Vaginismus Treatment

VAGINISMUS

Dyspareunia and vaginismus, which are sexual pain disorders, are considered to be very sensitive problems for spouses because they cause mood changes, disrupt sexual intimacy and prevent vaginal intercourse.

Vaginismus is defined as a recurrent or persistent difficulty in the entry of a penis, finger and/or object into the vagina even though the woman wants it.

In general, there is phobic pain avoidance and fear of pain or previous pain experience.

Involuntary contraction of pelvic muscles at varying levels occurs during vaginismus.

However, before the diagnosis of vaginismus is made, it is necessary to establish that there is no structural or physical pathology.

When the current literature is reviewed, vaginismus can be classified according to its severity as follows:

• Grade 1: Spasm limited only to the levator ani and resolves with the patient being sedated
• Grade 2: Levator ani spasm persisting during gynecologic, urologic or proctologic examination
• Grade 3: Spasm of levator ani and hip muscles during gynecological examination
• Grade 4: Mild neurovegetative arousal, levator spasm, leg adduction, defense and retraction
• Grade 5: Severe defensive neurovegetative arousal and refusal of gynecological examination

Although the incidence of vaginismus in adult women is reported to vary between 0.5-1%, the exact rates are not known.

However, it has been reported that mild hyperactivity of the pelvic muscles may accompany grade 1-2 vaginismus and allow sexual intercourse, albeit painful.

Pathophysiology: Vaginal sensitivity is one of the most important conditions necessary for sexual intercourse. In order for sensitivity to be fully realized, there must be complete anatomical and functional tissue integrity at the time of arousal and rest.

Mucosal and cutaneous normal trophic structure, adequate hormonal levels, absence of inflammation, normal tone of the perivaginal muscles, vascular, connective and neurologic integrity and normal immune response are all recognized as necessary for a normal vaginal configuration.

Vaginal sensitivity can also be modulated by psychosexual, mental and interpersonal factors and a deficiency in these factors can result in poor arousal and vaginal dryness.

However, the generally accepted view is that: Muscle stimulation secondary to fear of penetration and anxiety causes a defensive perivaginal muscle contraction, resulting in the clinical picture of vaginismus.

More recently, it has been reported that disappointments due to pain during the first sexual experience or childhood sexual abuse may play a role in the development of vaginismus. Vaginismus is one of the most important pathologies that cause serious marital problems between spouses. Vaginismus is reported to frequently accompany dyspareunia and other female sexual dysfunctions.

Diagnosis-Treatment: In sexual pain disorders, reliable clinical history and careful physical examination are of great importance in ensuring accurate diagnosis and treatment. In the proper diagnosis and treatment of patients with vaginismus, 3 main points should be correctly identified:

1) The severity of the phobic condition developed against penetration

2) The degree of hypertonia of the pelvic floor muscles specified in the Lamont classification

3) Coexisting personal and/or related psychosexual problems

Psychosexual and/or behavioral therapy: It is the first-line treatment for vaginismus present throughout life. This treatment modality should be carried out in parallel with pelvic floor muscle rehabilitation and pharmacologic treatments against intense phobias. The presence of other co-morbid female sexual dysfunctions should also be investigated.

Pharmacologic Treatment: Depending on the degree of phobic structure, it includes pharmacological treatment aimed at relieving anxiety Botulin A toxin injections into the levator ani muscle with the consent of the patient may also be useful

Treatment of psychosexual behavior: The topics to be considered during this treatment are as follows:

*The presence of negative effects (fear, disgust, dislike of being touched, loss of self-confidence, dissatisfaction with body image, fear of not being liked by the partner) should be noted.

*Educating the patient about pelvic muscle control and having the patient self-test whether he/she can maintain this control in front of the mirror

*Patients should be encouraged to touch, massage and inform themselves about themselves. In patients with a partner, sex-play/exercise with their partner should be recommended in order to ensure desire, arousal and clitoral orgasm. It should be stated that sexual intercourse should not be performed until the pelvic floor muscles are relaxed.

*In cases where pelvic muscle relaxation is achieved, the patient should be educated primarily on how to insert a dilator.

*Contraception methods should be discussed in cases who do not want to have children.

*Sharing control with the spouse should be discussed.

*Spouses should be warned to ensure that the penetration of the penis during sexual intercourse is under the control of the woman.

*Pharmacologic treatment may be considered against possible performance anxiety that may arise in the man. For this purpose, the use of phosphodiesterase type-5 inhibitors may be beneficial.

*In the presence of significant psychodynamic and relational problems; concurrent psychotherapy, sex therapy and treatment of partners should be recommended