Vulvodynia and vaginismus are classified as “Genito-pelvic pain/Penetration Disorders” by the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5). These conditions lead to recurrent difficulties with one or more of the following: vaginal penetration during intercourse, vulvovaginal or pelvic pain during penetration attempts, fear about pain in anticipation of, during or as a result of penetration and/or tension of the pelvic floor muscles during attempted vaginal penetration, for a minimum duration of 6 months. More precisely, vulvodynia is defined as vulvar pain that occurs without an identifiable cause, while vaginismus is characterized by involuntary contraction of the pelvic floor muscles. The aetiology of these conditions is unknown, but it is thought to be multifactorial, with physical and psychological factors. An estimated 16% of women in the USA experience recurrent pain during intercourse but the exact prevalence of genito-pelvic pain/penetration disorder is unknown and data from population-based studies have suggested that about 40% of affected women are never diagnosed.
Vaginismus is a leading cause of painful sex and is characterised by persistent difficulties of the woman to allow vaginal entry of a penis, finger or object, despite the woman’s expressed wish to do so. GPs play an integral role in diagnosing and managing vaginismus. A differential diagnosis of vaginismus can be made with a thorough history-taking, genital examination and single-digit vaginal examination (if able). Validating a person’s experience with vaginismus is the first step in its management. Management should be multidisciplinary, including GPs, sexual counsellors, clinical psychologists, physical therapists, pain specialists and gynaecologists. Successful treatment of vaginismus is generally multidisciplinary and involves a combination of patient education, pelvic floor muscle relaxation, use of vaginal trainers and psychological therapy. Botulinum toxin injections can be considered in refractory cases, in conjunction with physical and psychological therapies.
The Diagnostic and Statistical Manual of Mental Disorders-Fifth edition (DSM-5) of the American Psychiatric Association (APA), which is one of the most widely used diagnostic tools at present, classifies female sexual disorders into three types of disorders: arousal or sexual interest, female orgasm, and genito-pelvic pain/penetration disorders (GPPPD). GPPPD include a variety of sexual disorders commonly associated with persistent pelvic pain, among which are usually found dyspareunia, vulvodynia, and vaginismus.
Vulvodynia and vaginismus are classified as “Genito-pelvic pain/Penetration Disorders” by the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5). These conditions lead to recurrent difficulties with one or more of the following: vaginal penetration during intercourse, vulvovaginal or pelvic pain during penetration attempts, fear about pain in anticipation of, during or as a result of penetration and/or tension of the pelvic floor muscles during attempted vaginal penetration, for a minimum duration of 6 months. More precisely, vulvodynia is defined as vulvar pain that occurs without an identifiable cause, while vaginismus is characterized by involuntary contraction of the pelvic floor muscles. The aetiology of these conditions is unknown, but it is thought to be multifactorial, with physical and psychological factors. An estimated 16% of women in the USA experience recurrent pain during intercourse but the exact prevalence of genito-pelvic pain/penetration disorder is unknown and data from population-based studies have suggested that about 40% of affected women are never diagnosed.
Dyspareunia is defined as genito-pelvic pain during or immediately after vaginal penetration. This condition affects 7.5% of sexually active women aged 16–74 years, with the highest prevalence reaching up to 10.4% and 9.5% in both more advanced (55–64 years) and younger (16–24 years) ages, respectively [6,7]. Superficial dyspareunia is closely related to vulvodynia, which is characterized by the presence of persistent pain in the vulvar area for more than three months without an identifiable cause. Between 8 and 15% of women of reproductive age are estimated to present this dysfunction.
On the other hand, vaginismus affects 5–17% of women and can also be included within this group of GPPPD, where any form of vaginal penetration, whether sexual or not, is often painful or impossible. Given the difficulty in differentiating and establishing criteria to discriminate between dyspareunia and vaginismus, since they respond to symptoms and/or health conditions that frequently coexist and are not mutually exclusive, the APA regrouped them within GPPPD in 2013. However, at present, these terms are often used indiscriminately, which generates confusion for both health professionals and patients.
