The Diagnosis and Treatment of Vaginismus

1. The Diagnosis and Treatment of Vaginismus KCNPNM Annual Conference April 2014 By Jean D. Koehler, Ph.D. And Susan Dunn, P.T.

2. Koehler Disclosures • Proctor and Gamble – Consultant and interviewer for Stage 3 clinical trials on testosterone patch for women – 2003-2004 • Proctor and Gamble- Regional Consultant’s Board- 2004- 2005 • Ortho-McNeil- Pharmaceuticals- Advisory Board of Female Sexual Dysfunction experts- November 2004 • Boeringer Ingleheim- Speaker’s Bureau-2010

3. Vaginismus DefinitionProposed by Rosemary Basson, M.D. The persistent or recurrent difficulties of the woman to allow vaginal entry of the penis, a finger, and/or any object despite the woman’s expressed desire to do so. There is often phobic avoidance, involuntary pelvic floor muscle contraction, and the anticipation/fear/experience of pain. Structural abnormalities must be ruled out/addressed. Basson et al, 2004

4. DSM V- 302.76 (Women’s) Genito-Pelvic Pain/Penetration Disorders • Marked vulvovaginal pain in penetration attempts (dyspareunia) • Marked anxiety about penetration or anticipated penetration • Marked tightening of pelvic floor muscles during attempted penetration (was called Vaginismus in prior manuals)

5. Types of Vaginismus • Primary- never achieved attempted coitus • Secondary- onset after pain free coitus • Total- penetration not possible through the PC muscle • Partial- penetration achieved, but painful • Situational- only with some penetrants • with penis but not speculum or visa versa • with larger sized partner but not smaller sized • with gyn exam, but not with coitus

6. Incidence of Sexual Pain Disorders US general population data- Michael et al, 1994 • Consistent coital pain in females-10-15% International general population data- Lewis et al, 2004 • Vaginismus- 6% • Coital pain- 2-20% The Cochrane Database of Systemic Reviews- McGuire and Hawton, 2002 Vaginismus in medical settings- 4-12% Vaginismus in sexual Dysfunction Clinics- 5-17% Women of childbearing age- est. .5-1% Graziottin, A. 2008

7. The BIO-PSYCHO-SOCIAL APPROACH TO VAGINISMUS DIAGNOSIS and TREATMENT

8. Factors Impacting Changes in Female Sexual Function - Variables from Mid Aged Woman’s Sexual Functioning Study Europe and Australia(Graziottin & Dennerstein in press,2005) Partnerstatus Wellbeing Psychological Interpersonal Stress Sexual Function Throughout a Woman’s Lifespan Menopause Stress Sociocultural Biological Parity Exercise BMI Health Age c. J Alexander ‘05

9. Medical Conditions That May Lead to Vaginismus • PVD- provoked vestibulodynia- one of most common causes of dyspareunia in pre-menopausal women (Smith 2014) • Estrogen, testosterone deficiency • OC use before 16, and for up to 2-4 years (Davis 2013) • Vulvovaginal atrophy in menopausal women (Hope 2010) • Pelvic floor disorders • Vaginal infection- i.e. recurrent yeast, herpes, bacterial vaginosis, HPV? • Vulvardermatoses, i.e. lichens sclerosis • Allergy to condoms, semen • Endometriosis • Radiation therapy • Injury from force –rape • Prior painful vaginal/urological medical interventions- especially in childhood/teen years- iatrogenic? • Female Genital Mutilation • Genetic abnormalities- i.e. septatehyman

10. Psycho-social Conditions Correlating to Vaginismus- Research Results • Pre-existing General Anxiety Disorder1 • Personality features- fear of new experiences, catastrophizing thoughts about pain, disgust propensity, low self-esteem2, 3 • Specific fear of penile vaginal penetration2 • Less self stimulation2 • Increased prevalence of desire and arousal problems2 • 1-Watts and Nettle, 2010 • 2- van Lankveld et al., 2010 • 3- Borg, C. et al. 2012

11. Possible Psychosocial Causes- Clinical Observations • Strict religious proscriptions against sexual interaction/especially coitus • Body Myths • Phobia to vaginal penetration, sometimes of any orifice • Sexual abuse or assault history- • Poor or unsure relationship with sexual partner • Fear of unplanned pregnancy, delivery pain • Secretly unwanted pregnancy • Stuck developmentally as a “good little girl”, not wanting to grow up sexually and disappoint parents

12. The New Treatment Team for Sexual Pain Disorders • Pelvic Pain MD/NP • Pelvic Floor Physical Therapist • Certified Sex Therapist/ Psychotherapist

13. Case Example of the team approachTara

14. Role of the Gyn Provider - • When the patient presents painful penetration as the reason for the office visit • When the providers notices an inability to perform a speculum exam

15. Sexual History for Vaginismus • Is she in a sexually active relationship? • Is penetration possible? If so, is it painful? • Is it painful only at penetration? When else? • Describe the pain? Locations, intensity, sharp/dull, etc. • How anxious does she feel at the thought of penetration? • Can she insert a tampon or finger without pain? • How long has this been a problem? • Was the onset sudden or gradual? Is it present all the time? • Is pain experienced at times other than with intercourse? • Is she able to become aroused and climax at all with self or partner? • How anxious does she feel about the thought of a genital • examination? If so, what about it makes her anxious? • Has she ever had a traumatic sexual experience or history of physical/emotional/sexual abuse? • What does she believe is causing her penetration pain? • Koehler adapted from Crowley T,2009 & Kingsberg SA,2007

