Introduction

Since 1990, there has been some progress in vulvodynia and vestibulodynia research, but vaginismus is not a topic that has promoted much work. Reliable studies are largely from three countries: Canada, the Netherlands, and Scandinavia. Barriers to research may include 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. It is relevant and interesting that “vaginismus” is the only diagnosis in the Diagnostic and Statistical Manual of Mental Disorders III (DSM III)¹ that relies mainly on non-psychiatric clinicians for diagnosis. Behavioral health researchers are not able to do a diagnostic reliability study without the participation of a gynecologist and few gynecologists appear interested.²

Definitions of vaginismus

For over 150 years, the defining diagnostic characteristic of vaginismus has been vaginal muscle spasm. Gynecologist Marion Sims first used the term (although earlier allusions to the condition exist) in an 1862 address to the Obstetrical Society of London, describing vaginismus as “involuntary spasmodic closure of the mouth of the vagina, attended with such excessive supersensitiveness as to form a complete barrier to coition.”³ Years later, Masters and Johnson described “spastic” and “involuntary reflex” of the pelvic musculature…affecting a woman’s freedom of sexual response by severely, if not totally, impeding coital function.”⁴ The definition of vaginismus as muscle spasm interfering with sexual intercourse⁵ appeared in the DSM-III and has persisted through the DSM-IV-TR.⁶ Vaginismus has continued to be widely regarded as a psychosomatic problem associated with the criterion of vaginal spasm interfering with intercourse.⁷ While debate on diagnostic distinction between dyspareunia and vaginismus continues, a significant change was made in the fifth edition of the Diagnostic and Statistical Manual of Mental disorders. The diagnosis of Genito-Pelvic Pain/Penetration Disorder (GPPPD) was introduced to replace the hitherto separate diagnoses of Dyspareunia and Vaginismus, previously under the subcategory of sexual pain disorders.⁸

While the multidimensional diagnosis of GPPPD is more compatible with scientific research and clinical practice, some experts believe that the term fails to capture the complexity of sexual difficulties in women who have never been able to experience intercourse (lifelong vaginismus), and runs the risk that the baby (lifelong vaginismus) is thrown out with the bathwater (sexual pain disorders).⁹ These experts suggest that GPPPD should be further qualified to indicate that “vaginal intercourse has never been possible,” and that more research is necessary to understand the nature and causes of the substantive avoidance of intercourse noted in the majority of women with lifelong vaginismus.¹⁰ Others indicate that women with lifelong vaginismus can experience penetration after a few hours of treatment therapy exposure¹¹ and that the contention that lifelong vaginismus is fundamentally different from acquired vaginismus is not based on any systematic data.¹²

It is considered primary or lifelong vaginismus (LLV) in a woman who has never been able to tolerate intromission. Secondary or acquired vaginismus (AQV) occurs when penetration was possible in the past but is no longer possible. The DSM also suggests that some women may suffer from situational vaginismus where they may be able to tolerate gynecological examinations but not penile penetration (or vice versa).

More recent conceptualization has focused on fear and avoidance as a cause of vaginal spasm, looking at the problem from the other direction. This 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.¹³

Prevalence

There are no epidemiological studies examining the population prevalence of vaginismus¹⁴ The prevalence rates in clinical settings have been reported to range between 5-17%.¹⁵

Etiology of primary or life-long vaginismus (LLV)

Fear, Anxiety and Phobia

Fear, previously suggested as the crucial diagnostic variable that may distinguish vaginismus from dyspareunia, has only been recently evaluated by self-report, physiological, and behavioral measures. Fear was significantly greater in women suffering from vaginismus as compared to women suffering from dyspareunia/provoked vulvodynia, all of whom displayed more fear than controls.¹⁶ These data support and extend a study of 93 women with acquired vaginismus (AQV) and 75 women with lifelong vaginismus (LLV), showing that fear of pain because of previous painful experiences was universally endorsed as a primary cause for vaginal penetration problems.¹⁷ An earlier study,¹⁸had shown that women with LLV identified fear as being linked to what they had heard or read about pain or possible injury with intercourse. Fear of pain and fear of loss of control, then, leads women with vaginismus to avoid situations involving any vaginal entry: tampon insertion, vaginal examination, as well as intimacy that might lead to sexual intercourse/penetration.¹⁹

