|Other names||Vaginism, genito-pelvic pain disorder|
|Symptoms||Pain with sex|
|Usual onset||With first sexual intercourse|
|Causes||Fear of pain|
|Risk factors||History of sexual assault, endometriosis, vaginitis, prior episiotomy|
|Diagnostic method||Based on the symptoms and examination|
|Treatment||Behavior therapy, gradual vaginal dilatation|
|Prognosis||Generally good with treatment|
|Frequency||0.5% of women|
Vaginismus is a condition in which involuntary muscle spasm prevents vaginal penetration. This often results in pain with attempts at sex. Often it begins when sexual intercourse is first attempted.
The underlying cause is generally a fear that penetration will hurt. Risk factors include a history of sexual assault, endometriosis, vaginitis, or a prior episiotomy. Diagnosis is based on the symptoms and examination. It requires there to be no anatomical or physical problems and a desire for penetration on the part of the woman.
Treatment may include behavior therapy such as graduated exposure therapy and gradual vaginal dilatation. Surgery is not generally indicated. Botulinum toxin is being studied. About 0.5% of women are affected. Outcomes are generally good with treatment.
Signs and symptoms
Severity and pain during vaginal penetration varies.
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.
A few of the main factors that may contribute to primary vaginismus include:
- a condition called vulvar vestibulitis syndrome, more or less synonymous with focal vaginitis, a so-called sub-clinical inflammation, in which no pain is perceived until some form of penetration is attempted
- urinary tract infections
- vaginal yeast infections
- sexual abuse, rape, other sexual assault, or attempted sexual abuse or assault
- knowledge of (or witnessing) sexual or physical abuse of others, without being personally abused
- domestic violence or similar conflict in the early home environment
- 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
- chronic pain conditions and harm-avoidance behaviour
- any physically invasive trauma (not necessarily involving or even near the genitals)
- generalized anxiety
- negative emotional reaction towards sexual stimulation, e.g. disgust both at a deliberate level and also at a more implicit level
- strict conservative moral education, which also can elicit negative emotions
Vaginismus has been classified by Lamont according to the severity of the condition. Lamont describes four degrees of vaginismus: In first degree vaginismus, the person has spasm of the pelvic floor that can be relieved with reassurance. In second degree, the spasm is present but maintained throughout the pelvis even with reassurance. In third degree, the people elevates the buttocks to avoid being examined. In fourth degree vaginismus (also known as grade 4 vaginismus), the most severe form of vaginismus, the person 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 person experiences a visceral reaction such as sweating, hyperventilation, palpitations, trembling, shaking, nausea, vomiting, losing consciousness, 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.
Although the pubococcygeus muscle is commonly thought to be the primary muscle involved in vaginismus, Pacik identified two additionally-involved spastic muscles in people who were treated under sedation. These include the entry muscle (bulbocavernosum) and the mid-vaginal muscle (puborectalis). Spasm of the entry muscle accounts for the common complaint that people often report when trying to have intercourse: "It's like hitting a brick wall".
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 a 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.
Further factors that may contribute to either secondary or primary vaginismus include:
- Fear of losing control
- Not trusting one’s partner
- Self-consciousness about body image
- History of sexual abuse, rape, sexual assault, or attempted sexual abuse or assault
- Misconceptions about sex or unattainable standards for sex from exaggerated sexual materials, such as pornography or abstinence
- Fear of vagina not being wide or deep enough / fear of partner’s penis being too large
- Undiscovered or denied sexuality
The diagnosis of vaginismus, as well as other diagnoses of female sexual dysfunction, can be made when "symptoms are sufficient to result in personal distress." The DSM-IV-TR defines vaginismus as "recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse, causing marked distress or interpersonal difficulty".
A Cochrane review found little high quality evidence regarding the treatment of vaginismus in 2012. Specifically it is unclear if systematic desensitisation is better than other measures including nothing.
According to Ward and Ogden's qualitative study on the experience of vaginismus (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 people who had a strict religious upbringing); and traumatic early childhood experiences (not necessarily sexual in nature).
