Vaginismus is an involuntary tightening of the vagina due to a conditioned reflex of the muscles in the area during vaginal penetration. This involuntary vaginal muscle spasm makes any kind of vaginal penetration painful or impossible. It can affect any form of vaginal penetration, including sexual intercourse, insertion of tampons and menstrual cups, and the penetration involved in gynecological examinations. While there is a lack of evidence to definitively identify which muscle is responsible for the spasm, the pubococcygeus muscle, sometimes referred to as the "PC muscle", is most often suggested. The reflex causes the muscles in the vagina to tense suddenly. Other muscles such as the levator ani, bulbocavernosus, circumvaginal, and perivaginal muscles have also been suggested.

A woman with vaginismus 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, as well as the pain during penetration (including sexual penetration), varies from woman to woman. Vaginismus can be classified into two types:

Primary vaginismus

A woman is said to have primary vaginismus when she is unable to have penetrative sex or experience vaginal penetration without pain. It is commonly discovered in teenage girls and women in their early twenties, as this is when many girls and young women in the Western world first attempt to use tampons, have penetrative sex, or undergo a Pap smear. Women with vaginismus may be unaware of the condition until they attempt vaginal penetration. A woman may be unaware of the reasons for her condition.

Secondary vaginismus

Secondary vaginismus occurs when a person 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, while in some cases it may be due to psychological causes, or to a combination of 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. Peri-menopausal and menopausal vaginismus, often due to a drying of the vulvar and vaginal tissues as a result of reduced estrogen, may occur as a result of "micro-tears" first causing sexual pain then leading to vaginismus.

Moreover, vaginismus has been classified by Lamont according to the severity of the condition. Lamont describes four degrees of vaginismus:

  • the first degree - the patient has spasm of the pelvic floor that can be relieved with reassurance
  • the second degree - the spasm is present but maintained throughout the pelvis even with reassurance
  • the third degree - the patient elevates the buttocks to avoid being examined
  • the fourth degree - (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

Pacik expanded the Lamont classification to include a fifth degree in which the patient experiences a visceral reaction such as sweating, hyperventilation, palpitations, trembling, shaking, nausea, vomiting, losing consciousness, wanting to jump off the table, or attacking the doctor. The Lamont classification continues to be used to the present and allows for a common language among researchers and therapists.

A simplified and more versatile version of the classification includes symptoms that vary over four ranges:

  • the first range - minor discomfort that may diminish during intercourse 
  • the second range - burning and tightness persist 
  • the third range - entry and movement are painful
  • the fourth range - penetration is impossible and forced entry is extremely painful

Also due to anxiety and anticipation of pain, the body is trying to protect itself from harm, thus, it automatically tightens vaginal muscles. Couples may go through several attempts which only results in more pain and greater reflect response – tightness. The body tries to fight the pain, therefore, it tries to brace more and make the muscle reaction stronger. All these ongoing processes can lead to lack of desire and avoidance of intimacy. Altogether, there is clearly a difference between lifelong penetration difficulties related to fear and avoidance, which when overcome result in a woman learning that sex is not painful and the development of difficulties with penetration associated with finding attempted penetration painful. 

Associated Diseases

  • a condition called vulvar vestibulitis syndrome, more or less synonymous with focal vaginitis, a so-called sub-clinical inflammation, in which no pain is perceived until some form of penetration is attempted
  • urinary tract infections
  • vaginal yeast infection
  • dyspareunia – painful intercourse
  • female orgasmic disorder
  • pelvic pain
  • endometriosis

Complications

Unresolved vaginismus can negatively affect a woman's sexual life and present a challenge for a couple. 

Risk Factors
  • sexual abuse, rape, other sexual assault, or attempted sexual abuse or assault
  • knowledge of (or witnessing) sexual or physical abuse of others, without being personally abuse
  • domestic violence or similar conflict in the early home environment
  • fear of pain associated with penetration, particularly the popular misconception of "breaking" the hymen upon the first attempt at penetration, or the idea that vaginal penetration will inevitably hurt the first time it occurs
  • chronic pain conditions and harm-avoidance behaviour
  • any physically invasive trauma (not necessarily involving or even near the genitals
  • generalized anxiety
  • stress
  • negative emotional reaction towards sexual stimulation, e.g. disgust both at a deliberate level and also at a more implicit level
  • strict conservative moral education, which also can elicit negative emotions
  • fear of losing control
  • not trusting one’s partner
  • self-consciousness about body image
  • misconceptions about sex or unattainable standards for sex from exaggerated sexual materials, such as pornography or abstinence
  • fear of vagina not being wide or deep enough / fear of partner’s penis being too large
  • undiscovered or denied sexuality (specifically, being asexual or lesbian)
  • undiscovered or denied feelings of being transgender (specifically, a trans man)

Due to the discomfort when attempting penetration for some women entry of the penis may be impossible, thus, women suffering from vaginismus might be also struggling with infertility. Also, they may fail to consummate their marriage and inability to conceive can lead to even greater pain and depression. Since the woman cannot have sexual intercourse with partner, she may perceive herself as a failure and feel even more pressured and anxious. It is important not to blame yourself for this condition and it is highly recommended to seek a professional advice. With professional advice and help women can cure vaginismus and could even conceive.

