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Genevieve and Paul, a couple in their early twenties complain that they have not
consummated their marriage so far, despite being married for 2 years.
This is because Genevieve experiences severe pain in the lower vagina when penetrative
intercourse is attempted.
The medical, surgical, family and drug histories of both partners are unremarkable. Nor is
there a history of past sexual abuse or psychological or social difficulties.
Both parties drink only socially and do not smoke or use recreational drugs.
On examinatiom Genevieve looks well with stable vital parameters. Her heart, lungs,
abdomen and CNS evaluation show no abnormalities. Pelvic examination reveals: (a) the vulvar
region appears normal; (b) no abnormal discharges; (c) insertion of the examining finger results
in severe pain spasms of the outer one-third of the vagina.
1. Salient features
(+) severe pain in the lower vagina when penetrative intercourse is attempted
(+) insertion of examining finger results in severe painand spasms of the outer one-third of the
vagina
2). What are the relevant laboratory investigations, should there be, that can aid the
diagnosis?
Specify whether:
Lifelong: The disturbance has been present since the individual became sexually active.
Acquired: The disturbance began after a period of relatively normal sexual function
Current treatments for vaginismus can be divided into four main categories: pelvic floor
physiotherapy, pharmacological treatments, general psychotherapy and sex/cognitive behavioral
therapy.
The rationale for the use of pelvic floor physiotherapy in the treatment of vaginismus is that it
will aid in developing awareness and control of the vaginal musculature as well as restore
function, improve mobility, relieve pain and overcome vaginal penetration anxiety.
Physical therapists use a variety of techniques to achieve these goals, such as breathing and
relaxation, local tissue desensitization, vaginal dilators, pelvic floor biofeedback and manual
therapy techniques
Pharmacological treatment
Three main types of pharmacological treatment have been proposed for vaginismus: local
anesthetics (e.g., lidocaine), muscle relaxants (e.g., nitroglycerin ointment and botulinum toxin)
and anxiolytic medication
Local anesthetics, such as lidocaine gel, have been proposed based on the rationale that
vaginismic muscle spasms are due to repeated pain experienced with vaginal penetration and,
hence, the use of a topical anesthetic aimed at reducing the pain is hypothesized to resolve the
spasm . A 5% lidocaine gel was applied on the hyperesthetic areas of the vaginal and topical
nitroglycerin ointment, hypothesized to treat the muscle spasm by relaxing the vaginal muscles,
was also discussed only in a case study.
Botulinum toxin, a temporary muscle paralytic, has been recommended in the treatment
of vaginismus with the aim of decreasing the hypertonicity of the pelvic floor muscles.
Another pharmacological treatment that has been proposed is the use of anxiolytics, such
as IV diazepam, in conjunction with psychotherapy based on the hypothesis that vaginismus is a
psychosomatic condition resulting from past trauma and, thus, anxiety reducing medication will
resolve the symptoms.
General psychotherapy
In couples therapy, vaginismus is conceptualized as a problem for the couple and the treatment
tends to focus on the couple’s sexual history and any other problems that may be occurring in the
relationship.
In the 1970s, Masters and Johnson reported that vaginismus could be easily treated with
behaviorally oriented sex therapy that included vaginal dilatation.
The first step of their treatment consists of the physical demonstration of the vaginal
muscle spasm to the patient (and her partner) during a gynecological examination. The couple is
then instructed to insert a series of dilators of graduated sizes at home guided by both the patient
and her partner with the aim of desensitizing the patient to vaginal penetration. Masters and
Johnson’s treatment regimen also emphasized the importance of education regarding sexual
function and the development and maintenance of vaginismus in order to relieve the
psychological impact of the condition.
As a result of the influence of Masters and Johnson, several studies were conducted on
the efficacy of sex therapy in the treatment of vaginismus with excellent success rates reported
resulting in continued utilization of this treatment for vaginismus.
The first ever randomized controlled therapy outcome study for vaginismus was recently
published. This study investigated a cognitive behavioral sex therapy for the treatment of
vaginismus. The treatment included the sexual education and vaginal dilatation technique as in
Masters and Johnson’s treatment protocol. It was also comprised of cognitive therapy, relaxation
and sensate focus exercises.
Participants received the treatment for 3 months either in group therapy or in bibliotherapy
format. At
The treatment was comprised of education on the fear and avoidance model of vaginal
penetration as well as of a maximum of three 2 h sessions of in vivo exposure to the stimuli
feared during vaginal penetration. A replicated (n = 10) randomized single-case A–B phase
design was used. The results showed that nine out of ten participants were able to engage in
intercourse following treatment and these findings persisted at a 1-year follow-up. In addition,
the exposure treatment was successful in decreasing fear and negative penetration beliefs.
