Although any painful condition may make a woman reluctant to be examined, most women are able to overcome reluctance for the sake of an answer regarding the symptoms that brought them in to the office. Pain related to a severely inflammatory vulvar or vaginal condition is usually immediately obvious to the clinician, who sees significant erythema, blistering, ulceration, or other skin damage that may point to a diagnosis with minimal touch. Each case must be taken on an individualized basis. Acute physical problems must be evaluated in some way, with the patient’s permission. If the patient is able to undress and sit on the exam table, and even abduct her legs in stirrups, and nothing is visibly wrong, fear can be considered, but it cannot be thought to be the whole problem.

In the office or exam room, prior to the actual examination, some women give a variety of signals that reveal fear of genital touch. They may give verbal clues: “I’m not very good at these exams. I have never been able to use a tampon. I hate that tool thing that they put in the vagina.” They may tell you straightforwardly that they have never been able to be examined. They may also demonstrate non-verbal behavior such as reluctance to remove underwear or to assume lithotomy position. Occasionally, they may have panic attacks that include hyperventilation, nausea and vomiting, diaphoresis, tachycardia and dystonic muscle contractions in their extremities. Even if the woman is able to undress and position herself in stirrups, she may be unable to abduct her legs for the exam. Years ago, Masters and Johnson noted that this reaction pattern may be elicited by the woman’s mere anticipation of the examiner’s physical approach rather than the actual act of touching.¹ Under these circumstances, clinicians are understandably reluctant to go forward with the examination.

Faced with the verbal and nonverbal behavior described above, a clinician needs to recognize that it is not possible to know, at this point, in terms of vulvovaginal symptoms, what is going on. In the absence of an obvious extremely uncomfortable skin disorder, this information is going to be known only when an adequate examination can be done, perhaps at this visit, possibly not for many visits. In the case of the patient with no visible problem, one, some, or all of the problems listed below may have created the situation the patient describes:

• anxiety or phobia (a phobia is an irrational and excessive fear of an object or situation)
• past adverse experience with gynecologic or urological examinations or procedures
• sexual trauma or abuse
• undiagnosed vulvovaginal disease
• vulvar pain from a known cause
• vulvodynia (pain from an unknown cause)
• pain related to pelvic floor dysfunction
• pelvic floor dysfunction as a learned response to pain

These problems may have been diagnosed as vaginismus. This poorly studied condition has been attributed to vaginal muscle spasm. Recently, this criterion has been called into question. Although many experts believe that pelvic floor dysfunction (also called high tone pelvic floor dysfunction, pelvic floor myalgia or shortening of the pelvic floor muscles) is a more accurate description, the term vaginismus persists.

The topic of vaginismus (Pelvic Floor Dysfunction/Vaginismus) is separately covered and includes the multiple pathways to intolerance of touch, examination, tampon use, or sexual intercourse.

Recommendations exist on how to approach the pelvic examination for women with a history of sexual trauma.²

Here, we discuss management of the first visit, including desensitization techniques that may facilitate examination, provided that the patient agrees.

Before proceeding to examination, any verbal or non-verbal clues necessitate a more extensive history and, at a minimum, discussion of the extent of the examination that will be acceptable to the woman. A contract to stop at any point must be in place if the exam is to go forward. At a maximum, postponement of the examination occurs until issues can be adequately addressed. To continue brings the risk of traumatizing the woman and complicating future therapy.^{3 4 5}

The source of the woman’s reaction will have to be determined through gentle questioning and as much examination as is possible at the first visit. For urgent situations, such as the possibility of malignancy, evaluation under anesthesia (EUA) may be necessary. In our experience, examination attempts after pre-medication with short-acting diazepam or lorazapam are not successful because the patients’ self-protective behaviors break through. Even conscious sedation can be defeated by this degree of fear. In addition, with sedation or anesthesia, no symptom mapping of pain can be done, and differentiation between anxiety/phobia, vulvar pain, vulvodynia, and vaginismus (possibly pelvic floor dysfunction) cannot be made. We do not, therefore, use EUA unless there is a critical need for it.

Partial inspection with no touch on the part of the clinician

Sometimes, partial inspection of the genitalia can be done if the patient can touch and separate the labia herself. Using inspection alone, if allowed by the patient, the clinician may be able to arrive at some beginning hypothesis about architectural structures and the status of the vulvar skin in terms of color, texture, and integrity. These patients can sometimes do their own vaginal swabs for pH testing, wet prep, KOH, and yeast culture, while they cannot tolerate genital touch by an “other.” Obtaining even this much information may give the clinician some preliminary data toward diagnosis, but work with desensitization will still need to go forward.