16. Preparing for the Initial Exam with a Primary Vaginismus Patient

17. LISTEN-to your patient if she expresses fear andWATCH -for fearful body language • Let her decide who will be present • Let her decide the extent of the initial exam • Ask her if she can think of anything to facilitate the exam

18. EXPLAIN THE EXAM • First show a film to all new pelvic exam patients if you can or • Describe each step in advance as you proceed • Offer sedation(Valium 5mg.) if needed • Let her know she can interrupt the exam at any time without being a failure

19. REASSURE HER that you will let her have control of the exam • Pacing of insertion • Inserting speculum herself • Using a pediatric speculum • Starting with your finger only while the patient bears down • Or postponing internal exam pending completion of physical therapyor sex therapy

20. EDUCATE HER • Give her a mirror to see her vulva • Explain her anatomy/correct misinformation • Clarify what structures are normal or abnormal • Ask her how she’s coping during the exam • If exam is normal, explain how her fear and pelvic floor hypertonus tricks her into believing she’s too small for penetration

21. What if you still can’t examine her? • Have her practice the Rosenbaum Mindfulness Protocol • In case that doesn’t work, in the same visit: • Give her contact info of either a pelvic floor P.T. or • Sex therapist or • Both • Let her choose which approach appeals to her

22. Rosenbaum Mindfulness Protocol • Uses mindfulness accompanied by systematic desensitization to reduce anxiety • Can be first practiced at home • Can be practiced in the provider’s exam room ahead of the examination or on a prior day • See handout for protocol • Rosenbaum and Padoa- 2012 • Rosenbaum- 2011

23. Further At-home steps when no sex therapist or pelvic floor physical therapist available • Once she has proceeded through these steps, she may continue to utilize the anxiety reduction techniques as they apply to self-touch of the genitals, self-touch of the vulvar vestibule and vaginal finger insertion. • She may further apply these techniques for gradual dilator use with the practitioner and with her partner. This progression includes self-insertion of the dilator, self-insertion with her partner holding dilator as well, her partner inserting the dilator with the client holding it as well, and finally, her partner inserting the dilator.

24. The Role of the Gyn Provider in Secondary Vaginismus

25. TREAT ANY CO-MORBID MEDICAL CONDITIONS IF POSSIBLE Case example of Secondary vaginismus originating with medical problems

26. What Other Office-Based Treatments Can Medical Providers Try?

27. Provider- led Modified Sensate Focus • Good for couples seeking infertility treatment • diagnosed with primary vaginismus • no sex therapist or pelvic floor physical therapist in the area • Results: • Most resolved vaginismus • Half became pregnant • Nonpregnant evaluated for other sources of infertility • See handout • Jindal and Jindal, 2010

28. Botulinum Toxin (Botox) • Botox for treatment resistant cases • No good controlled studies and adverse events need to be documented • But pre vs. post treatment show it’s effectiveness • Ferreira and Souza 2012 Meta-Analysis • Adverse events • two cases of mild stress incontinence • one case of excessive vaginal dryness of 82 patients in one study Pacik,P. AesthPlastSurg (2011) 35:1160–1164

29. What predicts successful treatment? • Reducing penetration fears • Attributing the problem to psychological causes • Positive attitude toward one’s genitalia • Strong wish to become pregnant • Better sexual knowledge • Homework compliance • Pretreatment martial satisfaction van Lankveld et al., 2010

30. What predicts longer treatment? • Pretreatment sexual desire problems • Fear of STI’s • Negative parental attitudes towards sex • Previous operations for vaginismus • History of physical abnormality- like septum vaginitis • van Lankveld et al., 2010

31. What doesn’t predict treatment outcome? • Sexual abuse history- • Higher rate among vaginismus patients, but sexual abuse history doesn’t predict future vaginisimus • Other sexual dysfunctions in either partner vanLankveld, Jacques et al. 2010 ;

32. Pregnancy Considerations Sexual pain patients wishing to conceive should avoid these topical or intravaginal agents: • Gabapentin • Baclofen • Diazepam • Amitriptyline • Rosenbaum TY and Padoa. ACME Information: Managing Pregnancy and Delivery in Women with Sexual Pain Disorders. Review. J Sex. Med., Vol. 9, Issue 7, Article first published online: 3 JUL 2012

33. REFER HER IF NEEDED To a Pelvic Floor PT and/or Certified Sex Therapist • Before proceeding with the exam if she prefers • If she is unable to complete the exam • For treatment of nonmedical causes of her vaginismus • If there are mixed psychogenic and medical causes

34. Vulvodynia • Defined by the International Society for the Study of Vulvovaginal Diseases (ISSVD) as vulval discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurological disorder. • Patients can be further categorized by anatomical region (i.e. generalized vuvlodynia, hemivulvodynia, clitorodynia) and also by whether the pain is provoked or unprovoked.

35. