Vaginismus:When a Woman's Body says No to Sex

1. Vaginismus Vaginismus Aboubakr Elnashar Benha University Hospital, EGYPT 11.9.2015 ABOUBAKR ELNASHAR

2. CONTENTS 1. DEFINE 2. INCIDENCE 3. TYPES 4. CAUSES 5. DIAGNOSIS 6. CLASSIFICATION 7. TREATMENT  CONCLUSION ABOUBAKR ELNASHAR

3. 1. DEFINITION 1862 Dr. Marion Sims Introduced the term “vaginismus” Reflex-like contraction of the cir-cumvaginal musculature, resulting in non-consummation of marriage. ABOUBAKR ELNASHAR

4. Old: Recurrent or persistent involuntary contraction of the outer 1/3 of the vagina interfering with sexual intercourse Vaginal spasm has been considered the defining diagnostic characteristic of vaginismus for150 y. This remarkable consensus, based primarily on expert clinical opinion, is preserved in the DSMIVTR. ABOUBAKR ELNASHAR

5. Studies: 1. Vaginal muscle spasm  has never been validated  EMG: 28% of the vaginismus (Reissing et al, 1999) 2. Vaginismus cannot be reliably dd from superficial dyspareunia (Basson, 1996; Har-Toov et al., 2001; Kaneko, 2001; de Kruiff et al., 2000; van Lankveld et al., 1996; Ng, 2001; Okawa, 2001; Pukall et al., 2000; Reissing et al., 1999, 2004; Wijma et al., 2000) ABOUBAKR ELNASHAR

6. 3. lack of consensus regarding a. Definition of the term 'muscle spasm  involuntary muscle cramp, a defensive mechanism or  hypertonicity of the pelvic floor muscles. b. Which muscles are involved in vaginismus.  muscles of the outer 1/3 of the vagina, the pelvic muscles or the circumvaginal and perivaginal muscles, [Van de Wiel, 1990]  bulbocavernosus, the levator ani and puboccoccygeus. [Lamont, 1994] ABOUBAKR ELNASHAR

7. Recent: International Definitions Committee”, 2005 Persistent or recurrent difficulties of the women to allow vaginal entry (penis, finger, and/or object…). despite her expressed wish to do so.. ABOUBAKR ELNASHAR

8. Clinical syndrome that consists of overlapping elements of Hypertonic pelvic floor muscles Pain Anxiety, and Difficulty in penetration. [Crowley, 2009) There is variable: (phobic) avoidance, involuntary pelvic muscle contraction and anticipation/fear/experience of pain. The syndrome of vaginismus, vestibulodynia, and dyspareunia overlap (Ter Kuile et al, 2005) Superficial dyspareunia and vaginismus can be similar, which makes diagnosing vaginismus difficult. ABOUBAKR ELNASHAR

9. American Psychiatric Association, 2013 Diagnostic and Statistical Manual of Mental Disorders (DSM 5) Vaginismus and dyspareunia single diagnostic entity called "genitopelvic pain/penetration disorder.“ part of the spectrum of painful intercourse, the difference being a matter of severity ABOUBAKR ELNASHAR

10. 2. INCIDEENCE True incidence is unknown [Bacik, 2014] Most common reason for unconsummated marriages. Family planning clinic: 12% Sexual dysfunction clinics: 5-40% ABOUBAKR ELNASHAR

11. 3. TYPES 1. Primary 1. Spasmodic [Leiblum, 2000] spasm of the vagina 2. Non spasmodic. lifelong, never able to have intercourse Secondary acquired, past history of vaginal penetration without problems. 2.Global unable to place any thing in the vagina situational able to use a tampon, tolerate a pelvic examination but cannot have intercourse ABOUBAKR ELNASHAR

12. 4. CAUSES Most often, never delineated. Multidimensional condition Physical and a psychological condition [Rosenbaum, 2013]. ABOUBAKR ELNASHAR

13. Causes of painful intercourse Superficial pain Lack of sexual arousal Vulvovaginitis: trichomoniasis, herpes simplex infection, candidiasis, furunculosis Atrophic vaginitis Vulvar dermatoses: lichen sclerosus, lichen planus, or lichen simplex chronicus Drugs or radiotherapy Deep pain Endometriosis PID ABOUBAKR ELNASHAR

14. Predisposing factors: Anxiety disorders Precipitating factors Painful SI Painful Pelvic EX Sexual assault Childhood abuse PID Gyn surgery Urogenital atrophy Maintaining factors When a couple continue trying to have intercourse despite the pain: reinforce spasm of the musculature. ABOUBAKR ELNASHAR

