History

Fact Explanation
Complaint of vaginal tightness and introital pain. Vaginismus is defined as recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina, which interferes with coitus and causes distress and interpersonal difficulty. Patient may complain of a discomfort, burning or pain and reject to have any sort of vaginal penetration including sexual intercourse, insertion of tampons and the gynecological vaginal examination. This is thought to be due to involuntary vaginal muscle spasm precipitated by real or imagined attempts at vaginal penetration. Vaginismus is deemed primary if the patient has never been able to have experience vaginal penetration without pain. [1,2,3] Secondary vaginismus is when a patient with past history of vaginal penetration without problems develops vaginismus later. Secondary vaginismus is often associated with dysparunia. [1,2,3,4]
Perceives penetration as an unpleasant experience. Patient may have a preconceived notion due to past sexual abuse, painful first attempt of coitus or vaginal examination. [1,2]
Extreme fear of penetration Patient is anxious due to a belief that her vagina is too small to accommodate an erect penis. Fear of pregnancy or intimacy is also a cause. Sometimes she may faint during a penetration. [1,3,5,6]
Unexpressed negative feelings towards the sexual partner Unexpressed conflict with the partner can also precipitate vaginismus . [1,5,6]
Past gynecological history Vaginismus can be attributed to physical illnesses such as pelvic inflammatory disease (PID) and endometriosis. [1,2,7]
References
  1. CROWLEY,T , RICHARDSON, D. GOLDMEIER, Recommendations for the management of vaginismus: BASHH Special Interest Group for Sexual Dysfunction,Int. J. STD AIDS [online] . 2006 jan,17,1,14-18. [viewed 19 May 2014] Available from: http://www.bashh.org/documents/1303/1303.pdf
  2. FRANK, JE, MISTRETTA Patricia, JOSHUA Will. Diagnosis and Treatment of Female Sexual Dysfunction Am Fam Physician[online]. 2008 Mar,1,77(5),635-642.[viewed 19 May 2014] Available from: http://www.aafp.org/afp/2008/0301/p635.html
  3. SZASZ G, STUART F, MAURICE WL, GARRY M. The Treatment of Vaginismus Can Fam Physician [online] 1977 Aug:98-99 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2378892
  4. MALLESON J. Vaginismus: Its Management and Psychogenesis Br Med J [online] 1942 Aug 22, 2(4259):213-216 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2163992
  5. SHEVA MARCUS BAT. Botox for the Treatment of Vaginismus: A Case Report. J Womens Health Care [online] 2014 December [viewed 18 May 2014] Available from: doi:10.4172/2167-0420.1000150
  6. ROSENBAUM TALLI YEHUDA. Physiotherapy Treatment of Sexual Pain Disorders. Journal of Sex & Marital Therapy [online] 2005 July, 31(4):329-340 [viewed 19 May 2014] Available from: doi:10.1080/00926230590950235
  7. HARISH THIPPESWAMY, MULIYALA KRISHNAPRASAD, MURTHY PRATIMA. Successful management of vaginismus: An eclectic approach. Indian J Psychiatry [online] 2011 December [viewed 19 May 2014] Available from: doi:10.4103/0019-5545.82548

Examination

Fact Explanation
Physical examination Usually unremarkable. [1]
Examination of the external genitalia This is mandatory. It is done to exclude the presence of any organic pathology. [1,2]
Vaginal examination Usually the patient will not allow the doctor to do a local examination due to the intense fear of pain. The patient should be examined when they are comfortable and ready, and by a clinician who is experienced in genital examination. If it is permitted, pelvic examination may reveal a tight vagina. [1,2]
Mental status examination May show depressive symptoms, ideas of hopelessness and worries about non-consummation of marriage. [1]
References
  1. CROWLEY,T , D.RICHARDSON, D. GOLDMEIER, Recommendations for the management of vaginismus: BASHH Special Interest Group for Sexual Dysfunction,Int. J. STD AIDS [online] . 2006 jan,17,1,14-18. [viewed 19 May 2014] Available from: http://www.bashh.org/documents/1303/1303.pdf
  2. FRANK,JE, PATRICIA MISTRETTA JOSHUA WILL Diagnosis and Treatment of Female Sexual Dysfunction Am Fam Physician[online]. 2008 Mar,1,77(5),635-642.[viewed 19 May 2014] Available from: http://www.aafp.org/afp/2008/0301/p635.html

