September 17, 2007
September 10, 2007
September 9, 2007
Vaginismus Symptoms
Vaginismus Symptoms
Depending on the intensity, vaginismus symptoms range from minor burning sensations with tightness to total closure of the vaginal opening with impossible penetration.
Common symptoms of vaginismus
Burning or stinging with tightness during sex
Difficult or impossible penetration, entry pain, uncomfortable insertion of penis
Unconsummated marriage
Ongoing sexual discomfort or pain following childbirth, yeast/urinary infections, STDs, IC, hysterectomy, cancer and surgeries, rape, menopause, or other issues
Ongoing sexual pain of unknown origin, with no apparent cause
Difficulty inserting tampons or undergoing a pelvic/gynecological exam
Spasms in other body muscle groups (legs, lower back, etc.) and/or halted breathing during attempts at intercourse
Avoidance of sex due to pain and/or failure
Vaginismus is vaginal tightness causing discomfort, burning, pain, penetration problems, or complete inability to have intercourse. The vaginal tightness results from the involuntary tightening of the pelvic floor (especially the pubococcygeus (PC) muscle group), although the woman may not be aware that this is the cause of her penetration or pain difficulties.
Did You Know?
Vaginismus is a common cause of ongoing sexual pain and is also the primary female cause of sexless (unconsummated) marriages. Sexual pain can affect women in all stages of life; even women who have had years of comfortable sex. While temporarily experiencing discomfort during sexual intercourse is not unusual, ongoing problems should be diagnosed and treated.
Examples of the effects of vaginismusLeft diagram - As the man approaches the woman to attempt intercourse, her PC muscle group (darkly shaded) involuntarily tightens the vaginal entrance making intercourse painfully impossible ‘like bumping into a wall’. This type of vaginismus makes penetration impossible. Right diagram - In other cases of vaginismus, penetration may be possible, but the woman experiences periods of involuntary tightness causing burning, discomfort, or pain.
Variations in the experience of vaginismus
Vaginismus can be triggered in both younger and older women, in those with no sexual experience and those with years of experience. Not all women experience vaginismus the same way, and the extensiveness of vaginismus varies:
Some women are unable to insert anything at all.
Some women are able to insert a tampon and complete a gynecological exam, yet are unable to insert a penis.
Others are able to partially insert a penis, although the process is very painful.
Some are able to fully insert a penis, but tightness and discomfort interrupt the normal progression from arousal through to orgasm and bring pain instead.
Some women are able to tolerate years of uncomfortable intercourse with gradually increasing pain and discomfort that eventually interrupts the sexual experience.
Women may also experience years of intermittent difficulty with entry or movement and have to constantly be on their guard to control and relax their pelvic area when it suddenly ‘acts up’.
Vaginismus Symptom Severity Range
1. Minor discomfort or burning with tightness is experienced with vaginal entry or thrusting but may diminish.
2. More significant burning and tightness is experienced with vaginal entry or thrusting and tends to persist.
3. Involuntary tightness of the vaginal muscles makes entry and movement difficult and painful.
4. Partner is unable to penetrate due to tightly closed vaginal opening. If entry is forced significant pain results.
How does vaginismus cause problems?
With vaginismus, the mind and body have developed a conditioned response against penetration. The body has learned to expect or anticipate pain upon penetration, so that the powerful PC muscle ‘flinches’ or contracts to protect against the potential of intercourse pain. This can be equated to automatically blinking one’s eyes and wincing when an object is hurled toward us. It is not something a woman thinks about doing - it just happens (see Causes).
The tightened PC muscles may cause burning or pain with sex or may completely block entry. Instead of preventing pain, the tightening of the PC muscle group ultimately causes pain; although acting as a defense mechanism against pain, the opposite effect results.
Vaginismus has a wide range of manifestations, from impossible penetration, to intercourse with discomfort, pain or burning, all resulting from involuntary pelvic tightness. When a woman has never been able to have pain-free sexual intercourse due to penetration difficulties, it is generally classified as primary vaginismus. When a woman develops the vaginismus condition after having previously enjoyed problem-free sex, it is generally classified as secondary vaginismus. Depending upon the classification, there may be some minor differences in the way in which vaginismus is treated.
Primary Vaginismus
When a woman has never at any time been able to have pain-free intercourse due to vaginismus tightness, her condition is known as primary vaginismus.
Primary vaginismus refers to the experience of vaginismus with ‘first-time’ intercourse attempts. Typically, primary vaginismus will be discovered when a woman attempts to have sex for the very first time. The spouse/partner is unable to achieve penetration and it is like he just bumps into a ‘wall’ where there should be the opening to the vagina. Entry is impossible or extremely difficult. Primary vaginismus is the common cause of sexless, unconsummated marriages. Some women with primary vaginismus will also experience problems with tampon insertion or gynecological exams. The PC muscles constrict and tighten the vaginal opening making it uncomfortable or in many cases virtually impossible to have entry. When tightened, attempts to insert anything into the vagina produce pain or discomfort.
Some women also experience related spasms in other body muscle groups or even halted breathing. Generally, when the attempt to put something in the vagina has ended, the muscles relax and return to normal. For this reason, medical examinations often fail to reveal any apparent problems unless the tightness occurs and is noted during the pelvic exam.
Secondary Vaginismus
Vaginismus Risk Factors
Vaginismus can strike any woman at any time at any age. Contributing factors could include:
Pelvic pain due to a medical condition, infection, physical trauma or assault, age-related changes, or painful physical events such as childbirth.
Emotional distress, anxiety, fear, relational difficulties, or other similar emotions that relate to sex, intimacy, past trauma, or relationships.
The anticipation pelvic pain due to some past or present condition or situation.
Other causes.
Secondary vaginismus sexual pain can affect women in all stages of life – even women who have had many years of pain-free intercourse.
Secondary vaginismus refers to the experience of tightness pain or penetration difficulties later in life, after previously being able to have normal, pain-free intercourse. It typically follows or is triggered by temporary pelvic pain or other related problems. It can be triggered by medical conditions, traumatic events, relationship issues, surgery, life-changes (e.g. menopause), or for no apparent reason (see Causes for more examples). Secondary vaginismus is the common culprit where there is continued, ongoing sexual pain or penetration tightness where there had been no problem before.
Most commonly, secondary vaginismus strikes women experiencing temporary pelvic pain problems such as urinary or yeast infections, pain from delivering babies, menopause, or surgery. The initial pain problems are addressed medically, healed, and/or managed, yet women continue to experience ongoing sexual pain or penetration difficulties due to vaginismus. While the initial temporary pain was experienced, their bodies developed a conditioned response resulting in ongoing, involuntary vaginal tightness with attempts at intercourse.
Left untreated, vaginismus often worsens, because the experience of ongoing sexual pain further increases the duration and intensity of the involuntary PC muscle contraction. The severity of secondary vaginismus may escalate so that sex or even penetration is no longer possible without great difficulty. Some women will also experience difficulty with gynecological exams or tampon insertion. Vaginismus can also impede a woman’s ability to experience orgasm during intercourse, as any sudden pangs of pain will abruptly terminate the arousal buildup toward orgasm.
Vaginismus is involuntary - not intentional
It is important to note that vaginismus is not triggered deliberately or intentionally by women. It happens involuntarily without their intentional control and often without any awareness on their part. Vaginismus has a variety of causes, often in response to a combination of physical or emotional factors. The mystery of the problem can be very frustrating and distressing for both women and their partners. Despite the fact that vaginismus is involuntary and can strike any woman, many women feel intense shame from being unable to have intercourse and keep their pain private, feeling uncomfortable sharing their secret with anyone.
“It always felt tight and uncomfortable. I never realized it was vaginismus.”
“I experience burning pain upon penetration attempts.”
