Vaginismus

September 29, 2011

Vaginismus is defined as the involuntary spasm of the pelvic muscles surrounding the outer third of the vagina. Such spasm may interfere with or prevent sexual intercourse. In some cases, vaginismus may prevent insertion of almost anything into the vagina, including tampons, fingers, or speculums used in gynecologic examinations.

The psychiatric diagnosis of vaginismus is described in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). The essential feature of the disorder is the “recurrent or persistent involuntary contraction” of the involved vaginal muscles, which interferes with sexual intercourse. To make the diagnosis of vaginismus, the symptoms must (a) cause marked distress or interpersonal difficulty, (b) cannot be better accounted for by another major psychiatric disorder,and (c) cannot be due exclusively to the direct physical effects of a medical condition. Although pain is not part of this definition, most women with vaginismus either experience pain or fear pain with vaginal penetration. That being the case, distinguishing vaginismus from dyspareunia (genital pain with sexual intercourse) can be difficult. The diagnosis should be confirmed by careful pelvic examination, preferably by a thoughtful, sensitive physician well versed in the care of women with sexual dysfunction.

The rate of vaginismus in the general population is estimated at 1% or less. The rate is higher in women referred to sexual dysfunction and medical clinics, ranging between 5% and 42%. The spasm of vaginismus is typically triggered by anticipation of or actual attempts at vaginal penetration. Responses and reactions of women with the disorder vary. Fear of pain or other factors can prevent any attempts at sexual intercourse for some women, while other women and their partners do attempt penetration but report the sensation of “the penis hitting a brick wall” approximately 1 inch into the vagina.

Vaginismus is a significant and very troubling problem for women who experience it and for their partners. It is considered one of the main causes of “unconsummated marriage,” and may make conception impossible. It is almost always the source of strong feelings on the part of the woman and her partner. It may also prevent adequate gynecological care. Feelings such as frustration, embarrassment, humiliation, and inadequacy are common among women with this disorder. This is not to say that women with vaginismus are always sexually unresponsive. In fact, the opposite is true: Many women with the disorder are sexually responsive, experience orgasm with clitoral stimulation, and engage in satisfying, nonpenetrative sexual relationships.

A large number of possible causes for vaginismus have been proposed. The most widely accepted view is that vaginismus is a conditioned response to any unpleasant stimulus affecting the pelvic/genital region or sexual functioning of a woman. That is, the spasm that is characteristic of vaginismus may have at one time been a voluntary reaction on the part of a woman when encountering an unpleasant event or stimulus affecting the pelvic area (such as pain, surgery, or forceful intercourse). Later, when faced with stimuli that the woman perceives as similar to the original unpleasant stimulus, the spasm becomes “conditioned” or automatic and occurs involuntarily. This response of spasm is then reinforced by phobic avoidance of vaginal penetration and by beliefs that such penetration is harmful or painful.

Treatment of vaginismus is usually two-pronged, and includes (a) eliminating erroneous beliefs or thoughts which reinforce the response of involuntary muscle spasm and (b) desensitization exercises to eliminate anxiety about vaginal penetration and allow resolution of the fear response (muscle spasm). The first treatment aim is accomplished through education (e.g., about the size of the vagina and likelihood of pain) and by challenging erroneous beliefs and thoughts. The second aim is accomplished through relaxation exercises and gradual exposure to vaginal penetration. The woman is taught to gradually begin exploring her genital region, both visually and manually, and then to begin insertion of her fingers or dilators into the vaginal area, proceeding from smallest to largest. It is of utmost importance that the patient controls this process and how rapidly it proceeds. Many treatment programs also include vaginal muscle exercises to teach voluntary control over such muscles.

Treatment is individualized to a woman’s needs and wishes. For example, women who do not consider sexual intercourse important but wish to bear children may consider artificial insemination. When to include partners in treatment is an individualized decision. Problems such as impotence and premature ejaculation are common among male partners of vaginismic women. The partners should be treated at the same time, although many such problems will improve with treatment of the woman’s vaginismic response. Physical problems that act to reinforce the vaginismic response should be treated as well.

Originally, sex therapists such as Masters and Johnson reported cure rates of virtually 100% for vaginismus. Currently, reported cure and improvement rates are less dramatic, but most therapists report good success rates. Many factors play into the course of this disorder. The woman’s motivation to overcome the condition is the most important. Greater marital/relationship satisfaction, type of vaginismus (e.g., acquired rather than lifelong), and overall sexual comfort and enjoyment may all be associated with better response to treatment. Finally, the outcome of treatment is variable. Some women may be able to tolerate vaginal penetration but never find it truly pleasurable, while others will experience great pleasure and/or orgasm during coitus and will be able to include vaginal intercourse in a rich, satisfying sexual life thereafter.

See Also: Dyspareunia, Pain, Sexual dysfunction

Suggested Reading

  • Kaplan, H. S. (1974). The new sex therapy: Active treatment of sexual dysfunctions. New York: Brunner/Mazel.
  • Lamont, J. A. (1978). Vaginismus. American Journal of Obstetrics and Gynecology, 131(6), 633-636.
  • Leiblum, S. R., & Rosen, R. C. (Eds.). (2000). Principles and practice of sex therapy (3rd ed.). New York: Guilford Press.

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