Vaginismus

Last updated
Vaginismus
Other namesVaginism, genito-pelvic pain disorder [1]
1116 Muscle of the Female Perineum.png
Muscles included
Specialty Gynecology, Urology, Sexual Medicine
Symptoms Pain with sex [2]
Usual onsetWith first sexual intercourse [3]
CausesFear of pain [3]
Risk factors History of sexual assault, endometriosis, vaginitis, prior episiotomy [2]
Diagnostic method Based on the symptoms and examination [2]
Differential diagnosis Dyspareunia [4] , Vulvodynia [5]
Treatment Behavior therapy, gradual vaginal dilatation [2]
Prognosis Generally good with treatment [6]
Frequency1-7% of the female population [5]

Vaginismus is a condition in which involuntary muscle spasm interferes with vaginal intercourse or other penetration of the vagina. [2] This often results in pain with attempts at sex. [2] Often it begins when vaginal intercourse is first attempted. [3] Vaginismus may be considered an older term for pelvic floor dysfunction. [7]

Contents

The formal diagnostic criteria specifically requires interference during vaginal intercourse and a desire for intercourse. However, the term vaginismus is sometimes used more broadly to refer to any muscle spasm occurring during the insertion of some or all types of objects into the vagina, sexually motivated or otherwise, including the usage of speculums and tampons. [6] [8]

The underlying cause is generally a fear that penetration will hurt. [3] Risk factors include a history of sexual assault, endometriosis, vaginitis, or a prior episiotomy. [2] Diagnosis is based on the symptoms and examination. [2] It requires there to be no anatomical or physical problems (e.g., pelvic floor dysfunction, vulvodynia, vestibulodynia, etc) and a desire for penetration. [3] [9]

Treatment may include behavior therapy such as graduated exposure therapy and gradual vaginal dilatation. [2] [3] Surgery is not generally indicated. [6] Botulinum toxin (botox), a muscle spasm treatment, is being studied. [2] There are no epidemiological studies of the prevalence of vaginismus. [10] Estimates of how common the condition is are varied. [11] One textbook estimates that 0.5% of women are affected. [2] However, rates in clinical settings indicate that between 5–17% of women experience vaginismus. [10] Outcomes are generally good with treatment. [6]

Signs and symptoms

Physical symptoms may include burning, and sharp pain or pressure in and around the vagina upon penetration. [12] Psychological symptoms include increased anxiety. [12] Pain during vaginal penetration varies. [13]

Despite it being a fairly common female sexual dysfunction, there is low social awareness of vaginismus and women around the world face difficulties finding support, even through the healthcare system. [14] An integrative review published in 2023 found that studies on vaginismus show it often takes years to finally receive a diagnosis [14]

Causes

Primary vaginismus

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. [15]

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

The cause of primary vaginismus is often unknown. [19]

Vaginismus has been classified by Lamont [20] 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 person 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. [21]

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". [15]

Secondary vaginismus

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. [22]

Mechanism

Specific muscle involvement is unclear, but the condition may involve the levator ani, bulbocavernosus, circumvaginal, or perivaginal muscles. [11]

Diagnosis

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." [23] 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". [23]

Treatment

A Cochrane review found little high quality evidence regarding the treatment of vaginismus in 2012. [24] Specifically it is unclear if systematic desensitisation is better than other measures including nothing. [24]

Psychological

According to a 2011 study, 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 (nonsexual) physical abuse. [25]

Physical

Dilators for treating vaginismus Set of five vaginal dilators in different sizes.png
Dilators for treating vaginismus

Often, when faced with a person experiencing painful intercourse, a gynecologist will recommend reverse Kegel exercises and provide some additional lubricants. [26] [27] [28] 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. Achieving sufficient arousal during foreplay is crucial for the release of lubrication which can contribute to the ease of sexual penetration and pain-free intercourse.

