Vaginismus is an involuntary painful contraction (spasm) of the pelvic floor muscles on attempting penetrative sexual intercourse, or to allow Gynaecological examination (e.g. Bimanual exam or inserting speculum for Cervical Screening test etc), or on trying to insert a tampon. (Shutting off). In a more difficult degree, generalized muscle spasm could happen with panic attack or temporary cessation of breathing.
Vaginismus is a penetration disorder in that any form of vaginal penetration such as tampons, finger, vaginal dilators, Gynaecological examinations, and intercourse is often painful or impossible. Compared with other sexual pain disorders such as vulvodynia and vestibulodynia. It is the most common reason for unconsummated marriages.
Vaginismus, is categorically as one of the conditions of the Female Sexual Disorders-listed under the terminology of “Dyspareunia”( meaning pain experienced during intimate relationship) and often is under diagnosed and therefore inadequately treated, yet affecting approximately 1-7% of females worldwide.
The most common muscle group affected is the pubococcygeus (PC) muscle group. These muscles are involved in urination, intercourse, orgasm, bowel movements and in childbirth.
Vaginismus could be primary or secondary.
Secondary Vaginismus: develops after a woman had experienced normal sexual function. It usually happens with infection (yeast or UTI), or Lichen Sclerosis, or at menopause or a traumatic event as post childbirth or pelvic surgery or in relationship issues. Even after eliminating the causative factor, the pain & the spasm continue as if the body becomes conditioned to respond in the same way.
Vaginismus does not always have an obvious cause, but commonly caused by:
Emotional things: like fear of pain, strict upbringing where sex is not discussed or seen as a taboo, fear of pregnancy or sense of guilt or anxiety or previous traumatic life events or traumatic sexual experience.
Physical causes hypothesis: like oversensitive nerves at the vaginal opening, inflammation or injury in the area, following traumatic childbirth experience or could be secondary to vulvodynia or degenerative skin conditions or side effect of certain medicines.
Without treatment, it can lead to frustration and distress, and it may get worse. However, treatment is possible.
Lamont Classification (grades):
· First Degree Vaginismus: as spasm of the pelvic floor that could be relieved with reassurance and the patient could relax for Gynaecological Examination & screening tests.
· Second Degree Vaginismus: generalized spasm of the pelvic floor as a steady state despite reassurance, and the patient was unable to relax for the exam.
· Third Degree Vaginismus: The pelvic floor spasm was sufficiently severe that the patient would elevate her buttocks to avoid being examined.
· Fourth Degree Vaginismus: The most severe form described by Lamont. The patient would totally retreat by elevating the buttocks, moving away from the pelvic exam, and tightly closing the thighs to prevent any examination.
· Fifth Degree Vaginismus: in addition to the above mentioned, there is generalised body muscle spasm with temporary cessation of breathing.
A detailed & purposedly designed history taking & clinical examinations are carried out by Gynaecologists. In addition, Gynaecologists use an “specific criteria questionnaire” that helps to differentiate between primary & secondary vaginismus.
Vaginismus treatment has the potential for a high rate of success. Stratifying the severity of vaginismus allows the clinician to choose among numerous treatment options and to better understand what the patient is experiencing. Vaginismus is both a physical and an emotional disorder. Hence the need for the multimodal approaches that aim to reduce the automatic tightening of the involved muscles and eliminating the fear of pain.
1-Education and counselling: Providing information about anatomy of the feminine area & sexual response cycle & readjusting the views inherent in certain cultures in relation to sexual intercourse.
2- Cognitive & behavioural therapy: a type of psychotherapy in which negative patterns of thought about the self and the world are challenged in order to alter unwanted behaviour patterns
3- Psychosexual support: is the use of targeted counselling, or longer-term psychotherapy to help address sexual problems. It is a talking-based treatment and doesn’t involve touch such as massage.
4- topical or regional Analgesia injections e.g use of numbing creams (lignocaine gel) to desensitise the area. In some cases, there might be a place to use regional analgesia infiltration to assess the tones of the affected muscles e.g Dorsal Nerve. This is administered by the Gynaecologist to allow assessment when required.
5- Pelvic floor control exercises & physiotherapy based machines: like muscle contraction and relaxation activities, or Kegel exercises, to “desensitise” the voluntary control of the pelvic floor muscles.
6- Insertion or dilation training: Once a woman can do this without pain, she will learn to use a plastic dilator. If she can insert this without pain, the next step will be to leave it in for 10 to 15 minutes, to let the muscles get used to the pressure. When the woman feels comfortable with this, she can allow her partner to put his penis near the vagina, but not inside. When she is completely comfortable with this, the couple can try to build up gradually their intercourse experience according to the woman’s response.
