Vaginismus
Vaginismus is a condition which affects a woman's ability to engage in any form of vaginal penetration, including sexual penetration, insertion of tampons, and the penetration involved in gynecological examinations. This is the result of a conditioned reflex of the pubococcygeus muscle, which is sometimes referred to as the 'PC muscle'. The reflex causes the muscles in the vagina to tense suddenly, which makes any kind of vaginal penetration, including sexual penetration, either painful or impossible.
Prevalence of Vaginismus
Vaginismus has been reported by 12% of women attending outpatient clinics.
Presentation of Vaginismus
There are several symptoms of vaginismus, including:
- involuntary (against your will) spasm of the muscles in the vagina
- fear of pain or real pain
- intense fear of penetration
- loss of sexual desire if penetration is attempted
- pain if penetrated by a tampon, finger or penis.
Women who have vaginismus usually like or want to have sex. In fact, many women with vaginismus enjoy closeness and share sexual pleasure with their partner. They are able to achieve orgasm during mutual masturbation, through foreplay and oral sex. It is only when sexual intercourse is suggested or attempted that the vagina tightens to prevent penetration.
Causes of Vaginismus
There are many different causes of vaginismus, although it is not always fully understood why the condition happens.
Some cases appear to have a physical cause such as
Injury e.g. tears at childbirth
Inflammation of the vagina
- infection e.g. candida (thrush)
- spermicides
- latex (rubber) in condoms
Inflammation of the bladder (cystitis - urinary tract infection)
Vaginal dryness
- inadequate foreplay
- lack of oestrogen (menopause) - atrophic vaginitis
Deep dyspareunia
Even if the original physical cause has disappeared, vaginismus can still continue to happen.
Fear that the vagina is too small for sexual intercourse.
Unpleasant / painful sexual experiences, usually at a young age or the first sexual experience.
sexually abuse, assault or rape
Strict upbringing where sex was never discussed, or unhelpful messages leading to feelings of guilt and shame can be another cause of vaginismus.
Inadequate sex education, being told sex is painful or sexual desire is wrong can cause fear and anxiety of sex leading to vaginismus.
Religious or cultural taboos or the fear of getting pregnant can also contribute to vaginismus.
Relationship problems can be a factor in vaginismus.
The conditioned reflex can create a vicious circle for vaginismic women. For example, if a teenage female learns that the first time she engages in penetrative sex that it will be painful, she may develop vaginismus because she expects pain. If she then attempts to engage in penetrative sex, the muscle spasm will make penetrative sex painful. This and each further attempt at sexual penetration confirms her fear of pain and may worsen the condition. Naturally, penetration may be painful without vaginismus or psychological prere quisite as well.
There is often (phobic) avoidance, involuntary pelvic muscle contraction and anticipation/fear/experience of pain. Structural or other physical abnormalities must be ruled out. There may be an associated fantasy; for example, that the vagina is too small to accommodate a penis. There are no studies comparing treatments of vaginismus.
Diagnosis of Vaginismus
Diagnosis is based on the woman's medical history, the symptoms and a physical examination, if possible.
Any physical disorders that may be causing or contributing to vaginismus will need to be treated, for example, an injury or infection.
However, if the cause of the condition is psychological, then counselling for the woman and her partner (if she is in a relationship) is needed.
The good news is, that with few exceptions, vaginismus can be cured.
You will be taught a technique to relax the muscle spasms in the vagina. It involves gradually appreciating that the vaginal capacity is adequate by using a set of vaginal trainers. These are four smooth, penis-shaped cones that gradually increase in size and length. There is some evidence that short-term therapy involving insertion of vaginal trainers is effective where the outcome measure is the ability to have penetrative vaginal intercourse. Success rates from 72?100% have been reported with short-term treatment varying from two to 15 sessions.
A set of vaginal trainers. A woman with vaginismus can gradually introduce these at her own pace and can learn that her vaginal capacity is adequate for intercourse.
Insert the smallest one first and use a lubricant to help if you want to. Go at your own pace and make sure you are relaxed before trying. Once you feel comfortable inserting the smallest one, move onto the second size, and so on. It does not matter how long it takes you to do this, whether it is a day, weeks or months. Just do whatever you feel comfortable with so you gain confidence and feel more in control of your own body.
When you get to the stage where you can tolerate the larger cones without feeling anxious or any pain, then you and your partner may want to try having sexual intercourse.
If you do not think that the cone method is right for you, take the time and get to know your own body. Take a warm, relaxing bath and lie somewhere comfortable. When you feel ready, touch yourself around the vaginal area. If you feel yourself tensing up, stop and take a moment to slow your breathing down. Relax and try again. Do this for a few days before you move onto the next stage.
If you feel comfortable touching yourself, try to put your finger very gently inside your vagina. If you are ready, over the next few days, gently push your finger further inside and feel around. You will find that your vagina is very flexible and supple.
If you have reached this stage, try putting a tampon inside. Put some lubricant on the tampon so it will be easier to insert. If you have a supportive partner, ask them to help you with each stage. Spend time with your partner being sensual. Explore each other's bodies through touch and massage.
When you are relaxed enough to attempt intercourse, make sure you are fully aroused before attempting penetration. Remember to take things slowly and gently.
Medical Training For Sexual Dysfunction Management
A postal questionnaire was sent to the 218 GPs on the Camden and Islington Health Authority List. A total of 133 GPs responded to the questionnaire. Although only eight had a special interest in sexual health, 41 and 50 reported a special interest in mental and women's health, respectively. Forty-six had received postgraduate training in taking a sexual history, 45 in the diagnosis of a sexual problem, 49 in the management of sexual dysfunction, 39 in psychosexual counselling and 24 had training in all four areas. Most GPs (87) categorized sexual dysfunction as medium priority, 25 as high priority and 18 as low priority.
Doctors find it difficult to address the sexual problems of patients because of
- Lack of training
- Lack of practice
- Fear of ?opening the flood gates?
- Covert presentation of the problem
- Lack of time
- Lack of effective treatments
- Associated stigma
- Embarrassment of doctor, patient or both
- Sensitive subject
- Difficult subject
Training in psychosexual problems should be considered by all obstetricians and gynaecologists. The Institute of Psychosexual Medicine offers a brief, focused course for medical practitioners on psychosomatic therapy for sexual and related difficulties. The initial aim of training is to increase the skills of doctors who encounter women with psychosexual and related problems in their practice. The British Society of Sexual and Relationship Therapists offers training for practitioners of differing backgrounds in psychosexual couple counselling, using a cognitive behavioural approach.
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This is the personal website of David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist at Whipps Cross University Hospital, London - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.
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