Inability to Experience Penetrative Vaginal Intercourse (formerly Vaginismus/Pelvic floor dysfunction)

Introduction

Vaginismus has been a problem child for over 150 years. Gynecologist Marion Sims in 1862 spoke in an address to the Obstetrical Society of London, describing what he called vaginismus as “involuntary spasmodic closure of the mouth of the vagina, attended with such excessive supersensitiveness as to form a complete barrier to coition.”1

After Sims’ description, the medical world expended great effort to confirm the hypertonic, spasmotic muscle state of vaginismus, and to consider, without supporting evidence, this as a largely psychosomatic diagnosis. For years afterward, a struggle occurred to understand what was pain with sex (dyspareunia) or what was sexual pain (“vaginismus”). Early findings indicated that some women with dyspareunia also had pain with nonsexual types of mechanical stimulation of the vulvar region, such as tampon insertion or wearing tight clothing. In addition, these women failed to exhibit more psychosexual problems than women without dyspareunia, other than distress about their pain.2 Subsequent research confirmed that it was not vaginal spasms or pain measures which distinguished women with vaginismus from those with dyspareunia. Women with vaginismus did, however, display higher muscle tonicity, lower muscle strength, and significantly greater distress and avoidance behavior during pelvic examinations.3 And finally, long expected findings of fear and avoidance behaviors appeared to be the primary distinguishing features.4

Evolution of “Sexual Pain Disorders”

The earliest documented female sexual dysfunction is painful intercourse. Its first mention was in a set of scrolls, the Ramesseum Medical Papyrus IV,  dating approximately to the end of the eighteenth century.5  This ancient Egyptian record identified the pain in the vulva; the relationship to sexual intercourse was explicit. Approximately 4,000 years later, the emphasis on sexual interference persisted as gynecology and psychiatry/psychology evolved over the past century. Starting in the 1930s, dyspareunia was the term used to refer to painful intercourse; the term translates from ancient Greek as “difficult mating” and was first coined in 1874.6  Although Sims had used the term “vaginismus” in the 1860s, its symptoms had been described as early as the 1500s with a pointed reference to its interference with penetration.7 

Barriers to research may have included a presumed low prevalence of the condition, the challenge of performing vaginal examinations in this population, and concern that examination itself might bring further emotional injury.  Small sample sizes, varying recruitment methods, idiosyncratic methodologies, and the lack of independent replication of studies have blocked progress. Probably, the greatest barrier in nosology and classification has been the definition of what vaginismus is: how it is defined. Figuring out the role of “vaginal spasm vs pelvic floor dysfunction” unleashes myriad questions. What is muscle spasm? What is hypertonicity? Is pain experienced? What kind? How does one differentiate dyspareunia from vulvar pain? Is vaginismus sexual pain? What about abuse?  Finally, a critical element: is fear a discriminating factor?

Challenges of classification

The term dyspareunia appeared in the DSM in the second edition of the manual under “psychophysiological genitourinary disorders,” invoking causal emotional factors.8 It was the DSM-III that grouped together sexual function difficulties under “psychosexual dysfunctions.”9 Then, there were further changes in the DSM-III-R to “sexual dysfunctions,” under which were subsumed the “sexual pain disorders”—dyspareunia and vaginismus. 10

DSM-IV continued the classification11 and its later text revision (DSM-IV-TR).12 These publications initiated an ongoing dispute that questioned whether women were well or ill-served by the addition of their sexual difficulties in a manual of mental disorders. Proponents celebrated the long-awaited recognition of female sexual problems with the hope that addition of these details to the literature would lead to more effective treatments, such as those available for men (e.g., Viagra).13 Detractors warned against the medicalization of sexual difficulties likely to be based on relationships and on the societal marginalization of women’s sexuality. The extent to which desire, arousal, and orgasm problems in women should be attributed to medical, psychological, or relational/social factors promoted hot debate. The sexual pain disorders, however, were distinctive because of their involvement of a somatic experience: pain. Research efforts in the mid-1990s began to investigate the extent to which these disorders were actually connected to sexual intercourse, other than incidentally.

Given the historical focus on pain that occurred with penile-vaginal penetration, scant attention had been paid to the actual location of the pain, always the line of inquiry for other pain disorders. Research on the properties and mapping of the pain indicated that (a) it was largely located in very specific parts of the genital region, and (b) subtypes had unique pain profiles.14 These findings called into question the vague and undocumented psychogenic or psychosexual explanations of the past. This early research, as well as later findings, severed the causal connection between the sex and the pain.16

