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Genito-Pelvic Pain/Penetration Disorder (Vaginismus)
Jeffrey D. Quinlan, MD, FAAFP
image BASICS
Genito-pelvic pain/penetration disorder is the name of the conditions formally known as vaginismus and dyspareunia. Vaginismus results from involuntary contraction of the vaginal musculature. Primary vaginismus occurs in women who have never been able to have penetrative intercourse. Women with secondary vaginismus were previously able to have penetrative intercourse but are no longer able to do so.
DESCRIPTION
  • Persistent or recurrent difficulties for 6 months or more with at least one of the following:
    • Inability to have vaginal intercourse/penetration on at least 50% of attempts
    • Marked genito-pelvic pain during at least 50% of vaginal intercourse/penetration attempts
    • Marked fear of vaginal intercourse/penetration or of genito-pelvic pain during intercourse/penetration on at least 50% of vaginal intercourse/penetration attempts
    • Marked tensing or tightening of the pelvic floor muscles during attempted vaginal intercourse/penetration on at least 50% of occasions
  • The disturbance causes marked distress or interpersonal difficulty.
  • Dysfunction is not as a result of:
    • Nonsexual mental disorder
    • Severe relationship stress
    • Other significant stress
    • Substance or medication effect
  • Specify if with a general medical condition (e.g., lichen sclerosis, endometriosis) (1).
Pregnancy Considerations
  • 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.
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).
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
  • 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
image DIAGNOSIS
DSM-5 has combined vaginismus and dyspareunia in a condition called genito-pelvic pain/penetration disorder.
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.
  • Partner factors
  • Relationship factors
  • Individual vulnerability factors
  • Cultural/religious factors
  • Medical factors
Test Interpretation
Not available; may be needed to check for secondary causes
image 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” under “Etiology and Pathophysiology”).
  • Role for pelvic floor physical therapy and myofascial release
  • P.403

  • 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 sensatefocused 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” 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:
  • Obstetrics/gynecology
  • Pelvic floor physical therapy
  • Psychiatry
  • Sex therapy
  • Hypnotherapy
SURGERY/OTHER PROCEDURES
Contraindicated
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Biofeedback
  • Functional electrical stimulation
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Desensitization techniques of gentle, progressive, patient-controlled vaginal dilation
Patient Monitoring
General preventive health care
DIET
No special diet
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
REFERENCES
1. American Psychiatric Association. Diagnostic Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
2. Landry T, Bergeron S. How young does vulvo-vaginal pain begin? Prevalence and characteristics of dyspareunia in adolescents. J Sex Med. 2009;6(4): 927-935.
3. ter Kuile MM, Both S, van Lankveld JJ. Cognitive behavioral therapy for sexual dysfunctions in women. Psychiatr Clin North Am. 2010;33(3):595-610.
4. Melnik T, Hawton K, McGuire H. Interventions for vaginismus. Cochrane Database Syst Rev. 2012;(12):CD001760.
5. Pereira VM, Arias-Carrión O, Machado S, et al. Sex therapy for female sex dysfunction. Int Arc Med. 2013;6(1):37.
6. Crowley T, Goldmeier D, Hiller J. Diagnosing and managing vaginismus. BMJ. 2009;338:b2284.
7. Pacik PT. 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
&NA;
  • Basson R, Wierman ME, van Lankveld J, et al. Summary of the recommendations on sexual dysfunctions in women. J Sex Med. 2010;7(1, Pt 2):314-326.
  • Jeng CJ, Wang LR, Chou CS, et al. Management and outcome of primary vaginismus. J Sex Marital Ther. 2006;32(5):379-387.
  • Pacik PT. Understanding and treating vaginismus: a multimodal approach. Int Urogynecol J. 2014; 25(12):1613-1620.
  • Reissing ED, Binik YM, Khalifé S, 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 JS, Carey MP. Prevalence of sexual dysfunctions: results from a decade of research. Arch Sex Behav. 2001;30(2):177-219.
  • ter Kuile MM, van Lankveld JJ, de Groot E, et al. Cognitive-behavioral therapy for women with lifelong vaginismus: process and prognostic factors. Behav Res Ther. 2007;45(2):359-373.
See Also
&NA;
Dyspareunia; Sexual Dysfunction in Women
Codes
&NA;
ICD10
  • N94.2 Vaginismus
  • N94.1 Dyspareunia
Clinical Pearls
&NA;
  • 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.