Vaginismus

Original Editor - Muskan Rastogi Top Contributors - Muskan Rastogi, Laura Ritchie, Kim Jackson and Lucinda hampton

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Definition

Vaginismus is a penetration disorder in which any form of vaginal penetration is painful or impossible. It has traditionally been referred to as an involuntary contraction of the pelvic floor muscles due to actual or anticipated pain associated with vaginal penetration. It causes women to feel pain, fear and anxiety with penetration attempts.It is often associated with psychological problems, leading to poor sexual quality of life (SQOL).

Anatomy

Muscles hypothesised to be involved:-

• Levator ani
• Puborectalis ( with deep external anal sphincter)
• Bulbocavernosus muscle ( with external anal sphincter)

Prevalence and Incidence

It affects about 1-7% of the female population worldwide. In primary care settings the same rate goes up to 30%further drastically increasing to 42% in specialized clinics for female sexual disorders.

Etiology

The etiological factors are- ( the given etiological factors are still not well established by the literature)

Organic pathologies

• Congenital abnormalities
• Local infections
• Trauma associated with childbirth
• Genital surgery or radiotherapy
• Vaginal lesions and tumors

Psychological factors

• Sexual abuse

• A negative attitude toward sexuality
• Relationship difficulties
• Fear of first-time sex (pain, bleeding, tearing, ripping, penis too large, vagina too small, sexually transmitted diseases, fear of pregnancy)
• Fear of gynecological examinations
• A maternal influence involving grandmothers, mothers, twins, and sisters-The influence is due to merely hearing about the difficulties faced by them and the patient may manifest it as a subsequent fear of penetration.

Quality of life

This condition influences the quality of life, in the most serious form it can result in an unconsummated marriage, and sterility and thus further result in the couple leading a separate life. It is correlated with poor sexual quality of life and even the male partners may have important effects on the development, maintenance, and exacerbation of vaginismus ( in lifelong vaginismus -LLV).Common psychological symptoms seen are depression, anxiety, low self-esteem, insecure attachment styles, histrionic/hysterical traits, and alexithymia.

Symptoms

These symptoms are defined accordingly given by the Diagnostic and Statistical Manual of Mental Disorders (DSM, the American Psychiatric Association), fifth edition(DSM-5)-

• Difficulty having intercourse
• Genito-pelvic pain
• Fear of pain or vaginal penetration
• Tension of the pelvic floor muscles.

Other symptoms-

• Inability to use OR remove a tampon (often noted at a young age)
• Complaints that attempted coitus is like “hitting a wall”
• An inability to tolerate a gynaecological examination.

Pathophysiology/Mechanism

• It is theorized that it is a disorder of the sacral reflex arc conducting the stimulus . Further research is needed to establish this fact.

Types

• Primary Vaginismus
• Secondary Vaginismus

Grades

In 1978 Lamont described the first four grades and a grade 5 was then later added by Pacik. The Lamont grades were based on the patient's conduct during gynaecological examination and history taking whereas the Pacik grade 5 takes into account the severe fear and anxiety seen in the patient while performing the examination.

GRADES	DESCRIPTION
Lamont grade 1	Patient is able to relax for pelvic examination
Lamont grade 2	Patient is unable to relax for pelvic examination
Lamont grade 3	Buttocks lift off the table. Early retreat
Lamont grade 4	Generalized retreat: buttocks lift up, thighs close, patient retreats
Pacik grade 5	Generalized retreat as in level 4 plus visceral reaction, which may result in any one or more of the following: palpitations, hyperventilation, sweating, severe trembling, uncontrollable shaking, screaming, hysteria, wanting to jump off the table, a feeling of becoming unconscious, nausea, vomiting, and even a desire to attack the doctor

Assessment

History

A thorough medical and psycho-sexual history is needed to be taken. Female Sexual Function Index (FSFI) or alternatively Vaginal Penetration Cognition Questionnaire (VPCQ) should be used. Other reasons for pain during coitus such as herpes virus, lichen sclerosis, and others need to be ruled out as a source of sexual pain, as well as a consideration of Vulvodynia and Vestibulodynia.

Clarify patient's penetration history, the amount of pain, and separately the amount of anxiety, with various types of penetration scored 1–10, 10 being the worst possible pain or anxiety. Pain and anxiety are scored by the patient for tampons, cotton tipped applicators, fingers, gynecological examinations, dilators, and intercourse.

