Vaginismus

Vaginismus is persistent or recurrent involuntary contraction of the muscles of the pelvic floor and outer third of the vagina in anticipation of, or during, attempted vaginal penetration. It causes marked fear, avoidance and distress. Prevalence is 1 to 6 percent of women presenting with sexual problems, and many couples present with unconsummated marriage.

In current classification it is one component of genito pelvic pain/penetration disorder. This groups together fear or anxiety about pain, vulvovaginal or pelvic pain during intercourse, difficulty with penetration, and tension of pelvic floor muscles. They are not separated into vaginismus and dyspareunia.

It is typically a learned conditioned response. Fear of pain reinforces muscle spasm and avoidance in a self-sustaining cycle.

Contributing factors include:

• Sexual trauma or abuse.
• Strict religious or cultural upbringing and negative sexual messages.
• Painful first intercourse.
• Medical causes of dyspareunia (vulvodynia, vaginal atrophy, infection, lichen sclerosus, endometriosis).
• Fear of pregnancy or childbirth.
• Anxiety and relationship factors.

• Inability or marked difficulty with penile penetration, insertion of tampons, or speculum or digital examination; the woman may describe a sense of a barrier or wall, burning, tearing or pain.
• Spasm of the thighs (adductor tightening), withdrawing, holding the breath and avoiding intercourse; desire and arousal are usually intact and other sexual activity may be enjoyable.
• Primary (lifelong) if penetration has never been possible; secondary (acquired) if it follows a period of normal function, often after childbirth, surgery, menopause, infection or trauma.
• Situational (only with partners) or generalised (all attempts).
• Anxiety, distress, relationship strain, avoidance of gynaecological care (delayed cervical screening) and fertility difficulties from unconsummation.

• Diagnosis is clinical, by history: persistent difficulty with penetration, marked fear or anxiety about it, and tension of pelvic floor muscles, lasting at least 6 months and causing significant distress, not better explained by another condition or by substances.
• Ask about onset, trauma, pain, partner issues and fertility goals; establish consent and control throughout.
• Perform examination only with full consent and at the woman's pace. Inspect the vulva and observe for involuntary closure and muscle contraction. Assess for vulvodynia with cotton swab testing.
• If tolerated, use a single gentle finger examination to assess pelvic floor tone, tenderness and trigger points. Do not force examination.
• If examination is impossible, do not insist. Consider examination under anaesthesia only when needed to exclude pathology and with consent.
• Exclude organic causes: infection, atrophy, lichen sclerosus, scar, imperforate hymen or transverse septum, endometriosis, and congenital abnormalities.

Treatment is multimodal and graded, led by the woman.

• Education and reassurance: explain anatomy and the reflexive nature of the spasm; the vagina is normal and the response is involuntary.
• Cognitive behavioural and sex therapy: address fear, catastrophic beliefs and avoidance; relaxation training, mindfulness, and graded exposure. This has the best evidence of effect.
• Pelvic floor physiotherapy: awareness of contraction and relaxation, biofeedback, breathing, and manual release of trigger points.
• Graded vaginal dilators (or fingers), from the smallest to larger sizes, with lubricant, in a relaxed setting, 10 to 20 minutes daily or every other day, progressing to the next size once the current size is comfortable. Success rates over 70 to 90 percent.
• Couple therapy where relationship issues contribute; involve the partner in graded sensate focus exercises.
• Topical lidocaine 2 to 5 percent gel or cream applied 5 to 10 minutes before attempts to reduce pain and the anticipatory reflex.
• Botulinum toxin A: 50 to 150 units injected into the bulbospongiosus and pubococcygeus muscles under local anaesthesia or sedation, for refractory cases, with dilator therapy afterwards; effect lasts about 3 to 6 months.
• Treat contributing conditions: vaginal oestrogen (estradiol 10 microgram vaginal tablet daily for 2 weeks then twice weekly) for atrophy, treatment for lichen sclerosus, or endometriosis.
• Anxiolytics and antidepressants are used for comorbid anxiety or depression but are not primary treatment of vaginismus.
• Fertility: couples with unconsummated marriage can proceed to intrauterine insemination if needed.
• Response to treatment is good; relapse may occur with stress and requires renewed dilator use.