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.
Often, when faced with a person experiencing painful intercourse, a gynecologist will recommend Kegel exercises and provide some additional lubricants. 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.
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. Similar in its mechanism of treatment, lidocaine has also been tried as an experimental option.
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. Results from these medications have not been consistent.
True epidemiological studies of vaginismus have not been done, as diagnosis would require painful examinations that those with vaginismus would most likely avoid. Data available is primarily reported statistics from clinical settings.
A study of vaginismus in Morocco and Sweden found a rate of 6%. 18-20% of people in British and Australian studies were found to have manifest dyspareunia, while the rate among elderly British people was as low as 2%.
A 1990 study of people presenting to sex therapy clinics found reported vaginismus rates of between 12% and 17%, while a random sampling and structured interview survey conducted in 1994 by National Health and Sexual Life Survey documented a 10%-15% rate of painful sexual intercourse in the past six months, but did not differentiate between vaginismus and dyspareunia.
The most recent study-based estimates of vaginismus cases range from 5% to 47% of those presenting for sex therapy or complaining of sexual problems, with significant differences across cultures. It seems likely that a society's expectations of person's sexuality may particularly impact on those with the vaginismus.
- Maddux, James E.; Winstead, Barbara A. (2012). Psychopathology: Foundations for a Contemporary Understanding. Taylor & Francis. p. 332. ISBN 9781136482847.
- Ferri, Fred F. (2016). Ferri's Clinical Advisor 2017 E-Book: 5 Books in 1. Elsevier Health Sciences. p. 1330. ISBN 9780323448383.
- "Vaginismus". Merck Manuals Professional Edition. April 2013. Retrieved 15 October 2018.
- Domino, Frank J. (2010). The 5-Minute Clinical Consult 2011. Lippincott Williams & Wilkins. p. 1394. ISBN 9781608312597.
- "Vaginismus". NHS. 2018-01-11. Retrieved 15 October 2018.
- Braddom, Randall L. (2010). Physical Medicine and Rehabilitation E-Book. Elsevier Health Sciences. p. 665. ISBN 978-1437735635.
- Reissing, Elke; Yitzchak Binik; Samir Khalife (May 1999). "Does Vaginismus Exist? A Critical Review of the Literature". The Journal of Nervous and Mental Disease. 187 (5): 261–274. doi:10.1097/00005053-199905000-00001. PMID 10348080.
- Pacik PT (December 2009). "Botox treatment for vaginismus". Plast. Reconstr. Surg. 124 (6): 455e–6e. doi:10.1097/PRS.0b013e3181bf7f11. PMID 19952618.
- Borg, Charmaine; Peters, L. M.; Weijmar Schultz, W.; de Jong, P. J. (February 2012). "Vaginismus: Heightened Harm Avoidance and Pain Catastrophizing Cognitions". Journal of Sexual Medicine. 9 (2): 558–567. doi:10.1111/j.1743-6109.2011.02535.x. PMID 22024378.
- Borg, Charmaine; Peter J. De Jong; Willibrord Weijmar Schultz (June 2010). "Vaginismus and Dyspareunia: Automatic vs. Deliberate: Disgust Responsivity". Journal of Sexual Medicine. 7 (6): 2149–2157. doi:10.1111/j.1743-6109.2010.01800.x. PMID 20367766.
- Borg, Charmaine; Peter J. de Jong; Willibrord Weijmar Schultz (Jan 2011). "Vaginismus and Dyspareunia: Relationship with General and Sex-Related Moral Standards". Journal of Sexual Medicine. 8 (1): 223–231. doi:10.1111/j.1743-6109.2010.02080.x. PMID 20955317.
- "Vaginismus". Sexual Pain Disorders and Vaginismus. Armenian Medical Network. 2006. Retrieved 2008-01-07.
- Lamont, JA (1978). "Vaginismus". Am J Obstet Gynecol. 131 (6): 633–6. doi:10.1016/0002-9378(78)90822-0. PMID 686049.