Examination

Checking the Degree of vaginal muscle hypertonus/spasm

Degree of spasm	Description
1-2	Minimal/mild degrees of vaginal hypertonus/spasm
3	Considerable vaginal hypertonus/spasm. Finger penetration possible, but vaginal musculature is tight. The patient is uncomfortable with the examination.
4	Presence of vaginal muscle spasm. Bulbocavernosus seems like a tightly closed fist and digital penetration is difficult to impossible without sedation.

Diagnosis

It is based on history and symptoms of the patient.

Documenting the amount of pain and anxiety with various forms of vaginal penetration is helpful in understanding a patient's perception of penetration pain. The diagnosis of vaginismus is made by a history of severe pain during intercourse or intercourse being impossible which feels like "Hitting a brick wall" or "There is no hole down there" is indicative of vaginal spasm of the opening of vagina and is often diagnostic of severe vaginismus, which is an important differentiation from Dyspareunia, Vulvodynia, and Vestibulodynia.

This history and the inability to tolerate a gynecological examinations are two important diagnostic features of severe vaginismus.

Patients with vaginismus may have an aversion to pelvic touch related to the fear of pain and behavioral avoidance ,and may not permit pelvic examination, cotton-tipped testing, and EMG evaluation.

Patients who score themselves as "10's" (severe pain and severe anxiety) with all forms of penetration have much more difficulty incorporating the suggestion of therapy.

Differential diagnosis

• Dyspareunia
• Vulvodynia
• Vestibulodynia

Prognosis

Patients who are able to tolerate some forms of penetration and who have lower pain and anxiety scores tend to be easier to treat in that they are able to cooperate with the proposed treatment. Hence their prognosis is also better when compared to other grades of vaginismus.

Management

Non-surgical management

Behavioural Sex Therapy

Psychological treatments for vaginismus-

• Marital
• Interactional
• Existential–experiential
• Relationship enhancement
• Hypnosis

These therapies are usually based on the assumption that vaginismus is a consequence of marital problems, negative sexual experiences in childhood or a lack of sexual education.

The therapy can be conducted in an individual or couple format. In individual therapy, the treatment is to identify and resolve underlying psychological problems that could be causing the disorder. In couples therapy, the disorder is designed as a problem for the couple and the treatment inclines to aim the couple’s sexual history and any other problems that may be occurring in the relationship.

Cognitive Behavioural Therapy

Vaginismus could be easily treated with behaviorally oriented sex therapy that includes vaginal dilatation as described by Masters and Johnson’s. In the first step of the treatment there is a physical demonstration of the vaginal muscle spasm to the patient (and the partner) during a gynecological examination. The couple is then directed to insert a series of dilators of graduated sizes at home guided by both the patient and her partner with the aim of desensitizing the patient to vaginal penetration. This treatment regimen also emphasized on the importance of education regarding sexual function and the development and maintenance of vaginismus in order to relieve from the psychological impact of the disorder.

Van Lankveld’s group reformulated their conceptualization of vaginismus from a sexual disorder to a vaginal penetration phobia. Their treatment for vaginismus focused more explicitly and systematically on the fear of coitus through the use of prolonged, therapist-aided exposure therapy. The treatment was comprised of education on the fear and avoidance model of vaginal penetration as well as of a maximum of three 2 h sessions of in vivo exposure to the stimuli feared during vaginal penetration. This exposure treatment is said to be successful in decreasing fear and negative penetration beliefs.

Pharmacological therapy

There are 3 main types of pharmacological treatment for vaginismus

1. Local anesthetics (e.g., lidocaine), Local anaesthetics, such as lidocaine gel, are based on the rationale that muscle spasms in vaginismus are due to repeated pain experienced with vaginal penetration and the use of a topical anaesthetic there will be a reduction in the pain and thus the spasm will be treated.
2. Muscle relaxants (e.g., nitroglycerin ointment and botulinum toxin) A topical nitroglycerin ointment, treat the muscle spasm by relaxing the vaginal muscles, Botulinum toxin, a temporary muscle paralytic, has been recommended in the treatment of vaginismus with the aim of decreasing the hypertonicity of the pelvic floor muscles. The patient who receives an injection of botulinum toxin is able to engage in ‘satisfactory intercourse'.
3. Anxiolytic medication use of anxiolytics, such as diazepam, in conjunction with psychotherapy based on the rationale that vaginismus is a psychosomatic condition resulting from past trauma and therefore anxiety-reducing medications will resolve the symptoms.

