetration is likely to remain painful or truly impossible until her vaginismus is addressed. This is a highly frustrating condition, as a lot of people, including doctors, may comment on her motives. Vaginismus does not mean that a woman is frigid, does not want intercourse or does not love her partner. Women with vaginismus may be able to engage in a variety of other sexual activities, as long as penetration is avoided. Sexual partners of vaginismic women may come to believe that vaginismic women do not want to engage in penetrative sex at all, though this may not be true. There is currently no indication that vaginismus reduces the sexual drive or arousal of affected women and as such it is likely that many vaginismic women wish to engage in penetrative sex to the same degree as unaffected women, but are deterred by the pain and emotional distress that comes with each attempt. Psychological pressure to "perform" sexually or become aroused quickly with a partner can be deteriorating.

Masturbation

Many people do not realize that even women without vaginismus commonly experience pain or discomfort upon attempting sexual penetration without being sufficiently aroused. Most women acknowledge sexual arousal as vital to achieving comfortable penetration.

One of the problems which may accompany vaginismus is that a woman may be extremely hesitant to engage in penetrative sexual activity with others, due to a fear of pain associated with any kind of vaginal penetration. Solo masturbation, with penetration, can alleviate this fear.

Orgasm need not be the only goal of masturbation. It may also serve to increase comfort with the genital area, to explore various sensations through genital and clitoral touch, and to become aware of those sensations which are relaxing and pleasurable. Sexual arousal causes changes in the shape and color of the vulva, as well as in the vaginal lubrication produced. As a woman becomes more aware of her individual sexual response, she can learn which sensations are best for bringing her to a state of arousal. She will then be better equipped to teach her partner which sensations feel best for her.

Emotional experiences

Frustration literally means disappointment. A woman who is willing to have intercourse and finds that her vagina fires off a reflex that makes intercourse impossible, is likely to have all sorts of emotions. Ranging from being amazed to grief to embarrassment. Some women unluckily already have negative associations with their genitals, including fears that their genitals are dirty, smelly, oddly shaped, or ugly. Now "useless" may be added. These associations can lead to negative emotions arising during any kind of sexual expression, including masturbation, and these emotions can take time to process. Feelings of extreme shame, inadequacy or fear of being "defective" can be deeply troubling. If multiple attempts to penetrate are made before treating vaginismus, it may lead to fear of sexual intercourse, and worsen the amount of pain experienced with each subsequent attempt. Relaxation, patience and self-acceptance are vital to a pleasurable experience.

References

• van der Velde J, Everaerd W (2001). "The relationship between involuntary pelvic floor muscle activity, muscle awareness and experienced threat in women with and without vaginismus". Behaviour research and therapy. 39 (4): 395–408. doi:10.1016/S0005-7967(00)00007-3. PMID 11280339.

• Crowley, Tessa (January 2006). "Recommendations for the management of vaginismus". International Journal of STD & AIDS. 17 (1): 14–18. doi:10.1258/095646206775220586. PMID 16409672. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)

• Nasab, M. (2003). "Management of vaginismus with cognitive-behavioral therapy, self-finger approach: A study of 70 cases" (– ^{Scholar search}). IJMS. 28 (2). {{cite journal}}: External link in |format= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

• Reissing E, E. (1999). "Does vaginismus exist? A critical review of the literature". The Journal of Nervous and Mental Disease. 187 (5): 261–271. doi:10.1097/00005053-199905000-00001. PMID 10348080. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)

• Ward, E. (1994). "Experiencing Vaginismus: sufferers beliefs about causes and effects". The Journal of Nervous and Mental Disease. 9 (1): 33–45. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)

External links

• Vaginismus.com A for-profit website that provides information and offers treatment guides and various kinds of self-help materials.
• Plastic Surgery PA Vaginismus A website containing educational resource articles about the diagnosis and treatment of vaginismus including the use of Botox to treat vaginismus.
• Plastic Surgery PA Vaginismus Describes the FDA approved study to use Botox for vaginismus.
• Vaginismus Awareness Network A non-profit site whose purpose is to raise awareness of vaginismus. It offers a self-treatment guide and many facts and tips to women, their partners and gynecologists.
• Vaginismus Treatment Vaginismus therapy by cognitive and behavioral techniques.
• Vagina Dilator.com A for-profit website that provides everything you need to train your vaginal muscles and pelvic floor.
• Vaginismus – Causes, Diagnosis, Treatment & Self Help entry in NHS Direct Health Encyclopaedia (UK)
• Vaginismus Research at University of Groningen, Netherlands (Females needed for recruitment)
• vaginismus-online.de Website made by gynaecologist, psychotherapist, sex therapist Dr.med. Julia Reeve, Vaginal dilators - Feminaform - film material - Site in German language at present- will be translated into English