- Pacik, PT.; Cole, JB. (2010). When Sex Seems Impossible. Stories of Vaginismus and How You Can Achieve Intimacy. Odyne Publishing. pp. 40–7.
- Pacik, Peter (2010). When Sex Seems Impossible. Stories of Vaginismus & How You Can Achieve Intimacy. Manchester, NH: Odyne. pp. 8–16. ISBN 978-0-9830134-0-2. Archived from the original on 2012-02-19. Retrieved 2011-12-29.
- Lahaie, MA; Boyer, SC; Amsel, R; Khalifé, S; Binik, YM (Sep 2010). "Vaginismus: a review of the literature on the classification/diagnosis, etiology and treatment". Women's Health (London, England). 6 (5): 705–19. doi:10.2217/whe.10.46. PMID 20887170.
- American College of Obstetricians Gynecologists Committee on Practice Bulletins-Gynecology (April 2011). "Practice Bulletin No. 119: Female Sexual Dysfunction". Obstetrics & Gynecology. 117 (4): 996–1007. doi:10.1097/aog.0b013e31821921ce. ISSN 0029-7844. PMID 21422879.
- Melnik, T; Hawton, K; McGuire, H (12 December 2012). "Interventions for vaginismus". The Cochrane Database of Systematic Reviews. 12: CD001760. doi:10.1002/14651858.CD001760.pub2. PMID 23235583.
- Reissing ED, Binik YM, Khalifé S, Cohen D, Amsel R (2003). "Etiological correlates of vaginismus: sexual and physical abuse, sexual knowledge, sexual self-schema, and relationship adjustment". J Sex Marital Ther. 29 (1): 47–59. doi:10.1080/713847095. PMID 12519667.
- "When sex hurts – vaginismus". The Society of Obstetricians and Gynecologists of Canada. n.d. Archived from the original on 2013-10-20.
- Herndon, Jaime (November 30, 2015). "Vaginismus". Healthline. George Kruick, MD. Retrieved December 22, 2016.
- Nazario, Brunilda, MD. (2012). "Women's Health: Vaginismus". WebMD. Retrieved December 22, 2016.
- "When sex gives more pain than pleasure". Harvard Health Publications. Harvard Health. May 2012. Retrieved December 22, 2016.
- nhs, nhs (2015). "NHS Choices Vaginal Trainers to treat vaginismus". NHS Choices Vaginismus treatment. NHS.
- Doleys, Daniel (6 December 2012). Behavioral Medicine. Springer Science & Business Media. p. 377. ISBN 9781468440706.
- Pacik, PT. Vaginismus: A Review of Current Concepts and Treatment using Botox Injections, Bupivacaine Injections and Progressive Dilation Under Anesthesia. Aesthetic Plastic Surgery Journal, doi:10.1007/s00266-011-9737-5
- Melnik, T; Hawton, K; McGuire, H (Dec 12, 2012). "Interventions for vaginismus". The Cochrane Database of Systematic Reviews. 12: CD001760. doi:10.1002/14651858.CD001760.pub2. PMID 23235583.
- Lewis RW, Fugl-Meyer KS, Bosch R, et al. (July 2004). "Epidemiology/risk factors of sexual dysfunction". J Sex Med. 1 (1): 35–9. CiteSeerX 10.1.1.565.3552. doi:10.1111/j.1743-6109.2004.10106.x. PMID 16422981.
- see Reissing et al. 1999; Nusbaum 2000; Oktay 2003
- "Critical literature Review on Vaginismus". Vaginismus Awareness Network. Retrieved 2008-01-08.
- Crowley T, Richardson D, Goldmeier D (January 2006). "Recommendations for the management of vaginismus: BASHH Special Interest Group for Sexual Dysfunction". Int J STD AIDS. 17 (1): 14–8. doi:10.1258/095646206775220586. PMID 16409672.
- Reissing ED, Binik YM, Khalifé S (May 1999). "Does vaginismus exist? A critical review of the literature". J. Nerv. Ment. Dis. 187 (5): 261–74. doi:10.1097/00005053-199905000-00001. PMID 10348080.