| Vaginismus | |
|---|---|
| Classification and external resources | |
| ICD-10 | F52.5, N94.2 |
| ICD-9 | 306.51 625.1 |
| DiseasesDB | 13701 |
| MedlinePlus | 001487 |
| MeSH | D052065 |
Vaginismus, sometimes anglicized vaginism is the German name for a condition which affects a woman's ability to engage in any form of vaginal penetration, including sexual intercourse, 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 intercourse—painful or impossible.
A vaginismic woman does not consciously control the spasm. The vaginismic reflex can be compared to the response of the eye shutting when an object comes towards it. The severity of vaginismus and the pain during penetration, including sexual penetration, varies from woman to woman.
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Primary vaginismus occurs when a woman has never been able to have penetrative sex or experience any kind of vaginal penetration without pain. It is commonly discovered in teenagers and women in their early twenties, as this is when many young women in the Western world will initially attempt to use tampons, have some form of penetrative sex, or undergo a Pap smear. Women who have vaginismus may not be aware of their condition until they attempt vaginal penetration. It may be confusing for a woman to discover she has vaginismus. She may believe that vaginal penetration should naturally be easy, or she may be unaware of the reasons for her condition.
A few of the main factors which may contribute to primary vaginismus include:
Occasionally, primary vaginismus is idiopathic.[1]
Vaginismus has been classified by Lamont[2] according to the severity of the condition. He describes four degrees of vaginismus: In first degree vaginismus, the patient has spasm of the pelvic floor which can be relieved with reassurance. In second degree, the spasm is present but maintained throughout the pelvis even with reassurance. In third degree, the patient elevates the buttocks to avoid being examined. In fourth degree vaginismus (also known as grade 4 vaginismus), the most severe form of vaginismus, the patient elevates the buttocks, retreats and tightly closes the thighs to avoid examination. The Lamont classification continues to be used to the present and allows for a common language among researchers and therapists.
Though spasm of the pubococcygeus muscle is commonly thought to be the primary muscle involved in vaginismus, Pacik identified 2 additional involved spastic muscles in treated patients under sedation. These include the entry muscle (bulbocavernosum) and the mid vaginal muscle (puborectalis). This accounts for the common complaint that patients often say when trying to have intercourse "It's like hitting a brick wall".[3]
Secondary vaginismus occurs when a woman who has previously been able to achieve penetration develops vaginismus. This may be due to physical causes such as a yeast infection or trauma during childbirth, or it may be due to psychological 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.
The prevalence of vaginismus has been reported to be 6% in two widely divergent cultures, Morocco and Sweden. The prevalence of manifest dyspareunia has been reported as low as 2% in elderly British women, yet as high as 18–20% in British and Australian studies.[4]
By another study vaginismus rates of between 12% and 17% have been reported in women presenting to sex therapy clinics (Spector and Carey 1990). National Health and Sexual Life Survey, which used random sampling and structured interviewing, found that between 10% and 15% of women reported having experienced pain during intercourse during the last 6 months (Laumann et al. 1994).[1]
The most recent study-based estimates of vaginismus range from 5% to 47% of people presenting for sex therapy or complaining of sexual problems, with significant differences across cultures (see Reissing et al. 1999; Nusbaum 2000; Oktay 2003). It seems likely that society's expectations of women's sexuality may particularly impact on these sufferers.[5]
There are a variety of factors that can contribute to vaginismus. These may be psychological or physiological, and the treatment required can depend on the reason that the woman has developed the condition. As each case is different, an individualized approach to treatment is useful. The condition will not necessarily become more severe if left untreated, unless the woman is continuing to attempt penetration, despite feeling pain. Some women may choose to refrain from seeking treatment for their condition.
According to the Cochrane Collaboration review of the scientific literature, "In spite of encouraging results reported from uncontrolled case series there is very limited evidence from controlled trials concerning the effectiveness of treatments for vaginismus. Further trials are needed to compare therapies with waiting list control and with other therapies."[6] Although few controlled trials have been carried out, many serious scientific studies have tested and proved the efficacy of the treatment of vaginismus. In all cases where the systematic desensitization method was used, success rates were close to 90–95% and even 100%. For an example of one of these studies, see Nasab, M., & Farnoosh, Z., or for a basic review, see Reissing's literature review (links below).
According to Ward and Ogden's qualitative study on the experience of vaginismus for women (1994), the three most common contributing factors to vaginismus are fear of painful sex; the belief that sex is wrong or shameful (often the case with patients who had a strict religious upbringing); and traumatic early childhood experiences (not necessarily sexual in nature).
