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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
- 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
- Abnormalities of the hymen
- History of difficult gynecologic examination
- Secondary
- Often situational
- Often associated with dyspareunia secondary to:
- Vaginal infection
- Inflammatory dermatitis
- Surgical or postdelivery scarring
- Endometriosis
- Inadequate vaginal lubrication
- Pelvic radiation
- Estrogen deficiency
- Conditioned 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 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
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 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
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 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.
- 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
- Resources
- American 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.