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Genito-Pelvic Pain/Penetration Disorder (Vaginismus)

- Primary - Psychological and psychosocial issues - Negative messages about sex and sexual relations in upbringing may cause phobic reaction. - Poor body image and limited understanding of genital area - History of sexual trauma

- Complete medical history - Full psychosocial and sexual history, including the following: - Onset of symptoms (primary or secondary) - If secondary, precipitating events, if any - Relationship difficulty/partner violence - Inability to allow vaginal entry for different purposes - Sexual (penis, digit, object) - Hygiene (tampon use) - Health care (pelvic examination)

- Infertility - Traumatic experiences (exam, sexual, etc.) - Religious beliefs - Views on sexuality

- Pelvic examination is necessary to exclude structural abnormalities or organic pathology. - Educating the patient about the examination and giving her control over the progression of the examination is essential, as genital/pelvic examination may induce varying degrees of anxiety in patients. - Referral to a gynecologist, family physician, or other provider specializing in the treatment of sexual disorders may be appropriate. - Contraction of pelvic floor musculature in anticipation of examination may be seen. - Lamont classification system aids in the assessment of severity - First degree: Perineal and levator spasm relieved with reassurance. - Second degree: Perineal spasm maintained throughout the pelvic exam. - Third degree: levator spasm and elevation of buttocks - Fourth degree: levator and perineal spasm and elevation with adduction and retreat

- Genito-pelvic pain penetration disorder may be successfully treated (2)[B]. - Outpatient care is appropriate. - Treatment of physical conditions, if present, is first line (see "Secondary"Ł under "Etiology and Pathophysiology"Ł). - Role for pelvic floor physical therapy and myofascial release - Some evidence suggests that cognitive-behavioral therapy may be effective, including desensitization techniques, such as gradual exposure, aimed at decreasing avoidance behavior and fear of vaginal penetration (3)[A]. - Based on a Cochrane review, a clinically relevant effect of systematic desensitization cannot be ruled out (4)[A]. - Evidence suggests that Masters and Johnson sex therapy may be effective (5)[B]. - Involves Kegel exercises to increase control over perineal muscles - Stepwise vaginal desensitization exercises - With vaginal dilators that the patient inserts and controls - With woman's own finger(s) to promote sexual self-awareness - Advancement to partner's fingers with patient's control - Coitus after achieving largest vaginal dilator or three fingers; important to begin with sensate-focused exercises/sensual caressing without necessarily a demand for coitus - Female superior at first; passive (nonthrusting); female-directed - Later, thrusting may be allowed.

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  • May first present during evaluation for infertility
  • Pregnancy can occur in patients with genito-pelvic pain/penetration disorder when ejaculation occurs on the perineum.
  • Vaginismus may be an independent risk factor for cesarean delivery.

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EPIDEMIOLOGY

Incidence

The incidence of vaginismus is thought to be about 1-17% per year worldwide. In North America, 12-21% of women have genito-pelvic pain of varying etiologies (2). á

Prevalence

  • True prevalence is unknown due to limited data/reporting.
  • Population-based studies report prevalence rates of 0.5-30%.
  • Affects women in all age groups.
  • Approximately 15% of women in North America report recurrent pain during intercourse.

ETIOLOGY AND PATHOPHYSIOLOGY

Most often multifactorial in both primary and secondary vaginismus á

  • PrimaryPsychological and psychosocial issuesNegative messages about sex and sexual relations in upbringing may cause phobic reaction.Poor body image and limited understanding of genital areaHistory of sexual traumaAbnormalities of the hymenHistory of difficult gynecologic examination
  • SecondaryOften situationalOften associated with dyspareunia secondary to:Vaginal infectionInflammatory dermatitisSurgical or postdelivery scarringEndometriosisInadequate vaginal lubricationPelvic radiationEstrogen deficiencyConditioned response to pain from physical issues previously listed

RISK FACTORS

  • Most often idiopathic
  • Although the exact role in the condition is unclear, many women report a history of abuse or sexual trauma.
  • Often associated with other sexual dysfunctions

COMMONLY ASSOCIATED CONDITIONS

  • Marital stress, family dysfunction
  • Anxiety
  • Vulvodynia/vestibulodynia

DIAGNOSIS

DSM-5 has combined vaginismus and dyspareunia in a condition called genito-pelvic pain/penetration disorder. á