It is not known whether this avoidance is based on anxiety or response to pain, or both. It is known, however, that pain alone does not explain avoidance behavior, since women with dyspareunia (actual pain with penetration) do not show avoidance of penetration as much as women with vaginismus do.²⁰

Women with LLV may have a negative and phobic relationship with their own bodies and vulvas,²¹ reinforcing research findings of negative self-image and increased perceptions of “genital incompatibility” that are higher than in control groups.²² Expectations of severe pain with genital touch or sexual intimacy sometimes result in unconsummated relationships, even after years of marriage. The woman may finally present alone or with her partner, searching for help with painful or impossible intercourse or the desire to conceive.

Women with vaginismus may have clinically diagnosed co-morbid anxiety disorders (e.g. agoraphobia without panic disorder or obsessive-compulsive disorder), although depression rates in this group are not increased.²³

Basic science research has accumulated some evidence that the pelvic floor musculature, similar to all muscles, is indirectly innervated by the limbic system, leading to strong physiologic reactions to emotional states.^24 25 This fact may lead to an assumption of muscle spasm being related to fear.

Pain and vaginismus

Vaginismus has been traditionally regarded as a syndrome different from the pain of dyspareunia; this concept is represented in the DSM-IV-TR where vaginismus and dyspareunia are considered two mutually exclusive sexual pain disorders. Historically, Lamont first suggested in 1978 that vaginismus is painful for women²⁶ and the American College of Obstetrics and Gynecology (ACOG),²⁷ the International Association for the Study of Pain, and the World Health Organization do include pain with the definition of vaginismus.²⁸ However, by the time of publication of the DSM-IV-TR, no one had ever empirically demonstrated that vaginismus was characterized by pelvic muscle spasm, could be differentiated from dyspareunia, or was reliably diagnosable.²⁹ Since the DSM-IV-TR, a number of studies have shown that a large percentage of women with vaginismus experience pain with vaginal intromission,^{30 31 32 33 34} and that the pain of vaginismus is similar to the pain of provoked vulvodynia.^{35 36 37} Women suffering from vaginismus, like those suffering from dyspareunia/PVD, experience significantly greater genital pain during attempted vaginal penetration than controls.³⁸

The question of whether pain is a primary or secondary problem is still undetermined, but it results, nonetheless, in a global impact on women’s sexuality. (Vulvovaginal Pain and Sexuality.)

While it has also been proposed that sexual pain disorders be reclassified as pain disorders rather than as sexual dysfunctions, this change did not occur in the DSM-V.³⁹

Vaginismus and muscle spasm

While the defining diagnostic symptom of vaginismus in all current nosologies is vaginal muscle spasm that interferes with intercourse,^40 41 vaginal muscle spasm has never been reliably demonstrated. An operational definition of the term “muscle spasm” does not exist, and there has been a lack of consensus regarding which muscles are involved in vaginismus. ⁴² Studies identifying specific muscle groups as the source of spasm did not indicate the method used to arrive at these conclusions.⁴³

On the other hand, there is now evidence that pelvic floor muscle tension significantly distinguishes women suffering from vaginismus from those with dyspareunia/PVD.⁴⁴This finding is consistent with an earlier study using digital palpation to evaluate pelvic floor muscle tension.⁴⁵More recent work investigating the associations among pelvic floor dysfunction, sexual function, and demographic and clinical characteristics in a population of women initiating physical therapy evaluation and treatment for pelvic floor-related dysfunctions (urinary incontinence, pelvic organ prolapse, vulvodynia, vaginismus, and constipation) showed that sexual dysfunction appears to be significantly correlated with age and high pelvic floor muscle tone.⁴⁶

Genital trauma and sexual abuse

In the United States in 2007, there were 248,300 victims of rape, attempted rape, or sexual assault.⁴⁷ Fifteen percent of sexual assault and rape victims are under age 12.⁴⁸ It has been traditional to consider the experience of sexual and/or physical abuse as an important etiological factor in vaginismus. Five out of six studies, however, found no evidence that physical or sexual abuse is more prevalent in women with vaginismus.⁴⁹ In the sixth study, women with vaginismus were twice as likely to report a history of attempted sexual abuse or sexual abuse by touching.⁵⁰ In an epidemiological study of women with vulvovaginal pain, women had significant histories of physical abuse or fear of physical abuse, but not sexual abuse.⁵¹ It seems probable to us that trauma and sexual abuse are factors for some but not all women with vaginismus.