Though strengthening exercises such as Kegel exercises were previously considered to be a helpful intervention for pelvic pain, new research suggests that these exercises, which function to strengthen the pelvic floor, may not be helpful or may make conditions that are caused by over-active muscles such as vaginismus worse. Exercises that stretch or relax the pelvic floor may be a better treatment option for vaginismus. [29] [30] [31]

To help develop a treatment plan that best fits the needs of their patient, a gynecologist or general practitioner may refer a person experiencing painful intercourse to a Pelvic floor physical therapist or occupational therapist. These therapists specialize in the treatment of disorders of the pelvic floor muscles such as vaginismus, pelvic floor dysfunction, dyspareunia, vulvodynia, constipation, and fecal or urinary incontinence. [30] [31] After performing a manual exam both internally and externally to assess muscle function and to isolate possible trigger points for pain or tightness on the muscles, pelvic floor physical or occupational therapists develop a treatment plan consisting of muscle exercises, muscle stretches, dilator training, electrostimulation, and/or biofeedback interventions. [30] Treatment of vaginismus often involves the use of Hegar dilators (sometimes called vaginal trainers), progressively increasing the size of the dilator inserted into the vagina. The technique is used to practice conscious diaphragmatic breathing (breathing in deeply allowing one's belly to expand) and allowing the pelvic floor muscles to lengthen during inhale; then exhale, bringing belly in and repeat. [32] [33] Research suggests pelvic floor physical or occupational therapy is one of the safest and most effective treatments for vaginismus. [31]

Many people find vaginal trainers like dilators helpful, but some often need more information on how to use them than is provided, or also seek out lubricant, topical anaesthetic or escitalopram, [14] a medicine commonly used to treat depression and anxiety. [34]

Neuromodulators

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. [11] [35] Similar in its mechanism of treatment, lidocaine has also been tried as an experimental option. [11] [36]

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. [11] Evidence for these medications, however, is limited. [11]

Epidemiology

There are no epidemiological studies of the prevalence of vaginismus. [10] Estimates of how common the condition is varies. [11] A 2016 textbook estimated about 0.5% of women are affected, [2] while rates in Morocco and Sweden were estimated at 6%. [37]

Among those who attend clinics for sexual dysfunction, rates may be as high as 12 to 47%. [2] [38]

History

The term vaginismus was developed by James Marion Sims in 1866 to describe the “hymeneal hyperaethesia with a spasmodic contraction of the sphincter vaginae” that, under examination, “will produce such agony as to cause the patient to shriek out, complaining at the same time that the pain is that of thrusting a sharp knife into the sensitive part.” [39] At that time, the condition was understood to be biological in origin and medically treatable. During the 1930-1960s, under the influence of Freudian psychology, gynecologists increasingly understood vaginismus as psychological in origin. As psychology turned away from Freudian ideas and toward behaviorism, the condition was re-cast as a learned fear or anxiety response. [40]

The Netflix miniseries Unorthodox depicted a young woman suffering from extreme pain during intercourse, which she was told was due to vaginismus.

See also

Related Research Articles

Vulvodynia is a chronic pain condition that affects the vulvar area and occurs without an identifiable cause. Symptoms typically include a feeling of burning or irritation. It has been established by the ISSVD that for the diagnosis to be made symptoms must last at least three months.

<span class="mw-page-title-main">Urinary incontinence</span> Uncontrolled leakage of urine

Urinary incontinence (UI), also known as involuntary urination, is any uncontrolled leakage of urine. It is a common and distressing problem, which may have a large impact on quality of life. It has been identified as an important issue in geriatric health care. The term enuresis is often used to refer to urinary incontinence primarily in children, such as nocturnal enuresis. UI is an example of a stigmatized medical condition, which creates barriers to successful management and makes the problem worse. People may be too embarrassed to seek medical help, and attempt to self-manage the symptom in secrecy from others.

Anorgasmia is a type of sexual dysfunction in which a person cannot achieve orgasm despite adequate stimulation. Anorgasmia is far more common in females than in males and is especially rare in younger men. The problem is greater in women who are post-menopausal. In males, it is most closely associated with delayed ejaculation. Anorgasmia can often cause sexual frustration.