HISTORY

  • Complete medical history
  • Full psychosocial and sexual history, including the following:Onset of symptoms (primary or secondary)If secondary, precipitating events, if anyRelationship difficulty/partner violenceInability to allow vaginal entry for different purposesSexual (penis, digit, object)Hygiene (tampon use)Health care (pelvic examination)InfertilityTraumatic experiences (exam, sexual, etc.)Religious beliefsViews on sexuality

PHYSICAL EXAM

  • Pelvic examination is necessary to exclude structural abnormalities or organic pathology.
  • Educating the patient about the examination and giving her control over the progression of the examination is essential, as genital/pelvic examination may induce varying degrees of anxiety in patients.
  • Referral to a gynecologist, family physician, or other provider specializing in the treatment of sexual disorders may be appropriate.
  • Contraction of pelvic floor musculature in anticipation of examination may be seen.
  • Lamont classification system aids in the assessment of severityFirst degree: Perineal and levator spasm relieved with reassurance.Second degree: Perineal spasm maintained throughout the pelvic exam.Third degree: levator spasm and elevation of buttocksFourth degree: levator and perineal spasm and elevation with adduction and retreat

DIFFERENTIAL DIAGNOSIS

  • Vaginal infection
  • Vulvodynia/vestibulodynia
  • Vulvovaginal atrophy
  • Urogenital structural abnormalities
  • Interstitial cystitis
  • Endometriosis

DIAGNOSTIC TESTS & INTERPRETATION

No laboratory tests indicated unless signs of vaginal infection are noted on examination. When diagnosing of this disorder has been conducted, five factors should be considered. á

  • Partner factors
  • Relationship factors
  • Individual vulnerability factors
  • Cultural/religious factors
  • Medical factors

Test Interpretation

Not available; may be needed to check for secondary causes á

TREATMENT

  • Genito-pelvic pain penetration disorder may be successfully treated (2)[B].
  • Outpatient care is appropriate.
  • Treatment of physical conditions, if present, is first line (see "Secondary"Ł under "Etiology and Pathophysiology"Ł).
  • Role for pelvic floor physical therapy and myofascial release
  • Some evidence suggests that cognitive-behavioral therapy may be effective, including desensitization techniques, such as gradual exposure, aimed at decreasing avoidance behavior and fear of vaginal penetration (3)[A].
  • Based on a Cochrane review, a clinically relevant effect of systematic desensitization cannot be ruled out (4)[A].
  • Evidence suggests that Masters and Johnson sex therapy may be effective (5)[B].Involves Kegel exercises to increase control over perineal musclesStepwise vaginal desensitization exercisesWith vaginal dilators that the patient inserts and controlsWith woman's own finger(s) to promote sexual self-awarenessAdvancement to partner's fingers with patient's controlCoitus after achieving largest vaginal dilator or three fingers; important to begin with sensate-focused exercises/sensual caressing without necessarily a demand for coitusFemale superior at first; passive (nonthrusting); female-directedLater, thrusting may be allowed.
  • Topical anesthetic or anxiolytic with desensitization exercises may be considered.
  • Patient education is an essential component of treatment (see "Patient Education"Ł section).

MEDICATION

  • Antidepressants and anticonvulsants have been used with limited success. Low-dose tricyclic antidepressant (amitriptyline 10 mg) may be initiated and titrated as tolerated (6)[B].
  • Topical anesthetics or anxiolytics may be utilized in combination with either cognitive-behavioral therapy or desensitization exercises as noted above (4)[B].
  • Botulinum neurotoxin type A injections may improve vaginismus in patients who do not respond to standard cognitive-behavioral and medical treatment for vaginismus.Dosage: 20, 50, and 100 to 400 U of botulinum toxin type A injected in the levator ani muscle have been shown to improve vaginismus (4)[B].
  • Intravaginal botulinum neurotoxin type A injection (100 to 150 U) followed by bupivacaine 0.25% with epinephrine 1:400,000 intravaginal injection (20 to 30 mL) while the patient is anesthetized may facilitate progressive placement of dilators and ultimately resolution of symptoms (7)[B].