Variety of techniques involving techniques that consists of a series of instrictions for touching activities can help couples to overcome anxiety and increase comfort with intercourse. The focus is placed on touch rather than on performance. To resolve the vaginismus and become fertile, women can either achieve sexual intercourse with intravaginal deposition of semen or try the natural way or assisted reproduction techniques. 

Vaginismus may present certain complications during gynaecological exams mainly due to pelvic tightness. Therefore, it is recommended to undergo treatment of vaginismus as soon as it is detected. If the treatment does not eliminate the problem, explaining the problem to physician and agreeing on next steps can reduce the feelings of discomfort. As for the delivery, the hormones released during the delivery widen woman’s body, thus the vaginismus should not have negative effect on delivery.

Since vaginismus is not intentional and since it is combination of either physical or non-physical (psychological) triggers or sometimes the cause is not identifiable, it is difficult to prevent it. Nevertheless, it is important to bear in mind that there no reason to feel shame or keep the pain private. Seeking professional advice can contribute to early recovery.

Some of symptoms include burning or stinging with tightness during sex, difficult or even impossible penetration or inserting tampons, difficult gynaecological exam, sexual discomfort, avoidance of sex due to pan and/or anxiety. The severe form of vaginismus also includes visceral reaction such as sweating, hyperventilation, palpitations, trembling, shaking, nausea, vomiting, losing consciousness, or wanting to jump off the table.

Vaginismus is treatable and even though women frequently describe having to work up the courage to ask for help, overcoming feelings of embarrassment and abnormality, and doubts about the legitimacy of their problem, it is important to seek a professional help. Practitioners can give specific advice about exercises and what is more important, they are knowledgeable about effective treatments. Having enough knowledge about exercises such as pelvic control exercises, progressive relaxation and touching exercise, insertion or dilation training or pain elimination techniques can contribute to successful treatment. Several techniques can be done at home or with help care provider. 

Often, when faced with a patient having painful intercourse, a gynecologist will recommend Kegel exercises and provide some additional lubricants. Unfortunately, strengthening the muscles that unconsciously tighten during vaginismus may be extremely counter-intuitive for some patients. Also, vaginismus has not been shown to affect a person’s ability to produce lubrication, thus providing lubricants may be extraneous to the actual condition.

Using vaginal trainers also known as dilators, remain the most widely recommended treatment for vaginismus. The role and purported mechanism of vaginal trainers in the treatment of vaginismus has ranged from stretching of the muscles after surgical division, reconditioning (retraining) muscles within an enhanced relationship, to educating a woman that beliefs underlying her fear of penetration are incorrect.

Having supportive partner is also very important; nevertheless, it is important to make sure that the partner understands the vaginismus. Practitioners can help enhance the communication between partners without blaming the relationship. Finding a peer support through societies, online forums and simply meeting people who understand the problem and sharing tips can be very helpful.

There are also vitamins and drugs that promise the treatment of vaginismus, nevertheless, their effect is not well-studied. Relaxing herbs (valerian, olive tree) could be used as natural lubricants or to reduce stress and anxiety but it is important to always seek someone who is well-educated in this type of treatment. Vaginismus have physical and mental cause, thus, appropriate therapies or relaxation techniques should be applied in treatment of vaginismus. 

Psychotherapy

According to Ward and Ogden's qualitative study on the experience of vaginismus (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). People with vaginismus 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 (non-sexual) physical abuse. Therefore, counselling, sex therapy, brief dynamic psychoanalysis or cognitive behavioural therapy could be helpful in treatment of vaginismus. These therapies could help to uncover underlying psychological causes (fear, anxiety, irrational thoughts and/or beliefs about sex). 

Pharmacotherapy

Anxiolytics and antidepressants are pharmacotherapies that have been offered to patients in conjunction with other psychotherapy modalities, or if these patients experience high levels of anxiety from their condition. Results from these types of pharmacologic therapies have not been consistent.

Surgical therapy

In some cases surgical widening of vagina can be performed.

If the intercourse is too painful, the self-insemination or intrauterine insemination can be underwent. Also ovarian stimulation could be done, nevertheless, it always depends on woman’s condition and severity of the vaginismus. Therefore, it is important to seek professional help and discuss all potential treatments.

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Sources

Vaginal disease ―sourced from Wikipedia licensed under CC BY-SA 3.0
Vaginismus ―sourced from Wikipedia licensed under CC BY-SA 3.0
Vaginismus ―sourced from World heritage encyclopedia licensed under CC BY-SA 3.0
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