“I’m still a virgin even though we’ve tried many times - it’s like he hits a wall.”
“Sex used to be great, but now I close up - it burns and stings.”
“Sex was fine until after thebaby - now it always hurts.”
“We can’t consummate our marriage - it’s impossible.”
“The doctor says there’s nothing wrong with me. So why does it still hurt?”
“When he starts to move, it feels uncomfortable and we have to stop.”
“Ever since the operation I feel burning pain when I try to get him in.”
“After menopause I began to feel soreness and now I tighten up.”
“I don’t wear tampons because itis too hard to get them in.”
“I seem to ‘tighten’ up down there even when I really want to have sex.”
“There’s no way I’m doing a pelvicexam again - it’s unbearable.”
“Sex has never been comfortable for me.”
Unconsummated Marriages & Impossible Penetration
With severe cases of vaginismus where there has never been penetration, is it really possible to overcome? Is there hope for unconsummated couples?
Yes. Fortunately vaginismus is highly treatable with full restoration of sexual intercourse. Couples completing treatment fully consummate and enjoy normal penetrative sex. See Feedback for many user contributed stories of overcoming penetration difficulties.Unconsummated Couple“My husband and I waited for each other for marriage, and ended up waiting a lot longer than we ever dreamed! Two years of marriage later, we still had been unable to consummate our marriage and enjoy that wedding night we’d looked forward to…” More »
Vaginismus is by far the most common cause of unconsummated marriages (where the problem is due to female issues). Couples often describe their attempts at intercourse as there being a “wall” where the vaginal opening should be. It is baffling to some women as to how this condition originated in them if they had no prior sexual contact or pelvic problems. Intercourse is impossible and painful insertion attempts reinforce the vaginismus response. The conditioned reflex continues to happen every time there is potential for vaginal penetration. The muscles act rebelliously, refusing to allow entry even though the woman may truly want to consummate and receive her spouse vaginally. This is extremely frustrating. For the aroused man, it is like running into a brick wall. For the woman, it is like her body is no longer under her control.
Sex is an activity involving many complex conditioned responses. Bodies do not start out as skilled reactors to sexual stimulus. Successful intercourse is learned through experience and interaction. The nervous system and musculature discover and remember what feels good, works, and what isn’t comfortable. Normally, the transition to intercourse becomes more pleasurable after the first few experiences. The mind and body allow entry and learn to anticipate intercourse positively. Healthy messages result and they generate arousal in anticipation of intercourse. In a woman with primary vaginismus, the mind and body never get the chance to be trained through positive intercourse experiences. The process of learning how to have successful intercourse is cut short when the vaginal muscles spasm as a protective device against pain. With the absence of any direct conscious control on the woman’s part, nerves controlling the vaginal muscles react to the anticipation of intercourse as a call to tightly constrict, brace, protect, and guard against the onset of potential penetration pain.
Will vaginismus go away on its own?
Vaginismus is a self-perpetuating condition that requires treatment to break the 'cycle of pain' and fully resolve.
Since vaginismus is an involuntary, self-perpetuating condition, it will not normally 'go away' unless properly addressed. The 'cycle of pain' that is triggered with vaginismus usually continues indefinitely (and typically worsens) until the woman learns how to control and override the pelvic floor muscle triggers that tighten the vaginal opening. As much as she may like to do so, a woman cannot simply 'will' vaginismus away, and it will not go away on its own.
Fortunately, vaginismus treatment has high success rates. A full recovery from vaginismus is the normal outcome of treatment, with pain-free intercourse restored.
Vaginismus Treatment
Vaginismus is considered one of the most successfully treatable female sexual disorder. Many studies have shown treatment success rates approaching nearly 100%. Treatment resolution follows a manageable, step-by-step process.
Overview
Vaginismus is highly treatable. Successful vaginismus treatment does not require drugs, surgery, hypnosis, nor any other complex invasive technique. Effective treatment approaches combine pelvic floor control exercises, insertion or dilation training, pain elimination techniques, transition steps, and exercises designed to help women identify, express and resolve any contributing emotional components. Treatment steps can often be completed at home, allowing a woman to work at her own pace in privacy, or in cooperation with her health care provider.
The sexual pain, tightness and penetration difficulties from vaginismus are fully treatable and can be completely overcome with no remaining pain or discomfort.
Women experiencing sexual tightness/pain, penetration problems, or unconsummated relationships can expect remarkable resolution of their vaginismus, allowing full, pain-free intercourse.
Treatment steps can usually be completed at home using a self-help approach, allowing a woman to work at her own pace in privacy, or in cooperation with her health care provider or specialist.
Vaginismus treatment exercises follow a manageable, step-by-step process (see Steps below).
Vaginismus is Highly Treatable
The sexual pain, tightness, burning or penetration difficulties caused by vaginismus are completely treatable, with high success rates for treatment. Couples are often amazed by the sudden life-changing effects of treatment. Those with penetration difficulties, or pain during intercourse, normally transition to pain-free and pleasurable intercourse following a step-by-step approach.
Is vaginismus really treatable; and if so, how long does it take to resolve?
Vaginismus is considered one of the most successfully resolved female sexual disorders. High treatment success rates are typical within reasonable time frames.
A Treatment Program is Important
Many of the steps to treat vaginismus are counter-intuitive and not immediately obvious. As failure at any point inhibits recovery (experiencing discomfort tends to intensify vaginismus - see ‘cycle of pain‘) and can cause avoidance or abandonment of progress, it is best to approach vaginismus with an educated understanding to ensure success in dealing with it.
What is involved in the successful treatment of vaginismus?
Outline of 10 step vaginismus resolution process
To aid women in getting proper treatment direction, we have assembled a comprehensive program in book/kit form as outlined below. The self-help program is a straight-forward, step-by-step approach used by many treatment professionals to successfully guide women through the complete process of overcoming vaginismus.
Self-help Kits
Complete vaginismus kits with 10 step treatment program books, dilators, video »
Vaginal Dilator Set
Medical-grade vaginal dilators with smooth, comfortable design & handle »
Vaginismus Books
Comprehensive self-help program recommended by specialists »
Treatment steps can usually be completed at home using a self-help approach, allowing a woman to work at her own pace in privacy, or in cooperation with her health care provider or specialist. Easy-to-follow instructions, supplemented with descriptive illustrations and helpful strategies, make the process a positive, successful experience. At the completion of the steps, pain and penetration problems due to vaginismus are typically fully resolved.
Step 1 - Understanding vaginismus
Step 1 provides an overview of vaginismus and how sexual pain, tightness, burning sensations or penetration difficulties may result from it. This approach helps women to get started by being proactive about their sexual health as understanding vaginismus is fundamental to the process of overcoming it. Topics also include how to obtain a solid diagnosis, treatment methods, relationship issues, pelvic/relaxation techniques, conditioned responses and muscle memories.
Step 2 - Sexual history review & treatment strategies
A balanced approach is taken to help women review and analyze their history. Exercises help identify and evaluate any events, emotions, or triggers contributing to vaginismus sexual pain or penetration problems. Checklists and detailed exercises map out a woman’s sexual history and pelvic pain events, working toward appropriate treatment strategies. Emotional reviews help detail any negative events, feelings, or memories that may collectively contribute to involuntary pelvic responses. Topics also include blocked or hidden memories and how to move forward when there have been traumatic events in a woman’s past.
Did You Know?
Vaginismus can be overcome without drugs, surgery, self-hypnosis, nor any other complex invasive technique.
Step 3 - Sexual pain anatomy
Women often lack complete information about their body’s sexual anatomy, function, and the causes of pelvic pain and penetration problems. Confusion regarding problems with inner vaginal areas and vaginal muscles frequently lead to misdiagnosis and frustration. Step 3 educates about these sexual body parts with emphasis on their role in sexual pain and penetration issues. Topics include how to distinguish what kind of pain or discomfort is normal with first-time or ongoing sex and what physical changes take place during arousal to orgasm cycles in the context of sexual pain or penetration problems. Anatomy areas such as the hymen and inner vulva are explained and demystified (for example there are six diagrams of hymen varieties to help distinguish hymen problems).
Differences in treatment
Note that treatment for those who have never been able to have pain-free intercourse (primary vaginismus) usually requires all ten steps, while those with secondary vaginismus may be able to shorten or bypass some steps (see also Is there a difference between the treatment for primary and secondary vaginismus?).
Step 4 - Vaginal tightness & the role of pelvic floor muscles
Female sexual pain and penetration difficulties typically involve some degree of involuntary tightening of the pelvic floor. This step focuses on the role of pelvic floor muscles, especially the pubococcygeus (PC) muscle group, explaining in great detail how once they are triggered they continue to cause involuntary tightness with attempts at intercourse. Effective vaginismus treatment focuses on retraining the pelvic floor to eliminate involuntary muscle reactions that produce tightness or pain. Learning how to identify, selectively control, exercise and retrain the pelvic muscles to reduce pain and alleviate penetration tightness and difficulties is an important step in vaginismus treatment.
Step 5 - Insertion techniques
For women with penetration difficulties or pain, techniques must be learned to allow initial entry without pain. In this step, women practice pubococcygeus (PC) muscle control techniques as they allow the entry of a small object (cotton swab, tampon, or finger) into their vagina, working completely under their control and pace. Any involuntary muscle contractions that had previously closed the entrance to the vagina and prevented penetration are overridden. Women begin to take full control over their pelvic floor and learn how to flex and relax the pelvic floor at will, eliminating unwanted tightness and allowing entry.
Using dilators without a program?
Note that vaginal dilators are typically not effective when used without guidance. They should not be used without proper physical instruction, exercises, transitional steps, etc. Dilators are simply one aspect of the vaginismus treatment process, and if used without pelvic control techniques they will likely be very ineffective. Involuntary muscle reactions are what produces the tightness and pain of vaginismus. The main focus of proper dilator use is in retraining the pelvic floor, not on stretching the vaginal opening.
See the FAQ - Using dilators without a program? for more information.
Step 6 - Graduated vaginal insertions
When used properly, vaginal dilators are effective tools to further help eliminate pelvic tightness due to vaginismus. Dilators provide a substitute means to trigger pelvic muscle reactions. The effective dilator exercises in Step 6 teach women how to override involuntary contractions, relaxing the pelvic floor so it responds correctly to sexual penetration. Graduated vaginal insertion exercises allow women to comfortably transition to the stage where they are ready for intercourse without pain or discomfort.
Step 7 - Sensate focus & techniques for couples to reduce pelvic floor tension
Helping with the transition to pain-free intercourse, this step explains sensate focus techniques for couples to use to reduce pelvic floor tension and increase intimacy. Couples begin to work together during this step as exercises teach how to successfully practice sensate focus (controlled sensual touch) and prepare for pain-free intercourse using techniques from earlier steps. The exercises are designed to build trust and understanding and assist in the process to adjust to controlled intercourse without pain.
Step 8 - Pre-intercourse readiness exercises
Finalizing preparations for couples to transition to fully pain-free intercourse, this step completes pre-intercourse readiness. Couples review and practice techniques that eliminate pelvic floor tension and prepare to transition to full intercourse. Preparing ahead of time to be able to manage, control and eliminate pain or penetration difficulties, the exercises assist with the final transition to pain-free intercourse.
Step 9 - Making the transition to intercourse
Step 9 explains the techniques used to eliminate pain and penetration difficulties while transitioning to normal intercourse. Many troubleshooting topics are covered (with supporting diagrams) such as positions to use to maximize control and minimize pain, tips to ensure more comfortable intercourse, etc.
Step 10 - Full pain-free intercourse & pleasure restoration
The final step toward overcoming vaginismus includes penis entry with movement and freedom from any pain or tightness. Step 10 exercises are designed to educate, build sexual trust and intimacy, and complete the transition to full sexual intercourse free of pain. Couples can begin to enjoy pleasure with intercourse, initiate family planning, and move forward to live life free from vaginismus.
Get Started Today
The complete self-help vaginismus kit includes everything that you need to overcome vaginismus in the privacy of your own home - the most effective resources available. Join the thousands of women who have successfully overcome vaginismus and are enjoying pain-free inercourse. Start Now »
Topical Lignocaine for Vaginismus: A Case Report
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.
Introduction
In DSM-IV-TR,[1] 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.[2] 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.
Case Report
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.
Discussion
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;[4] 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,[8] 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.[8] In our case, the male partner came up with erectile dysfunction and the diagnosis of vaginismus was revealed during detailed evaluation.
Masters and Johnson[8] 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.[8]
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.[14] Other less frequently reported approaches include hypnotherapy[15] and biofeedback.[16] Hassel[17] 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.
Introduction
In DSM-IV-TR,[1] 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.[2] 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.
Case Report
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.
Discussion
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;[4] 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,[8] 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.[8] In our case, the male partner came up with erectile dysfunction and the diagnosis of vaginismus was revealed during detailed evaluation.
Masters and Johnson[8] 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.[8]
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.[14] Other less frequently reported approaches include hypnotherapy[15] and biofeedback.[16] Hassel[17] 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.
Frequently Asked Questions
Vaginismus is a spasm in the musculature of the outer third of the vagina which makes insertion difficult or impossible. For some women, this muscle spasm is painful; for others, it is not. Most women experience pain if they try to insert something in spite of this spasm.
Is vaginismus always caused by abuse?
Is vaginismus always caused by abuse?
No. Some research suggests a correlation between vaginismus and abuse, and other studies show no relationship. Many women with vaginismus have been abused, and many have not. Just because you've never been abused doesn't mean you can't have vaginismus, any more than being abused would guarantee vaginismus.
What causes vaginismus?
What causes vaginismus?
It is widely believed that in most cases of vaginismus, the spasm is triggered either by pain or the anticipation of pain (emotional or physical pain). Much like the way an eyelid closes when something comes to close to the eye or a muscle flinches in response to an imminent punch, vaginismus is like a vaginal flinch.It is in some sense protecting the area, even though the woman doesn't want it to. Some women have fears or guilt regarding intercourse, others have physical pain problems, and still others have no obvious cause for their condition. One perplexing aspect of vaginismus is that often the spasm remains long after the woman has dealt with any anxieties or physical problems. So learning to control and eliminate this spasm is how one cures vaginismus.
If I have pain with intercourse, then do I necessarily have vaginismus?
If I have pain with intercourse, then do I necessarily have vaginismus?
Not necessarily. Painful intercourse can be caused by any number of factors, and vaginismus isn't even the most common. Often, painful sex due to other conditions may lead to vaginismus, so even if you do have vaginismus, you may have another underlying primary cause of pain.
The most common cause of chronic painful sex (or painful attempts at sex, depending on the severity) is vulvar vestibulitis syndrome (VVS), which is one of a number of vulvar pain disorder. VVS can occur at any age, and often with no obvious cause and usually no visible symptoms. It is simply an enhanced sensitivity in, on, or near the vaginal opening.
It should not hurt to touch any part of your vulva. If it does, you should look into the possibility that you may have a vulvar pain condition. They are extremely common, and only seldom diagnosed. Most women suffer in silence. Most doctors do not routinely test for VVS, but the test simply involves poking certain areas (corresponding to your vestibular glands) with a Q-tip and seeing if you have pain. There are other problems which can cause painful intercourse as well, including lichen sclerosis (a skin condition), interstitial cystitis (involves the bladder), essential vulvodynia (which causes nearly constant pain), and others.