ISSUES FOR REFERRAL

For diagnosis and treatment recommendations, the following resources may be consulted: á

  • Obstetrics/gynecology
  • Pelvic floor physical therapy
  • Psychiatry
  • Sex therapy
  • Hypnotherapy

SURGERY/OTHER PROCEDURES

Contraindicated á

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Biofeedback
  • Functional electrical stimulation

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Desensitization techniques of gentle, progressive, patient-controlled vaginal dilation á

Patient Monitoring

General preventive health care á

DIET

No special diet á

PATIENT EDUCATION

  • Education about pelvic anatomy, nature of vaginal spasms, normal adult sexual function
  • Handheld mirror can help the woman to learn visually to tighten and loosen perineal muscles.
  • Important to teach the partner that spasms are not under conscious control and are not a reflection on the relationship or a woman's feelings about her partner
  • Instruction in techniques for vaginal dilation
  • ResourcesAmerican College of Obstetricians & Gynecologists (ACOG), 409 12th St., SW, Washington, DC 20024-2188; 800-762-ACOG. http://www.acog.org/Valins L. When a Woman's Body Says No to Sex: Understanding and Overcoming Vaginismus. New York, NY: Penguin; 1992.

PROGNOSIS

Favorable, with early recognition of the condition and initiation of treatment á

REFERENCES

11 American Psychiatric Association. Diagnostic Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.22 Landry áT, Bergeron áS. How young does vulvo-vaginal pain begin? Prevalence and characteristics of dyspareunia in adolescents. J Sex Med. 2009;6(4):927-935.33 ter Kuile áMM, Both áS, van Lankveld áJJ. Cognitive behavioral therapy for sexual dysfunctions in women. Psychiatr Clin North Am. 2010;33(3):595-610.44 Melnik áT, Hawton áK, McGuire áH. Interventions for vaginismus. Cochrane Database Syst Rev. 2012;(12):CD001760.55 Pereira áVM, Arias-Carri │n áO, Machado áS, et al. Sex therapy for female sex dysfunction. Int Arc Med. 2013;6(1):37.66 Crowley áT, Goldmeier áD, Hiller áJ. Diagnosing and managing vaginismus. BMJ. 2009;338:b2284.77 Pacik áPT. Vaginismus: review of current concepts and treatment using botox injections, bupivacaine injections, and progressive dilation with the patient under anesthesia. Aesthetic Plast Surg. 2011;35(6):1160-1164.

ADDITIONAL READING

  • Basson áR, Wierman áME, van Lankveld áJ, et al. Summary of the recommendations on sexual dysfunctions in women. J Sex Med. 2010;7(1, Pt 2):314-326.
  • Jeng áCJ, Wang áLR, Chou áCS, et al. Management and outcome of primary vaginismus. J Sex Marital Ther. 2006;32(5):379-387.
  • Pacik áPT. Understanding and treating vaginismus: a multimodal approach. Int Urogynecol J. 2014;25(12):1613-1620.
  • Reissing áED, Binik áYM, Khalif ę áS, et al. Etiological correlates of vaginismus: sexual and physical abuse, sexual knowledge, sexual self-schema, and relationship adjustment. J Sex Marital Ther. 2003;29(1):47-59.
  • Simons áJS, Carey áMP. Prevalence of sexual dysfunctions: results from a decade of research. Arch Sex Behav. 2001;30(2):177-219.
  • ter Kuile áMM, van Lankveld áJJ, de Groot áE, et al. Cognitive-behavioral therapy for women with lifelong vaginismus: process and prognostic factors. Behav Res Ther. 2007;45(2):359-373.

SEE ALSO

Dyspareunia; Sexual Dysfunction in Women á

CODES

ICD10

  • N94.2 Vaginismus
  • N94.1 Dyspareunia

ICD9

  • 625.1 Vaginismus
  • 625.0 Dyspareunia

SNOMED

  • 266598008 vaginismus due to non-psychogenic cause (finding)
  • 71315007 Dyspareunia (finding)
  • 198402002 Dyspareunia due to non-psychogenic cause in the female

CLINICAL PEARLS

  • In a patient with suspected genito-pelvic pain penetration disorder, a complete medical history, including a comprehensive psychosocial and sexual history and a patient-centric, patient-controlled educational pelvic exam should be conducted.
  • This condition can be treated effectively.
  • Cognitive-behavioral therapy may be effective for the treatment of this condition.
  • Botox injection therapy is in the experimental stages but looks promising for the treatment of vaginismus. Bupivacaine and dilation under general anesthesia has also been tried as a treatment for vaginismus.