15. 5. DIAGNOSIS A. History Medical Psychosocial Sexual history, including any episodes of traumatic sexual experience (Crowley et al, 2009). A clear description of the pain, fear, and avoidance responses. The woman’s ability to tolerate genital exploration by herself or another. History of severe pain during intercourse or intercourse being impossible. • • • ABOUBAKR ELNASHAR

16.  Sexual history (Crowley, 2009) 1. Is penetration possible? 2. If so, is it painful? 3. Is it painful only at penetration? 4. How anxious does she feel at the thought of penetration? 5. Can she insert tampons or fingers? ABOUBAKR ELNASHAR

17. 6. How long has this been a problem? 7. Is she able to become aroused and climax at all? 8. What does she want to achieve? 9. How anxious does she feel about the thought of a genital examination? 10. What is it about the examination that makes her anxious? 11. Has she ever had a traumatic sexual experience? ABOUBAKR ELNASHAR

18. B. Genital examination To exclude organic pathology: herpes virus, lichen sclerosis, and others [Crowley, 2009) Several consultations may be needed before the woman is ready to be examined ABOUBAKR ELNASHAR

19. Before the examination 1. Give her control by reassuring her you will stop immediately if she wishes 2. Explain what you will do during the examination 3. Tell her she can ask questions at any point 4. Show her the smallest Cusco’s speculum and let her hold it 5. Explain that the vagina has the potential to expand and that muscle tension caused by anxiety can make penetration difficult 6. Demonstrate the degree of pressure you will use by pressing your finger on her hand ABOUBAKR ELNASHAR

20. During the examination 1. Be gentle and encourage her to relax her legs; do not use pressure to pull them apart 2. Place one finger on the external genitalia and ask her again for permission to inspect the vulva 3. Use cotton wool swabs to establish any point tenderness suggestive of vestibulodynia 4. Ask permission again before inserting one finger into the vagina 5. Lubricants may be helpful 6. Assess how well she tolerates this process ABOUBAKR ELNASHAR

21. Surface electromyography not useful for the routine diagnosis of vaginismus. {Studies of women with and without vaginismus, using electromyography, have found no difference in their ability to contract and release their pelvic floor}. (Engman et al, 2004) ABOUBAKR ELNASHAR

22. 6. CLASSIFICATION Lamont and Pacik Stratifying the severity of vaginismus {success in tt is related to the severity} depends on: 1. Degree of vaginal spasm 2. Degree of fear and anxiety ABOUBAKR ELNASHAR

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24. 7. TREATMENT Aim: •Break the vicious cycle •Replacing pain by pleasure spasm by relaxation •Make the women feels that she owns her vagina & can share it for sexual activity should she wish. Requirements: Warm, sympathetic attitude Great patience ABOUBAKR ELNASHAR

25. When should women be referred? 1. History of sexual trauma 2. Anxiety, phobic resistance to examination, or other mental health or relationship problems. Sexual therapists Psychiatrists, or Psychotherapists. Those who are less anxious: Vaginal trainers with support from their doctor. Treatment is a team effort ABOUBAKR ELNASHAR

26.  Lines of treatment: 1. Exploration of phobia History False beliefs 2. Sex education Anatomy Physiology 3. Control of muscles: Adductors: Relaxation exercise P coccygeus: Kegel s exercise ABOUBAKR ELNASHAR

27. 4. Systematic vaginal desensitization: Step 1:Insertion of a trainers under controlled relaxation Step 2: Sharing of control with husband Step 3: Insertion of penis with the woman in control Step 4: Transfer control of insertion of penis to husband 5. Botulinum toxin 6. Other modalities ABOUBAKR ELNASHAR

28. 1. EXPLORATION OF PHOBIA. Difficult 1. History of psychological causes should be addressed. History of childhood traumatic experience: recalled & the emotions which accompanied it relived in order to help the woman to come to terms with them ABOUBAKR ELNASHAR

29. 2. Dealing with false beliefs: (common myths): 1. Vagina is too small to allow penetration In fact: vagina is a “potential space”. At rest, the walls of the vagina lie touching each other, but separates to make room for something entering it Baby is able to travel through the vaginal canal during childbirth Vagina lengthens by 50% during sexual arousal: ABOUBAKR ELNASHAR accommodating almost any penis size.

