Vaginismus is a condition in which involuntary
muscle spasm
A spasm is a sudden involuntary contraction of a muscle, a group of muscles, or a hollow organ such as the bladder.
A spasmodic muscle contraction may be caused by many medical conditions, including dystonia. Most commonly, it is a muscl ...
interferes with
vaginal intercourse
Sexual intercourse (or coitus or copulation) is a sexual activity typically involving the insertion and thrusting of the penis into the vagina for sexual pleasure or reproduction.Sexual intercourse most commonly means penile–vaginal penetrat ...
or other penetration of the vagina.
This often results in
pain with attempts at sex.
[ Often, it begins when vaginal intercourse is first attempted.][
The formal diagnostic criteria specifically requires interference during vaginal intercourse and a desire for intercourse. However, the term ''vaginismus'' is sometimes used more broadly to refer to any muscle spasms occurring during the insertion of some or all types of objects into the vagina, sexually motivated or otherwise, including the usage of speculums and ]tampon
A tampon is a feminine hygiene, menstrual product designed to absorb blood and vaginal secretions by insertion into the vagina during menstruation. Unlike a Sanitary napkin, pad, it is placed internally, inside of the vaginal canal. Once inser ...
s.
The underlying cause is generally a fear that penetration will hurt.[ Risk factors include a history of ]sexual assault
Sexual assault is an act in which one intentionally sexually touches another person without that person's consent, or coerces or physically forces a person to engage in a sexual act against their will. It is a form of sexual violence, which ...
, endometriosis
Endometriosis is a disease of the female reproductive system in which cells similar to those in the endometrium, the layer of tissue that normally covers the inside of the uterus, grow outside the uterus. Most often this is on the ovaries, f ...
, vaginitis
Vaginitis, also known as vulvovaginitis, is inflammation of the vagina and vulva. Symptoms may include itching, burning, pain, discharge, and a bad smell. Certain types of vaginitis may result in complications during pregnancy.
The three main ...
, or a prior episiotomy
Episiotomy, also known as perineotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or obstetrician. Episiotomy is usually performed during second stage of labor to quickly enlarge the opening ...
.[ Diagnosis is based on the symptoms and examination.][ It requires there to be no ]anatomical
Anatomy () is the branch of biology concerned with the study of the structure of organisms and their parts. Anatomy is a branch of natural science that deals with the structural organization of living things. It is an old science, having it ...
or physical problems and a desire for penetration on the part of the woman.
Treatment may include behavior therapy
Behaviour therapy or behavioural psychotherapy is a broad term referring to clinical psychotherapy that uses techniques derived from behaviourism and/or cognitive psychology. It looks at specific, learned behaviours and how the environment, or oth ...
such as graduated exposure therapy and gradual vaginal dilatation.[ Surgery is not generally indicated.] Botulinum toxin
Botulinum toxin, or botulinum neurotoxin (BoNT), is a neurotoxic protein produced by the bacterium ''Clostridium botulinum'' and related species. It prevents the release of the neurotransmitter acetylcholine from axon endings at the neuromusc ...
(botox), a muscle spasm treatment, is being studied.[ There are no epidemiological studies of the prevalence of vaginismus.][Lahaie M-A, Boyer SC, Amsel R, Khalifé S, Binik YM. Vaginismus: A Review of the Literature on the Classification/Diagnosis, Etiology and Treatment. Women’s Health. 2010;6(5):705-719. doi:10.2217/WHE.10.46
] Estimates of how common the condition is vary.[ One textbook estimates that 0.5% of women are affected.][ However, rates in clinical settings indicate that between 5–17% of women experience vaginismus.] Outcomes are generally good with treatment.[
]
Signs and symptoms
Physical symptoms may include burning, and sharp pain or pressure in and around the vagina upon penetration. Psychological symptoms include increased anxiety. Pain during vaginal penetration varies.