Step 1 provides an overview of vaginismus and how sexual pain, tightness, burning sensations or
penetration difficulties may result from it. This approach helps women to get started by being
proactive about their sexual health as understanding vaginismus is fundamental to the process of
overcoming it. Topics also include how to obtain a solid diagnosis, treatment methods,
relationship issues, pelvic/relaxation techniques, conditioned responses and muscle memories.
A balanced approach is taken to help women review and analyze their history. Exercises help
identify and evaluate any events, emotions, or triggers contributing to vaginismus sexual pain or
penetration problems. Checklists and detailed exercises map out a woman’s sexual history and
pelvic pain events, working toward appropriate treatment strategies. Emotional reviews help
detail any negative events, feelings, or memories that may collectively contribute to involuntary
pelvic responses. Topics also include blocked or hidden memories and how to move forward
when there have been traumatic events in a woman’s past.
Women often lack complete information about their body’s sexual anatomy, function, and the
causes of pelvic pain and penetration problems. Confusion regarding problems with inner
vaginal areas and vaginal muscles frequently lead to misdiagnosis and frustration. Step 3
educates about these sexual body parts with emphasis on their role in sexual pain and penetration
issues. Topics include how to distinguish what kind of pain or discomfort is normal with first-
time or ongoing sex and what physical changes take place during arousal to orgasm cycles in the
context of sexual pain or penetration problems. Anatomy areas such as the hymen and inner
vulva are explained and demystified (for example there are six diagrams of hymen varieties to
help distinguish hymen problems).
Muscles Female sexual pain and penetration difficulties typically involve some degree of
involuntary tightening of the pelvic floor. This step focuses on the role of pelvic floor muscles,
especially the pubococcygeus (PC) muscle group, explaining in great detail how once they are
triggered they continue to cause involuntary tightness with attempts at intercourse. Effective
vaginismus treatment focuses on retraining the pelvic floor to eliminate involuntary muscle
reactions that produce tightness or pain. Learning how to identify, selectively control, exercise
and retrain the pelvic muscles to reduce pain and alleviate penetration tightness and difficulties is
an important step in vaginismus treatment.
For women with penetration difficulties or pain, techniques must be learned to allow initial entry
without pain. In this step, women practice pubococcygeus (PC) muscle control techniques as
they allow the entry of a small object (cotton swab, tampon, or finger) into their vagina, working
completely under their control and pace. Any involuntary muscle contractions that had
previously closed the entrance to the vagina and prevented penetration are overridden. Women
begin to take full control over their pelvic floor and learn how to flex and relax the pelvic floor at
will, eliminating unwanted tightness and allowing entry.
When used properly, vaginal dilators are effective tools to further help eliminate pelvic tightness
due to vaginismus. Dilators provide a substitute means to trigger pelvic muscle reactions. The
effective dilator exercises in Step 6 teach women how to override involuntary contractions,
relaxing the pelvic floor so it responds correctly to sexual penetration. Graduated vaginal
insertion exercises allow women to comfortably transition to the stage where they are ready for
intercourse without pain or discomfort.
Step 7 – Sensate Focus & Techniques For Couples To Reduce Pelvic Floor Tension
Helping with the transition to pain-free intercourse, this step explains sensate focus techniques
for couples to use to reduce pelvic floor tension and increase intimacy. Couples begin to work
together during this step as exercises teach how to successfully practice sensate focus (controlled
sensual touch) and prepare for pain-free intercourse using techniques from earlier steps. The
exercises are designed to build trust and understanding and assist in the process to adjust to
controlled intercourse without pain.
Step 8 – Pre-Intercourse Readiness Exercises
Finalizing preparations for couples to transition to fully pain-free intercourse, this step completes
pre-intercourse readiness. Couples review and practice techniques that eliminate pelvic floor
tension and prepare to transition to full intercourse. Preparing ahead of time to be able to
manage, control and eliminate pain or penetration difficulties, the exercises assist with the final
transition to pain-free intercourse.
Step 9 explains the techniques used to eliminate pain and penetration difficulties while
transitioning to normal intercourse. Many troubleshooting topics are covered (with supporting
diagrams) such as positions to use to maximize control and minimize pain, tips to ensure more
comfortable intercourse, etc.
The final step toward overcoming vaginismus includes penis entry with movement and freedom
from any pain or tightness. Step 10 exercises are designed to educate, build sexual trust and
intimacy, and complete the transition to full sexual intercourse free of pain. Couples can begin to
enjoy pleasure with intercourse, initiate family planning, and move forward to live life free from
vaginismus.
Lifelong: The disturbance has been present since the individual became sexually active.
Acquired: The disturbance began after a period of relatively normal sexual function