Women who have experienced genital trauma, or sexual or physical abuse may have received adequate behavioral health support and counseling (or personal resolution of issues) so as to move to as much closure as is possible for them, and to comfortable sexual function and toleration of pelvic examination. Others may not tolerate examination until effective behavioral health intervention is facilitated. A common defense mechanism for this trauma is incomplete memory and disassociation from the event, so that a woman may truthfully report no history of abuse. On the other hand, women may be reluctant to reveal a history of abuse for a variety of reasons, as exemplified by one of our patients who had reported her sexual abuse by a family member to her parents who did not believe her.

It is important to ask the woman who does not tolerate examination and who does not appear to have obvious explanations for her reticence, if this is her usual response and whether it is possible that someone has hurt her in the past. It may be necessary to explore this issue further as a relationship of trust develops between patient and clinician.

Undiagnosed vulvovaginal disorders

Many different organic factors can lead to vulvovaginal pain through a variety of pathways: congenital abnormality, acute or chronic inflammation, atrophy, loss of epithelial integrity, central nervous system sensitization, to name a few. See Table D-1 below.

Table D-1. Vulvovaginal Pain and Irritative Symptoms: Differential Diagnosis

Multiple factors and combinations of factors, although unproven by randomized, controlled trials, probably represent the explanation for most vulvovaginal pain, dyspareunia, and pelvic floor dysfunction in the form of vaginismus. One or myriad factors from Table D-1, ranging from poor sexual arousal with dryness to epithelial inflammation or infection, may trigger pain. The pain has consequences. Evidence mounts that women with provoked vulvodynia (PVD) present with pelvic floor muscle dysfunction characterized by increased pelvic floor muscle tone (hypertonicity) and increased muscle activity (hyperactivity) at rest, poor relaxation capacity following contraction, heightened contractile responses due to pain, and decreased distensibility of the tissues at the vaginal introitus. ^52 53 54 Psychosexual factors (shame, guilt, inadequacy) come into play.⁵⁵ Women attempt to be normal in function despite the pain. They have heard clinicians say that there is nothing wrong with them, (since vulvodynia includes pain without visible disease) and they feel they need to keep trying to be a good partner. Often, the end-result is the ongoing pain and irritative symptoms of the undiagnosed vulvovaginal disorder, pelvic floor dysfunction, and sexual dysfunction including fear of pain and sexual avoidance behavior.

Careful inspection, if allowed, is important to identify pathology so that structural or other physical abnormalities must be addressed.⁵⁶ Undiagnosed lichen sclerosus with introital restriction from synechial formation is always in the differential since this disease may have been present from childhood.

We do not have adequate answers for the questions that have arisen regarding pelvic floor dysfunction and/or muscle spasm as the cause of vaginismus. There is no agreement on whether the term spasm refers to an involuntary muscle cramp, a defensive mechanism, or hypertonicity of the pelvic floor.⁵⁷ Strong evidence-based studies do not exist. Existing studies show contradictory results. Three controlled EMG studies did not demonstrate a significant difference in ability to contract and relax the pelvic floor muscles in women with vaginismus compared to those without.^58 59 60 A fourth study directly investigated whether muscle spasm characterizes vaginismus. The results strongly suggest that vaginal muscle spasm does not characterize vaginismus and that different professionals diagnose spasm differently.⁶¹ Another study of 87 women showed that women with vaginismus demonstrated greater frequency of vaginal muscle spasm during a gynecological examination compared with healthy controls or women with dyspareunia from provoked localized vulvodynia, called vestibulodynia in the study. Only 28% of the vaginismus group had muscle spasm on examination, and only 24% reported muscle spasm with intercourse. ⁶²

