Genito-Pelvic Pain/Penetration Disorder (Vaginismus)

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 sclerosus, endometriosis)

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 (1).

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

Diagnosis

DSM-5 has combined vaginismus and dyspareunia in a condition called genito-pelvic pain/penetration disorder.

History

  • Complete medical history
  • Full psychosocial and sexual history, including the following:
    • Onset of symptoms (primary or secondary)
    • If secondary, precipitating events, if any
    • Relationship difficulty/partner violence
    • Inability to allow vaginal entry for different purposes
      • Sexual (penis, digit, object)
      • Hygiene (tampon use)
      • Health care (pelvic examination)
    • Infertility
    • Traumatic experiences (exam, sexual, etc.)
    • Religious beliefs
    • Views on sexuality

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 because 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

Treatment

  • Genito-pelvic pain/penetration disorder may be successfully treated (1)[B].
  • Meta-analysis of RCTs documented a trend toward higher efficacy of active treatment versus controls, whereas the meta-analysis of observational studies indicated that women with vaginismus benefit from a range of treatments in almost 80% of cases (2)[A].
  • Another meta-analysis of level 1 evidence found that 2/3 of the treatment effect for female sexual dysfunction is accounted for by placebo (3)[A]. These findings suggest that the current treatments for female sexual dysfunction are, overall, minimally superior to placebo, which emphasizes the ongoing need for more efficacious treatment for female sexual dysfunction.
  • Outpatient care is appropriate.
  • Treatment of physical conditions, if present, is first line (see “Secondary” under “Etiology and Pathophysiology”).
  • Most begin with pelvic floor physical therapy and myofascial release
  • 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 (4)[A].
  • Based on a Cochrane review, a clinically relevant effect of systematic desensitization cannot be ruled out (5)[A].
  • Evidence suggests that 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 sensate-focused 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 (4)[B].
  • Topical anesthetics or anxiolytics may be used in combination with either cognitive-behavioral therapy or desensitization exercises as noted above (5)[B].
  • Botulinum neurotoxin type A injections may improve vaginismus in patients who do not respond to standard cognitive behavioral and medical treatment for vaginismus (6)[B].
    • 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 (5)[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 (6)[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 and Alternative Medicine

  • Biofeedback
  • Functional electrical stimulation

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 and 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

Additional Reading

  • 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. [PMID:20092441]
  • Pacik PT. Understanding and treating vaginismus: a multimodal approach. Int Urogynecol J. 2014;25(12):1613–1620. [PMID:24894201]
  • Simons JS, Carey MP. Prevalence of sexual dysfunctions: results from a decade of research. Arch Sex Behav. 2001;30(2):177–219. [PMID:11329727]
  • 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. [PMID:16701078]

See Also

Dyspareunia ; Sexual Dysfunction in Women

Codes

ICD-10

  • N94.1 Dyspareunia
  • N94.2 Vaginismus

ICD-9

  • 625.0 Dyspareunia
  • 625.1 Vaginismus

SNOMED

  • 198402002 Dyspareunia due to non-psychogenic cause in the female
  • 266598008 vaginismus due to non-psychogenic cause (finding)
  • 71315007 Dyspareunia (finding)

Clinical Pearls

  • 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. Further research into the most effective methods is needed.
  • 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.

Authors

Jeffrey D. Quinlan, MD, FAAFP

Bibliography

  1. 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. [PMID:19207275]
  2. Maseroli E, Scavello I, Rastrelli G, et al. Outcome of medical and psychosexual interventions for vaginismus: a systematic review and meta-analysis. J Sex Med. 2018;15(12):1752–1764. [PMID:30446469]
  3. Weinberger JM, Houman J, Caron AT, et al. Female sexual dysfunction and the placebo effect: a meta-analysis. Obstet Gynecol. 2018;132(2):453–458. [PMID:29995725]
  4. Crowley T, Goldmeier D, Hiller J. Diagnosing and managing vaginismus. BMJ. 2009;338:b2284. [PMID:19541697]
  5. Melnik T, Hawton K, McGuire H. Interventions for vaginismus. Cochrane Database Syst Rev. 2012;(12):CD001760. [PMID:23235583]
  6. 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. [PMID:21556985]


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