The change in research focus to the properties of the pain experienced during sexual penetration or any other vaginal entry also illuminated the lack of clarity in the difference between dyspareunia and vaginismus. Pain was associated with the former, and a blocking muscle spasm was purportedly associated with the latter. But what if the distinction was a mere behavioral one with vaginismus on the extreme end of penetration avoidance?17
During the development of of the DSM fifth edition, painful penetration was mentioned in association with a wide variety of vocabulary: dyspareunia, vaginismus, vulvar vestibulitis (VV), vulvodynia, and provoked vulvodynia/vestibulodynia (PVD). Some of the terms had psychological connections; others were based in medicine.  All such characterizations were symptom-based rather than etiology-based, as etiology remained undiscovered. Amid this confusion, there were also pressing questions: Did painful intercourse (regardless of the vocabulary used) even belong in the sexual dysfunctions section of the manual? Did the manual even need a category of sexual dysfunction? Or, should it be classified as a pain disorder that just happens to interfere with sex?18 Research studies on results of treatment were starting to support programs that borrowed heavily from the multidisciplinary pain management literature.19  If a medical condition was deemed responsible for the pain, should that be a diagnostic rule-out if the medical diagnosis was simply a synonym for entry dyspareunia (e.g. PVD) with no etiologic indicators?  
Disregarding arguments to remove dyspareunia in the sexual dysfunctions section of the DSM-5 and reclassify it as a pain disorder, the DSM authors left painful penetration in the manual, but with dramatic revisions. The new diagnostic category, Genito-Pelvic Pain/Penetration Disorder (GPPPD), clearly emphasizes the pain and rejects the sex. The term “sexual pain disorders” disappeared, and, while penetration is in the diagnostic term, it presents as a desexualized, mechanical description of a pain-inducing stimulus. The inability to experience penetrative vaginal intercourse (PVI), previously diagnosed as vaginismus, was subsumed under genito-pelvic pain penetration disorder (GPPPD) along with dyspareunia. The new, sole pain category encompasses both dyspareunia and vaginismus, based on the argument of insufficient empirical evidence warranting a clear distinction between the two.20
The International Classification of Diseases (ICD)-11 approved criteria for the diagnosis of Sexual Pain Penetration Disorder (SPPD), excluding dyspareunia and vulvodynia, which are listed in the genito-urinary chapter. SPPD is based on the presence of marked and persistent difficulties with penetration including that due to involuntary tightening or tautness of the pelvic floor muscles during attempted penetration, and marked and persistent fear about vulvovaginal or pelvic pain in anticipation of, and during attempts at, penetration. Besides these factors, SPPD can be further specified by indicating whether the vaginal penetration problems are associated with one or more of the following: psychological or behavioral, relationship, or cultural factors, or medical conditions and consequences of medical treatments.21 
While the multidimensional diagnosis of GPPPD is more compatible with scientific studies and clinical practice, some experts believe that the term does not capture the complexity of sexual difficulties in women who have never been able to experience intercourse (lifelong vaginismus), running the risk that the baby (lifelong vaginismus) is thrown out with the bathwater (sexual pain disorders).22 These experts suggest that GPPPD should be clearly qualified to indicate that “vaginal intercourse has never been possible,” and that more research is necessary to understand the nature and causes of the marked avoidance of intercourse noted in the majority of women with lifelong vaginismus.24 The DSM-5 definition presents vaginismus as “persistent difficulties to allow vaginal entry of a penis, a finger, and/or any object, despite the woman’s expressed sic wish to do so. There is variable involuntary pelvic muscle contraction, (phobic) avoidance, and anticipation/fear/experience of pain.” Structural or other physical abnormalities must be ruled out/addressed.25

With the renewal of psychophysiological research on the properties of the pain, there was also budding interest in vulvodynia within the gynecology world. Hypersensitivity of the vulva without evident pathology had been described as early as 1880. Attention to vulvar disorders increased in the 1970s with the establishment of the International Society for the Study of Vulvovaginal Disease (ISSVD) and it has greatly accelerated over the past three decades.26 The term vulvar vestibulitis (VV), a subset of vulvodynia associated with entry pain, became almost synonymous with dyspareunia. It was subsequently replaced by the term provoked vestibulodynia (PVD) to distinguish it from generalized vulvar pain that was spontaneous.27  The provocation referred to any mechanical stimulation of the vulva, including tampon insertion, finger insertion, pelvic examinations, and, most notably, penile–vaginal penetration. The criteria for GPPPD were established:

Criteria for GPPPD

  • Criterion A requires ongoing or recurrent difficulties with one or more of the following:
  1. vaginal penetration during intercourse,
  2. vulvovaginal or pelvic pain with vaginal penetration,
  3. anticipatory fear and anxiety about penetration,
  4. and/or pelvic floor muscle tensing during attempts.
  • Criterion B requires that the symptoms have persisted for a minimum of 6 months,
  • Criterion C specifies the existence of significant associated distress.
  • Criterion D requires that the problem cannot be better explained by a nonsexual mental disorder, severe relationship conflict, or the effects of a substance, medication, or another medical condition.

Eight years after the publication of the DSM-5, it is unclear how much this new diagnostic category has affected either clinical practice or research. The latest edition of Principles and Practice of Sex Therapy, the well known text for the treatment of sexual problems, maintains a chapter on vaginismus and introduces one on GPPPD.28 The World Health Organization has followed the lead of the American Psychiatric Association in some ways but not in others. The 11th edition of the International Statistical Classification of Diseases and Related Health Problems (ICD) continues to use the term sexual pain disorders, but it lists these separately from sexual dysfunctions.29 The new category of sexual pain-penetration disorder subsumes the symptoms of vaginismus and has similar criteria to GPPPD. The term dyspareunia is retained, although classified under diseases of the genitourinary system, and it refers to pain caused by an identifiable physical etiology. Vulvodynia is also classified under diseases of the genitourinary system, under pain related to the vulva, vagina, or pelvic floor. Thus, on the DSM side there is an etiology-agnostic collapse of different types of pain disorders that can make sex difficult. Although Criterion D specifies a rule-out for medical conditions, it is weakly worded and arguably does not apply to a condition such as provoked vestibulodynia (PVD), given that the latter remains largely a pain of unknown etiology. In contrast, on the ICD side, there is a likely ill-placed faith in our ability to identify physical determinants of the pain and to separate these from psychological and relational ones. In this case, dyspareunia and PVD (assumed in the ICD to be physical in origin) are rule-outs for a diagnosis of sexual pain-penetration disorder (assumed in the ICD to be primarily psychogenic).This  confusion surrounding the terminology and classification of painful intercourse is not unexpected, considering that we continue to struggle to understand its etiologies. Different disciplines rope in different potential causes and then attach their claim. In a sense, the confusion is far preferable to the past disregard of women who experience pain during sex, their stigmatization, and harmful attitudes,30 typified by the disturbing old adage “dyspareunia is better than no pareunia at all.” The confusion is a sign that there are multiple attempts at understanding painful intercourse from various perspectives.