Desensitization with the purpose of allowing genital touch

Cognitive behavioural therapy uses desensitization techniques to help decrease many maladaptive behaviors. Desensitization is used to treat phobias and other behavioral problems involving anxiety. Patients are exposed, (in a safe place, with techniques of support), to anxiety-provoking situations that gradually become more challenging, in such a way that they are able to conquer their fear. The behavioral therapy approach of systematic desensitization to eliminate conditioned fear reaction is the core of treatment for severe fear of being touched and consequent pelvic floor dysfunction.

Desensitization and the building of strong rapport with the examiner may be initiated in the office setting at the first visit and followed by supplemental treatment, as indicated, from a behavioral health therapist, sex therapist, and pelvic floor physical therapist, as well as the patient’s partner. The effort on the part of caregivers is worth the investment of time. In a busy office setting, if this treatment cannot be offered, a referral is recommended. Insisting or forcing examination only negatively reinforces the patient’s anxiety and often results in further avoidance of exams. Clinicians often believe that kindness, gentleness and reassurance are enough to move forward in doing an exam. (Most women who come to the clinician’s office want to overcome their fear of pain and have the exam. The day they come in, they believe that that will be the day they can “do it.”) Health care providers need to be aware of patients’ verbal or non-verbal cues, and of their own position of authority over patients who may not protest during attempted exam but who may, nonetheless, be traumatized.

Initiating touch tolerance

Desensitization in these situations includes a progression of touch by the examiner that slowly builds trust and rapport with the patient. Every step of the exam is performed with the woman’s explicit permission. The first step starts with the examiner just sitting on the stool and turning on the light. If she is able, the woman lies supine on the table, her head comfortably elevated, with her knees bent; if possible, her feet are in the stirrups and she is able to slide down to the end of the table. After receiving permission from the patient (“I am going to put my hand on your knee. Is that all right?”), the examiner then initiates relaxation reinforcers such as single hip abduction and adduction, (“Now you are going to move your knee out to the side. Is that all right?”), with gradual progression to lithotomy position. To achieve single hip abduction and adduction, the examiner places a hand on one of the patient’s knees and requests that the she roll her knee out slowly, as far as is comfortable. The patient is asked to repeat this a few times until the examiner feels tension leave the leg muscle and notes that the movement can be done smoothly and comfortably. This maneuver helps to relax the psoas muscles and helps to establish a baseline for the clinician and the patient to work together as a team. The process is then repeated with the second leg and progresses, finally, to full lithotomy position.

Progressively, the examiner can then place hands gently but firmly on the abdomen and then the mons pubis, always proceeding with the patient’s permission and with inquiries directed at differentiation between psychological and emotional discomfort as opposed to feelings of physical pain. “How is this feeling? How is your anxiety level? Does this hurt or are you afraid that it is going to hurt?” A woman may start arching her back and closing her legs, hyperventilating, letting you know that she is not doing well, no matter what she says. Acknowledge this. “A lot of women having this exam become tearful, perspire, or feel that their heart is racing.”

Take a little break. Talk a little bit. Then have her slide down again and do the leg abductions to obtain lithotomy position. Proceed to the last place that was not stressful and stop there.

Relaxation techniques such as positive visualization (“See yourself going through the exam; relax your thighs and successfully complete the examination”) are useful strategies. Self-calming techniques are also helpful: (“Take some deep breaths. Do you need to take a break? Pretend that you are a cloth doll stuffed with sand which is trickling out. Your arms and legs are relaxing. Your abdomen is getting loose. Visualize being in your favorite, relaxing place where you feel calm and peaceful”). Show her how to talk herself down: “I’m in a safe place; I can breathe okay; I’m not having any pain; my examiner will stop if I tell her to; this is my anxiety. I am not having pain.”

When the patient is ready to proceed, the examiner progresses through graduated touch, always working from the outer to the inner structures. The examiner must be prepared to conclude any session where the patient’s anxiety is overwhelming or she requests to stop. Obviously, this process may not be completed at a single exam session; there may need to be a series of exam opportunities where the patient achieves mastery over anxiety and avoidance behaviors.

Pelvic floor “drop”

The purpose of teaching the pelvic floor drop maneuver is to promote the woman’s awareness of the difference between her own tight, pulled-in pelvic floor muscles and relaxed, soft, dropped muscles that allow physiological opening of the introitus.  The process facilitates lengthening of the pelvic floor muscles. A good way to understand tightening and relaxation of muscles is to think about what happens with flexion of the biceps—the triceps have to relax, or the flexion could not occur. The pelvic floor drop also utilizes a contraction of antagonistic muscles ( hip flexors, abductors, and external rotators, among others) to make the pelvic floor “turn off.”

“Pelvic floor drop” can often be taught, on the spot, in the office. The maneuver is not intended to be a repetitive pelvic floor exercise, but some women benefit from using the technique with intromission during intercourse. If this is successfully taught in the office setting, many women quickly understand the connection between pelvic floor hypertonicity and painful digital and speculum exams, with extrapolation to pain with vaginal penetration during sex. If, during the technique, there is no relaxation of the pelvic floor at all, the patient will not understand the association and could benefit from the expertise of the pelvic floor physical therapist who has many more treatment modalities at her fingertips than do most OB GYN or Internal Medicine clinicians.