Differential Diagnoses

Fact Explanation
Vulvar vestibulitis Chronic and painful inflammation of the vestibular structures. Candida and human papillomavirus (HPV) are the causative factor in most cases. Commonest symptom is vulvodynia (chronic pain) localized to the vulvar region. The pain is burning or cutting in character and may extend into the clitoris. Point tenderness elicited with a cotton swab is a common examination finding. The vestibule appears erythematous. [1,2]
Vulvodynia Is marked by a well-defined burning type entry pain at vulvar region aggravated with activities that put pressure on vulva such as sitting or bicycle riding. Etiology is believed to be an infection or irritant exposure. There are examination findings like mild erythema, leukoplakia, marked tenderness and ulceration. [1,3]
Atrophic tissue or impaired lubrication Well defined entry pain, vaginal dryness, irritation, friction and difficulty and pain with penetration are the usual features. Inhibited arousal phase is the cause of inadequate lubrication in young women, but estrogen deficiency predominates as a reason in older women. [1]
Endometriosis Deep and cyclical pain associated with menstruation. The pain can range from mild to severe cramping or stabbing mainly pelvic pain that occurs in the lower back and rectal area, and even down the legs. [1,4]
Urethral disorders (eg -cystitis) Infections of urinary tract manifest as suprapubic pain, frequency, nocturia , urgency, tenderness along the urethra or bladder. [1]
References
  1. HEIME, L.J. Evaluation and Differential Diagnosis of Dyspareunia, Am Fam Physician[online]. 2001,63,1535-44,1551-2. http://www.hawaii.edu/hivandaids/Evaluation%20and%20Differential%20Diagnosis%20of%20Dyspareunia.pdf
  2. LEDGER WJ, KESSLER A, LEONARD GH, WITKIN SS. Vulvar vestibulitis-a complex clinical entity. Infect Dis Obstet Gynecol [online] 1996, 4(5):269-75 [viewed 19 May 2014] Available from: doi:10.1155/S106474499600052X
  3. SADOWNIK LA. Etiology, diagnosis, and clinical management of vulvodynia. Int J Womens Health [online] 2014:437-449 [viewed 19 May 2014] Available from: doi:10.2147/IJWH.S37660
  4. CIRSTOIU M, BODEAN O, SECARA D, MUNTEANU O, CIRSTOIU C. Case study of a rare form of endometriosis. J Med Life [online] 2013 Mar 15, 6(1):68-71 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23599823

Management - General Measures

Fact Explanation
Partner education Both male and female partners should be educated that there is no mechanical obstruction at lower vagina and it is due to a psychological fear of trauma that stimulates muscle contractions. Basic knowledge of the anatomy and function of reproductive system and sexual behavior is useful in further management. [1,2] Partners should be informed that this condition is curable but may take some time. The treatment aims to break the vicious cycle & replacing pain by pleasure & spasm by relaxation. These goals should be achieved with great patience and warm, empathetic attitude towards the woman. [1,2,3]
Exploration of phobia Addressing psychological causes is very important. If there is a history of childhood traumatic experience, this has to be recalled and the emotions which accompanied it relived in order to help the the patient overcome them.[1,2,3,4]
Self exploration of sexual anatomy It has been found self exploration of genitalia is effective. Rather than an explanation by the physician on the anatomy and physiology of the genitalia. [1,5,6]
References
  1. CROWLEY,T , D.RICHARDSON, D. GOLDMEIER, Recommendations for the management of vaginismus: BASHH Special Interest Group for Sexual Dysfunction,Int. J. STD AIDS [online] . 2006 jan,17,1,14-18. [viewed 19 May 2014] Available from: http://www.bashh.org/documents/1303/1303.pdf
  2. FRANK,JE, PATRICIA MISTRETTA JOSHUA WILL Diagnosis and Treatment of Female Sexual Dysfunction Am Fam Physician[online]. 2008 Mar,1,77(5),635-642.[viewed 19 May 2014] Available from: http://www.aafp.org/afp/2008/0301/p635.html
  3. HARISH THIPPESWAMY, MULIYALA KRISHNAPRASAD, MURTHY PRATIMA. Successful management of vaginismus: An eclectic approach. Indian J Psychiatry [online] 2011 December [viewed 19 May 2014] Available from: doi:10.4103/0019-5545.82548
  4. ROSENBAUM TALLI YEHUDA. Physiotherapy Treatment of Sexual Pain Disorders. Journal of Sex & Marital Therapy [online] 2005 July, 31(4):329-340 [viewed 19 May 2014] Available from: doi:10.1080/00926230590950235
  5. MALLESON J. Vaginismus: Its Management and Psychogenesis Br Med J [online] 1942 Aug 22, 2(4259):213-216 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2163992
  6. SZASZ G, STUART F, MAURICE WL, GARRY M. The Treatment of Vaginismus Can Fam Physician [online] 1977 Aug:98-99 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2378892

