Vaginismus – Causes, Symptoms, Diagnosis, Treatment and Ongoing care
Vaginismus is a clinical syndrome that consists of overlapping elements of hypertonic pelvic floor muscles (recurrent or persistent involuntary contractions), pain, and avoidance of sexual intercourse leading to difficulty in vaginal penetration.
- It is defined as the recurrent or persistent difficulties of a woman to allow vaginal entry of a penis, a finger, and/or an object, despite the woman’s expressed wish to do so (1).
- Classified as a sexual pain disorder, along with dyspareunia and noncoital sexual pain disorder:
- Experience of pain is not required for the diagnosis of vaginismus, though in most women with vaginismus there is anticipation or fear of pain.
- Primary vaginismus is present when a woman has never been able to experience vaginal penetration without difficulty.
- Secondary vaginismus occurs when a woman who has previously been able to achieve penetration develops vaginismus.
- Can be complete (difficulty with attempts to insert anything into vagina) or situational (tampons or pelvic exams permitted)
- Etiology is often multifactorial.
- Women with vaginismus often avoid intercourse and may avoid appropriate health care.
- Treatment is based on the patient’s goals and is focused on patient education, therapy, and behavioral exercises.
- Pregnancy can occur in patients with vaginismus when ejaculation occurs on the perineum.
- Vaginismus is an independent risk factor for cesarean delivery (2)[C].
- True prevalence is unknown due to limited data/reporting.
- Population-based studies report prevalence rates of 0.5–30% (3).
- Affects women in all age groups
- Though the exact role in the condition is unclear, many women report a history of abuse or sexual trauma (4)[C].
- Often associated with other sexual dysfunctions
- Most often multifactorial in both primary and secondary vaginismus
- Psychologic 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
- Psychologic and psychosocial issues:
- Vaginal infection
- Inflammatory dermatitis
- Surgical or postdelivery scarring
- Inadequate vaginal lubrication
- Pelvic radiation
- Estrogen deficiency
- Conditioned response to pain from physical issues previously listed
Commonly Associated Conditions
- Marital stress, family dysfunction
Vaginismus is a clinical diagnosis.
- Complete medical history
- Full psychosocial and sexual history, including:
- Relationship difficulty
- Inability to allow vaginal entry for different purposes:
- Sexual (penis, digit, object)
- Hygiene (tampon use)
- Health care (pelvic exam)
- Past traumatic experiences
- Religious beliefs
- Views on sexuality
- 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 or other providers specializing in the treatment of sexual disorders may be appropriate.
- Lamont classification system aids in the assessment of severity:
- 1st degree: Perineal and levator spasm relieved with reassurance
- 2nd degree: Perineal spasm maintained throughout the pelvic exam
- 3rd degree: Levator spasm and elevation of buttocks
- 4th degree: Levator and perineal spasm and elevation with adduction and retreat (5)
Diagnostic Tests & Interpretation
No laboratory tests indicated
- Rarely found in primary vaginismus except for hymenal anomalies
- May be varied in secondary vaginismus, such as endometriosis or scarring
- Vaginal infection
- Vulvovaginal atrophy
- Urogenital structural abnormalities
- Interstitial cystitis
- Vaginismus may be successfully treated.
- Outpatient care is appropriate.
- Treatment of physical conditions is first-line if present (see secondary etiologies).
- Role for pelvic floor physical therapy and myofascial release
- Some evidence suggests that cognitive-behavioral therapy may be effective (6)[C]:
- Includes desensitization techniques such as gradual exposure, aimed at decreasing avoidance behavior and fear of vaginal penetration
- Evidence suggests that Masters and Johnson sex therapy may be effective (7)[C]:
- 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 3 fingers; important to begin with sensate-focused exercises/sensual caressing without necessarily a demand for coitus
- Female superior at 1st; passive (nonthrusting); female-directed
- Later, thrusting may be allowed.
- Topical anesthetic with desensitization exercises may be considered.
- Patient education is an essential component of treatment (see Patient Education section).
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 100–400 units of botulinum toxin type A injected in the levator ani muscle have been shown to improve vaginismus (8)[C].
Issues for Referral
For diagnosis and treatment recommendations, the following resources may be consulted:
- Pelvic floor physical therapy
- Sex therapy
Complementary and Alternative Medicine
- Functional electrical stimulation
Desensitization techniques of gentle, progressive, patient-controlled vaginal dilation
General preventive health care
No special diet
- 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
- American College of Obstetricians & Gynecologists (ACOG), 409 12th St., SW, Washington, DC 20024-2188; (800) 762-ACOG. www.acog.org
- Valins L. When a woman’s body says no to sex: Understanding and overcoming vaginismus. New York: Penguin, 1992.
Favorable with early recognition of the condition and initiation of treatment
1. Basson R, Wierman ME, van Lankveld J, et al. Summary of the recommendations on sexual dysfunctions in women. J Sex Med. 2010;7:314–26.
2. Goldsmith T, Levy A, Sheiner E, et al. Vaginismus as an independent risk factor for cesarean delivery. J Matern Fetal Neonatal Med. 2009;22(10):863–6.
3. Wimons JS, Carey MP. Prevalence of sexual dysfunctions: results form a decade of research. Arch Sex Behav. 2001;30:177–217.
4. Reissing E, Binik Y, Khalife S, et al. Etiological correlates of vaginismus: sexual and physical abuse, sexual knowledge, sexual self-schema, and relationship adjustment. J Sex Marital Ther. 2003;29:47–59.
5. Lamont J. Vaginismus. Am J Obstet Gynecol. 1978;131:632–6.
6. ter Kuile MM, van Lankveld JJDM, de Groot E, et al. Cognitive behavioral therapy for women with lifelong vaginismus: Process and prognostic factors. Behav Research and Therapy. 2008;45:359–373.
7. Jeng CJ, Wang LR, Chou CS, et al. Management and outcome of primary vaginismus. J Sex Marital Ther.2006;32:379–87.
8. Bertolasi L, Frasson E, Cappelletti JY, et al. Botulinum neurotoxin type A injections for vaginismus secondary to vulvar vestibulitis syndrome. Obstet Gynecol. 2009;114:1008–16.
Crowley T, Goldmeier D, Hiller J. Diagnosing and managing vaginismus. BMJ. 2009;338:b2284.
See Also (Topic, Algorithm, Electronic Media Element)
Dyspareunia; Sexual Dysfunction in Women
Algorithm: Sexual Dysfunction in Women
- 306.51 Psychogenic vaginismus
- 625.1 Vaginismus
- 79012001 vaginospasm (finding)
- 71787009 psychologic vaginismus (disorder)
- In a patient with suspected vaginismus, a complete medical history, including a comprehensive psychosocial and sexual history, and a patient-centric, patient-controlled educational pelvic exam should be conducted.
- Vaginismus can be treated effectively.
- Cognitive behavioral therapy may be effective for the treatment of vaginismus.
- Botox injection therapy is in the experimental stages but looks promising for the treatment of vaginismus.