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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.
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.
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