Etiology

The construction of an etiology for any clinical syndrome with vast connections to psychological and relational well-being is arduous. The act of intercourse is significantly altered by GPPPD; this new classification transforms sexual intercourse into a stage, a mere location where pain puts on its disagreeable act. We already utilize and will continue to utilize a multidisciplinary assessment and treatment approach that takes aim at all of the pain correlates. As recommended by the Fourth International Consultation on Sexual Medicine, this requirement is no small undertaking.31 Disciplines likely implicated are sex therapy, physical therapy, medicine, and surgery in some cases. The aim is to harness the combined and coordinated power of all relevant approaches to address and alleviate the pain as we work on refining its causes.32

And, we are getting closer. After forty years of sometimes conflicting research, there is strong evidence that the vulva and vagina have unique inflammatory and immunological properties, representing pain from pro-inflammatory substances as the etiology of genital pain.33 Also, specialized immunological blockers (lipids produced endogenously within the body), hold promise as a vestibulodynia treatment by resolving inflammation without impairing the host defense system.34

An increase in nerve fiber density in the vulvar vestibule has been reported in cases of PVD, but this increase is more closely linked to inflammation than to pain.35 Hypertonicity and weakened muscle control are prominent features.36  The cross-over of studies that focus on vulvodynia as opposed to vaginismus (GPPPD) is a natural consequence of the difficulties in the diagnosis of each. It is helpful to take information on both conditions to better help patients.

The fact that vulvodynia tends to overlap with other chronic pain conditions–chronic fatigue syndrome, chronic migraine, chronic low-back pain, chronic tension headaches, fibromyalgia, endometriosis, interstitial cystitis, and temporomandibular disorders–leads to the inference that central mechanisms are involved.37 Increased sensitivity to various types of sensory stimulation at sites outside of the genital region has been found in women with vulvodynia.38 Magnetic resonance imaging (MRI) studies have further supported a central nervous system role in the pathophysiology of vulvodynia, with differences between afflicted women and controls in structures and functional connectivity, as well as increased gray matter volume in the basal ganglia, sensorimotor cortices, and hippocampus.39 Farmer’s work with dynamic network perspectives on chronic pain further suggests that its continued experience results in neuronal changes that reinforce the abnormal processing of pain.40 Other biomedical factors associated with PVD are recurrent yeast infections 41 and contraceptive use.42 Sex steroid hormones appear to affect nociception (detection, transmission, and modulation of noxious sensory information) and pain sensitivity in general and in women with PVD.43 It remains important, however, to consider other forms of GPPPD, such as the deep pain during intercourse experienced by many women with endometriosis,44 as well as the penetration discomfort associated with postmenopausal vulvovaginal atrophy.45

Medical factors

If known causes of of vulvovaginal pain have been eliminated, pain and burning related to sexual intercourse comprise the problem.

It is no small accomplishment that, as stated above, after forty years of sometimes conflicting research, there is strong evidence that the vulva and vagina have unique inflammatory and immunological properties.46 Also, specialized immunological blockers (lipids produced endogenously within the body), hold promise as a vestibulodynia treatment by resolving inflammation without impairing the host defense system.47 In August 2023 Harlow et al released a study strongly supporting the auto-immune hypothesis. They identified all women born in Sweden between 1973 and 1996 diagnosed with localized provoked vulvodynia (LPV) or vaginismus, matching each case to two women born in the same year with no vulvar pain and no ICD vulvar pain codes. As a proxy for immune dysfunction, they used Swedish Registry data to identify immunodeficiences, single organ and multi organ autoimmune deficiencies, allergy and atopy, and malignancies involving immune cells across the course. Women with vulvodynia, vaginismus,  or both were more likely to experience immune deficiencies, single organ or multi -organ immune conditions and allergy/atopy conditions compared to controls. With increasing numbers of unique immune related conditions, risk was greater. The research suggests that women with vulvodynia may have a more compromised immune system either at birth or at points across the life course than women with no vulvar pain history. These findings reinforce the hypothesis that chronic inflammation launches the hyperinnervation that causes the debilitating pain in women with vulvodynia.48

Pelvic floor hypertonicity

It is amazing that is has taken so long to find evidence to support the 500-year old definition of vaginismus as related to spasms of the muscles of the pelvic floor. Only recently has the evidence been found to support the involvement of high pelvic floor muscle (PFM) tone in conditions such as vulvodynia and chronic pelvic pain. Evidence points to both the active-neurogenic and the passive-viscoelastic components being implicated. These alterations may arise from changes in local morphologic or mechanical properties, or may be cortically driven, which would be targeted differently with the available treatment modalities.49  We have known for decades that evidence supports the idea that the pelvic floor sculpture, similar to other muscle groups, is indirectly innervated by the limbic system and thus highly reactive to emotional stimuli and states.50

Psychosocial and behavioral factors

Negative sexual attitudes and lack of sexual education

In the vaginismus literature, there is frequent mention of “negative sexual attitudes:” negativity about sex before marriage and sexuality in general, sexual guilt, plus sexual ignorance and lack of sexual education. Many studies have a number of methodological limitations, e.g. small sample size, lack of adequate statistical analysis, lack of control groups, no standardized measurement tools, and lack of a standardized protocol to diagnose vaginismus.51

A 2021 systematic review and meta-analysis found a significant relationship between a history of sexual and emotional abuse and the diagnosis of dyspareunia. No statistically significant difference was observed between physical abuse, vaginismus, and dyspareunia.52

Affective, cognitive, and behavioral factors

Abundant research efforts of the last 30 years have resulted in a rich literature pointing to the important role of cognitive, affective, and behavioral factors in the experience of painful sex. 53  Anxiety and depressive symptoms appear to be prominent affective correlates of painful sex, and they may predate the pain. In a case–control study, 54  researchers found that adult women with vulvodynia who had not suffered childhood abuse were six times more likely to report an antecedent mood disorder than healthy controls.55  A recent matched-cohort study suggests that it is the increased psychiatric comorbidity consequent to childhood sexual abuse that may be directly related to vulvar pain.57