Management - Specific Treatments

Fact Explanation
Muscle relaxation exercises Relaxation exercises for the adductor muscles help the patient relax in anticipation of penetration. The doctor may hold the woman ‘s knees together firmly while she attempts to separate them, then slowly she is allowed to succeed. These maneuvers can be used to learn muscle relaxation. [1,2,3,4]
Kegel ‘s exercises These contraction /relaxation exercise help the patient gain control over the muscles surrounding the introitus. The patient must learn first to identify the muscle for herself. She is advised to sit on the toilet with her legs spread as far apart as possible. She should then start & stop the flow of urine. The patient should be advised to practice this exercise 20 times in a row 3 to 5 times every day. [1,2,3]
Systematic vaginal desensitization Fingers or commercial dilators of gradually increasing diameter can be used for systematic vaginal desensitization. The patient should insert her own finger into the vagina and see whether it is painful. Afterwards, the male partner should also be taught to insert the finger into the vagina in a to and fro motion, which can be combined with clitoral stimulation. The male should be educated about the stimulation of the 'G' spot. This process should be gradually intensifies over the next few days. If one finger can be inserted without a problem, subsequently the second finger should also be inserted and the procedure repeated. [1,2,4,6,7]
Intravaginal botulinum toxin injection Botulinum toxin A is a neurotoxin produced by Clostridium botulinum which causes muscle paralysis. The injection of Botox and insertion of a dilator under anesthesia with follow up progressive dilation is used in treatment for vaginismus. This is used in patients who are too fearful to begin dilation treatment or those who are unsuccessful during the progression of it. Most women are able to have pain free intercourse within 2-4 weeks after the procedure. [5,6]
Surgical treatment This is almost never required and may even be detrimental to achieving success as the resulting scar may aggravate the condition. However Fenton's operation is the last resort when all the above management options fail. A vertical incision is made at the fouchette to divide the attachment of the muscles to the perineal body. [5,6]
Artificial insemination For a couple who is still willing to conceive, this method is used. So that the subsequent child birth may help to dilate the vagina and relieve vaginismus. [3,6]
References
  1. CROWLEY,T , D.RICHARDSON, D. GOLDMEIER, Recommendations for the management of vaginismus: BASHH Special Interest Group for Sexual Dysfunction,Int. J. STD AIDS [online] . 2006 jan,17,1,14-18. [viewed 19 May 2014] Available from: http://www.bashh.org/documents/1303/1303.pdf
  2. SZASZ G, STUART F, MAURICE WL, GARRY M. The Treatment of Vaginismus Can Fam Physician [online] 1977 Aug:98-99 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2378892
  3. ROSENBAUM TALLI YEHUDA. Physiotherapy Treatment of Sexual Pain Disorders. Journal of Sex & Marital Therapy [online] 2005 July, 31(4):329-340 [viewed 19 May 2014] Available from: doi:10.1080/00926230590950235
  4. MALLESON J. Vaginismus: Its Management and Psychogenesis Br Med J [online] 1942 Aug 22, 2(4259):213-216 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2163992
  5. SHEVA MARCUS BAT. Botox for the Treatment of Vaginismus: A Case Report. J Womens Health Care [online] 2014 December [viewed 18 May 2014] Available from: doi:10.4172/2167-0420.1000150
  6. HARISH THIPPESWAMY, MULIYALA KRISHNAPRASAD, MURTHY PRATIMA. Successful management of vaginismus: An eclectic approach. Indian J Psychiatry [online] 2011 December [viewed 19 May 2014] Available from: doi:10.4103/0019-5545.82548
  7. FRANK,JE, PATRICIA MISTRETTA JOSHUA WILL Diagnosis and Treatment of Female Sexual Dysfunction Am Fam Physician[online]. 2008 Mar,1,77(5),635-642.[viewed 19 May 2014] Available from: http://www.aafp.org/afp/2008/0301/p635.html