Editors

KatjaKero

Vaginism

In vaginism, an involuntary spasm makes vaginal penetration difficult or impossible.
Aetiologically, it is considered to be a protective bodily reaction due to negative psychosexual experiences.
Other diseases and causes should be excluded.
A gynaecological examination should not be forced.
Vaginism can be treated by therapy (sexual counselling, sexual therapy, often also psychotherapy or trauma therapy, physiotherapy).

In vaginism, an involuntary spasm makes vaginal penetration difficult or impossible. Vaginism is continuous or recurring difficulty in allowing the insertion of a penis, a finger or an object (such as a tampon, sex toy) the woman wants to insert into her vagina.
Before diagnosing vaginism, it should be confirmed that there are no underlying structural causes or diseases of the genital area (such as infection/inflammation, endometriosis, scarring, a tight hymen, vaginal stenosis or aplasia, genital mutilation).

Vaginism is considered to be due to a variety of underlying biopsychosocial processes where two-way links between local functions in the pelvic and genital area and higher mental processes function inappropriately.
- Neurobiologically, vaginism is linked on the one hand to the amygdala responsible for emotion regulation, and, on the other hand, to the hippocampus and neocortex (responsible for symptoms associated with fear, disgust and denial of sexuality).
- Vaginism could probably best be described as the body's means of protection due to negative experiences, as ‘vaginal panic disorder'.
Fear of intercourse or other penetration may lead to anxiety and further to involuntary tension of pelvic floor muscles. Patients often start avoiding all intimacy and sex. Such avoidance behaviour may lead to a vicious circle.
In addition to anxiety, the patient may have other strong, often unrecognized, emotions, such as fear, disgust, shame and anger.
It is important to understand the aetiology, as this guides the treatment of patients suffering from the disorder and indicates whether psychological treatment should be included in addition to traditional gynaecological treatment.

Patients with vaginism often have comorbidities, most commonly anxiety disorder or depression.
There may also be a negative attitude towards sexuality and sometimes actual sexual disgust.
- Underlying factors may include
  - old-fashioned moral conceptions and values, religious conservatism, environmental factors
  - exposure to sexual or other violence in childhood, unpleasant experiences associated with the first experiences of intercourse or medical examinations.

Patients suffering from vaginism often describe that during intercourse or other penetration they feel as if there is a kind of ‘barrier'.
The patient cannot relax her vaginal muscles voluntarily.
This may be accompanied by anxiety, inappropriate fear, or panic-disorder-like physical sensations (such as increased heart rate, a tight feeling in the chest, blurred vision).
A wish to get pregnant may lead the patient to seek treatment.

The diagnosis is based on patient history and gynaecological examination.
The gynaecological examination should be done calmly and with caution, observing how the patient is responding. Examination is not always possible; it must not be forced.
- Performing a gynaecological examination under general anaesthesia should be considered, as necessary.
Vaginism can be divided into four grades.
1. The physician can insert one finger into the patient's vagina, and the muscle spasm can be felt.
2. The patient can tolerate insertion of the examiner's little finger into her vagina, but this is difficult and causes anxiety.
3. The patient shows fear and cannot tolerate insertion of even one of the examiner's fingers into her vagina or allows the examiner to touch only the vestibule of her vagina or her vulva; the patient feels extreme fear, horror and shame.
4. The patient is often crying, instinctively pulls back, lifts her pelvis up, squeezes her thighs together, tenses all her muscles and will not let the examiner as much as touch her vulvar area, or this can be done only with great difficulty.

The patient is incapable of recovering from her symptom just by conscious, voluntary relaxation.
Various forms and combinations of therapy are useful. Reinforcing the feeling of security is essential.
Therapy provided by a sexual therapist or psychotherapist with expertise in sexual disorders
- Trauma therapy is needed if there is an underlying experience of sexual or other violence.
Treatment of avoidance behaviour by helping the patient to accept the genital area as a part of her body is essential. Mirror exercises are used to help the patient perceive and accept her anatomy and to help her tolerate touching of her genital area with fingers or with special dilators. The exercises can be done alone or with a partner.
As the treatment of sexual disorders also largely addresses shame, a safe, approving couple relationship is very helpful in addition to therapy. It may help the patient become her true, human, imperfect self. Reinforcing the feeling of security is essential.
Mindfulness provides means for calming the body and hence for treating vaginism.
In the treatment, physiotherapy often plays a central role. In the most difficult cases, however, psychotherapeutic interventions are often needed before physiotherapy.