Within a cognitive behavioral framework, the anxiety and depressive symptoms of women with GPPPD and their partners are expected to be linked to certain thought patterns, beliefs, and attributions. Not surprisingly, personal etiologic theories have been associated with the experience of pain and sexual function independent of actual gynecologic findings. In one early study with 100 women reporting painful intercourse, those with psychosocial causal attributions for the pain reported higher levels of pain and distress, more problems with sexual function, more reports of sexual assault in their past, and lower relationship adjustment than women whose causal attributions were of a physical nature.58 In a later study investigating pain attributions on the dimensions of internality (personal responsibility), globality (extent to which the problem affects their life), and stability (likelihood of persistence), pain reports appeared unrelated.59  However, attributions were related to lower relationship adjustment, higher distress, and a greater interference of the pain with sexual function. Anxiety and fear also orient women toward the pain. Since painful sex is a problem that affects both the woman experiencing it and her partner, the behavior of both has the potential to affect the pain experience.

Interpersonal factors

An accumulation of evidence points toward the importance of interpersonal dynamics in the experience of pain, sexual impairment, and relationship adjustment. Negative partner attributions have been linked to poorer dyadic adjustment and lower sexual satisfaction in male partners.60 The extent to which partners engage in pain catastrophizing has also been linked with the affected woman’s pain level.61

The strongest relational predictor of pain experience and the couple’s sexual and relationship adjustment, however, is partner responses to the pain problem. Over a number of studies, Rosen and colleagues have identified three types of responses that have strong associations with outcomes.62  These are negative responses characterized primarily by (a) hostility, (b) solicitous responses in which sympathy and attention are predominant, and (c) facilitative ones in which there is an affectionate encouragement of adaptive coping. In numerous studies, greater facilitative responses by the partner have been associated with less pain, less sexual impairment, and greater sexual and relationship satisfaction.63 The contrary has been found in relation to negative and solicitous responses.64  The latest study delved into the interdependence of both partners’ responses in the context of GPPPD.65 Perceived partner responsiveness, defined as verbal and nonverbal expressions of understanding, validation, and caring in affected women as well as their partners, was associated with greater sexual function in both members of a given couple, although there was no association with pain. Finally, sexual communication is also associated with experiences of GPPPD. Many pain-free couples have difficulty with sexual communication, but the situation is worse in couples with GPPPD.66 For many of them, sex has become a minefield; avoidance of the topic feels safer. Research shows, however, that it is not. Lower communication is associated with more negative sexual and relationship outcomes, while greater and more collaborative sexual communication has been associated with less pain and greater satisfaction.67

Fear-Avoidance Model

There is growing evidence that some, but not all, people with chronic musculoskeletal pain avoid a wide variety of stimuli, including those directly (e.g. physical activities) and indirectly (e.g. social activities) associated with pain. A primary cognitive‐behavioural framework is the Fear‐Avoidance Model, which posits that pain catastrophizing and fear of pain (including avoidance, cognitions and physiological reactivity) are key antecedents to, and drivers of, pain intensity and disability, in addition to pain‐related psychological distress. The model was developed over 20 years ago and has been frequently employed in relation to problems with Penetrative Vaginal Intercourse (PVI).68 Elke Reissing stated it well when she said: A negative trigger associated with PVI “will lead to catastrophizing and/or maladaptive thinking: e.g. ‘my vagina is too small for penetration.’ These thoughts lead to specific often irrational or exaggerated fears about PVI: (‘I will experience excruciating pain and hemorrhage.’) To cope with this thinking, a woman may choose to avoid all activity related to vaginal penetration, or be hypervigilant during attempts. While avoidance may yield temporary relief, it will negatively reinforce the vicious cycle of fear avoidance.”69. Therapy to break the cycle involves confrontation and disconfirmation of the fears and expectations followed by focus on decreasing avoidance of feared stimuli.70 As previously mentioned, Lahai et al. reported that fear, as measured by self report, physiological, and behavioral measures was significantly greater in women suffering from vaginismus as compared to women suffering from dyspareunia/PVD, all of whom displayed significantly more fear than controls.71 Research that followed showed that women suffering from vaginismus not only fear vaginal penetration situations, but also may have a general heightened fear/anxiety susceptibility. 72 It is not yet know why the augmented susceptibility becomes focused on vaginal penetration.

Partner factors

Compared with controls, partners in a painful sexual relationship experienced significantly poorer sexual communication, and less satisfaction with sex. They had significantly less expression of affection in their relationships and were more likely, compared with controls, to experience a discrepancy between their relationship and what their idea of a satisfying relationship might be. “Male vaginismus” problems have long been reported and are considered involved in the etiology. Mutual sexual and subjective personality structures are influential in subconscious mate selection and vaginismus serves different purposes on both sides. Male sexual dysfunction does not have a prognostic effect.73 Male sexual problems (premature ejaculation, erectile dysfunction, hypoactive sexual dysfunction, low sexual desire) are sometimes a result and sometimes a predisposing factor. Vaginismus may develop in response to a man’s sexual problems, or vaginismus may cause sexual problems in men.74  75

Between groups, almost 73% (n = 32/44) of pain partners described a negative relational impact of vulvar pain. No significant differences in sexual desire, orgasmic experience, sexual esteem, relationship contentedness and consensus, psychological health, or importance of sex were found between groups. This study, which represents one of a few controlled studies to investigate partner functioning in the setting of provoked vulvar pain, has implications for future research, and bolsters the inclusion of partners in treatment.76 A reliable estimation of the prevalence of women’s inability to experience PVI is precluded by changing nosology and classification issues. No epidemiologically sound incidence or prevalence are available.77 Referral rates to clinics and other sources range from 5-17%.78. Higher prevalence rates have been reported in more conservative cultures where vaginismus has been reported as one of the most frequent causes for non-consummation of marriage and referral for “infertility.”79

Assessment and diagnosis

In the absence of an obvious single-pathway etiology, the assessment and treatment of GPPPD require an integrative and multidisciplinary approach. History, examination, and pain mapping are covered throughout the website and in Annotation K under diagnosis.The experts have made assessment clear: “Well! It differs for various people, and we can’t write a single structure for everyone. The most important story we have to listen to in the first sessions of the treatment process is the history of the patient’s vaginismus. Vaginismus treatment requires at least two or three hours of history.” 80

Thorough examination is equally essential. It may make sense to schedule the examination at another time. But, until an adequate examination can be performed, known causes of pain (see Table K-1 in Annotation K), vulvodynia, and vaginismus or pelvic floor dysfunction may be suspected but not confirmed.