These conditions are not widely understood or even recognized by many doctors, so most women with these disorders (especially young women) are likely to be misdiagnosed initially with vaginismus. If you suspect you have one of these disorders, treatment by a specialist is recommended.
How can I cure this?
The most common cause of chronic painful sex (or painful attempts at sex, depending on the severity) is vulvar vestibulitis syndrome (VVS), which is one of a number of vulvar pain disorder. VVS can occur at any age, and often with no obvious cause and usually no visible symptoms. It is simply an enhanced sensitivity in, on, or near the vaginal opening.
It should not hurt to touch any part of your vulva. If it does, you should look into the possibility that you may have a vulvar pain condition. They are extremely common, and only seldom diagnosed. Most women suffer in silence. Most doctors do not routinely test for VVS, but the test simply involves poking certain areas (corresponding to your vestibular glands) with a Q-tip and seeing if you have pain. There are other problems which can cause painful intercourse as well, including lichen sclerosis (a skin condition), interstitial cystitis (involves the bladder), essential vulvodynia (which causes nearly constant pain), and others.
These conditions are not widely understood or even recognized by many doctors, so most women with these disorders (especially young women) are likely to be misdiagnosed initially with vaginismus. If you suspect you have one of these disorders, treatment by a specialist is recommended.
How can I cure this?
Many women, though not all, find it necessary to treat the underlying causes of their vaginismus. For some this will involve therapy if emotional issues are involved, and for others they will have to treat vulvar pain conditions, while still others may not need to focus on what initially caused their problem (some may not even know their cause), and just focus on controlling the muscle.
Learning to control the muscle can be done in many different ways. The most common way is to gently insert progressively larger objects (called "dilators") into the vagina so that the muscle spasm is unlearned. Two excellent sources on the web for instructions on how to use dilators are http://www.med.umich.edu/obgyn/vulva/sandp.html(you have to scroll down a bit to find the right section), and www.marriagebuilders.com/graphic/mbi5049a_qa.html (scroll here too).
Other techniques our members have found helpful include relaxation exercises, stretches, biofeedback-assisted muscle rehabilitation, and focused exercises such as in Pilates.
Learning to control the muscle can be done in many different ways. The most common way is to gently insert progressively larger objects (called "dilators") into the vagina so that the muscle spasm is unlearned. Two excellent sources on the web for instructions on how to use dilators are http://www.med.umich.edu/obgyn/vulva/sandp.html(you have to scroll down a bit to find the right section), and www.marriagebuilders.com/graphic/mbi5049a_qa.html (scroll here too).
Other techniques our members have found helpful include relaxation exercises, stretches, biofeedback-assisted muscle rehabilitation, and focused exercises such as in Pilates.
"Dilators," in this context, don't actually dilate, so it's kind of unfortunate terminology. The word refers to any objects inserted vaginally to slowly condition the vaginal muscles to not tense up during penetration attempts. These can be candles, fingers, tampons, vegetables, dildoes, vibrators, or so-called "medical dilators." The medical ones aren't significantly different from dildoes, except that often a prescription is required, they are not available in festive colors, and in some cases, your insurance may cover them.
All of the different options listed here have been tried with some success. Depending on your financial situation, whether you are being treated by a doctor or self-treating, and your personal preference, any of these may help you. Some women prefer vibrators because they find the vibration tends to relax the muscles, while others prefer non-vibrating dilators.
Medical dilators are typically provided by physicians or therapists, and dildoes and vibrators may be purchased at sex shops. Two shops that have online ordering and discreet delivery are A Woman's Touch and Good Vibrations, but nearly every sex shop will carry products of this sort.
Should I use lubricant? If so, what kind?
All of the different options listed here have been tried with some success. Depending on your financial situation, whether you are being treated by a doctor or self-treating, and your personal preference, any of these may help you. Some women prefer vibrators because they find the vibration tends to relax the muscles, while others prefer non-vibrating dilators.
Medical dilators are typically provided by physicians or therapists, and dildoes and vibrators may be purchased at sex shops. Two shops that have online ordering and discreet delivery are A Woman's Touch and Good Vibrations, but nearly every sex shop will carry products of this sort.
Should I use lubricant? If so, what kind?
Yes. Especially if you are just practicing with dilators, you may not be aroused enough to provide adequate lubricant. Many drugstores carry personal lubricants. The most common ones available are KY (liquid is more highly recommended than the jelly) and Astroglide (also recommended). Many women prefer lubricants that are available at sex shops, for various reasons. Visit any online sex store and you will see many possibilities to choose from, and often the stores have good descriptions to help you choose. One popular lubricant is called Liquid Silk, and is only available from sex shops.
Are there any good vaginismus resources on the web?
Are there any good vaginismus resources on the web?
In Print?Yes. But they are few and far between. If you join the Vaginismus Internet list (see below), you will have access to links their members have found useful at: www.egroups.com/links/vaginismus
One resource that many women have found incredibly useful is support groups. There are three main support groups for vaginismus. One group is just for women with vaginismus, and is on egroups.com under the name Vaginismus. Another is just for partners of women with vaginismus, and is called VaginismusPartners. A third is for women with vaginismus, their partners, and medical professionals. It is called 1Vaginismus.
One resource that many women have found incredibly useful is support groups. There are three main support groups for vaginismus. One group is just for women with vaginismus, and is on egroups.com under the name Vaginismus. Another is just for partners of women with vaginismus, and is called VaginismusPartners. A third is for women with vaginismus, their partners, and medical professionals. It is called 1Vaginismus.
Vaginismus
Vaginismus (the German equivalent of the word Vaginism) is a condition which affects a woman's ability to engage in any form of vaginal penetration, including sexual penetration, insertion of tampons, and the penetration involved in gynecological examinations. This is the result of a conditioned reflex of the pubococcygeus muscle, which is sometimes referred to as the 'PC muscle'. The reflex causes the muscles in the vagina to tense suddenly, which makes any kind of vaginal penetration -- including sexual penetration -- either painful or impossible.
A vaginismic woman does not consciously control the spasm. The vaginismic reflex can be compared to the response of the eye shutting when an object comes towards it. The severity of vaginismus varies from woman to woman. Experience of vaginismus
The conditioned reflex can create a vicious circle for vaginismic women. One example: if a teenage female learns that the first time she engages in penetrative sex that it will be painful, she may develop vaginismus because she expects pain. If she then attempts to engage in penetrative sex, the muscle spasm will make penetrative sex painful. This and each further attempt at sexual penetration confirms her fear of pain and may worsen the condition. Naturally, penetration may be extremely painful without vaginismus or psychological prerequisite as well.
Primary vaginismus
Primary vaginismus occurs when a woman has never been able to have penetrative sex or achieve any kind of vaginal penetration. It is commonly discovered in teenagers and women in their early twenties, as this is when many young women in the Western world will initially attempt to use tampons, have penetrative sex, or undergo a pap smear. Women who have vaginismus may not be aware of their condition until they attempt vaginal penetration. It may be confusing for a woman to discover she has vaginismus. She may believe that vaginal penetration should be naturally easy, or she may be unaware as to the reason for her condition.
Some of the things that may cause primary vaginismus are:
sexual abuse
having been taught that sex is immoral or vulgar
the fear of pain associated with penetration, particularly that of breaking the hymen upon the first attempt at sexual penetration
Secondary vaginismus
Secondary vaginismus occurs when a woman who has previously been able to achieve penetration develops vaginismus. This may be due to physical causes such as a yeast infection or trauma during childbirth, or it may be due to psychological causes. The treatment for secondary vaginismus is the same as for primary vaginismus, although, in these cases, previous experience with successful penetration can assist in a more rapid resolution of the condition.