Women with vaginismus do not tolerate the insertion of a finger, tampon, speculum, sex toy, or penis. Without treatment, it is hard to imagine that they would be able to comply with the protocols of these studies. In fact, in Reissing’s 2004 study, over half the women with vaginismus refused to insert the EMG sensor in one of the two testing sessions. There were, however consistent data from this study showing that the structured protocol of manual measurement of the pelvic floor musculature, performed by physical therapists, is reliable and can differentiate women with vaginismus from matched controls. ⁶³

Despite these ambiguities, pelvic floor dysfunction, recognized as increased muscle tone (hypertonicity, not spasm), and muscle weakness, has moved to a position of importance in the understanding of vulvovaginal pain disorders,^64 65 since there is no empirical evidence supporting the 500-year old definition of vaginismus as muscle spasm. Hopefully, studies of pelvic floor dysfunction will continue to provide the answers to the pathology of vaginismus and to replace the term entirely. (Annotation L: The pelvic floor)

Disgust

Women with LLV show a propensity for feeling disgust easily, particularly in response to sexual stimuli.⁶⁶ They have never been able to allow genital and/or sexual touch, and often have a fear or distaste for vaginal containment (penis in vagina).⁶⁷ Even visualization by self or others is avoided. Many express dislike of their genitals, with negative comments that the vulva is ugly or disgusting in appearance. They may be unable or reluctant to view their vulvas in a hand mirror.

It is important to recognize, however, that some women who enjoy sexual intercourse and tolerate a pelvic examination without difficulty also think that the vulva is ugly and do not want to look at it in a mirror. “Ugh! How do you stand doing this?” is a frequently heard remark in our practice as women position themselves for examination.

Sexual knowledge

Women report that education during pelvic examination, (in which a clinician explains normal anatomy and function throughout the examination), is of benefit: moderately helpful for those with AQV, and very helpful for women with LLV. ⁶⁸

An older study of the etiology of vaginismus, however, does not support thinking that women with vaginismus hold negative sexual attitudes and/or have lower levels of sexual knowledge.⁶⁹

Cultural and religious beliefs

There is evidence that women with strict adherence to certain conservative values show less tolerance to a range of sexual behaviors.⁷⁰ High scores on conservative values tests, that is, the presence of rigid moral principles, limiting intimate actions and impulses, or concern with the idea of transgression (wrong doing), may play a negative role in sexual behavior. Moreover, if these values are part of a woman’s core beliefs and perspective from an early age (e.g., through education, cultural rules, or religion) they may ultimately elicit defensive associations and avoidance behavior in a sexual context.^71 72 It appears that it is the collective effect of high conservative values with low liberal values, rather than high conservative values alone, that characterizes some women with vaginismus. ⁷³

Relationship issues for a woman with vaginismus

Many women with vaginismus are not in a relationship and attribute this to the condition.⁷⁴ Some couples may enjoy a non-penetrative sexual relationship, although loss of interest and arousal issues are more common in this group.⁷⁵ Partners of women with vaginismus have been reported to suffer from their own sexual dysfunction, as well as to display passive and unassertive personalities, but controlled empirical findings with standardized personality evaluation instruments have not supported this view.⁷⁶

One retrospective study showed that male partners of women with vaginismus were no different from normal controls in personality characteristics and sexual problems.⁷⁷ But, partner collusion in maintaining vaginismus⁷⁸ has been reported in couples with pain disorders;⁷⁹ ironically, a sensitive and gentle partner may maintain vaginismus by accepting the avoidance of sexual activity. The suggestion is that the woman with vaginismus chooses her partner because he is passive and unassertive.⁸⁰

 Etiology of secondary or acquired vaginismus (AQV)

Many women who have experienced marked or severe intromission dyspareunia, painful gynecologic examinations, painful urologic procedures, or pain with attempts at tampon insertion, may rapidly develop AQV even after having been without problems previous to the negative experience. Fear of pain because of previous painful experiences is universally and strongly endorsed as a cause for vaginal penetration problems.⁸¹ This condition causes muscle hypertonicity and consequent intromission pain. Sometimes the degree of hypertonicity may be pronounced enough to prevent introduction of even a q-tip into the vaginal orifice. In our experience, vaginismus occurs on a continuum from ability to allow entrance of a swab or permit a limited digital exam despite severe perceived pain, to total inability to allow anything to enter the vagina.