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.  For example, a woman may give the history of pain on any attempt to have intercourse with burning pain and the sense of obstruction. Scarring lichen sclerosus may have narrowed the introitus causing pain on attempted entry and tightening in natural self-protection, resulting in pelvic floor hypertonicity.

An exam under anesthesia is done only to rule out malignancy. With anesthesia,  there is no muscle hypertonicity, pain, or avoidance behavior, likely a “normal” examination. Imagine the frustration of a woman and her partner upon hearing that statement. To them, this is not good news, as it might be in the physician’s perception. It is nothing short of torment to be told that nothing wrong can be seen.

Evaluation of the pelvic floor is another essential, often overlooked. Teaching about the pelvic floor is just beginning in some gynecology programs. If you do not know how to do the exam, refer your patient to a physical therapist who does.

Ruling out known causes of vulvar genito-pelvic pain is another essential. See Anno K, Table K-1.

Initiation of 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.

Help with anxiety

Many patients with vaginismus have anxieties affecting other areas in their lives. The clinician should regard anti-anxiety medication as a tool to help a woman achieve the goals of having an examination, working with dilators, and moving on to intercourse. Examination attempts after pre-medication with diazepam (Valium) or lorazapam (Ativan) are not successful because the patients’ self-protective behaviors break through. Long-term citalopram (Celexa) starting at 10-20 mg orally a day and building up to 40 mg orally a day, serves well in patients who are not taking other psychiatric medications. The well-known sexual side effects of most SSRIs and SNRIs need to be taken into consideration while determining priorities in treatment. We encourage consultation with a psycho-pharmacologist for patients who are already on psychiatric medications or who have situations that are more complex. See sections below on other approaches.

Pelvic floor physical therapy

Physical therapy is a treatment recommended for GPPPD by the Fourth International Consultation on Sexual Medicine.81 The first physical therapy intervention tested with women with PVD in randomized trials comparing different treatment options, with positive results was EMG biofeedback.82 Since then, physical therapy for genito-pelvic pain has been expanded to include pelvic floor education, manual manipulations, transcutaneous electrical nerve stimulation, use of dilators, and home exercises, with results equal to or better than those of other commonly used interventions (lidocaine, cognitive behavioral therapy) in randomized studies.83 A review of the effectiveness of multimodal physical therapy for PVD found that improvement in pain was reported by 71–80% of women. Physical therapy has also been effective in older women experiencing intercourse pain related to postmenopausal changes.84 Again, the key is to find a physical therapist who specializes in pelvic floor dysfunction and is sensitive to the anxiety that may characterize the GPPPD patient.

Electromyography can directly assess PFM activity as 8t measures the electrical signals which propagate along muse fibers after depolarization of the motor nerve. There is however, no diagnostic cut-off to evaluate motor control patterns. Despite the limitations of EMG, it has provided some evidence to support the presence of overactivity of the PFMs in women with vulvar pain.85

Manometry is used to measure resting pressure or the extent of pressure rise during PFM contraction using a sensor located in the urethra, vagina, or rectum. Higher vaginal resting pressure has been found in women with vulvodynia compared to controls.86
Ultrasonography: Real time 3-dimensional/4-dimensional ultrasound has very good inter-rater and test/re-test reliability for assessing morphological parameters in the mid-sagittal (e.g. bladder neck and anorectal junction positioning and angles) and axial (e.g. levator hiatus dimension) planes.87 Ultrasound imaging provides information about morphometry and thus these findings are not direct measures of muscle tone but rather are an inferred appraisal of global tone, and cannot discriminate between active and passive components.88 Overall, the evidence derived from the available assessment tools/techniques concurs to support the involvement of high PFM tone in conditions such as vulvodynia and chronic pelvic pain. Evidence points to both the active-neurogenic and the passive-viscoelastic components being implicated. These alterations may arise from changes in local morphologic or mechanical properties, or may be cortically driven, which would be targeted differently with the available treatment modalities.89