Treatment
There are a variety of factors that can contribute to vaginismus. These may be psychological or physiological, and the treatment required can depend on the reason that the woman has developed the condition. As each case is different, an individualized approach to treatment is useful.
The condition will not necessarily become more severe if left untreated, unless the woman is continuing to attempt penetration, despite feeling pain. Some women may choose to refrain from seeking treatment for their condition.
According to the Cochrane Collaboration review of the scientific literature, "In spite of encouraging results reported from uncontrolled case series there is very limited evidence from controlled trials concerning the effectiveness of treatments for vaginismus. Further trials are needed to compare therapies with waiting list control and with other therapies." [1]
Although few controlled trials have been carried out, many serious scientific studies have tested and proved the efficacy of the treatment of vaginismus. In all cases where the systematic desensitization method was used, success rates were close to 90-95% and even 100%. For an example of one of these studies, see Nasab, M., & Farnoosh, Z., or for a basic review, see Reissing's literature review. (links below)
Psychological treatment
According to Ward and Ogden's qualitative study on the experience of vaginismus for women (1994), the three highest ranked causes for vaginismus are usually fear of painful sex, strict religious upbringing where sex was viewed as wrong or not discussed, and early childhood traumatic experiences (not necessarily sexual in nature).
It is important to address the psychological aspects of the problem as well as the actual muscle spasm. A woman may choose to address the issue on her own terms, or she may avail the help of a therapist.
Many people -- even some professionals -- are not aware of the emotional difficulties associated with vaginismus, which can include low self-esteem, fears, and depression. Women with this condition may wish to seek an understanding professional who has previous experience with women who experience vaginismus. A therapist who has a positive attitude towards sex and the human body may be beneficial.
Physical treatment
Physical treatment of the internal spasms may include sensate focus exercises, exploring the vagina through touch, and desensitization with vaginal dilators. Dilating involves inserting objects, usually phallic in shape, into the vagina. In treating the spasms through dilation, the objects used gradually increase in size as the woman progresses. Medical dilators may be obtained online, though they may be expensive.
Sexuality
If a woman suspects she has vaginismus, sexual penetration is likely to remain painful or impossible until her vaginismus is addressed. Women with vaginismus may be able to engage in other sexual activities, as long as penetration is avoided. Sexual partners of vaginismic women may come to believe that vaginismic women do not want to engage in penetrative sex at all, though this may not be true. Many vaginismic women do wish to engage in penetrative sex, but are deterred by the pain and emotional distress that comes with each attempt.
Masturbation
Women with vaginismus may not realize that most women who do not have vaginismus usually do experience pain or discomfort if they attempt sexual penetration without prior sexual arousal. Most women acknowledge sexual arousal as integral to painless sexual penetration so self-exploration of the vaginal area through masturbation can be beneficial in addressing vaginismus.
One of the problems that can come with vaginismus is that a woman may be fearful to engage in sexual activity, due to the fear of pain with any kind of vaginal penetration. Solo masturbation, with or without penetration, can alleviate this fear, as well as the psychological pressure to 'perform' sexually or become aroused quickly, with a partner.
Despite popular belief, orgasm need not be the goal of masturbation. The reason may be to simply increase comfort with the genital area, to explore various sensations through genital and clitoral touch, and to become aware of those sensations which are relaxing and pleasurable. Sexual arousal causes changes in the shape and color of the vulva, as well as in the vaginal lubrication produced. As a woman becomes more aware of her individual sexual response, she can learn which sensations are best for bringing her to a state of arousal. She will then be better equipped to teach her partner(s) which sensations feel best for her.
Emotional experiences
A wide range of emotions may surface during masturbation and other forms of genital exploration. Some women have negative associations with their genitals, including fears that their genitals are dirty, smelly, oddly shaped, or ugly. These associations can lead to negative emotions arising during any kind of sexual expression, including masturbation, and these emotions can take time to process. Especially in the case of a vaginismic woman, feelings of shame, inadequacy or of being 'defective' can be deeply troubling. Relaxation, patience and self-acceptance are vital to a pleasurable experience.
The process of addressing vaginismus requires time, patience, and a focused personal intention to heal. In almost all cases it can be successfully treated.
A vaginismic woman does not consciously control the spasm. The vaginismic reflex can be compared to the response of the eye shutting when an object comes towards it. The severity of vaginismus varies from woman to woman. Experience of vaginismus
The conditioned reflex can create a vicious circle for vaginismic women. One example: if a teenage female learns that the first time she engages in penetrative sex that it will be painful, she may develop vaginismus because she expects pain. If she then attempts to engage in penetrative sex, the muscle spasm will make penetrative sex painful. This and each further attempt at sexual penetration confirms her fear of pain and may worsen the condition. Naturally, penetration may be extremely painful without vaginismus or psychological prerequisite as well.
Primary vaginismus
Primary vaginismus occurs when a woman has never been able to have penetrative sex or achieve any kind of vaginal penetration. It is commonly discovered in teenagers and women in their early twenties, as this is when many young women in the Western world will initially attempt to use tampons, have penetrative sex, or undergo a pap smear. Women who have vaginismus may not be aware of their condition until they attempt vaginal penetration. It may be confusing for a woman to discover she has vaginismus. She may believe that vaginal penetration should be naturally easy, or she may be unaware as to the reason for her condition.
Some of the things that may cause primary vaginismus are:
sexual abuse
having been taught that sex is immoral or vulgar
the fear of pain associated with penetration, particularly that of breaking the hymen upon the first attempt at sexual penetration
Secondary vaginismus
Secondary vaginismus occurs when a woman who has previously been able to achieve penetration develops vaginismus. This may be due to physical causes such as a yeast infection or trauma during childbirth, or it may be due to psychological causes. The treatment for secondary vaginismus is the same as for primary vaginismus, although, in these cases, previous experience with successful penetration can assist in a more rapid resolution of the condition.
Treatment
There are a variety of factors that can contribute to vaginismus. These may be psychological or physiological, and the treatment required can depend on the reason that the woman has developed the condition. As each case is different, an individualized approach to treatment is useful.
The condition will not necessarily become more severe if left untreated, unless the woman is continuing to attempt penetration, despite feeling pain. Some women may choose to refrain from seeking treatment for their condition.
According to the Cochrane Collaboration review of the scientific literature, "In spite of encouraging results reported from uncontrolled case series there is very limited evidence from controlled trials concerning the effectiveness of treatments for vaginismus. Further trials are needed to compare therapies with waiting list control and with other therapies." [1]
Although few controlled trials have been carried out, many serious scientific studies have tested and proved the efficacy of the treatment of vaginismus. In all cases where the systematic desensitization method was used, success rates were close to 90-95% and even 100%. For an example of one of these studies, see Nasab, M., & Farnoosh, Z., or for a basic review, see Reissing's literature review. (links below)
Psychological treatment
According to Ward and Ogden's qualitative study on the experience of vaginismus for women (1994), the three highest ranked causes for vaginismus are usually fear of painful sex, strict religious upbringing where sex was viewed as wrong or not discussed, and early childhood traumatic experiences (not necessarily sexual in nature).
It is important to address the psychological aspects of the problem as well as the actual muscle spasm. A woman may choose to address the issue on her own terms, or she may avail the help of a therapist.
Many people -- even some professionals -- are not aware of the emotional difficulties associated with vaginismus, which can include low self-esteem, fears, and depression. Women with this condition may wish to seek an understanding professional who has previous experience with women who experience vaginismus. A therapist who has a positive attitude towards sex and the human body may be beneficial.
Physical treatment
Physical treatment of the internal spasms may include sensate focus exercises, exploring the vagina through touch, and desensitization with vaginal dilators. Dilating involves inserting objects, usually phallic in shape, into the vagina. In treating the spasms through dilation, the objects used gradually increase in size as the woman progresses. Medical dilators may be obtained online, though they may be expensive.
