Understanding and Treating Vaginismus

Abstract

This article was written to raise the awareness of clinicians about vaginismus, an underdiagnosed and inadequately treated condition characterized by painful intercourse. Although it was first described over 150 years ago, vaginismus is rarely taught in medical schools and residencies or discussed at medical meetings. Despite numerous hypotheses on possible causes, its etiology is unknown. Vaginismus affects 5% to 17% of women seen in a clinical setting. Its true incidence is unknown, because many patients remain silent about this problem. Women with this disorder cannot tolerate vaginal penetration via intercourse, tampons, vaginal dilators, or gynecological examinations because of severe pain resulting from involuntary spasm of the vaginal muscles. Vaginal penetration is impossible for these women despite their desire to achieve it. Because of inadequate education and training, many clinicians are unable to diagnose and treat vaginismus. Women with primary vaginismus have never experienced pain-free intercourse, whereas those with secondary vaginismus were comfortable with intercourse at one time in their lives prior to progression to painful intercourse. A carefully constructed medical and psychosexual history and use of the Female Sexual Function Index facilitate the diagnosis of this disorder. The ability to successfully treat severe vaginismus requires a careful consideration of its diagnostic features, which include (1) a history of intercourse feeling such as hitting a wall that is suggestive of vaginal spasm of the introitus and (2) the inability to tolerate a gynecological examination. The presence of spasm or its severity and the degree of fear and anxiety over vaginal penetration distinguish between mild and severe forms of this disorder. Women with situational vaginismus cannot tolerate certain forms of penetration such as intercourse, but insertion of tampons or finger penetration is possible. Women with complete vaginismus are unable to tolerate any vaginal penetration. There is potential for a high rate of treatment success in patients with vaginismus unlike other sexual pain disorders such as vulvodynia and vestibulodynia. Vaginismus is a physical and psychological condition, and both components must be treated. Treatments that have been used to help women overcome vaginismus include dilators, physical therapy, sex counseling, psychotherapy, hypnotherapy, cognitive behavioral therapy, and a multimodal program using botulinum toxin A (onabotulinum toxin A). Kegel exercises, hymenectomy, lubricants, topical anesthetics, antidepressants, antianxiety medication, sedatives, alcohol, hallucinogenic drugs, and muscle relaxants are not shown to be helpful. For 10 years, the author has been developing a treatment program utilizing botulinum toxin A injections, bupivacaine injections, progressive dilation under anesthesia, and posttreatment counseling. This article describes his prospective pilot study that involved 30 patients with vaginismus. Effectiveness was assessed using Female Sexual Function Index scores and daily logs. At 1 year after treatment with this multimodal program, comfortable intercourse (or use of large dilator by single women without partners) was achieved in 97% of the patients. No recurrences or adverse events were noted. Long-term follow-up and blinded, randomized studies are needed to confirm these findings. No improvement in the diagnosis or management of this treatable disorder can be achieved without greater awareness among clinicians and physicians in training. The emotional needs of patients must be addressed whatever treatment is used. Stratifying the severity of vaginismus is important to determine the best course of treatment. Posttreatment counseling and follow-up are essential for success regardless of the treatment program used.