Vaginismus

Vaginismus is when the muscles around your vagina tighten involuntarily whenever there is an attempt to penetrate it with something. This could be your partner’s penis, your finger or a tampon. Vaginismus makes sexual intercourse difficult or impossible (the vagina can completely close up) and it can be painful. The symptoms can vary from one woman to the next. Because it disrupts or completely stops your sex life, vaginismus can cause distress and relationship problems and may prevent you from starting a family. It can also make gynaecological and pelvic examinations difficult or impossible. In some cases, a woman may need an anaesthetic before a doctor can examine her. The condition is fairly common, especially in teenage girls and women in their twenties and thirties. It is likely that many women will experience it at some point, even if they have had a history of enjoyable and painless sex.

Types of Vaginismus -There are two types of vaginismus:

  • Primary vaginismus is when you have never been able to have sex because of the condition.
  • Secondary vaginismus is when you have previously been able to have sex but now find it difficult or impossible.

Causes of Vaginismus

Many factors can cause vaginismus, but it is not always fully understood why the condition happens. For some women, it may be caused by a traumatic past experience, such as a difficult childbirth or sexual abuse. They may associate sexual activity with pain and learn to avoid intercourse as a way of avoiding further pain.

Sexual issues - There are various different sexual experiences or issues to do with sex which may contribute to vaginismus. An unpleasant sexual experience at a young age, such as a clumsy, painful sexual encounter or examination, can make the body respond in a protective way to stop further pain. Sexual abuse, assault or rape could also cause vaginismus. Having difficulty understanding sex, or having feelings of shame or guilt around sex, could also contribute to vaginismus. For example, you might feel uncomfortable with sex if: a) You've had a very strict upbringing where it was never discussed. b) You have been told that sexual desire is wrong or sex is painful. c) You are affected by cultural or religious taboos around sex.

Causes of pain during sex –Any causes of pain during sexual intercourse (dyspareunia) may lead to a woman developing a fear of painful sex. Research suggests that the fear of painful sex may be an important contributing factor to vaginismus. The following may all cause painful sexual intercourse:

  • previous surgery to the genital area
  • an infection of the genital area,
  • radiotherapy to the pelvic area
  • vaginal dryness, which can occur after the menopause
  • lack of sexual arousal
  • side effects of some medicines

Endometriosis and pelvic inflammatory disease are both conditions that can cause pain deeper within the pelvis, including pain during sexual intercourse.

Other possible causes of vaginismus include fear that the vagina is too small for sexual intercourse, fear of getting pregnant, the after-effects of childbirth, relationship problems, tiredness or depression

Symptoms of vaginismus

Symptoms of vaginismus include the following:

  • difficult or impossible penetration of the vagina, because the muscles in the vagina have tightened
  • burning or stinging pain and tightness of the vagina if penetrated by a tampon, finger or penis
  • fear of pain
  • intense fear of penetration and avoidance of sex
  • loss of sexual desire if penetration is attempted

Symptoms of vaginismus vary in severity:

  • Some women are unable to insert anything into their vagina.
  • Some women can insert a tampon and complete a gynaecological exam, but intercourse isn’t possible.
  • Other women can try to have intercourse, but it is very painful.
  • Some women are able to have intercourse, but tightness and pain prevent orgasm.
  • Some women experience years of occasional difficulty with sex and have to be constantly ready to control and relax their vagina when the symptoms occur.

Symptoms of vaginismus are completely involuntary and you cannot do anything to stop them. The body has learned to associate penetration with pain. Whenever the body expects penetration, the vaginal muscles tighten as a protective reaction. It is not true that women who have vaginismus do not like or do not want to have sex. Many women with vaginismus enjoy closeness and share sexual pleasure with their partner. They can achieve orgasm during mutual masturbation, foreplay and oral sex. It is only when sexual intercourse is suggested or attempted that the vagina tightens to prevent penetration.

Diagnosing vaginismus

The diagnosis of vaginismus is based on your medical history, your symptoms and a physical examination, if possible. It is helpful to have detailed information on possible causes described above. This often involves reflecting on quite persoanl issues, such as history of previous traumatic sexual experience. An examination of the genital area is necessary to rule out a physical cause of vaginismus, such as injury or infection.

You may also need to be referred for some counselling, and you could suggest it to your partner too.

Treating vaginismus

Treatment of vaginismus depends on whether the cause can be identified. If there is an obvious physical cause, such as an injury or infection, this can be treated with appropriate medication. If the cause is psychological, it may be treated using sex therapy, where you are helped to gradually overcome it using vaginal trainers and relaxation techniques. You will be given counselling or cognitive behavioural therapy (CBT) if necessary.

Sex therapy

Sex therapist will give advice on self-help techniques and may offer counselling to address any underlying psychological issues (such as fear or anxiety) or arrange cognitive behavioural therapy to change any irrational or incorrect beliefs about sex and, if necessary, to educate you about sex. Your treatment plan will be based on your needs. You will be encouraged to take full control of your self-help treatment and go at your own pace. If you have a partner, they can also be involved in your treatment.