30. 2. Fear of tearing of the hymen: pain, bleeding. In fact most women: minor and temporary discomfort ± happen without her awareness ABOUBAKR ELNASHAR

31. 2. SEX EDUCATION Woman and her husband More effective than condescending remarks in decreasing patient anxiety [Huber et al,2009]. 1. Genital anatomy PC (pubococcygeus) muscles, that tightens involuntarily when vaginismus is experienced. ABOUBAKR ELNASHAR

32. Self exploration of sexual anatomy (guided tour) Semi-sitting position legs apart mirror placed in front of her vulva, she explores her genitalia (with the doctor) explaining the anatomy & physiology. ABOUBAKR ELNASHAR

33. 2. Sexual physiology & behavior How their genital organs are put together & how they both function. The vagina muscles do not contract on their own, the reasons of their contraction are the negative thoughts and beliefs about sexuality and sexual intercourse. Brain is responsible of vaginismus,not vagina: name of this sexual dysfunction must be brainismus, not vaginismus. ABOUBAKR ELNASHAR

34. 3. CONTROL OF MUSCLES a. Relaxation exercises  to the adductor muscles To help her to relax when anticipates vaginal penetration. The doctor hold the woman ‘s knees together firmly while she attempts to separate them, then slowly she is allowed to succeed. ABOUBAKR ELNASHAR

35. Progressive relaxation used to manage anxiety, and women should use it before finger or trainer insertion. beneficial {increased sense of control and altered thinking} alternately tensing and relaxing groups of muscles in a prescribed sequence example, starting from the feet and moving upwards.  before self fingering or insertion of vaginal trainers. ABOUBAKR ELNASHAR

36. b. Contraction /relaxation exercise (Kegel ‘s exercise) To gain control over the muscles surrounding her introits . 1. The patient must learn first how to identify the muscle for herself. 2. She is advised to sit on the toilet with her legs spread as far apart as possible. 3. If she then starts & stops the flow of urine, she becomes aware of the pubococcygeus action. ABOUBAKR ELNASHAR

37. 4. Once the muscle is identified, the woman can practice contracting it repeatedly whenever she has time or 10-15 times a day ABOUBAKR ELNASHAR

38. Recommended for every woman especially •To strengthen or restore pelvic floor muscle tone. • To increase sexual health and sexual confidence with her partner. • To avoid incontinence or are currently experiencing urinary stress/urge incontinence. •Giving or has given birth. • Going through menopause. ABOUBAKR ELNASHAR

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40. 4. SYSTEMATIC VAGINAL DESENSITIZATION OF THE FEAR OF VAGINAL PENETRATION Vaginal dilatation exercises are a misnomer {vagina is not physically stretched} Behavioural therapy to treat phobias and other behavioural problems that involve anxiety. ABOUBAKR ELNASHAR

41. Trainers: fingers, commercial dilators, tampons, specifically designed specula such as Simms, Amiell, Stanley. •The choice depend on the patient preference & comfort level. •Fingers are preferred {allow to feel the muscles contracting. easy to remove if she starts to feel any discomfort}. ABOUBAKR ELNASHAR

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43. Approaches 1. Gradual using vaginal self-dilatation Starting with the smallest one she inserts larger vaginal trainers over time until one the size of a penis can be inserted comfortably. Rapid using vaginal mould insertion. Duration: 2-6 weeks (2-15 sessions) Rapid desensitization is preferred (Biswas & Ratnam,1995) ABOUBAKR ELNASHAR

44. 2. In-vitro: The dilator is introduced by the doctor or In-vivo: the dilator is introduced by the patient No discernible differences between the 2 forms of systematic desensitization (Cochrane SR, 2002) ABOUBAKR ELNASHAR

45. Success rate: 72-100% success in uncontrolled trials and case series. limited evidence to recommend the use of systematic desensitisation (Cochrane SR, 2001) ABOUBAKR ELNASHAR

46. Program Step 1: Insertion of a trainers under controlled relaxation: In private, in a relaxed & nonsexual setting at home. do the exercises with a finger inside the vagina. clip your fingernails and use a lubricating jelly. Or do the exercises in a bathtub, where water can be a natural lubricant. Your finger needs to be inserted 5-6 cm. That's up to about the first knuckle joint. Start with one finger and work your way up to 3 The insertion of digits is a slow and graduated process and can take weeks of nightly exercises. ABOUBAKR ELNASHAR

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48. Step 2: Sharing of control with husband. When she has become comfortable with this process, her partner’s fingers are introduced. while she maintains control how quickly the fingers are placed. The husband becomes active in the vaginal dilatation exercises only when the patient is emotionally & physically ready & after anxiety of being touched is extinguished. When she is comfortable inserting the larger dilators, she can instruct her husband how to place the dilator in her vagina ABOUBAKR ELNASHAR

49. Step 3: Insertion of penis with the woman in control. Sitting or kneeling over her husband, female superior position & inserting his penis herself. ABOUBAKR ELNASHAR

50. Step 4: Transfer control of insertion of penis to husband ABOUBAKR ELNASHAR