Cognitive behavioral therapy specific to sexuality

Cognitive behavioral therapy is a psychotherapeutic approach to emotional, behavioral, or cognitive dysfunction through a goal-oriented, systematic process that focuses on alleviating symptoms and on the “here and now.” The foundation of cognitive behavioral therapy is the idea that changing maladaptive thinking will result in change in affect and in behavior.90 Therapists or computer-based programs use CBT techniques to help individuals challenge their thought patterns and beliefs and replace common cognitive errors such as over-generalizing, magnifying negatives, minimizing positives, and catastrophic thinking, with more realistic and effective thoughts, thus decreasing emotional distress and self-defeating behavior.91 The combination of CBT with sex therapy in the treatment of vaginismus has success rates from 75-100%,92 93 94 if the definition of success is the ability to have vaginal-penile penetration. Closely related treatment strategies include:95 CBT for GPPPD borrows heavily from the pain management literature in its emphasis on targeting the cognitions, emotions, and behaviors that are likely to be pain magnifiers. In addition, it focuses on sexual function and satisfaction as well as on personal well-being and relationship adjustment. As aforementioned, CBT performs well in comparison to medical treatments and physical therapy in terms of pain reduction. Its added value is its impact on important other aspects of women’s and couples’ lives. In that regard, it has generally outperformed other treatments. In one aforementioned randomized study, women who were assigned to group CBT reported improvements in intercourse pain at a 2.5-year follow-up equivalent to those who had a vestibulectomy.96 In another randomized clinical trial comparing individual CBT to supportive psychotherapy, women in the CBT arm had not only a greater reduction in pain, but also increased sexual function.97 Similarly, a study comparing group CBT to a corticosteroid cream regimen found that CBT led to greater improvements in pain but also in sexual function.  Finally, in a study comparing CBT to physical therapy, sexual function improvements were limited to the CBT group.98 In recent years, CBT for GPPPD has received both an enhancement and a challenge from the introduction of mindfulness as an intervention. From the viewpoint that the behavior change orientation of CBT might create pressure and expectations for women with genito-pelvic pain, some researchers are arguing for the acceptance-based approach embodied in mindfulness.99 Drawing from the literature on the application of mindfulness to other types of chronic pain, mindfulness has been proposed as an alternative for individuals who do not respond to CBT, at the very least. Indications are that it has added value and complements CBT. Veehof et al developed a mindfulness-based group CBT program (MCBT) and in a wait-list control study found improvements at 6 months in pain catastrophizing, hypervigilance, and sexual distress. Pain during intercourse remained unchanged.100 More recently, a partially randomized comparison of MCBT and CBT for the treatment of PVD found the two modalities to be equally effective in reducing pain with vaginal penetration, clinically assessed pain, and sex-related distress at 12 months post-treatment.101 Findings on the important role of relationships have led to the development of an intervention focusing on the couple dynamic in cases of PVD.102 This is the only intervention specifically designed for couples and based on the research on relevant dyadic factors, in addition to the other elements of CBT found to be effective. Although this was a small study with only 9 couples, outcomes were promising. Pre- to post-treatment, there was a significant decrease in pain and improvements in sexual functioning and sexual satisfaction in women. Their partners also reported increases in sexual satisfaction. Both the women and their partners reported increases in relationship satisfaction and decreases in pain catastrophizing. Seventy-five percent of couples reported moderate progress to complete resolution of PVD following treatment. Finally, in GPPPD cases where anxiety and fear of penetration pain predominate (vaginismus), in vivo exposure is an important component of the intervention arsenal. In a multi-site, wait-list randomized controlled trial with 70 women with lifelong vaginismus, intercourse was possible for 90% of women after an intervention that consisted of three 2-hour exposure sessions per week.103 The significant reduction in negative penetration beliefs and avoidance behaviors can reasonably be attributed to the exposure. In vivo exposure can be therapist guided in a hospital setting, or it can be home based.104

Desensitization with vaginal dilators (trainers)

In the case of vaginismus, once some acceptance of touch has been achieved, vaginal dilators, starting with the smallest, then gradually increasing in size over time, can be used for desensitization until patients are able to tolerate something going in and out of the vagina. Although dilators can, at times, be used to enlarge a vagina which has developed strictures, their name is misleading. For the majority of cases, a dilator is not used to enlarge, but rather to desensitize. Giving a woman a set of dilators without extensive education and demonstration of insertion, and without return demonstration from the woman, is not helpful, since the sight of the entire set is discouraging, and the thought of inserting them is frightening. Most of the time, she will not initiate use. Sometimes the term “vaginal trainer” is used since “dilator” inaccurately suggests that the vagina is too small. It is essential that both clinician and patient recognize that this treatment is a desensitization to fear of pain, not a progressive enlargement of the vagina.
Instruction in dilator use
Instruction can occur in the office or an experienced pelvic floor physical therapist can also work to achieve desensitization with vaginal dilators. Usually a single dilator is given at a time. The sight of a range of sizes may be frightening. Giving dilators without any hands-on instruction is inappropriate. After learning trust and relaxation techniques, the woman receives gradual exposure to vaginal touch, then penetration: her own fingers first, then the vaginal dilator, then, eventually, dilators inserted with a partner. We consider the use of xylocaine 2-5% ointment applied topically in the introitus prior to the use of the dilators essential to prevent the ongoing negative reinforcement of pain. (Xylocaine may cause some temporary stinging after application, the duration of which is up to 60 seconds. Then the skin will numb. It is important to warn the patient that this may happen.)

When the clinician feels that desensitization has progressed enough for a woman to be comfortable with the idea of inserting something into the vagina, progression to dilators can occur. The patient ideally begins with the smallest size that fits comfortably (with the prior use of xylocaine) into the introitus. We use rigid, white, Syracuse dilators ranging in size from extra small (1/2” or 13 mm) to large (1 3/8” or 35 mm). The local use of xylocaine with dilators is essential; insertion of a dilator that causes pain is a negative reinforcer and perpetuates the pain. Xylocaine provides both numbing and lubrication. As above, we warn patients that some women experience uncomfortable burning for up to 60 seconds after application of the medication to the mucosal tissue, until it begins to work to numb the skin. This is not harmful but it is disconcerting. Extra lubrication may be desired (Annotation P: Vaginal secretions, pH, microscopy, and cultures, section on Lubricants).

We dispense one dilator at a time with the idea of creating an achievable goal. The patient continues to practice with increasing sizes until she can insert a dilator the size of her partner’s penis (measured in the erect state with dental tape). She works at her own speed to the large Syracuse dilator. When she can, with xylocaine, use a standard dildo purchased from a sex shop (if she is willing to try that), she has achieved adequate desensitization for intercourse. Eventually, she will be able to discontinue use of the anesthetic, but it acts as a “security blanket” for a time. When she is ready to attempt vaginal penetration with her partner, she first uses Lidocaine (xylocaine) 2-5% ointment applied generously and left on for at least five to ten minutes, then wiped off gently and a lubricant applied prior to trying penetration. As she realizes that pain is not present, she can discontinue xylocaine use.  In some cases, women are very reluctant to touch themselves with their own fingers, although open to the idea of trying the dilators. Non-latex gloves can be provided to allow the patient to have a barrier between her own fingers and her vulva or vagina in applying the xylocaine. Otherwise, patients sometimes want to apply topical medications with paper products such as toilet paper. Once intromission is achieved, care must be taken to discuss conception or contraception. See section on Lubricants that are safe with condoms or safe for conception.

