Vaginismus is a sexual dysfunction in which spasm of vaginal musculature precludes penetrative intercourse. In many cases associated pain or fear of pain may contribute to the maintenance of vaginismus. We report a case of primary vaginismus with associated pain that benefited from topical application of lignocaine gel along with systematic desensitization resulting in successful consummation, and suggest that it may be a useful adjunct during finger dilatation in the treatment of vaginismus, specifically in patients who have associated pain or areas of hyperesthesia in the introitus.
In DSM-IV-TR, vaginismus is classified as a sexual dysfunction and is included in the subcategory of sexual pain disorders. The main diagnostic criterion is the presence of a 'recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with intercourse'; the muscle spasm is described as readily observable and in some cases, as 'so severe or prolonged as to cause pain'. In contrast, gynecological examinations have found vaginal or pelvic spasm in only a third of vaginismic patients. Although pain is not a primary feature of DSM-IV-TR criteria of vaginismus, in practice it is an integral part of the experience.[2,3] Vaginismus can be classified as either primary or secondary. Primary vaginismus occurs when the woman has never been able to have penetrative intercourse because of the involuntary contraction of her vaginal muscles, which is sometimes referred to as 'unconsummated marriage'; secondary vaginismus occurs when a woman has previously been able to have intercourse but is no longer able to be penetrated because of the involuntary muscle spasm. We report a case of primary vaginismus with associated pain that benefited from finger dilatation along with topical application of lignocaine gel resulting in successful consummation.
A married couple presented in the psychosexual clinic with history of non-consummation of marriage for 1 ½ years because of erectile dysfunction in the husband. On detailed history, it became apparent that the problem was vaginismus leading to pain during intercourse, and consequential refraining from penetrative intercourse owing to anticipation of coital pain in the wife (aged 21 years) and the husband (aged 24 years) had erectile failure secondary to lack of cooperation from the wife. To avoid this, the couple barely attempted intercourse more than once a fortnight. Previous gynecological consultations did not reveal any anatomical abnormality or local pathology. On per vaginal examination, the attempt to insert the examining finger elicited reflex spasm of the outer third of the vagina as well as report of pain by the patient, which confirmed our diagnosis of vaginismus.
The couple was educated regarding sexual anatomy, physiology and proper coital techniques. They were encouraged to engage in sexual activity and spend more time during foreplay before attempting coition to enhance sensual pleasure and allay anxiety. Systematic desensitization in the form of gradual dilatation of vagina using lubricated fingers was started but the frequency of sexual activity did not change because of fear of pain. In a subsequent follow-up, 5% lignocaine gel was applied locally in the outer third of vagina and finger dilatation was carried out after 2 min. With reassurance, it was possible to admit two fingers without any wince or complaint of pain from the patient, which allowed us to gain her confidence. In the same setting, we demonstrated to the couple that three fingers could be inserted gradually without any pain or spasm and advised the patient to use lignocaine gel before attempting intercourse. In the follow-up after 2 weeks, the couple reported success in coition with complete penetration, at times without using lignocaine gel and the frequency of intercourse increased to almost daily.
Although vaginismus is considered a sexual pain disorder, the experience of pain is not necessary for the diagnosis, and the nature, severity or causal mechanism of 'vaginismic pain' is still debated. Pain or fear of pain is suggested as a symptom rather than a cause of vaginismus; however, some authors have stressed its possible causal and maintaining role in the disorder.[5,6] It has been suggested that patients diagnosed as having vaginismus can be conceptualized as having either 'vaginal penetration aversion/phobia' or 'genital pain disorder', or both, implying different approach in the management.[2,7]
Vaginismus may be of such severity that a marriage cannot be consummated, as exemplified in our case. If severe vaginismus existed before attempted consummation of a marriage, primary or secondary impotence can result from repetitive failures at intromission. In our case, the male partner came up with erectile dysfunction and the diagnosis of vaginismus was revealed during detailed evaluation.
Masters and Johnson had remarked regarding an unusual physical response pattern of women afflicted with vaginismus, 'the patient usually attempts to escape the examiner's approach by withdrawing toward the head of the table, even raising her legs from the stirrup, and/or constricting her thighs in the midline to avoid the implied threat of the impending vaginal examination'; this pattern may be more common in patients having associated pain symptoms. Although some authors have suggested that conducting an early gynecological examination is potentially damaging for the progress of therapy because of unnecessary pain or discomfort,[9,10] if a non-traumatic pelvic exploration is conducted and a markedly apprehensive woman somewhat reassured in the process, it is a first step in the therapeutic reversal of the involuntary spasm of the vaginal outlet, and the diagnosis of vaginismus can easily be established by a one-finger pelvic examination.
A lack of sex education has been noted in vaginismic women,[11,12] especially among the less educated. Therefore, normal sexual anatomy and physiology should be discussed with the couple to dispel the misconceptions. Treatment of vaginismus includes progressive vaginal dilatation and vaginal muscle exercises intended to desensitize the woman to vaginal penetration and to develop voluntary control of the vaginal muscles, thus preventing spasm, and other psychotherapeutic interventions targeting phobia, negative conditioning, feeling of guilt or pain.[7,13] Systematic desensitization, in vivo or imaginal, using graded dilators along with relaxation, results in reduction of anxiety through gradual approach of feared stimulus. Other less frequently reported approaches include hypnotherapy and biofeedback. Hassel had reported a patient with vaginismus in which a hyperesthetic area could be identified, and on application of 5% lignocaine gel topically the spasm decreased allowing insertion of three fingers. Similarly, in our case, the spasm of pelvic muscles with secondary pain was relieved by topical 5% lignocaine gel thus allowing consummation of marriage. Therefore, it may be a useful adjunct during finger dilatation or other behavioral approaches in the treatment of vaginismus which can be used at home before intercourse, specifically in patients who have associated pain or areas of hyperesthesia in the introitus, although further studies are needed.