Vaginismus is defined as ‘persistent or recurrent difficulties of the woman to allow vaginal entry of a penis, a finger, and/or any object, despite the woman’s expressed wish to do so’.Clinically, people with vaginismus often present with varying degrees of increased pelvic floor muscle tone and involuntary contractions of the pelvic floor muscles, which make vaginal penetration difficult, painful or impossible. As a result, people will avoid opportunities of vaginal penetration due to the pain or the associated fear and anxiety in anticipation of pain.
As of 2013, the Diagnostic and Statistical Manual of Mental Disorders (fifth edition) merged vaginismus and dyspareunia into a new, title of ‘genito-pelvic pain/penetration disorder’ (GPPPD). This change has received considerable criticism because it prevents the differentiation of vaginismus from other conditions associated with dyspareunia, such as provoked vestibulodynia (pain at the entrance to the vagina, elicited by touch or pressure, in the absence of any identifiable pathology).
The incidence of vaginismus is thought to be about 1–7% worldwide, and the disorder is cross-cultural. In clinical settings, the incidence may be as high as 5–17%. Patients tend to be secretive about their problems and often do not discuss this with anyone else, including their doctors. For this reason, the incidence of vaginismus may be underreported.
Currently, there is no defined aetiology for vaginismus. Most researchers and clinicians agree that vaginismus is a psychophysiological problem involving cognitive, behavioural and physiological factors.
Clinical and research reports indicate that women with vaginismus hold negative views about sexuality, particularly premarital sexual activity. Their background can include a strict religious or sexual upbringing as well as the belief that sex is wrong or that penetration will cause pain, injury, and bleeding. These women may fear that their vagina is too small. In addition, they may fear pregnancy, childbirth, or HIV. A history of sexual molestation at a young age has been reported by Reissing et al., and this appears to be two times more common among vaginismus patients.
Sex-related cognitions are embedded through an individual’s sociocultural context, including their family, friends and religious beliefs. People with vaginismus have consistently reported negative sex-related cognitions developing from a sociocultural context, in particular being brought up in a family where sex was not discussed, sex education was not provided and sex was seen as wrong and sinful.7 Societies where sex is taboo and female sexuality is repressed have a higher prevalence of sexual dysfunction, including vaginismus. Implicit sex-related cognitions have a direct influence on the pelvic floor: people with vaginismus have higher levels of disgust and greater pelvic floor muscle contraction in response to sex-related images and videos than healthy controls.
The fear-avoidance model of pain is often used to conceptualise the development and maintenance of vaginismus. The model outlines how a negative experience with penetration can lead to catastrophic thinking and the resultant fear of penetration. This gives rise to two options: one, to avoid all activities relating to vaginal penetration or, two, to become hypervigilant to stimuli associated with penetration. Hypervigilance can lead to exaggerated defensive pelvic muscle contractions, making it difficult to achieve penetration during a subsequent attempt. An inability to achieve penetration might result in more pain and confirm negative experiences associated with penetration. In this way, the experience of vaginismus is then exacerbated and perpetuated in a vicious cycle.
Organic causes need to be considered such as sexually transmitted diseases, endometriosis, hymeneal and congenital abnormalities, trauma associated with genital surgery or radiotherapy, scarring from childhood trauma, vaginal atrophy, childbirth or surgery, pudendal neuralgia, pelvic inflammatory disease, pelvic organ prolapse, peripheral vascular disease, infections, vaginal lesions and cancer.
Diagnosing vaginismus can be challenging, particularly as people will often present with concomitant vulva, pelvic floor and pelvic pain. The ability to make a diagnosis of vaginismus can be compromised by an inability to perform a satisfactory gynaecologic examination, especially in the more severe vaginismus cases. For this reason, a detailed history is important. Most of my patients have diagnosed their problem by searching the Internet. Vaginismus should be part of the differential diagnosis for patients who have an aversion to vaginal penetration, be it tampon, finger, speculum, dilator, or penis, and for those who have never had pain-free intercourse.
