Vaginismus is involuntary spasm or contraction of the muscles surrounding the lower third of the vagina with attempts at any form of vaginal penetration. It involves the muscles just below the skin called the perineal muscles and the deeper pelvic floor muscles (PFM). Once you have experienced pain with attempts at penetration, it makes the next time even more difficult, as a fear of pain can increase your pain as well as heighten the muscle contraction, further compounding the pain.
Vaginismus is a paradox, it is involuntary contraction of voluntary muscles. Primary vaginismus is where no vaginal penetration has ever been successful, this includes tampons, intercourse and ultrasound etc. Secondary vaginismus is where vaginal penetration was possible in the past but is now no longer possible due to a variety of reasons which may lead to fear of pain with attempts at penetration.
Women who fear pain with penetration will contract their PFM unknowingly, as a protective mechanism. This can then lead to the contraction of other surrounding muscles such as the legs, buttocks and hips, often squeezing their legs closed. Many women perceive that the pain they experience is very harmful but this is not the case; some will also have anxious reactions to attempts at penetration such as crying, hyperventilating, heart racing, sweating. All of these perpetuate the cycle of: fear of pain -> muscle contraction -> increased pain -> increased muscle contraction and so on.
Vaginismus is poorly understood. It is thought to affect 1-7 % females, is cross-cultural and has no definite cause. Many women have never managed a tampon, a vaginal ultrasound, a vaginal examination, a Pap smear (except under general anaesthetic in hospital).
Some women may have definite views regarding sexual activity, sexuality, or premarital sexual activity and virginity. Some may have had a strict and or religious upbringing, possibly with limited education about sex. Some women may have preconceived ideas that sexual intercourse will cause pain or injury, that their anatomy is abnormal, that they have no vagina or their vagina is too small. Some women may be undergoing extreme stress in their lives. Some may also have mental health issues such as anxiety, depression, fears, phobias or a past that includes childhood sexual abuse, sexual assault or violence.
Some women have had none of these issues or scenarios in their life, it just seems they experienced some difficulty and pain at first attempts and this has begun the cycle of fear of pain and muscle contraction. For most women with vaginismus avoidance is also an issue, if they have partner they often avoid attempts at intercourse and even intimacy, or if they don’t have a partner, they may avoid dating for fear of intimacy leading to attempts at intercourse.
It is always important for the health care practitioners looking after you to address any possible physical contributors to vaginismus. There are many and if they are overlooked you may be spending time on therapies that may not be appropriate for you. Not all cases of vaginismus are psychological.
Some physical conditions to consider and discuss with your doctor or allied health practitioner include:
Undiagnosed endometriosis may be a contributor. This is often associated with period pain, pain with bowel opening, non-menstrual pelvic pain and pain with, or inability to manage sexual intercourse due to pain.
Infections in other parts of your body that require the frequent use of antibiotics can lead to undiagnosed recurrent vulvo-vaginal thrush. This can make the skin sore and lead to pain at attempts at penetration.
Some sexually transmitted infections, for example vulval warts or herpes, may lead to secondary vaginismus in some women if there is ongoing pain after the STI has been treated, but the pain is unmanaged.
Tissue or nerve hypersensitivity at the entry of the vagina, such as with pudendal nerve pain (the pelvic and perineal nerve), also called pudendal neuralgia.
Vulval skin conditions, such as Lichen sclerosus, eczema, dermatitis, psoriasis.
Vulval pain. Skin changes can occur after menopause, early menopause or menopause after breast cancer treatment. Irregular periods, long term absent periods or long term use of the oral contraceptive pill may also affect the vulval skin integrity due to under oestrogenisation of the tissues. Thinning of the skin, dryness, redness, splitting and irritation may occur, which may cause skin pain with attempts at penetration that can lead to the anticipatory PFM contraction that is vaginismus.
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Click HereHow your vaginismus is managed will depend on all the factors that may be contributing to your pain, and this will be individualized for you. Some common treatment approaches may include:
Some women don’t need to see a psychologist / sex therapist or counsellor and are able to manage with an experienced pelvic floor physiotherapist only. The physiotherapist will guide them through a PFM stretching programme using vaginal dilators, also referred to as trainers or accommodators.
Some women need to see a psychologist / sex therapist or counsellor first, for CBT, counselling, EMDR, hypnosis or self-hypnosis as appropriate, then when they are ready, physical therapies with an experienced pelvic floor physiotherapist may be added.
Some women do better if they see a psychologist / sex therapist or counsellor concurrently with their pelvic floor physiotherapist.
Some women may see a pelvic floor physiotherapist first. The physiotherapist may believe they are not ready for physical therapies yet and suggest they see a psychologist / sex therapist or counsellor first or concurrently.
With all physical therapies it is important that you contribute at home to ensure you gain the most from your treatments. It is very important to commit to the daily homework as discussed with your physiotherapist, as you will not make reasonable progress if you do not do the stretches.
Some women may have tried all or some of the above approaches and may still be struggling with vaginismus and may benefit from Botulinum Toxin Type A treatment. This is also known as BONTA, Botox® or Dysport®. The treatment involves injections of Botulinum Toxin Type A into the PFM to provide a temporary window of opportunity to rehabilitate and stretch the over contracting PFM. Botulinum Toxin Type A injections may not be suitable for all women and need to be discussed with your doctor and pelvic floor physiotherapist.
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