Sexuality
If a woman suspects she has vaginismus, sexual penetration is likely to remain painful or impossible until her vaginismus is addressed. Women with vaginismus may be able to engage in other sexual activities, as long as penetration is avoided. Sexual partners of vaginismic women may come to believe that vaginismic women do not want to engage in penetrative sex at all, though this may not be true. Many vaginismic women do wish to engage in penetrative sex, but are deterred by the pain and emotional distress that comes with each attempt.
Masturbation
Women with vaginismus may not realize that most women who do not have vaginismus usually do experience pain or discomfort if they attempt sexual penetration without prior sexual arousal. Most women acknowledge sexual arousal as integral to painless sexual penetration so self-exploration of the vaginal area through masturbation can be beneficial in addressing vaginismus.
One of the problems that can come with vaginismus is that a woman may be fearful to engage in sexual activity, due to the fear of pain with any kind of vaginal penetration. Solo masturbation, with or without penetration, can alleviate this fear, as well as the psychological pressure to 'perform' sexually or become aroused quickly, with a partner.
Despite popular belief, orgasm need not be the goal of masturbation. The reason may be to simply increase comfort with the genital area, to explore various sensations through genital and clitoral touch, and to become aware of those sensations which are relaxing and pleasurable. Sexual arousal causes changes in the shape and color of the vulva, as well as in the vaginal lubrication produced. As a woman becomes more aware of her individual sexual response, she can learn which sensations are best for bringing her to a state of arousal. She will then be better equipped to teach her partner(s) which sensations feel best for her.
Emotional experiences
A wide range of emotions may surface during masturbation and other forms of genital exploration. Some women have negative associations with their genitals, including fears that their genitals are dirty, smelly, oddly shaped, or ugly. These associations can lead to negative emotions arising during any kind of sexual expression, including masturbation, and these emotions can take time to process. Especially in the case of a vaginismic woman, feelings of shame, inadequacy or of being 'defective' can be deeply troubling. Relaxation, patience and self-acceptance are vital to a pleasurable experience.
The process of addressing vaginismus requires time, patience, and a focused personal intention to heal. In almost all cases it can be successfully treated.
Vulvar Anatomy: Naming your parts!
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vaginismus treatment
A good sexual rule of thumb is, Don't have intercourse if it's painful. If you ever experience pain during intercourse, stop. Then see a doctor to help you determine the cause of the pain and help you overcome the problem. When the physical cause of the pain is eliminated, go back to having intercourse painlessly and enjoyably. To do otherwise invites disaster.
It's true that when important emotional needs, such as sexual fulfillment, are unmet, there is a risk for an affair. But having sex at all costs is not the solution. In fact, if you follow my Policy of Joint Agreement (never do anything without an enthusiastic agreement between you and your spouse) you would never have sex in a way that's painful to you. Instead, you would pursue painless sexual options until you have resolved the problem.
Most women throughout most of their lives experience no pain whatsoever when they have intercourse. The vagina is designed for intercourse, and works very well for that purpose under most conditions. But, once in a while, most women do experience pain during intercourse. When they do, they should identify and treat the problem before having intercourse again.
There are primary and secondary causes of vaginal pain during intercourse. The primary causes are those that are responsible for the initial pain or discomfort. Secondary causes are those that are created by the pain itself if intercourse continues. These can trigger vaginal pain long after the primary causes have been overcome.
Primary Causes of Vaginal Pain
One of the most common primary causes of vaginal pain during intercourse is a dry vagina. Usually, when a woman is sexually aroused, fluids are secreted in the vagina that keep the lining well lubricated. But if a woman is not sexually aroused, or if fluids are not secreted for some other reason, intercourse can cause very painful damage to the vaginal lining. And in some cases, the lining of the vagina can actually tear, resulting in post-intercourse bleeding.
There are two ways to avoid a dry vagina during intercourse. The first is to avoid intercourse until you are sexually aroused. The second way is to use an artificial water-based vaginal lubricant, such as K-Y jelly, Vagisil Intimate Moisturizer, or Replens Vaginal Mosturizer, as a substitute or backup for natural lubricant.
Since vaginal secretion is usually an indication of a woman's sexual interest, I usually recommend that intercourse wait until she experiences sexual arousal and natural lubrication. I want couples to avoid getting into the habit of sex that's passionless for her. But if natural secretion is an unreliable indicator of your sexual arousal, I would certainly recommend an artificial lubricant.
If you're not sure if a dry vagina is the cause of your pain, use an artificial lubricant once. If there is no pain under those conditions, then you have proof that it's the cause of your distress.
Another common cause of vaginal discomfort during intercourse is bacterial infection. This occurs frequently in women, and an antibiotic will generally cure the problem within a week or so. A related problem is bladder infections. While the problem may be in the bladder or urethra, not in the vagina, it often causes discomfort during intercourse.
A visit to your doctor will identify and treat a bacterial infection so that you will have minimal interruption in your sexual fulfillment. But be sure to make the appointment as soon as intercourse is uncomfortable. Otherwise it can develop into a secondary cause of vaginal pain that I will explain later.
There are other diseases that can cause pain or discomfort during intercourse. Vaginal endometriosis is one of them. When your doctor examines you for possible bacterial infection, be sure to ask him or her about endometriosis, because it is often overlooked during an examination. Your doctor examination will also be able to check for any vaginal tumors or venereal diseases that may be causing your discomfort. These problems may take longer to treat than bacterial infections, but whatever the problem turns out to be, don't have intercourse until it has been overcome.
If you have experienced vaginal bleeding after intercourse, your doctor should also be able to identify its source, and treat it for you. Sometimes a scratch or tear in the lining caused by something other than intercourse can be the cause of your problem.
It is very important for you to be comfortable with regular pelvic examinations. Otherwise you may let a medical problem become so far advanced that it causes you permanent injury. If you are embarrassed to see a male doctor, find a female doctor. But whatever you do, don't let your inhibitions prevent you from experiencing painless intercourse.
If your doctor can identify the source of your vaginal discomfort, don't have intercourse until the problem is treated and overcome to his or her satisfaction. Some problems can be treated in a week or less, while others, like endometriosis may take months to overcome.
If you are unable to have intercourse during treatment for a vaginal disease, that doesn't mean you'll be forcing your husband to rush off to have sex with someone else. I suggest that your husband be informed by your doctor of what it is you are going through, and how you will be treated. A major problem you may face is your husband's failure to see your sexual reluctance for what it is: vaginal pain brought on by a physical cause. If he doesn't believe you when you explain that it's the pain that makes you reluctant, his ignorance puts your sexual relationship, and probably your marriage, at risk. But once he understands the nature of the problem, and knows that it isn't an affair or some other emotional cause, he will be happier with alternatives to intercourse while you wait for your treatment to take effect.
In some cases, a husband's thoughtlessness is remembered long after the painful symptoms are gone. If your husband tries to force you to have painful intercourse with him and threatens you if you do not cooperate, your memories of his insensitivity will be a far greater barrier to your future sexual relationship than your disease ever could have been. Don't let him create those barriers to your future together. Insist that there be no sex unless you enjoy the experience with him. It's not only in your best interest, but in his best interest too. If you go ahead and try to make love when it's painful to you, you may have a very difficult time making love to him in the future.
A Secondary Cause of Vaginal Pain
What should you do if you eliminate the primary causes, and you still experience vaginal pain? What if your doctor finds no physical cause for your discomfort during intercourse? That can be very discouraging to most women, who begin to think that it's all in their heads. If the pain is not physically caused, then it must be psychological, right?