Dyspareunia is painful sexual intercourse due to medical or psychological causes. The term dyspareunia covers both female dyspareunia and male dyspareunia, but many discussions that use the term without further specification concern the female type, which is more common than the male type. In females, the pain can primarily be on the external surface of the genitalia, or deeper in the pelvis upon deep pressure against the cervix. Medically, dyspareunia is a pelvic floor dysfunction and is frequently underdiagnosed. It can affect a small portion of the vulva or vagina or be felt all over the surface. Understanding the duration, location, and nature of the pain is important in identifying the causes of the pain.

Persistent genital arousal disorder (PGAD), originally called persistent sexual arousal syndrome (PSAS), is spontaneous, persistent, unwanted and uncontrollable genital arousal in the absence of sexual stimulation or sexual desire, and is typically not relieved by orgasm. Instead, multiple orgasms over hours or days may be required for relief.

Sexual dysfunction is difficulty experienced by an individual or partners during any stage of normal sexual activity, including physical pleasure, desire, preference, arousal, or orgasm. The World Health Organization defines sexual dysfunction as a "person's inability to participate in a sexual relationship as they would wish". This definition is broad and is subject to many interpretations. A diagnosis of sexual dysfunction under the DSM-5 requires a person to feel extreme distress and interpersonal strain for a minimum of six months. Sexual dysfunction can have a profound impact on an individual's perceived quality of sexual life. The term sexual disorder may not only refer to physical sexual dysfunction, but to paraphilias as well; this is sometimes termed disorder of sexual preference.

<span class="mw-page-title-main">Pelvic floor dysfunction</span> Medical condition

Pelvic floor dysfunction is a term used for a variety of disorders that occur when pelvic floor muscles and ligaments are impaired. The condition affects up to 50 percent of women who have given birth. Although this condition predominantly affects women, up to 16 percent of men are affected as well. Symptoms can include pelvic pain, pressure, pain during sex, urinary incontinence (UI), overactive bladder, bowel incontinence, incomplete emptying of feces, constipation, myofascial pelvic pain and pelvic organ prolapse. When pelvic organ prolapse occurs, there may be visible organ protrusion or a lump felt in the vagina or anus. Research carried out in the UK has shown that symptoms can restrict everyday life for women. However, many people found it difficult to talk about it and to seek care, as they experienced embarrassment and stigma.

Sexual medicine or psychosexual medicine as defined by Masters and Johnsons in their classic Textbook of Sexual Medicine, is "that branch of medicine that focuses on the evaluation and treatment of sexual disorders, which have a high prevalence rate." Examples of disorders treated with sexual medicine are erectile dysfunction, hypogonadism, and prostate cancer. Sexual medicine often uses a multidisciplinary approach involving physicians, mental health professionals, social workers, and sex therapists. Sexual medicine physicians often approach treatment with medicine and surgery, while sex therapists often focus on behavioral treatments.

Vulvar vestibulitis syndrome (VVS), vestibulodynia, or simply vulvar vestibulitis, is vulvodynia localized to the vulvar vestibule. It tends to be associated with a highly localized "burning" or "cutting" type of pain. Until recently, "vulvar vestibulitis" was the term used for localized vulvar pain: the suffix "-itis" would normally imply inflammation, but in fact there is little evidence to support an inflammatory process in the condition. "Vestibulodynia" is the term now recognized by the International Society for the Study of Vulvovaginal Disease.

<span class="mw-page-title-main">Vaginal dilator</span> Medical instrument used to stretch the vagina

A vaginal dilator is an instrument used to gently stretch the vagina. They are used when the vagina has become narrowed, such as after brachytherapy for gynecologic cancers, and as therapy for vaginismus and other forms of dyspareunia.

Vaginal contractions are contractions of the pelvic muscles surrounding the vagina, especially the pubococcygeus muscle. Vaginal contractions are generally an involuntary muscular response to orgasm. Though usually an involuntary response, some women can control the muscles of the vagina to perform vaginal contractions at will. Vaginal contractions enhance the sexual experience and pleasure for both parties during sexual intercourse.

A vaginal disease is a pathological condition that affects part or all of the vagina.

Yitzchak M. "Irv" Binik is an American-Canadian psychologist whose main research interest is human sexuality, specifically sexual pain.