Pelvic floor physiotherapy

It involves:-

• Counselling

• Breathing exercises
• Relaxation exercises
• Local tissue desensitization/Gradualized desensitization
• Habituation
• Vaginal dilators
• Pelvic floor biofeedback
• Manual therapy techniques
• Electrotherapeutic currents

TREATMENT PROTOCOL

1. Counsel the patient- Educate the patient about the anatomy and physiology of the vulva, vagina, and pelvic floor muscles with the help of diagrams, pictures, and models. Explain the protective role of voluntary muscle contraction in response to pain or expected pain and emphasize the fact that the pain does not automatically imply that there is tissue damage but is rather helping to communicate to us the threat or perceived danger. Explain the whole treatment procedure. Reassure the patient that the treatment can be discontinued whenever they want, the therapist would not treat when they are anxious or fearful, the treatment will progress at the patient's pace. Encourage the patient to invite their partner(if has one) to attend any or all of the treatment sessions and to involve the partner in-home exercises protocol whenever possible.
2. Ask the patient to lie in a supine position with knees bent and feet flat on the bed; head elevated on pillows so constant eye contact could be kept between the therapist (positioned at the foot of the treatment bed) and the patient. If the patient felt any pain or anxiety they need to articulate this by saying, “Stop.” The word “Stop” would indicate to the therapist to stop the movement or technique and stay still until the pain or anxiety is reduced or ceased. Until the pain ceases take this opportunity to discuss the role of the nervous system and neuroplasticity in the treatment of vaginismus.
3. Progression of the treatment session a. Being able to tolerate perineal pressure with the palm of the therapist’s hand. b. Looking at genitalia with a mirror. c. Tolerating the therapist resting one finger on the introitus. d. Tolerating the insertion of the finger into the vagina. e. Tolerating movement of the finger inside the vagina.
4. This progression enables the usage of manual techniques to enhance proprioception and voluntary control of the pelvic floor muscles; techniques included stretches, myofascial and trigger point releases, and massage.
5. Kegel exercises are to be given with resistance only and with a focus on relaxation rather than contraction. This implies that the patient can now carry out contract/relax exercises with a dilator vaginally inserted to assist in proprioception.
6. Two finger insertion to inserting a tampon then to a series of three graduated dilators, at last, a speculum is used in a gradual manner to increase patient's confidence.
7. Teach the patient how to relax (“drop”) her pelvic floor muscles, ask them to practice this during the day if the patient feels that the muscles are tense, and then focus on dropping the pelvic floor during any insertion technique.
8. Electromyographic biofeedback with a vaginal sensor should be used as a teaching tool whenever the therapist feels it's appropriate. With this technique, the patient can see the effect of contraction and relaxation of the pelvic floor muscles in a form of a graph whilst showing electrical muscle activity on the computer screen and thereby learning to recognize the sensation of a relaxed pelvic floor while receiving feedback from the electromyographic display.
9. Transcutaneous electrical nerve stimulation, a low-intensity, biphasic electrical current delivered by a vaginal sensor, can be used to reduce pain through nociceptive inhibition in the dorsal horn of the spinal cord.
10. Treatment techniques (e.g., stretches, dilator insertion) are assigned for home practice, either done by the patient alone or with her partner. Home exercises involve the patient inserting a finger, thumb, or dilator into the vagina, which is progressed to the movement of fingers, then to massage of the vaginal walls and stretching of the opening of the vagina at 4, 6, and 8 o’clock. Therapist should also suggest relaxation and breathing exercises at home. Massaging the vaginal walls gives the patient a chance to palpate the muscular tension and to experience what contraction and relaxation of the pelvic floor muscles feel like, thereby improving proprioceptive awareness. If the massage is done by the therapist -it is done in lithotomy position under infrared light to increase blood flow.Sensation focus technique can be done by the partner at home, where the partner massages the entire body except breast and genital areas without penetration which causes the patient to feel relaxed and calm.
11. Each step mentioned above should be practiced until there is no pain or anxiety before moving on to the next step. Once the patient can tolerate insertion and movement of the larger dilator, preferably by her partner, the transition to intercourse should be encouraged. Also, motivate the patient the use stops as needed and focus on keeping the pelvic floor muscles relaxed at all times.

Use of interferential current for treatment of vaginismus is still under trial.

Surgical management

Removal of hymenal remnants-Hymenectomy.

Combination Treatment of Sacral Erector Spinae Plane Block and Progressive Dilatation is under trial.