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A woman experiencing painful intercourse due to vaginismus should not despair. It is a highly treatable condition and this is without surgery or medication

Management of painful intercourse

The first thing that needs to be done is to take a careful and very detailed history. It is important to establish:

The timing of onset of the problem,

The actual location of the pain (superficial, deep or both)

The timing (i.e. at penetration, on deep insertion, after rather than during)

Whether it occurs every time or just on occasions

The nature of the pain (stabbing, burning, sharp etc)

Whether it occurs in some positions and not others

The information gathered here together with the examination findings will go a long way in establishing the underlying cause. Needless to say, definitive treatment depends on establishing the cause and instituting the correct treatment for that.

It is also important to stress here that in some cases of painful intercourse, despite thorough investigations, no cause is identified. This can be quite frustrating because no specific measures can be instituted to overcome the problem. However, this is no reason for despair. A combination of general measures, typically involving the woman’s gynaecologist, a psychosexual counsellor and crucially, the couple will eventually see the problem resolved. However, this requires motivation, patience and perseverance.

Treating vaginismus

Whilst we don’t intend to go into detail with regard to treatment for the various conditions mentioned above, vaginismus is a special case. This is because it is the major cause of primary dyspareunia. It also causes some cases of secondary dyspareunia.

The genital tract is completely normal in vaginismus. This is the fundamental basis of the diagnosis of vaginismus. Every possible anatomical abnormality, inflammatory or any other disease process has to be ruled out before reaching a diagnosis of vaginismus.

Whilst it is important to establish or rule out any history of possible sexual abuse in the woman’s past, it is essential not to be fixated on this. Many women with this condition will have no such history.

Once the diagnosis has been arrived at, it is the beginning of a careful and often long process of solving the problem. With patience and perseverance, the majority of women overcome vaginismus.


Psychosexual counselling in vaginismus

Psychosexual counselling plays a crucial role in the majority of cases of vaginismus. The pain in vaginismus tends to have a psychological basis which needs to be dealt with if the problem is going to be successfully overcome. There may be:

A history of sexual abuse, in childhood or later.

A strict religious upbringing associating sex with guilt or sin

A feeling that the genital tract is dirty or ugly

Anxiety at the time of the first penetrative sexual experience with the expectation that the breaking of hymen will be painful. When this happens for real, she may approach any future attempt at penetrative sex with the same level of dread. This creates a vicious circle.

Vaginismus in all these situations has one underlying physiological process: The reflex intense spasms of the lower perineal muscles (pubococcygeus muscle). This virtually shuts down the vaginal canal. Any attempt at penetration, even with a finger, is bound to be difficult, sometimes impossible and always painful.

Self-help measures in vaginismus

The gynaecologist and counsellor will all have one common role. This is to facilitate the woman’s ability to take those measures which will help overcome this problem.

While it is ideal to have a regular steady partner who will participate and support the woman on this journey of recovery, a woman who is not in a steady relationship can also be helped. The measures should be geared to fit her situation and carried out at her own pace.

The counsellor should help the woman identify, discuss and resolve any relevant psychological issues.

Genital exploration, usually with masturbation, to achieve arousal and, more importantly, conscious relaxation. This, in time, will lead to painless penetration. This can be achieved only in the privacy of the woman’s own home. That is the environment where she is in total control. A partner can help in achieving this but is not always necessary. In some cases, he might even be a hindrance. It is important to individualise.

Vaginal dilators: The gynaecologist may prescribe graduated vaginal dilators. These are very useful. The woman will carefully insert the lubricated dilators in her vaginal, starting with the smallest one and going up in size as she becomes more comfortable. It is a gradual process which requires patience and perseverance. They should ideally be used after pelvic floor re-training (below).

Pelvic floor re-training: Specific pelvic floor exercises aimed at consciously controlling the perineal muscle action (contraction and relaxation). The first step will be to educate the woman about the source of the problem, namely the involuntary muscle spasms. Next is to help identify those muscles, re-train the pelvic floor so that she can consciously control the muscle action thereby minimizing and eventually eliminating the involuntary contraction at the centre of the problem. This is a gradual process and should never be rushed. After this, the vaginal dilators can be used.

Success rate of vaginismus treatment

When well structured, a program for treating vaginismus is almost always successful. The doctor and counsellor’s roles are important but only as facilitators. Proper scientific studies show that around 90% of women who seek help for this do eventually overcome it.

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Last update: September 21. 2012