7-Medical Management: “Botulinum Neurotoxin Type A” injection:
Vaginal Botox injections for the treatment of vaginismus has received increasing attention since the technique was first described in a 1997 case report.
Dr. Nadia Yousri, is a Gynaecologist & an expert in treating Vaginismus with the Botulinum A, Neurotoxin-Muscle Relaxing injections safely with an approach that allows 1st proper Gynaecological assessment to determine the exact muscles involved, to plan the exact points of injection & the does required.
Post procedure instructions are explained to maintain the success of the treatment & its kick start for natural intimate relationship.
It is advisable that the process of Neurotoxin injection is to be done by an Experienced Gynaecologist, understandably to avoid occurrence of serious complications due to injecting the wrong set of muscles or the wrong dose; creating problems like severe urinary incontinence, persistent stool incontinence, paraplegia or systemic complications that could last for several weeks.
Published by Dr. Nadia Yousri, FRCOG, Aesthetic Regenerative Gynaecology Consultant©
All copyrights reserved to www.drnyaesthetics.com©®
YouTube: Dr. Nadia Yousri: https://youtu.be/PdTObUhTnyo
Links to the press:-
1- Dr Nadia Yousri- the keynote Expert in the Webinar of Vaginismus Treatment by the Neurtoxin. Published 2 by the international IMCAS ACADEMY website on 27th of May 2022
–Vaginismus Treatment: Clinical Trials Follow Up 241 Patients. Pacik PT, Geletta S. Sex Med. 2017 Jun;5(2):e114-e123.
–Interventions for vaginismus. Melnik T, Hawton K, McGuire H. Cochrane Database Syst Rev. 2012 Dec 12;12(12):CD001760
–Understanding and treating vaginismus: a multimodal approach.Pacik PT. Int Urogynecol J. 2014 Dec;25(12):1613-20.
–The Neurobiology and Psychiatric Perspective of Vaginismus: Linking the Pharmacological and Psycho-Social Interventions.
Kadir ZS, Sidi H, Kumar J, Das S, Midin M, Baharuddin N. Curr Drug Targets. 2018;19(8):916-926
– Outcome of Medical and Psychosexual Interventions for Vaginismus: A Systematic Review and Meta-Analysis.
Maseroli E, Scavello I, Rastrelli G, Limoncin E, Cipriani S, Corona G, Fambrini M, Magini A, Jannini EA, Maggi M, Vignozzi L. J Sex Med. 2018 Dec;15(12):1752-1764
– Botulinum neurotoxin type A injections for vaginismus secondary to vulvar vestibulitis syndrome. Bertolasi L, Frasson E, Cappelletti JY, Vicentini S, Bordignon M, Graziottin A. Obstet Gynecol. 2009 Nov;114(5):1008-1016
– Methodological approaches to botulinum toxin for the treatment of chronic pelvic pain, vaginismus, and vulvar pain disorders.Karp BI, Tandon H, Vigil D, Stratton P. Int Urogynecol J. 2019 Jul;30(7):1071-1081.
–Botulinum Toxin A Injections Into Pelvic Floor Muscles Under Electromyographic Guidance for Women With Refractory High-Tone Pelvic Floor Dysfunction: A 6-Month Prospective Pilot Study.
Morrissey D, El-Khawand D, Ginzburg N, Wehbe S, O’Hare P 3rd, Whitmore K. Female Pelvic Med Reconstr Surg. 2015 Sep-Oct;21(5):277-82.
–Improvement in pelvic pain with botulinum toxin type A – Single vs. repeat injections.
Nesbitt-Hawes EM, Won H, Jarvis SK, Lyons SD, Vancaillie TG, Abbott JA. Toxicon. 2013 Mar 1;63:83-7.
–Vaginismus: review of current concepts and treatment using botox injections, bupivacaine injections, and progressive dilation with the patient under anesthesia.
Pacik PT. Aesthetic Plast Surg. 2011 Dec;35(6):1160-4.
– Successful use of botulinum toxin type a in the treatment of refractory postoperative dyspareunia.
Park AJ, Paraiso MFR. Obstet Gynecol. 2009 Aug;114(2 Pt 2):484-487
–Vaginismus Treatment: Clinical Trials Follow Up 241 Patients.
Pacik PT, Geletta S. Sex Med. 2017 Jun;5(2):e114-e123.
-The Vaginismus Network
-Vaginismus Support Group