Treatment with medications

Topical medications including local anesthetics and topical nitroglycerin, have been tried with some success but the reports are case studies only. No controlled research has examined the use of systemic medications such as anxiolytics and tricyclic antidepressants in the treatment of GPPPT/ vaginismus. More recently, the neurotoxin and temporary muscle paralytic, Botulinum toxin (Botox®) has been used for both provoked vestibulodynia (PVD) and vaginismus with the theory that it may reduce peripheral hypersensitivity and pelvic floor hypersensitivity. A small placebo-controlled study used Botox to treat women with vaginismus whose symptoms failed to improve after treatment with biofeedback.105 Eight women in the active treatment group were all able to engage in comfortable intercourse following treatment and follow-up of ten months, as compared with five women who received saline injections only and failed to improve. The study is encouraging, but limited by lack of diagnostic criteria for vaginismus, independent determination of treatment outcome, and by the small sample size. In a comparative prospective observational study, 99 women were treated from September 2016 to August 2021 with Botulinum toxin diluted with preservative free saline (150U and 200 U). Injections were performed into, above, and below the right and left bulbospongiosus muscle and the lateral submucosal areas of the introits and perineal body using an insulin syringe. Patients were recalled after 2 weeks and the postoperative outcome was recorded using the preoperative questionnaire. Mean age of women was 30.2 years. Baseline and clinical characteristics were comparable between the 2 groups. Significant improvements were seen in the pain and anxiety scores of finger penetration, dilator use, intercourse, and cotton swab in individual groups. Comparisons between 150 u and 200 U of Botox were not statistically significant. Researchers concluded that low dose and high dose Botox can be used to treat vaginismus (SVP).106
In the past, peripheral tissue was targeted with topical anesthetics such as lidocaine, or the central nervous system with antidepressants known to be effective against pain. The research, however, has not supported the efficacy of these interventions.107 Surgical vestibulectomy, the excision of the part of the vestibular mucosa that supposedly contains the pathologic density of nerve fibers, is regarded as the most efficacious approach for cases of PVD, although it is also an invasive one. Typically performed under general anesthesia, it is a day surgery and considered minor. Initially, vestibulectomy appeared to outperform other treatments in the short term. In a retrospective chart review comparing vestibulectomy to conservative medical treatments such as tricyclic antidepressants, numbing agents, and topical estrogen, vestibulectomy resulted in lower pain ratings at 2 months, but there was no difference at 36 months.108 When a randomized controlled study comparing vestibulectomy to group cognitive behavioral sex therapy (CBT)/pain management and EMG biofeedback, reduction of pain with intercourse in the vestibulectomy group was twice that seen in the other groups at 6 months. But, in the 2.5-year follow-up, reduction of pain with intercourse was no different in the vestibulectomy group than in the CBT group.109  Sufficient data to answer definitively the question of whether vestibulectomy is superior in efficacy do not exist.   The surgical option for PVD appears to be effective and considerably more expeditious, but there is a persistent hesitancy in the literature toward this treatment option despite the research. Whether that hesitancy is driven by clinicians or their patients is not clear.
Botulinum toxin, causing temporary muscle paralysis has been used for years in the treatment of vaginismus with the hope of reducing the hypertonicity of the pelvic floor muscles. A 2012 systematic review and meta-analysis indicated that botulinum toxin appears to be an effective therapeutic option. The study, however did  not include controls.110   A 2022 study has also demonstrated equal success with 150 to 200 units of Botulinum toxin, but again, there were no controls in the investigation.111 Analysis of thirty-eight reports concluded that the toxin can be safely and tolerably injected into pelvic floor muscles in women; the authors also identified a critical need for high-quality clinical trials for this treatment.112

Sex therapy

Sex therapy is the application of professional and ethical skills in the field of psychotherapy to deal with the problems of sexual function in people. Sex therapy is a dynamic approach to very real human problems. It is based on the assumptions that sex is good, that relationships should be meaningful, and that interpersonal intimacy is a desirable goal. 113 Currently, sex therapy is a type of talk therapy and does not included hands-on evaluation or treatment. It can be complementary to physical therapy, which is very much hands on. Masters and Johnson114 developed straightforward sex therapy interventions for vaginismus that were considered highly effective. The woman and her partner received a demonstration of her vaginal spasm, then learned the use of graduated dilators inserted by the woman and, later, by her partner. Finally, she worked with vaginal containment of the dilator and eventually insertion of her partner’s penis. The plan included sexual education once spasm was alleviated, as well as treatment of any psychological factors (e.g., sexual trauma) contributing to the symptoms.