While vaginismus may be solely an anxiety disorder, physical or neurogenic genital pain and AQV are closely related co-morbidities.⁸² We know from Glazer’s work (Annotation L: The pelvic floor) that women with vulvodynia exhibit abnormalities in the pelvic floor contractile amplitudes of tonic, phasic, and endurance contractions as compared with non-affected women,⁸³ and that rehabilitation of the pelvic floor muscles via surface electromyography has been successful in reducing pain and increasing sexual interest, pleasure, and activity.⁸⁴ Whether the reason is anxiety and phobia, physical pain of known cause, or pain of unknown cause, the instinct to pull back or tighten up is a self- protective mechanism.

Some experts believe that vaginismus always involves hypertonicity of the pelvic floor muscles; the hypertonicity then causes its own sensations of pain.⁸⁵ It is likely that tension begins as a protective, guarding response to pain at the vestibule. With time, this response results in an increase in the resting tone of the muscles. The protective response and increased tone result in an increasing pressure at the level of the vestibule during intercourse. This further increases pain that, in turn, perpetuates and increases the protective guarding response. Pelvic floor hypertonicity, thus, is a potent maintaining and exacerbating factor in the cycle of pain with provoked vulvodynia (vulvar vestibulitis).⁸⁶

In summary, it appears that the inability to insert anything into the vagina may be:

• anxiety and fear-related with pelvic floor dysfunction,
• pain (multiple etiologies)-related with pelvic floor dysfunction
• both anxiety and pain-related

All three of these conditions respond to physical therapy to the pelvic floor along with other modalities to manage any known cause of pain, the pain itself, as well as psychosexual support and treatment of any existing depression. Hopefully, continuing accumulation of evidence will soon allow replacement of the term “vaginismus” with a term that encompasses all the elements involved. One expert has already suggested genito-pelvic pain/penetration disorder. ⁸⁷

Diagnosis of vaginismus

While Masters and Johnson indicated that a pelvic examination is necessary, diagnosis of vaginismus has often been based on women’s self-reports of difficulty achieving vaginal penile penetration and avoidance of pelvic examination, or conclusions from sex therapists without examination.

The Algorithm for diagnosis of vulvovaginal disorders

Following the steps of the algorithm from history through examination allows a clinician to evaluate all the parameters involved in what is called vaginismus:

• History suggestive of anxiety, phobia, and psychosexual dysfunction.
• Known causes of vulvovaginal symptoms such as structural abnormalities, inflammatory and/or scarring conditions of the vulva.
• Symptom mapping and classification of painful areas on the vulva or in the vestibule by Q-tip testing. (Annotation I, Pain mapping). Mapping identifies sources of the natural defensive response of tightening when pain is elicited (or expected) in these areas. If there is pain without a known cause on Q-tip touch, vulvodynia is the diagnosis.
• Digital evaluation of the pelvic floor muscles (Annotation L: The pelvic floor). Entry may not be possible or may demonstrate hypertonicity with tight, painful levators.
• Speculum examination, wet mount and cultures, and bimanual for information about a vaginal or pelvic cause.

Confirmation comes from a pelvic floor physical therapist who does EMG testing to show that muscles are hypertonic and weak. All of these conditions may be present in the same patient.

History is covered in Annotation B. Besides the vulvovaginal and medical history, some essential psychosexual domains are:

The Sexual History

What is her sexual orientation?

Is she in a relationship? Marital status/length of time in current relationship/number of partners

Is she sexually active? Has she ever been sexually active? Obtain specifics of sexual activity: vaginal or anal intercourse, oral sex receiving/giving, self stimulation, vibrator, sex toys.

Is she able to be touched, to arouse and lubricate?

Is vaginal penetration possible? Has it ever been possible? Is she able to use a tampon or insert a finger?

Is she able to climax?

Is she satisfied with sexual activity? With frequency of sex?

