What is Vaginismus?
Freud made his most provocative chauvinistic statement when he stated, “Analysis terminable and interminable, that women must come to accept her secondary status and compensate for her lack of a penis by having a baby and a husband; but something is always lacking. Man has to overcome his castration fear, which can reflect itself in passive traits; but, if success will come a man emerges as a complete human being; the woman can never achieve this.”
Clearly we have come a long way since these distorted views. Kinsey and Masters and Johnson have done tremendous research in the area of female sexuality and female dysfunction.
Vaginismus is a condition defined by involuntary spasm or constriction of the musculature surrounding the vaginal outlet and the outer third of the vagina. This can affect women of any age, at the earliest attempts of sexual activity up to the elderly years. It may vary in severity. Vaginismus is not the same as dyspareunia, which is painful intercourse. Vaginismus is common in nonconsumated marriages and upon the very first sexual interaction the spasm may occur. There can be organic causes of this such as hymenal abnormalities. Sexually transmitted diseases such as genital herpes or other infections can cause initial pain and then spasm, as well as atrophic vaginitis. The majority of cases that this examiner has seen have had a psychogenic foundation. The vast majority of these individuals have been brought up with the view that sex is dirty, that it is a sin. Interestingly enough, women have married men with a similar background and one also sees some primary impotence with these men, especially if the woman has vaginismus. Vaginismus can also stem from a severe traumatic experience, i.e. rape or sexual abuse. Women with severe cases of vaginismus cannot even use a tampon during menstruation, and pelvic exams are next to impossible due to the increased anxiety.
What is the treatment of Vaginismus?
A very thorough history needs to be performed. It is important to go back to childhood to uncover any potential traumas. If pelvic examinations are impossible, there are ways to increase the likelihood by using an Otoscope (a very small speculum) and moving slowly from head to toe looking in the ears, explaining what you are seeing, taking a very slow and methodical approach, explaining everything done in order to decrease anxiety. Another method is to start out with a very small speculum and slowly enlarge the size, which aids in dispelling anxiety and fear during the examination. A Benzodiazapine like Valium can be effective, or Xanax to decrease anxiety.
Joint therapy is very important. Initially the woman may not want that, and one must respect her wishes and start out with individual therapy, slowing bringing in her husband, explaining to her the necessity of open communication. Anatomy needs to be discussed in detail, which also helps to reduce anxiety.
Teaching the woman how to constrict her pelvic area is a very useful paradoxical approach. It is extremely helpful if a woman can tighten her pelvic area and hold this for 3-4 seconds, then relax (Kegel exercises). Doing this repetitiously is very helpful. One does not know what relaxation feels like unless they know what stress and tension feels like. This maneuver is highly effective.
Vaginal dilators are very helpful, starting out very small and slowly increasing in size. Usually the woman is extremely surprised when the largest sized dilator is reached, and she sees she can place this in the vaginal vault without any pain or problems. This combined with anti-anxiety medication or muscle relaxants, is very effective.