Combined approaches

A randomized, controlled, therapy outcome study for vaginismus investigated CBT with sexual education and use of vaginal dilators using the Masters and Johnson’s protocol. Treatment was by group therapy or by bibliotherapy (a therapy that uses an individual’s relationship to the content of books, poetry, and other written words as therapy). Post-treatment, 18% of participants reported successful attempted penile-vaginal intercourse versus none of the women in the control group. There was no significant difference in efficacy of group versus bibliotherapy treatment. After three month and 12 month follow-ups, 19% of the CBT sex therapy group and 18% in the bibliotherapy group had achieved intercourse.115 Since the success rates were low, and since the groups’ internal data analyses suggested that successful outcome was mediated by changes in fear of intercourse and avoidance behavior, the group re-conceptualized their view of vaginismus from a sexual disorder to a vaginal penetration phobia. Their next study emphasized fear of intercourse. Treatment included education regarding fear and avoidance along with three two-hour sessions of exposure to the stimuli feared during intromission. The study treatment succeeded in decreasing fear and negative beliefs regarding penetration. Nine out of ten women were able to engage in intercourse following treatment with persistence of success at follow-up in a year.116

Surgery

Vestibulectomy is used in the treatment of painful intercourse and provoked vulvodynia (PVD), covered in Annotation K (Link). It has not been studied for vaginismus. Surgery for vaginismus, with hymenectomy, was the original treatment proposed by Marion Sims117 to facilitate vaginal dilation. Hymenectomy, however, is not effective in treating vaginismus.118

Overall, the evidence derived from the available assessment tools/techniques concurs to support the involvement of high PFM tone in conditions such as vulvodynia and chronic pelvic pain. Evidence points to both the active-neurogenic and the passive-viscoelastic components being implicated. These alterations may arise from changes in local morphologic or mechanical properties, or may be cortically driven, which would be targeted differently with the available treatment modalities.119

Integration and Synchronicity

Although the different treatment approaches have been presented separately, the ideal strategy may be to engage in all relevant treatments concurrently.120 Because GPPPD is highly likely to have impacts on multiple aspects of sexual function, individual well-being, and relational adjustment, CBT-oriented sex therapy is recommended in all cases. Even if vestibulectomy is the treatment of choice for PVD, the surgery cannot target the individual and relational challenges that persistent pain may leave in its wake. Much research is needed to further investigate the effectiveness of multidisciplinary treatment programs, theoretically sound though they may be. To date, one study of a multidisciplinary treatment for PVD has evidenced significant improvements in pain and sexual distress over time.121 Finally, individuals who have had gender-affirming surgeries also need support to enhance sexual function with their new bodies. Although the vast majority of individuals who undergo these surgeries report significant increases in body satisfaction and decreases in gender dysphoria, new genitals and/or postsurgical pain can make sex difficult.122 Genital pain during sex in individuals with newly constructed genitals is likely to be improved by many of the interventions well known to sex therapists (e.g., vaginal dilatation, sensate focus). GPPPD in individuals who have undergone gender-affirming surgeries needs to be addressed with the same treatments that have shown efficacy with cisgender individuals, in addition to a recognition of the special challenges facing this population. It is imperative to focus on the role of race and ethnicity, as well, in cases of GPPPD. Cultural differences, discrimination, and health care disparities are likely to factor prominently. Within an American context, higher rates of vulvodynia have been found in Hispanic women, and lower rates have been found in black women.123  In a study of 1,786 women assessed for the onset of vulvodynia (provoked or unprovoked), the incidence rate among Hispanic women was twice that of white women, while the incidence among black women was half of that among white women.124 There is concern that we might be underestimating GPPPD in black women because they describe their symptoms differently. The “burning” pain descriptor has been a major determinant of a vulvodynia diagnosis, and yet in one study of 92 women with clinically confirmed PVD, 84% of white women used the burning descriptor compared to only 22% of black women.125 Racial/ethnic (and gender) differences in symptom presentation have been found across a broad array of disorders too numerous to list here. GPPPD may simply be another case in point. If diagnoses are based primarily on white symptom presentations, there is a good chance that black women are being underdiagnosed and undertreated. The already formidable barriers to diagnosis and treatment of GPPPD are likely multiplied in ethnically and racially diverse women. In addition to access issues, minority women must also contend with racialized stereotypes about pain and sexuality as well as a health care system composed of primarily white Eurocentric practitioners.126 Treatment outcome research will benefit from active recruitment of diverse samples and from clinical training to outline the complex intersectionality in which GPPPD plays out for women of color.

There is no difference between treatment methods in terms of success rates. But in women with a history of GPPPD/vaginismus in their relatives or in the presence of a partner who says that it is his or her fault, there is greater resistance to treatment.

CONCLUSION

The etiologic complexity of GPPPD, the slow-moving (if voluminous) research effort, and the clinical resistance to the adoption of evidence-based treatments require a high tolerance for ambiguity and a dogged determination to keep working at solving the GPPPD puzzle. Certainly, a lot of pieces have been laid down in the last 30 years. Full resolution of the problem can remain the ultimate aspiration, but, in its absence, clinical management of the pain is the natural focus. The future research effort centering on pain resolution or on its management, is going to require randomized clinical trials with a strong biopsychosocial design. The current dearth of such trials may be attributable to the fact that national funding agencies have not prioritized GPPPD as a concerning and highly prevalent women’s health problem. It is likely that GPPPD’s association with sex and gender continues to blur the focus on pain. We need to test the theoretically sound recommendations for integrated treatment. The fact that simultaneously delivered multidisciplinary treatment makes sense is insufficient; demonstrated clinical efficacy is requisite for evidence-based clinical practice. Additionally, for health care systems and insurance to accept the tall order of integrated treatment, there has to be hard evidence of successful outcomes. The GPPPD diagnosis is in a position of marked change if the current research on PVD bears fruit. After forty years of sometimes conflicting research, there is strong evidence that the vulva and vagina have unique inflammatory and immunological properties. Also, specialized immunological blockers (lipids produced endogenously within the body), hold promise as a vestibulodynia treatment by resolving inflammation without impairing the host defense system. Studies on brain functioning are clarifying understanding of pain in all spheres of human experience. If the inflammatory-immunology theory proves accurate we may have a hitherto unfettered grasp on the pathophysiology as well as treatment of vulvar and vaginal pain. In the meantime, clinicians of all types have a central role, ideally positioned to develop and coordinate multidisciplinary teams to treat as many relevant dimensions as possible. With the unprecedented research advancement in the past few years, we are in a position to witness steady and and incremental progress to, perhaps one day soon, complete the puzzle.

 

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