A woman who has never had pain-free intercourse is considered to have vaginismus, and this can range from mild to severe. In severe cases of vaginismus, intercourse usually is impossible, and burning pain can last for days for some patients who make the attempt. A history of never having had comfortable intercourse is important in differentiating vaginismus from dyspareunia. Dyspareunia, a term of ancient Greek origin meaning ‘‘difficult mating’’, is painful intercourse, which can range from mild to severe.
A woman with primary vaginismus has never had comfortable penetration, and this is the most common reason for unconsummated marriages. A woman with secondary vaginismus has experienced normal sexual relations and often has given birth to a child, but some happening such as an infection or childbirth has triggered current pain with attempted penetration.
Vulvodynia is pain involving any part of the vulva that may or may not be associated with vaginismus. Vestibulodynia (vulvar vestibulitis) is pain in the vestibule. Provoked vestibulodynia is pain in the vestibule as a result of touching the area with a cotton-tipped applicator. It is important to ask the patient details about the pain because some patients have more of a panic reaction than pain because the tested area ‘‘is too close for comfort.’’
A genital examination may be required to make a differential diagnosis of vaginismus. A visual inspection of the vulva might indicate fissures, ulcerations, atrophy, fungal infections or other superficial skin issues, such as genital warts or herpes simplex virus. External swabs or low vaginal swabs to assess for other possible pathologies are indicated. A cotton tip should then be used to assess pain with touch or light pressure around the vestibule to assess for provoked vestibulodynia.
A single-digit vaginal examination might be useful to assess the pelvic floor muscles. Palpating slowly through 360 degrees will allow for an assessment of pelvic floor tenderness or tightness. The patient should be observed during the examination. Signs of anxiety or distress such as gluteal tightening, elevation of the buttocks off the table or toe curling are indications that the examination should cease. In these patients, a speculum examination should not be performed until therapeutic interventions have been trialled to manage symptoms.
Lamont in 1978 classified vaginismus according to the patient’s history and behaviour during a gynaecologic examination. With the mildest form of vaginismus, grade 1, the patient is noted to have tight vaginal muscles but can relax enough with coaxing to have a gynaecologic examination. With grade 2 vaginismus, the muscles are noted to be tight, and the patient is unable to relax, but an examination can be done. The patient with a grade 3 vaginismus elevates her buttocks to avoid examination. With the most severe form of vaginismus, grade 4, the patient elevates her buttocks, retracts, and adducts her thighs to avoid being examined.
Given that people with vaginismus and pelvic pain more broadly often report feeling unheard or dismissed by health professionals, the first step in encountering these patients in a clinical situation should be validation – that their pain is real, they are believed and the pain is not all in their head. Validation is an important step in building a strong therapeutic alliance, which has been shown to positively influence how and when people with vaginismus seek treatment.
Pain-specific questions
Medical history
Psychosocial context
Relationship/sexual history
Adapted from Heim (2001)15 and Crowley et al (2009).
The latest clinical practice guidelines on female sexual dysfunction recommend an individualised, multidisciplinary approach for vaginismus, tailored according to an individual’s underlying contributing factors and any existing comorbidities. When vaginismus is considered through the fear-avoidance model of pain, the importance of a multidisciplinary approach is evident. Physical interventions are required to address the contributions of the pelvic floor muscles to decrease pain with penetration, and psychosexual interventions are required to address accompanying catastrophising thoughts and fear around penetration. Relevant health professionals involved in managing vaginismus might include general practitioners (GPs), sexual counsellors, clinical psychologists, physical therapists, pain specialists and gynaecologists. In most cases, successful treatment of vaginismus occurs with a combination of patient education, pelvic floor muscle relaxation, use of vaginal trainers and psychological therapy.