Not necessarily. In fact, most cases of persistent vaginal discomfort are not due to primary causes at all, but rather to a reflex called vaginismus. It's not psychological or emotional, it's very physical. Vaginismus is a painful reflex that is created in association with a primary cause of vaginal pain. In other words, if you experience vaginal pain from any one of the primary causes I've mentioned, vaginismus can develop secondarily. Long after the primary cause is ended, the vaginismus can persist.
This reflex responds to stimulation of the vaginal opening. If you suffer from vaginismus, you will notice it most when you first try to insert something into your vagina. The opening involuntarily contracts and pain is immediately felt. In extreme cases, the contraction is so tight that nothing can penetrate it.
From this description, you can see how it would interfere with intercourse. Regardless of how sexually aroused you might be, or how lubricated your vagina might be, as soon as you try to insert your husband's penis, you would experience excruciating pain. It may be difficult to insert his penis, because the vaginal opening becomes constricted. In some cases, it is impossible to insert a penis.
Naive couples often don't know what to make of vaginismus. Some of my clients believed it was God's punishment for their having sex before marriage. Others have blamed it on the sins of their parents. But whatever its cause, it certainly feels like punishment for something. Only after I am able to explain the cause of the reflex and help them eliminate it, do they realize that sin has nothing to do with it.
There is a tried and proven way to overcome the vaginismus reflex. If you follow this procedure, I guarantee your success. I recommend that you follow the exercises I recommend in the privacy of your bathroom, or when you are alone in the house. Your husband should not be included until the later sessions.
First determine how strong the reflex is and what triggers it. The way to determine its strength is to insert your finger into the vaginal opening to see what happens. If there is no reaction to your finger, insert something increasingly wider, like candles, until you can trigger the reflex. It will be an involuntary contraction of the opening as you try to insert the object, and it will be painful.
Notice how large the object must be before the reflex is triggered, and how tight the opening gets. The smaller the triggering object, and the tighter the opening, the more difficult it will be to extinguish the reflex. If you can't get your finger into the opening without extreme pain, you have a very well developed case of vaginismus. But regardless of its intensity, it can be eliminated.
The way to eliminate this reflex is to set aside a few minutes each day, preferably several times a day, to expose the opening of your vagina to penetration without triggering the reflex. If you can associate vaginal penetration with no pain or discomfort, the reflex will be extinguished. But remember, even an occasional triggering of the reflex can strengthen it.
Begin each session by covering your finger with water-based lubrication (such as K-Y jelly, Vagisil Intimate Moisturizer, or Replens Vaginal Mosturizer). Very slowly, lubricate the opening of the vagina with your finger, then slowly insert your finger about an inch. Even in the worst cases of vaginismus, a finger can be inserted so slowly into a lubricated vaginal opening that the reflex is not triggered. In a slow circular motion, gently rub the vaginal opening with your finger in ever-increasing circles. Remember to go slowly enough not to trigger the reflex or experience any discomfort. After you have rubbed the opening for about a minute without any pain or discomfort, slowly insert your finger into the vagina, and in a circular motion gently rub the inside of the vagina as far as your finger will go. Then remove your finger, and do the same thing all over again. Do it about five times before you end the session.
You will notice that after the first insertion of your finger, the opening is much less sensitive, and you will be able to penetrate much more quickly without triggering a reflex. Move your finger slowly enough so that you avoid any discomfort. But after a while, you will find that you can move it very freely without pain.
You may end the first session thinking that you have overcome the reflex, only to discover at the beginning of the next session that it is back. So start the next session very slowly and carefully, doing again what you did during the first session. When you think you are ready, use a larger object than your finger, such as a candle, and increase the diameter of the object until it is about the size of a penis. Be sure to re-lubricate whatever you choose to insert, and go slowly to avoid the reflex.
The number of sessions to completely eliminate the reflex will depend on the severity of the vaginismus. But when it is eliminated, you should be able to insert an object the size of a penis, with lubrication, fairly rapidly without any pain or discomfort.
There are some women who are not comfortable touching themselves, and would prefer having their husbands carry out these exercises. While it can work, the problem with anyone else doing it is that no one but you knows precisely how much pressure to use, and your husband would inadvertently trigger the reflex far more often than you would. That means that it would take much longer for you to overcome vaginismus with his help.
His turn should come after you are convinced that the reflex is extinguished. Up to this point, obviously, you should have avoided intercourse, because it would have brought the reflex back. But when you think the reflex is gone, it's time to start having intercourse again. Unfortunately, you will find that after you have learned to insert a penis-sized object into your vagina without incident, the reflex may suddenly reappear the first time your husband tries to insert his penis.
To prepare for that common outcome, the first time you have intercourse you should insert his penis yourself. Use plenty of lubricating fluid, and lay on top of him when you do it so you can control the penetration. He should lay motionless so that the penetration and thrusting is done only by you so you can stop whenever you experience the least amount of discomfort. Eventually, you will be able to insert his penis without any pain, thrust as fast and deep as you want, and experience no discomfort whatsoever. The vaginismus reflex will have been eliminated.
If it ever comes back, it will be in a much milder form, and you will be able to eliminate it in a day or so by going back to inserting his penis yourself and controlling the thrusting motion during intercourse.
To repeat what I have already said numerous times, whenever you experience any pain during intercourse, stop immediately. Then solve the problem before resuming intercourse.
It's true that when important emotional needs, such as sexual fulfillment, are unmet, there is a risk for an affair. But having sex at all costs is not the solution. In fact, if you follow my Policy of Joint Agreement (never do anything without an enthusiastic agreement between you and your spouse) you would never have sex in a way that's painful to you. Instead, you would pursue painless sexual options until you have resolved the problem.
Most women throughout most of their lives experience no pain whatsoever when they have intercourse. The vagina is designed for intercourse, and works very well for that purpose under most conditions. But, once in a while, most women do experience pain during intercourse. When they do, they should identify and treat the problem before having intercourse again.
There are primary and secondary causes of vaginal pain during intercourse. The primary causes are those that are responsible for the initial pain or discomfort. Secondary causes are those that are created by the pain itself if intercourse continues. These can trigger vaginal pain long after the primary causes have been overcome.
Primary Causes of Vaginal Pain
One of the most common primary causes of vaginal pain during intercourse is a dry vagina. Usually, when a woman is sexually aroused, fluids are secreted in the vagina that keep the lining well lubricated. But if a woman is not sexually aroused, or if fluids are not secreted for some other reason, intercourse can cause very painful damage to the vaginal lining. And in some cases, the lining of the vagina can actually tear, resulting in post-intercourse bleeding.
There are two ways to avoid a dry vagina during intercourse. The first is to avoid intercourse until you are sexually aroused. The second way is to use an artificial water-based vaginal lubricant, such as K-Y jelly, Vagisil Intimate Moisturizer, or Replens Vaginal Mosturizer, as a substitute or backup for natural lubricant.
Since vaginal secretion is usually an indication of a woman's sexual interest, I usually recommend that intercourse wait until she experiences sexual arousal and natural lubrication. I want couples to avoid getting into the habit of sex that's passionless for her. But if natural secretion is an unreliable indicator of your sexual arousal, I would certainly recommend an artificial lubricant.
If you're not sure if a dry vagina is the cause of your pain, use an artificial lubricant once. If there is no pain under those conditions, then you have proof that it's the cause of your distress.
Another common cause of vaginal discomfort during intercourse is bacterial infection. This occurs frequently in women, and an antibiotic will generally cure the problem within a week or so. A related problem is bladder infections. While the problem may be in the bladder or urethra, not in the vagina, it often causes discomfort during intercourse.
A visit to your doctor will identify and treat a bacterial infection so that you will have minimal interruption in your sexual fulfillment. But be sure to make the appointment as soon as intercourse is uncomfortable. Otherwise it can develop into a secondary cause of vaginal pain that I will explain later.