Vaginal trainers

A technique to relax the muscles in the vagina involves using a set of vaginal trainers. These are four smooth, penis-shaped cones of gradually increasing size and length, which can be used in the privacy of your own home. The smallest one is inserted first, using a lubricant if needed. Once you feel comfortable inserting the smallest one, you can move on to the second size, and so on. It is important to go at your own pace and it does not matter how long it takes, whether it is days or months. When you can tolerate the larger cones without feeling anxious or any pain, you and your partner may want to try having sexual intercourse. It is important to note that in cases of vaginismus the vaginal cones are not "stretching" a vagina that is "too narrow". Women who experience vaginismus have a perfectly normal-sized vagina. The cones are simply teaching the vagina to accept penetration without automatically contracting the pelvic floor muscles.

Relaxation and touching

If the cone method is not right for you, relaxation and exploration exercises may help. A bath, massage and breathing exercises are good ways to relax while you get to know your body. Your therapist may also teach you a technique called progressive relaxation. This involves tensing and relaxing different muscles in your body in a particular order. You can then practise tensing and relaxing your pelvic floor muscles before trying to insert your finger or a cone. If you reach the stage where you can put your finger inside your vagina, you can try to insert a tampon, using lubricant if needed. It is important to take things slowly and gently and, when you are ready for intercourse, make sure you are fully aroused before attempting penetration.

Sensate focus

If you are in a relationship, you could try sensate focus. This is a type of sex therapy that you and your partner complete together. It starts with you both agreeing not to have sex for a number of weeks or months. During this time, you can still touch each other, but not in the genital area (or a woman’s breasts). Set aside a time when it is just the two of you. Massage, touch or stroke each other, with or without clothes on. Explore your bodies, knowing that you will not have sex. After the agreed period of time has passed, you can begin touching each other’s genital areas. You may want to spend several weeks gradually increasing the amount of time spent touching the genital areas. You can also begin to use your mouth to touch your partner, for example, licking or kissing them. This can build up to include penetrative sex.

Enlarging the vagina

Surgery can be carried out to enlarge your vagina. This may be necessary if, for example, previous surgery to this area has meant that scar tissue has formed and is either blocking or restricting your vagina. This can occur if it was necessary for doctors to make a cut in your perineum during childbirth. A small operation called a Fenton's procedure can be done to remove the scar tissue. The operation involves neatly cutting out the scar tissue and sewing together the clean-cut edges with small stitches. These should dissolve on their own after a few weeks. The operation will be carried out under either local anaesthetic or general anaesthetic.

BOTOX TREATMENT FOR VAGINISMUS (AND VULVODYNIA)

Botox, a drug derived from a Botulinum toxin, interferes with the transmission of a chemical (acetylcholine) that is responsible for muscle activation. When administered correctly, Botox is as safe as aspirin. Botox has been used for decades to weaken over-active muscles and glands in patients with conditions such as cerebral palsy, stroke, excessive sweating, and migraines, as well as for cosmetic purposes. First used in 1997 for the treatment of Vaginismus, Botox prevents the involuntary spasms that define this condition, allowing women to progressively dilate more comfortably and overcome their fear of penetration. Botox shows few side effects (vaginal dryness being the most common).

How is Treatment of Vaginismus with Botox™ Done?

The first assessment is to find out if you can allow the administration of local anaesthesia cream to do the procedure or whether it is necessary to do the procedure under sedation, or in very few ladies, under general anaesthesia. If you require sedation or general anaesthesia the procedure of this will be different, as you may need to be admitted into the ward or day-case area, rather than in outpatient treatment area. This is extremely useful for women who cannot allow a doctor to touch their genitals in order to conduct an exam. Once the patient is sedated or topical anaesthetic administered, more topical local anaesthesia will be used in the vaginal walls with a massaging technique to break any spasms the introital muscles. This procedure is then followed by injections of Botox™. This massage allows the muscles to relax so that a large dilator can be inserted while the patient once the area has been numbed or if anaesthesia is used. The vaginal dilator in left in place. There is a recovery and rest period after the procedure. During that time you will be taught to remove and re-insert the dilators and then sent home with the dilators and instructions. Follow-up visits are scheduled soon after the first treatment. It is often necessary to have a second or third treatment.

How Does Botox™ Treat Vaginismus or Vulvodynia?

The use of Botox™ relaxes the muscle spasm that causes tightening of the vagina and the resulting pain when attempting intercourse. The same principle applies when it is used for the treatment of painful conditions of the vulva, generally now called Vulvodynia. Botox achieves successful treatment, by numbing the pain-sensitive nerves causing the pain at rest or pain with insertion of tampons, or pain at intercourse. It is important to ensure that there is no limiting skin band causing the pain at penetration, as this will usually need minor surgical treatment. After the procedure, you will immediately find that you have already achieved what is usually the hardest first step, the insertion of the first dilator. The anaesthesia works to ensure that your first experience with the dilator is without much pain, if any, at all. In fact, most patients report that the presence of the dilator does not cause any concern or pain.

Results

What has been observed in research on the use of Botox™ for Vaginismus and Vulvodynia is a very high (75 - 80%) rate of success (meaning pain-free intercourse) within two-to-eight weeks of the treatment. A success rate of 90% has been reported in some clinic series (Pacik 2009). Although Botox™ only lasts two-to-three months when used cosmetically, once the vagina is dilated, additional treatment is generally not necessary, or if a series of treatment if agreed at the beginning, then usually after the third treatment episode. Possible side-effects of Botox : headache, flu-like symptoms, nausea, redness at the injection site, muscle weakness