Is there a history of any kind of abuse, accidents, trauma? Did she tell anyone about it? Did she obtain counseling? How does she feel about it now?

What is the current relationship like?

The Psychological History:

What is her stress level, degree of support from others, including partner

What is her satisfaction with life over all?

What is the amount of worry in general that she has?

What is the amount of worry related to vulvar problem?

Did she experience depression prior to vulvar problem ?

Does she have depression after having the vulvar problem?

What are her coping mechanisms?

Does she have any psychiatric illness (diagnosed or perceived by clinician)?

A clear history of the pain

Does the touch of foreplay hurt?

If penetration is not possible, how much of the time does this happen? How long has this been a problem?

Is penetration painful? Is that the only time there is pain?

A clear picture of the fear and avoidance behavior.

How much anxiety does she feel about the idea of penetration?

Has she ever had a traumatic sexual experience? What kind of help has she received for this?

Until an adequate examination can be performed, known causes of pain, vulvodynia, and vaginismus or pelvic floor dysfunction may be suspected but not confirmed. 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.

Discussion of intolerance of the genital examination in Annotation D (Annotation D) includes some simple anxiety desensitization techniques that may facilitate examination. Desensitization is also discussed below.

Treatment approaches

Addressing the patient holistically

It is likely that treatment success varies with each individual based on a complex interplay of factors, all needing to be addressed if treatment is to be successful. Even if we had the magic bullet to eliminate an identifiable etiologic factor, there is still layer after layer of physiologic, sexual, relationship, and cognitive emotional response that maintains the pain and contributes to a woman’s distress. A recent literature review emphasized the work needing to be done to understand the complex and multifaceted issues that exist with genital sexual pain; it did not provide clear evidence in support of the superiority of any treatment.⁸⁸ Another examination of the literature showed that treatment effectiveness was equivalent regardless of presumed medical or psychiatric etiology,  indicating that presumed etiology may not be helpful in selecting treatment.⁸⁹

Another essential consideration is the goal of treatment. Successful penetration without pain is usually an initial focus; associated enjoyment and increase in pleasure defines treatment success for many, although conception is the only goal for some. One study suggests that, to date, it does not appear that increase in pleasure has been an accompanying factor with successful vaginal penetration. ⁹⁰

Treatment is therefore tailored to the woman’s history and personal goals. It first includes education about the normal vulva and vagina, normal sexual response, then education about her set of factors: any vulvovaginal pathology, pelvic floor muscle pathology, the role of psychological factors, such as fear and anxiety, and the partner/relationship factor, to help her conceptualize her pain problem within all these influences.

The treatment options outlined have proved helpful in our practice whether vaginismus has been lifelong or acquired.

Uni-modal treatment interventions, for example, vestibulectomy or sex therapy only, may be less likely to result in complete pain relief if the conditioned, protective response of muscle guarding, hypertonicity, and lack of muscle control are not addressed.⁹¹

The holistic treatment plan includes elimination or alteration of most of the factors, both pain-related and non-pain-related. Any known cause of the pain leading to vaginismus needs to be treated; then the pain itself needs treatment. (Annotation K: Vulvar pain and provoked or unprovoked vulvodynia). Referral for psychological support is advised for suspected anxiety and phobia, genital trauma or sexual abuse, and other behavioral health or relationship problems. Sexual therapy referral may also be necessary to help address disgust, religious, and cultural issues.

Examination

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 for the purpose of allowing genital touch

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 threatening, 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 vaginismus.

Desensitization and the building of strong rapport with the examiner may be initiated in the office setting and with supplemental aid 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 means of 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.”) Caregivers 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.

Anxiety

Many patients with vaginismus have anxieties affecting other areas in their lives. In our practice, we think of anti-anxiety medication 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. In our experience, 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, has served us well in patients who are not taking other psychiatric medications. 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 pharmacologic and therapeutic approaches.

Pelvic floor “drop”

A useful technique to facilitate either digital or speculum insertion is pelvic floor “drop.” This is a short-cut method of achieving pelvic floor relaxation, which can 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. The idea here is for a woman to relax the pelvic floor, and learn the degree that pelvic floor relaxation facilitates digital exam and speculum introduction, as well as, eventually, vaginal penetration.

