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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
The definition of vaginismus varies but may be described as "involuntary contraction of the vaginal musculature, which usually results in the failure of penetration". It may affect a woman's ability to allow penetrative sexual intercourse, gynaecological examination, tampon insertion and/or the use of internal contraceptive devices. The severity, pain involved and whether it is universal or situational varies between affected women.
This can occur when there is adequate arousal but may be related to other sexual problems, as vaginismus is part of a spectrum of female sexual dysfunction. These problems are common and may be related to numerous factors in the woman's life:
- Unrelated disease
- Relationship problems
- Drug abuse
- Alcohol problems
- Hormonal changes
- Prescribed drugs
This is an issue many women find difficult to bring to their doctor, and therefore figures are likely to be underestimates. Community estimates of the prevalence of vaginismus are 0.5-1%. This increases to 4.2-42% in specialist and clinical settings.
A Cochrane review found some studies quoted even higher prevalence rates and commented that the wide variety in the figures found for the prevalence of vaginismus may be the consequence of the unclear and differing definitions used in the studies.
Research methodology is flawed in this area and there is a lack of meaningful data on psychological causes. Negative perceptions of the woman's own sexuality are common. Events such as an early adverse sexual experience (although not necessarily assault or rape) or unsympathetic genital examination are thought to contribute. Cultural factors are thought to contribute in some.
An organic factor may be a vestibulodynia - a tender area at the entrance to the vagina. This may be caused by postmenopausal oestrogen deficiency, trauma associated with genital surgery, abnormalities of the hymen, genital tract infections, skin disorders or pelvic radiotherapy.
Conditions leading to lack of arousal/lubrication may also increase the likelihood of vaginismus, such as diabetes mellitus, spinal cord injury, multiple sclerosis and relationship issues.
Vaginismus may be primary in nature, or secondary. If primary, the woman has never been able to have penetrative intercourse without pain, or never been able to achieve penetrative intercourse. It may also be discovered when first attempting to use tampons, or at a first gynaecological examination or smear. Secondary vaginismus describes these symptoms developing in a woman who has previously been able to allow penetration. In this situation, a precipitating cause, whether organic or psychological, may be easier to detect.
Most women are very reluctant to discuss their sexual problems and so, for them to consult their GP, the patient must view the problem as being serious. Alternatively, their partner may have encouraged them to consult their GP.
It is necessary to ask a number of questions to ascertain the exact nature of the problem. As well as the problem of inability to achieve penetration associated with vaginismus, the woman may complain of:
- Lack of interest in sex when their partner wants it.
- Inability to become aroused.
- Dryness and lack of lubrication.
- Inability to use tampons.
- Inability to achieve orgasm (anorgasmia).
- Dyspareunia - this may be due to lack of arousal and/or poor lubrication but may indicate other disorders, such as pelvic inflammatory disease (PID) and endometriosis or disorders causing irritation of the vestibule.
- A history of traumatic examination or sexual experience.
- The clinician should take a careful gynaecological, obstetric, sexual and urological history to determine if there is any obvious likely cause.
- Examination of the external genitalia and vagina is essential, looking for any congenital urogenital anomalies, scarring, lichenification, ulceration or inflammation.
- Pelvic examination may be difficult with vaginismus and require patience and maybe a second visit. Time should be taken to explain examination and to obtain consent at each step. Reassure the woman that you will stop examining at any point if she wishes or if it is too painful to continue. During examination try to ascertain at what point there is pain or muscular contraction and what the trigger for this is. Establish if she is able to voluntarily relax the musculature and whether penetration is possible.
Treat any physical cause found. If a physical cause has been excluded, treatment usually consists of education, counselling and behavioural exercises. Cochrane reviews have found that studies have not been adequate to ascertain the relative benefit of the treatment options and warn that results should be interpreted with caution.Treatment should be tailored to the needs of the woman and her partner, if she is in a relationship. The woman's objectives should be explored. These may be penetrative painless intercourse, tampon use, or painless vaginal examination:
- Where the goal is for the woman to be more comfortable with her genitals, relaxation techniques and self-exploration of the genitals and insertion of 'vaginal trainers' can be used. These are smooth plastic rods that are graduated in size and length; they have a handle and lubrication gel to use when inserting them. The latest Cochrane review found some limited evidence for the efficacy of this "systematic desensitisation" technique.
- If she is in a relationship, a sensate focus programme may be offered to the couple. This is a series of structured touching activities which help couples overcome anxiety and increase comfort with physical intimacy. The focus is on touch rather than performance and intercourse is initially "banned".
- Other psychological and behavioural therapies used include cognitive behavioural therapy (CBT), relaxation therapy and hypnotherapy. Education is an important component.
- Couples may refer themselves for sexual counselling to a service such as "Relate".
- Lidocaine is sometimes used where pain is a principal problem.
- Consider hormone replacement therapy in post-hysterectomy and perimenopausal women.
- When the main goal is conception, information about assisted conception should be given.
- Injections of botulinum toxin have been found to be useful in some but there are no randomised controlled trials.[3, 8]
There is little good-quality evidence to inform this. The willingness of the woman to come forward with the problem and participate in treatment may be a significant factor, although spontaneous improvement has been noted in up to 10% of women with vaginismus.
Vaginismus may result in marital or relationship difficulties and may affect quality of life adversely. It may be associated with poor self-esteem, depression and anxiety. Infertility may be an issue.
The woman may be unable to participate in the cervical screening programme, although if penetrative intercourse has never occurred, she would fall into a lower-risk group for cervical carcinoma anyway.
Further reading and references
Simonelli C, Eleuteri S, Petruccelli F, et al; Female sexual pain disorders: dyspareunia and vaginismus. Curr Opin Psychiatry. 2014 Nov27(6):406-12. doi: 10.1097/YCO.0000000000000098.
Hope ME, Farmer L, McAllister KF, et al; Vaginismus in peri- and postmenopausal women: a pragmatic approach for general practitioners and gynaecologists. Menopause Int. 2010 Jun16(2):68-73. doi: 10.1258/mi.2010.010016.
Crowley T, Goldmeier D, Hiller J; Diagnosing and managing vaginismus. BMJ. 2009 Jun 18338:b2284. doi: 10.1136/bmj.b2284.
Melnik T, Hawton K, McGuire H; Interventions for vaginismus. Cochrane Database Syst Rev. 2012 Dec 1212:CD001760. doi: 10.1002/14651858.CD001760.pub2.
Lewis RW, Fugl-Meyer KS, Corona G, et al; Definitions/epidemiology/risk factors for sexual dysfunction. J Sex Med. 2010 Apr7(4 Pt 2):1598-607.
Cacchioni T, Wolkowitz C; Treating women's sexual difficulties: the body work of sexual therapy. Sociol Health Illn. 2011 Feb33(2):266-79. doi: 10.1111/j.1467-9566.2010.01288.x.
Long CY, Liu CM, Hsu SC, et al; A randomized comparative study of the effects of oral and topical estrogen therapy on the vaginal vascularization and sexual function in hysterectomized postmenopausal women. Menopause. 2006 Sep-Oct13(5):737-43.
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 Dec35(6):1160-4. doi: 10.1007/s00266-011-9737-5. Epub 2011 May 10.