Vaginismus patients 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 physical abuse.[7]
For some women, especially those with primary vaginismus, it is important to address the psychological aspects of the problem as well as the actual muscle spasm. A woman may choose to address the issue on her own terms, or she may avail the help of a therapist. Some women, especially those with secondary vaginismus, may rely on a physical rather than psychological treatment and also be successful. There are emotional difficulties associated with vaginismus, which can include low self-esteem, fears, and depression.
Physical treatment of the internal spasms may include sensate focus exercises, exploring the vagina through touch, and desensitization with vaginal dilators. Dilating involves inserting objects, usually phallic in shape, into the vagina. In treating the spasms through dilation, the objects used gradually increase in size as the woman progresses. Medical dilators may be obtained online, though they may be expensive.
Botox is a relatively new treatment for vaginismus, first described in 1997 [8]. Ghazizadeh and Nikzad reported on the use of botulinum toxin in the treatment of refractory vaginismus in 24 patients. In this study, Dysport (a type of Botox) 150-400 mIU (Ipsen Ltd, United Kingdom) was used. 23 patients were able to have vaginal examinations one week post procedure showing little or no vaginismus. One patient refused vaginal examination and did not attempt coitus. Of the 23 patients, 18 (75%) achieved satisfactory intercourse, 4 (17%) had mild pain and one patient was unable to have intercourse because of her husband’s impotence. A second dose of Dysport was needed on one patient. There were no recurrences during the 2-24 month follow-up period.[9]
A controlled study using Botox for one group of patients was compared to saline in another. 8 women treated with the Botox were able to achieve satisfactory intercourse whereas 5 women who were injected with saline controls showed no response. None of the 8 women who had Botox required any further treatment. The procedure is simple, easy, cost-effective, not time-consuming and can be achieved on an outpatient basis. No complications were reported.[10]
Pacik reported the use of intravaginal Botox, and progressive dilation under sedation in 20 patients. 12 of these patients were a Lamont level 4 primary vaginismus, the most severe form of vaginismus. He reports a 90%+ success rate of patients achieving intercourse in 2 weeks to 3 months. In this series there were no complications and no recurrences. [3]
If a woman suspects she has vaginismus, sexual penetration is likely to remain painful or truly impossible until her vaginismus is addressed. Women with vaginismus may be able to engage in a variety of other sexual activities, as long as penetration is avoided. Sexual partners of vaginismic women may come to believe that vaginismic women do not want to engage in penetrative sex at all, though this may not be true. Many vaginismic women strongly wish to engage in penetrative sex, but are deterred by the pain and emotional distress that comes with each attempt.
Many people do not realize that it is common, even in patients who do not suffer from vaginismus, for a woman to experience pain or discomfort if she attempts sexual penetration without first being sufficiently aroused. Most women acknowledge sexual arousal as vital to achieving comfortable penetration, so self-exploration of the vaginal area through masturbation can be beneficial in addressing vaginismus.
One of the problems which may accompany vaginismus is that a woman may be extremely hesitant to engage in penetrative sexual activity with others, due to a fear of pain associated with any kind of vaginal penetration. Solo masturbation, with or without penetration, can alleviate this fear, as well as the psychological pressure to "perform" sexually or become aroused quickly with a partner.
Despite popular belief, orgasm need not be the goal of masturbation. It may serve simply to increase comfort with the genital area, to explore various sensations through genital and clitoral touch, and to become aware of those sensations which are relaxing and pleasurable. Sexual arousal causes changes in the shape and color of the vulva, as well as in the vaginal lubrication produced. As a woman becomes more aware of her individual sexual response, she can learn which sensations are best for bringing her to a state of arousal. She will then be better equipped to teach her partner which sensations feel best for her.
Vaginismus does not necessarily prevent a woman from achieving orgasm.
A wide range of emotions may surface during masturbation and other forms of genital exploration. Some women have negative associations with their genitals, including fears that their genitals are dirty, smelly, oddly shaped, or ugly. These associations can lead to negative emotions arising during any kind of sexual expression, including masturbation, and these emotions can take time to process. Especially in the case of a vaginismic woman, feelings of extreme shame, inadequacy or fear of being "defective" can be deeply troubling. If multiple attempts to penetrate are made before treating vaginismus, it may lead to fear of sexual intercourse, and worsen the amount of pain experienced with each subsequent attempt. Relaxation, patience and self-acceptance are vital to a pleasurable experience.
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