Causes
Primary vaginismus
Vaginismus occurs when penetrative sex or other vaginal penetration cannot be experienced without pain. It is commonly discovered among teenage girls and women in their early twenties, as this is when many girls and young women first attempt to use tampon
A tampon is a feminine hygiene, menstrual product designed to absorb blood and vaginal secretions by insertion into the vagina during menstruation. Unlike a Sanitary napkin, pad, it is placed internally, inside of the vaginal canal. Once inser ...
s, have penetrative sex, or undergo a Pap smear
The Papanicolaou test (abbreviated as Pap test, also known as Pap smear (AE), cervical smear (BE), cervical screening (BE), or smear test (BE)) is a method of cervical screening used to detect potentially precancerous and cancerous processes in t ...
. Awareness of vaginismus may not happen until vaginal penetration is attempted. Reasons for the condition may be unknown.[
A few of the main factors that may contribute to primary vaginismus include:
* chronic pain conditions and harm-avoidance behaviour
* negative emotional reaction towards sexual stimulation, e.g. disgust both at a deliberate level and also at a more implicit level
* strict conservative moral education, which also can elicit negative emotions
Primary vaginismus is often unknown cause.]
Vaginismus has been classified by Lamont according to the severity of the condition. Lamont describes four degrees of vaginismus: In first degree vaginismus, the person has spasm of the pelvic floor that can be relieved with reassurance. In second degree, the spasm is present but maintained throughout the pelvis even with reassurance. In third degree, the person elevates the buttocks to avoid being examined. In fourth degree vaginismus (also known as grade 4 vaginismus), the most severe form of vaginismus, the person elevates the buttocks, retreats and tightly closes the thighs to avoid examination. Pacik expanded the Lamont classification to include a fifth degree in which the person experiences a visceral reaction such as sweating, hyperventilation, palpitations, trembling, shaking, nausea, vomiting, losing consciousness, wanting to jump off the table, or attacking the doctor.
Although the pubococcygeus muscle is commonly thought to be the primary muscle involved in vaginismus, Pacik identified two additionally-involved spastic muscles in people who were treated under sedation. These include the entry muscle ( bulbocavernosum) and the mid-vaginal muscle (puborectalis
The levator ani is a broad, thin muscle group, situated on either side of the pelvis. It is formed from three muscle components: the pubococcygeus, the iliococcygeus, and the puborectalis.
It is attached to the inner surface of each side of the ...
). Spasm of the entry muscle accounts for the common complaint that people often report when trying to have intercourse: "It's like hitting a brick wall".
Secondary vaginismus
Secondary vaginismus occurs when a person who has previously been able to achieve penetration develops vaginismus. This may be due to physical causes such as a yeast infection
Candidiasis is a fungal infection due to any type of '' Candida'' (a type of yeast). When it affects the mouth, in some countries it is commonly called thrush. Signs and symptoms include white patches on the tongue or other areas of the mouth ...
or trauma during childbirth
Childbirth, also known as labour and delivery, is the ending of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million births globall ...
, while in some cases it may be due to psychological causes, or to a combination of causes. The treatment for secondary vaginismus is the same as for primary vaginismus, although, in these cases, previous experience with successful penetration can assist in a more rapid resolution of the condition. Peri-menopausal and menopausal vaginismus, often due to a drying of the vulvar and vaginal tissues as a result of reduced estrogen, may occur as a result of "micro-tears" first causing sexual pain then leading to vaginismus.
Mechanism
Specific muscle involvement is unclear, but the condition may involve the pubococcygeus muscle, levator ani
The levator ani is a broad, thin muscle group, situated on either side of the pelvis. It is formed from three muscle components: the pubococcygeus, the iliococcygeus, and the puborectalis.
It is attached to the inner surface of each side of the ...
, bulbocavernosus, circumvaginal, or perivaginal muscles.
Diagnosis
The diagnosis of vaginismus, as well as other diagnoses of female sexual dysfunction, can be made when "symptoms are sufficient to result in personal distress." The ''DSM-IV-TR'' defines ''vaginismus'' as "recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse, causing marked distress or interpersonal difficulty".
