Pharmacotherapy of vaginismus

Pharmacotherapy of vaginismus is a type of therapy, which is focused on release of excessive tension of the pelvic floor muscles (Pic. 1).

Vaginismus is characterized by recurrent or persistent involuntary contraction of the perineal muscles surrounding the outer third of the vagina when penile, finger, tampon, or speculum penetration is attempted. 

Three main types of pharmacological treatment have been proposed for vaginismus: local anesthetics (e.g., lidocaine), muscle relaxants (e.g., botulinum toxin) and anxiolytic medication.

Anesthetics

Lidocaine

Topical application of lidocaine gel can be used during finger dilatation in patients, who have associated pain or areas of hypertensia (areas with increased pressure) in the introitus of vagina (the opening that leads to the vaginal canal). Gel is often used at home before intercourse.

Muscle relaxants

Botulinum toxin injection

Botulinum toxin injection is the most used cure with promising results. Botox causes a weakening and paralysis of the target muscles of pelvic floor. Depending on how many muscles are involved in idividual, the amount of Botox is used. The dose of Botox is divided into main muscles (especially pubococcygeus), because very often these are blocking the penetration. Botox is administred to the woman under general anaesthesia, light sedation or without it, depending on patient or clinician preference. The toxin is injected into vaginal wall with a needle. 

The injection of Botox and insertion of a dilator (medical implement used to expand an opening of or vaginal introitus) under anesthesia with follow up progressive dilation also has shown to be a safe and effective treatment for vaginismus. Most women are able to have pain free intercourse within 2-4 weeks after the procedure. 

The effect of botox can last for up to 6 months. The effect is usually reduced over time, but the medication can be repeated. Sometimes the high doses can lead to antibody formation, which have impact on therapeutic effect. To avoid this, it is reccomended to have treatment no more frequently than every 3 months.

Anxiolytic medication

When vaginismus is accompanied by severe anxiety or panic, anxiolytic medication may be a useful adjunct to psychotherapy.

Every women can have different degree of relief and duration of medication due to severity of condition. 

It is neccessary to evaluate women to find out the underlying condition of vaginismus. A botox therapy is not a substitution for more traditional methods of managing the vaginismus such as psychosexual counselling which uses psychotherapeutic or behavioural techniques. 

Although no random controlled trials have been done with this treatment, experimental studies with small samples have shown it to be effective, with sustained positive results through 10 months. 

Also any contraindications to botulinum toxin must be ruled out. The major contraindications are pregnancy and breastfeeding, blood clotting disorders and disorders of muscle activity such as myasthenia gravis (muscular weakness).

While botulinum toxin is generally considered safe in a clinical setting, there can be serious side effects from its use. Side effects from therapeutic use can be much more varied depending on the location of injection and the dose of toxin injected. 

A local discomfort from injection is the most common side effect. Botulinum toxin can be injected into the wrong muscle group or spread from the injection site, causing paralysis of unintended muscles. Rare side effects include arrhythmia (irregular heart beat), heart attack, and in some cases seizures, respiratory arrest, and death, which include from paralysis of critical muscle groups.

The Botox procedure coupled with sexuality counseling/education can help their patients conquer vaginismus once and for all. Almost 99% of cases can be successfully cured.