Technique of pelvic floor “drop”

The easiest way to teach this maneuver in the exam room is to ask the patient (while she is on the examining table in lithotomy position) to tighten her pelvic floor muscles as if trying to avoid the passage of gas or urine and then to relax them, “dropping” the pelvic floor. There is no involvement of the abdominal muscles with this part of the maneuver. At the end of the “drop,” she uses the abdominal muscles very gently to push her anus out slightly as if bearing down to pass stool. The examiner explains the process and assures the patient that the exam will be discontinued if she is too uncomfortable, thus reinforcing trust and the teamwork aspects of care. The technique may serve as the beginning of a patient’s awareness that she can develop cognitive control over her own pelvic floor muscles. If the patient performs the maneuver correctly, the examiner will see (or feel if a finger is placed gently against the perineum or introitus) the vulva bulge out. If the woman is unable to drop her pelvic floor muscles, she often arches her back and tenses her buttocks, thighs, and abdominal muscles. Instruct her, “Allow your legs to open out because this helps relax your pelvic floor; keep your back flat on the table, your buttocks loose and try again, without using any other part of your body, to squeeze as if holding back gas or urine, then let the muscles relax; then simply push the rectum out.” We try these instructions once or twice.

If successful, the examiner then asks the patient to relax, and then to repeat the drop, holding the push for a count of six. The hold keeps the pelvic floor dropped to facilitate digital exam or insertion of a small pediatric speculum, if allowed by the patient. Some patients quickly learn this technique and are amazed at how much more physically comfortable they are with either digital exam or speculum insertion.

Vaginal dilators are an important part of the desensitization process, covered in detail in the section on Pelvic Floor Dysfunction/Vaginismus (Pelvic Floor Dysfunction/Vaginismus). Dilator use requires teaching, how-to demonstration to the patient, and return demonstration to the clinician. Without the experience in the office, often not possible at a first visit, a woman is unlikely to use a set of dilators. Dilators are not used to “dilate” or open the vagina. The smooth, rounded rods in graduated sizes are inserted by the woman in the privacy of her home, on a planned schedule, to enable her to feel safe and in control while learning what size object she can insert without pain, only as tolerated. Use of dilators for desensitization is most successful when accompanied by pelvic floor physical therapy.

We have found the techniques of pelvic floor physical therapy, in the hands of experienced, knowledgeable practitioners, to be invaluable, if properly timed in the process of diagnosis and treatment. It is always important to diagnose or rule out vulvovaginal disease such as lichen sclerosus before sending the patient for pelvic floor physical therapy. The therapy is difficult to initiate if the vulva is actively inflamed; once the epithelium is in control, the referral can be made. The right physical therapist is crucial; she should be someone who is well educated and experienced in pelvic floor dysfunction, as well as in incontinence, which is commonly taught to physical therapists. Compassion, patience, and commitment to the process of desensitization are equally important.

It is essential to explain to the patient what pelvic floor physical therapy is and how it works (Annotation L: The pelvic floor), since, for many patients, physical therapy is associated with injuries and sports trauma.

Anxiety about the gynecological exam and anxiety related to other life issues is common for women. Its existence needs to be addressed with care to avoid conveying the message that “this is all in your head.” This can be done at the end of the visit, noting that anxiety worsens all disease processes and that addressing this will be an important part of the plan.

When the timing is appropriate, anti-anxiety medication may be offered as a tool to help the patient achieve the goals of having an examination, having a Pap smear, working with dilators, and moving on to intercourse/vaginal penetration. Long-term citalopram starting at 10-20 mg orally a day and building up to 40 mg orally a day, has served us well in patients who are not taking other psychiatric medications. Once pelvic floor issues are resolved, the changes in libido often associated with SSRI’s can then be addressed. We encourage consultation with a psycho-pharmacologist for patients who are already on psychiatric medications or who have situations that are more complex. Pharmacological interventions and other anxiety-relieving approaches are discussed in Pelvic Floor Dysfunction/Vaginismus (Pelvic Floor Dysfunction/Vaginismus).

There will be patients who cannot touch themselves, do muscle work, or tolerate examiner touch or visualization at all. These patients may need referral for treatment of underlying anxiety disorders with anti-anxiolytics and psychotherapy, as well as other types of therapy. Ultimately, evaluation and treatment still require the desensitization techniques. If you feel comfortable, invite the woman to return and try again. Otherwise, you may want to develop your skills further, or make the appropriate referrals that may include gynecology, dermatology, mental health, physical therapy, and sex therapy. It is important for both clinician and patient to understand that overcoming the problems that have led to intolerance to touch may involve a commitment to a multi-specialty treatment program, a journey to achieve the goal of full examination. Developing this team will require networking with other clinicians who care about helping women with these problems.