Treatment
A Cochrane review
Cochrane (previously known as the Cochrane Collaboration) is a British international charitable organisation formed to organise medical research findings to facilitate evidence-based choices about health interventions involving health professi ...
found little high quality evidence regarding the treatment of vaginismus in 2012. Specifically it is unclear if systematic desensitisation
Systematic desensitization, or graduated exposure therapy, is a behavior therapy developed by the psychiatrist Joseph Wolpe. It is used when a phobia or anxiety disorder is maintained by classical conditioning. It shares the same elements of both c ...
is better than other measures including nothing.[
]
Psychological
According to a 2011 study, those with vaginismus are twice as likely to have a history of childhood sexual interference and held less positive attitudes about their sexuality, whereas no correlation was noted for lack of sexual knowledge or (nonsexual) physical abuse.
Physical
Often, when faced with a person experiencing painful intercourse, a gynecologist will recommend reverse Kegel exercise
Kegel exercise, also known as pelvic-floor exercise, involves repeatedly contracting and relaxing the muscles that form part of the pelvic floor, now sometimes colloquially referred to as the "Kegel muscles". The exercise can be performed many t ...
s and provide some additional lubricants. Although vaginismus has not been shown to affect a person's ability to produce lubrication, providing additional lubricant can be helpful in achieving successful penetration. This is due to the fact that women may not produce natural lubrication if anxious or in pain. Achieving sufficient arousal during foreplay
Foreplay is a set of emotionally and physically intimate acts between one or more people meant to create sexual arousal and desire for sexual activity. Although foreplay is typically understood as physical sexual activity, nonphysical activiti ...
is crucial for the release of lubrication which can contribute to the ease of sexual penetration
Sexual penetration is the insertion of a body part or other object into a body orifice, such as the mouth, vagina or anus, as part of human sexual activity or animal sexual behavior.
The term is most commonly used in statute law in the context ...
and pain-free intercourse.
Though strengthening exercises such as Kegel exercises were previously considered to be a helpful intervention for pelvic pain, new research suggests that these exercises, which function to strengthen the pelvic floor, may not be helpful or may make conditions that are caused by over-active muscles such as vaginismus worse. Exercises that stretch or relax the pelvic floor may be a better treatment option for vaginismus.
To help develop a treatment plan that best fits the needs of their patient, a gynecologist or general practitioner may refer a person experiencing painful intercourse to a Pelvic floor physical therapist or occupational therapist. These therapists specialize in the treatment of disorders of the pelvic floor muscles such as vaginismus, dyspareunia
Dyspareunia ( ) is painful sexual intercourse due to medical or psychological causes. The term ''dyspareunia'' covers both female dyspareunia and male dyspareunia, but many discussions that use the term without further specification concern the f ...
, vulvodynia
Vulvodynia is a chronic pain syndrome that affects the vulvar area and occurs without an identifiable cause. Symptoms typically include a feeling of burning or irritation. It has been established by the ISSVD that for the diagnosis to be made ...
, constipation
Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement ...
, and fecal
Feces ( or faeces), known colloquially and in slang as poo and poop, are the solid or semi-solid remains of food that was not digested in the small intestine, and has been broken down by bacteria in the large intestine. Feces contain a relati ...
or urinary
The urinary system, also known as the urinary tract or renal system, consists of the kidneys, ureters, bladder, and the urethra. The purpose of the urinary system is to eliminate waste from the body, regulate blood volume and blood pressure, con ...
incontinence. After performing a manual exam both internally and externally to assess muscle function and to isolate possible trigger points for pain or tightness on the muscles, pelvic floor physical or occupational therapists develop a treatment plan consisting of muscle exercises, muscle stretches, dilator training, electrostimulation, and/or biofeedback
Biofeedback is the process of gaining greater awareness of many physiology, physiological functions of one's own body by using Electronics, electronic or other instruments, and with a goal of being able to Manipulation (psychology), manipulate t ...
interventions. Treatment of vaginismus often involves the use of Hegar dilators
Hegar dilators are dilators used to treat vaginismus, induce Cervix, cervical dilation, and for penile implant, inflatable penile implant procedures.