Female genital disease is a disorder of the structure or function of the female reproductive system that has a known cause and a distinctive group of symptoms, signs, or anatomical changes. The female reproductive system consists of the ovaries, fallopian tubes, uterus, vagina, and vulva. Female genital diseases can be classified by affected location or by type of disease, such as malformation, inflammation, or infection.

Sex after pregnancy is often delayed for several weeks or months, and may be difficult and painful for women. Painful intercourse is the most common sexual activity-related complication after childbirth. Since there are no guidelines on resuming sexual intercourse after childbirth, the postpartum patients are generally advised to resume sex when they feel comfortable to do so. Injury to the perineum or surgical cuts (episiotomy) to the vagina during childbirth can cause sexual dysfunction. Sexual activity in the postpartum period other than sexual intercourse is possible sooner, but some women experience a prolonged loss of sexual desire after giving birth, which may be associated with postnatal depression. Common issues that may last more than a year after birth are greater desire by the man than the woman, and a worsening of the woman's body image.

<span class="mw-page-title-main">Atrophic vaginitis</span> Medical condition

Atrophic vaginitis is inflammation of the vagina as a result of tissue thinning due to not enough estrogen. Symptoms may include pain with sex, vaginal itchiness or dryness, and an urge to urinate or burning with urination. It generally does not resolve without ongoing treatment. Complications may include urinary tract infections.

Vaginal stenosis is an abnormal condition in which the vagina becomes narrower and shorter due to the formation of fibrous tissue. Vaginal stenosis can contribute to sexual dysfunction, dyspareunia and make pelvic exams difficult and painful. The lining of the vagina may also be thinner and drier and contain scar tissue. This condition can result in pain during sexual intercourse or a pelvic exam. Vaginal stenosis is often caused by radiation therapy to the pelvis, an episiotomy, or other forms of surgical procedures. Chemotherapy can also increase the likelihood of developing vaginal stenosis. Vaginal stenosis can also result from genital reconstructive surgery in people with congenital adrenal hyperplasia.

<span class="mw-page-title-main">Hard flaccid syndrome</span> Medical condition

Hard flaccid syndrome (HFS), also known as hard flaccid (HF), is a chronic painful condition characterized by a semi-rigid penis at the flaccid state, a soft glans at the erect state (cold glans syndrome), pelvic pain, low libido, erectile dysfunction, erectile pain, pain on ejaculation, penile sensory changes (numbness or coldness), lower urinary tract symptoms, contraction of the pelvic floor muscles, and psychological distress. Other complaints include rectal and perineal discomfort, cold hands and feet, and a hollow or detached feeling inside the penile shaft. The majority of HFS patients are in their 20s–30s and symptoms significantly affect one's quality of life.

Pelvic floor physical therapy (PFPT) is a specialty area within physical therapy focusing on the rehabilitation of muscles in the pelvic floor after injury or dysfunction. It can be used to address issues such as muscle weakness or tightness post childbirth, dyspareunia, vaginismus, vulvodynia, constipation, fecal or urinary incontinence, pelvic organ prolapse, and sexual dysfunction. Licensed physical therapists with specialized pelvic floor physical therapy training address dysfunction in individuals across the gender and sex spectra, though PFPT is often associated with women's health for its heavy focus on addressing issues of pelvic trauma after childbirth.

References

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  3. 1 2 3 4 5 6 "Vaginismus". Merck Manuals Professional Edition. April 2013. Archived from the original on 18 January 2021. Retrieved 15 October 2018.
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  16. ↑ 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. S2CID   22249757.
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  39. ↑ Sims, James Marion (1866). Clinical notes on uterine surgery: with special reference to the management of the sterile condition. New York: William Wood & Co. pp. 315, 318.
  40. ↑ Srajer, Hannah (2023). "Imperfect Intercourse: Sexual Disability, Sexual Deviance, and the History of Vaginal Pain in the Twentieth-Century United States". Journal of American History. 109 (4): 782–803. doi:10.1093/jahist/jaad001 . Retrieved 29 March 2024.

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