Treatment options and level of supporting evidence for vaginismus
Treatment | Description | Level of evidenceA |
Patient education | Education about vaginismus, vulvovaginal anatomy and pelvic floor anatomy can help people understand the underlying mechanisms and contributing factors to their experience | IIB
|
Pelvic floor muscle relaxation | Various methods can be used to achieve this, including verbal instruction, EMG biofeedback, ultrasound biofeedback and the use of trainers (previously known as dilators) | IIB |
Vaginal trainers | Trainers (previously known as dilators) are plastic or silicon rods with a round end, used to apply pressure at the vaginal entrance and, if possible, inserted into the vagina.Trainers usually come in sets of increasing size to be progressed through. Some practitioners prefer to teach patients to use their own fingers in place of trainers. | IIB |
Systematic desensitisation | Systematic desensitisation is a type of behavioural sex therapy where pelvic floor muscle relaxation and insertion of a dilator or finger into the vagina is used to reduce the anxiety and fear associated with penetration | I |
Cognitive behavioural therapy | Graded exposure exercises are incorporated with cognitive restructuring to reduce sexual avoidance behaviours | I |
Pharmacological therapy | Most medications for vaginismus have limited evidence and are, therefore, not recommended by clinical practice guidelines. Botulinum toxin A injections to the puborectalis and pubococcygeus are increasingly being used for treating vaginismus but have limited supporting evidence. | NS
Botulinum toxin A IV |
A: National Health and Medical Research Council level of evidence.
B: As part of a wider, multidisciplinary treatment program.
EMG, electromyography biofeedback; IV, intravenously; NS, treatment not supported by literature.
Adapted from Clinical assessment and management of vaginismus by Jane Chalmers
The use of Botox to treat vaginismus was first reported by Brin and Vapnek in 1997. This reported case of secondary vaginismus was managed first with 10 units of Botox followed by 40 units of Botox. The patient was able to have intercourse for the first time in 8 years. The results persisted during the 24 months of follow-up evaluation. Ghazizadeh and Nikzad reported on the use of botulinum toxin to treat refractory vaginismus in 24 patients. As a result, 23 patients were able to have vaginal examinations 1 week after the procedure, showing little or no vaginismus. Abbott et al. reported results from a double-blinded, randomized, controlled, and statistically analyzed study conducted to evaluate chronic pain and pelvic floor spasms. In this study, 60 patients were divided into two groups of 30 patients each. One group received 80 units of botulinum toxin A (20 units/ml) injected into the pelvic floor muscles, and the other group received saline as a placebo. Pelvic floor pressures measured by vaginal manometry were noted to be significantly improved in the botulinum toxin type A group. Quality-of-life measurements were higher in the botulinum toxin group.
The number of times the injections are done varies among providers, some injecting each woman up to eight times whilst others inject only once or twice. The muscles injected varied among the studies, including piriformis, and pelvic floor muscles of obturator internus, puborectalis, pubococcygeus, bulbospongiosus, iliococcygeus, and coccygeus. One RCT and one observational study on vulvodynia both described injections into the submucous layer but not into the muscles themselves.
Botulinum toxin injections into pelvic floor muscles are generally safe and well tolerated. Adverse effects of Botulinum injections include flu-like symptoms, constipation, stress incontinence, faecal incontinence and vaginal dryness. These side effects are usually reversible within 6 to 12 weeks.
Currently, there is insufficient evidence to recommend botulinum toxin injection as a first-line treatment for Chronic pelvic pain. However, it appears to be safe to use. Future studies of higher quality with standardized injection protocol, outcome measures and a clinically meaningful method of result reporting are needed to establish its treatment efficacy. However, Botulinum toxin can be an effective therapeutic option for patients with vaginismus particularly in treatment-refractory patients.
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