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 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 beginnings 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, 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 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.

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 can occur in the office or an experienced pelvic floor physical therapist can also work to achieve desensitization with vaginal dilators.

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.)

Instruction in dilator use

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 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. Once intromission is achieved, care must be taken to discuss contraception or conception. 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 Lidocaine. Otherwise, patients sometimes want to apply topical medications with paper products such as toilet paper.

Pelvic floor physiotherapy

The woman who cannot be touched at all for exam will not be ready, in most cases, for referral to a pelvic floor physical therapist, unless the physical therapist is well educated about and and experienced in treating women with vaginismus and vulvar pain conditions. She needs to be very compassionate, very patient, and have a lot of time to devote to the process of desensitization described above. It is always important to diagnose or rule out vulvovaginal disease before sending the patient for pelvic floor physical therapy. We have found the techniques of pelvic floor PT, in the hands of experienced, knowledgeable practitioners, to be invaluable, if properly timed in the process of diagnosis and treatment.

See Annotation L: The pelvic floor, for this discussion

Pharmacologic treatment

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 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. Several uncontrolled studies with Botox have achieved promising results.^92 93 94 A small placebo-controlled study used Botox to treat women with vaginismus whose symptoms failed to improve after treatment with biofeedback.⁹⁵ 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.

General psychology

Marital, interactional, existential-experiential therapies, relationship enhancement, and hypnosis have all been studied,⁹⁶ with the pre-supposition that vaginismus arises from lack of sexual information, negative childhood sexual experience, or marital discord. Individual therapy to identify and resolve psychological problems, and couples work to focus on the couple’s sexual history and relationship issues, exist. Most reports are case studies or lack control groups and follow-up data.^97 98

Cognitive behavioral therapy (CBT)

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.⁹⁹ Therapists or computer-based programs use CBT techniques to help individuals challenge their 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.¹⁰⁰ The combination of CBT with sex therapy in the treatment of vaginismus has success rates from 75-100%,^{101 102 103} if the definition of success is the ability to have vaginal-penile penetration.

Closely related treatment strategies include:¹⁰⁴

Progressive relaxation: alternately tensing and relaxing groups of muscles in a prescribed sequence, such as from feet upwards. This is taught to women to use before self-fingering or insertion of vaginal trainers.

Sensate focus: a series of structured touching activities designed to help couples overcome anxiety and increase comfort with physical intimacy. The focus is on touch rather than performance. Intercourse is initially banned and couples use homework exercises to gradually move through stages of intimacy to penetration.

Hypnotherapy: uses an induced state of heightened relaxation and altered awareness during which the person is open to suggestions that may alter certain behaviors.

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 new, 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.¹⁰⁵

Masters and Johnson¹⁰⁶ 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.

A randomized, controlled, therapy outcome study for vaginismus investigated CBT with sexual education and use of vaginal dilators using 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.¹⁰⁷

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. ¹⁰⁸

Surgery

Vestibulectomy is used in the treatment of painful intercourse and provoked vulvodynia (PVD). (Annotation K: Vulvar pain and provoked and unprovoked vulvodynia). It has not been studied for vaginismus. Surgery for vaginismus, with hymenectomy, was the original treatment proposed by Marion Sims¹⁰⁹ to facilitate vaginal dilation. Hymenectomy, however, is not effective in treating vaginismus.¹¹⁰

When examination is not possible

There will be patients who cannot touch themselves, do muscle work, or tolerate examiner touch or visualization at all. These patients may need treatment of underlying anxiety disorders with anti-anxiolytics and psychotherapy. Ultimately, evaluation and treatment still require the desensitization techniques. If you feel comfortable with the process, invite the woman to return and try again. Otherwise, you may want to develop your skills further or to find someone to whom to refer her. You and your patient need to understand that a commitment to a multi-specialty treatment program is a journey that may include gynecology, dermatology, behavioral health, physical therapy, and sex therapy to achieve the goal of full examination. Developing this team will require networking with other clinicians who care about helping women with these problems.

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