Description
Hegar dilators were developed and introduced by Alfred Hegar in 1879 originally for ...
(sometimes called vaginal trainers), progressively increasing the size of the dilator inserted into the vagina. The technique is used to practice conscious diaphragmatic breathing
Diaphragmatic breathing, abdominal breathing, belly breathing, or deep breathing, is breathing that is done by contracting the diaphragm, a muscle located horizontally between the thoracic cavity and abdominal cavity. Air enters the lungs as the ...
(breathing in deeply allowing one's belly to expand) and allowing the pelvic floor muscles to lengthen during inhale; then exhale, bringing belly in and repeat. Research suggests pelvic floor physical or occupational therapy is one of the safest and most effective treatments for vaginismus.
Neuromodulators
Botulinum toxin A (Botox) has been considered as a treatment option, under the idea of temporarily reducing the hypertonicity of the pelvic floor muscles. Although no random controlled trials have been done with this treatment, experimental studies with small samples have shown it to be effective, with sustained positive results through 10 months.[ Similar in its mechanism of treatment, ]lidocaine
Lidocaine, also known as lignocaine and sold under the brand name Xylocaine among others, is a local anesthetic of the amino amide type. It is also used to treat ventricular tachycardia. When used for local anaesthesia or in nerve blocks, lidoca ...
has also been tried as an experimental option.
Anxiolytic
An anxiolytic (; also antipanic or antianxiety agent) is a medication or other intervention that reduces anxiety. This effect is in contrast to anxiogenic agents which increase anxiety. Anxiolytic medications are used for the treatment of anxi ...
s and antidepressant
Antidepressants are a class of medication used to treat major depressive disorder, anxiety disorders, chronic pain conditions, and to help manage addictions. Common side-effects of antidepressants include dry mouth, weight gain, dizziness, hea ...
s are other pharmacotherapies that have been offered to people in conjunction with other psychotherapy modalities, or if these people's experience high levels of anxiety from their condition.[ Evidence for these medications, however, is limited.][
]
Epidemiology
There are no epidemiological studies of the prevalence of vaginismus. Estimates of how common the condition is varies.[ A 2016 textbook estimated about 0.5% of women are affected,][ while rates in ]Morocco
Morocco (),, ) officially the Kingdom of Morocco, is the westernmost country in the Maghreb region of North Africa. It overlooks the Mediterranean Sea to the north and the Atlantic Ocean to the west, and has land borders with Algeria to ...
and Sweden
Sweden, formally the Kingdom of Sweden,The United Nations Group of Experts on Geographical Names states that the country's formal name is the Kingdom of SwedenUNGEGN World Geographical Names, Sweden./ref> is a Nordic country located on ...
were estimated at 6%.
Among those who attend clinics for sexual dysfunction, rates may be as high as 12 to 47%.
See also
* Hymen
The hymen is a thin piece of mucosal tissue that surrounds or partially covers the external vaginal opening. It forms part of the vulva, or external genitalia, and is similar in structure to the vagina.
In children, a common appearance of the h ...
* Penis captivus
Penis captivus is a supposed occurrence during human sexual intercourse when the muscles in the vagina clamp down on the penis much more firmly than usual, making it impossible for the penis to be withdrawn from the vagina. According to a 1979 ar ...
* Vulvodynia
Vulvodynia is a chronic pain syndrome that affects the vulvar area and occurs without an identifiable cause. Symptoms typically include a feeling of burning or irritation. It has been established by the ISSVD that for the diagnosis to be made ...
References
Further reading
*
{{Diseases of the pelvis, genitals and breasts
Noninflammatory disorders of female genital tract
Gynaecologic disorders
Midwifery
Wikipedia medicine articles ready to translate
Sexual dysfunctions
Sexual health
Women's health