There are other diseases that can cause pain or discomfort during intercourse. Vaginal endometriosis is one of them. When your doctor examines you for possible bacterial infection, be sure to ask him or her about endometriosis, because it is often overlooked during an examination. Your doctor examination will also be able to check for any vaginal tumors or venereal diseases that may be causing your discomfort. These problems may take longer to treat than bacterial infections, but whatever the problem turns out to be, don't have intercourse until it has been overcome.
If you have experienced vaginal bleeding after intercourse, your doctor should also be able to identify its source, and treat it for you. Sometimes a scratch or tear in the lining caused by something other than intercourse can be the cause of your problem.
It is very important for you to be comfortable with regular pelvic examinations. Otherwise you may let a medical problem become so far advanced that it causes you permanent injury. If you are embarrassed to see a male doctor, find a female doctor. But whatever you do, don't let your inhibitions prevent you from experiencing painless intercourse.
If your doctor can identify the source of your vaginal discomfort, don't have intercourse until the problem is treated and overcome to his or her satisfaction. Some problems can be treated in a week or less, while others, like endometriosis may take months to overcome.
If you are unable to have intercourse during treatment for a vaginal disease, that doesn't mean you'll be forcing your husband to rush off to have sex with someone else. I suggest that your husband be informed by your doctor of what it is you are going through, and how you will be treated. A major problem you may face is your husband's failure to see your sexual reluctance for what it is: vaginal pain brought on by a physical cause. If he doesn't believe you when you explain that it's the pain that makes you reluctant, his ignorance puts your sexual relationship, and probably your marriage, at risk. But once he understands the nature of the problem, and knows that it isn't an affair or some other emotional cause, he will be happier with alternatives to intercourse while you wait for your treatment to take effect.
In some cases, a husband's thoughtlessness is remembered long after the painful symptoms are gone. If your husband tries to force you to have painful intercourse with him and threatens you if you do not cooperate, your memories of his insensitivity will be a far greater barrier to your future sexual relationship than your disease ever could have been. Don't let him create those barriers to your future together. Insist that there be no sex unless you enjoy the experience with him. It's not only in your best interest, but in his best interest too. If you go ahead and try to make love when it's painful to you, you may have a very difficult time making love to him in the future.
A Secondary Cause of Vaginal Pain
What should you do if you eliminate the primary causes, and you still experience vaginal pain? What if your doctor finds no physical cause for your discomfort during intercourse? That can be very discouraging to most women, who begin to think that it's all in their heads. If the pain is not physically caused, then it must be psychological, right?
Not necessarily. In fact, most cases of persistent vaginal discomfort are not due to primary causes at all, but rather to a reflex called vaginismus. It's not psychological or emotional, it's very physical. Vaginismus is a painful reflex that is created in association with a primary cause of vaginal pain. In other words, if you experience vaginal pain from any one of the primary causes I've mentioned, vaginismus can develop secondarily. Long after the primary cause is ended, the vaginismus can persist.
This reflex responds to stimulation of the vaginal opening. If you suffer from vaginismus, you will notice it most when you first try to insert something into your vagina. The opening involuntarily contracts and pain is immediately felt. In extreme cases, the contraction is so tight that nothing can penetrate it.
From this description, you can see how it would interfere with intercourse. Regardless of how sexually aroused you might be, or how lubricated your vagina might be, as soon as you try to insert your husband's penis, you would experience excruciating pain. It may be difficult to insert his penis, because the vaginal opening becomes constricted. In some cases, it is impossible to insert a penis.
Naive couples often don't know what to make of vaginismus. Some of my clients believed it was God's punishment for their having sex before marriage. Others have blamed it on the sins of their parents. But whatever its cause, it certainly feels like punishment for something. Only after I am able to explain the cause of the reflex and help them eliminate it, do they realize that sin has nothing to do with it.
There is a tried and proven way to overcome the vaginismus reflex. If you follow this procedure, I guarantee your success. I recommend that you follow the exercises I recommend in the privacy of your bathroom, or when you are alone in the house. Your husband should not be included until the later sessions.
First determine how strong the reflex is and what triggers it. The way to determine its strength is to insert your finger into the vaginal opening to see what happens. If there is no reaction to your finger, insert something increasingly wider, like candles, until you can trigger the reflex. It will be an involuntary contraction of the opening as you try to insert the object, and it will be painful.
Notice how large the object must be before the reflex is triggered, and how tight the opening gets. The smaller the triggering object, and the tighter the opening, the more difficult it will be to extinguish the reflex. If you can't get your finger into the opening without extreme pain, you have a very well developed case of vaginismus. But regardless of its intensity, it can be eliminated.
The way to eliminate this reflex is to set aside a few minutes each day, preferably several times a day, to expose the opening of your vagina to penetration without triggering the reflex. If you can associate vaginal penetration with no pain or discomfort, the reflex will be extinguished. But remember, even an occasional triggering of the reflex can strengthen it.
Begin each session by covering your finger with water-based lubrication (such as K-Y jelly, Vagisil Intimate Moisturizer, or Replens Vaginal Mosturizer). Very slowly, lubricate the opening of the vagina with your finger, then slowly insert your finger about an inch. Even in the worst cases of vaginismus, a finger can be inserted so slowly into a lubricated vaginal opening that the reflex is not triggered. In a slow circular motion, gently rub the vaginal opening with your finger in ever-increasing circles. Remember to go slowly enough not to trigger the reflex or experience any discomfort. After you have rubbed the opening for about a minute without any pain or discomfort, slowly insert your finger into the vagina, and in a circular motion gently rub the inside of the vagina as far as your finger will go. Then remove your finger, and do the same thing all over again. Do it about five times before you end the session.
You will notice that after the first insertion of your finger, the opening is much less sensitive, and you will be able to penetrate much more quickly without triggering a reflex. Move your finger slowly enough so that you avoid any discomfort. But after a while, you will find that you can move it very freely without pain.
You may end the first session thinking that you have overcome the reflex, only to discover at the beginning of the next session that it is back. So start the next session very slowly and carefully, doing again what you did during the first session. When you think you are ready, use a larger object than your finger, such as a candle, and increase the diameter of the object until it is about the size of a penis. Be sure to re-lubricate whatever you choose to insert, and go slowly to avoid the reflex.
The number of sessions to completely eliminate the reflex will depend on the severity of the vaginismus. But when it is eliminated, you should be able to insert an object the size of a penis, with lubrication, fairly rapidly without any pain or discomfort.
There are some women who are not comfortable touching themselves, and would prefer having their husbands carry out these exercises. While it can work, the problem with anyone else doing it is that no one but you knows precisely how much pressure to use, and your husband would inadvertently trigger the reflex far more often than you would. That means that it would take much longer for you to overcome vaginismus with his help.
His turn should come after you are convinced that the reflex is extinguished. Up to this point, obviously, you should have avoided intercourse, because it would have brought the reflex back. But when you think the reflex is gone, it's time to start having intercourse again. Unfortunately, you will find that after you have learned to insert a penis-sized object into your vagina without incident, the reflex may suddenly reappear the first time your husband tries to insert his penis.
To prepare for that common outcome, the first time you have intercourse you should insert his penis yourself. Use plenty of lubricating fluid, and lay on top of him when you do it so you can control the penetration. He should lay motionless so that the penetration and thrusting is done only by you so you can stop whenever you experience the least amount of discomfort. Eventually, you will be able to insert his penis without any pain, thrust as fast and deep as you want, and experience no discomfort whatsoever. The vaginismus reflex will have been eliminated.
If it ever comes back, it will be in a much milder form, and you will be able to eliminate it in a day or so by going back to inserting his penis yourself and controlling the thrusting motion during intercourse.
To repeat what I have already said numerous times, whenever you experience any pain during intercourse, stop immediately. Then solve the problem before resuming intercourse.
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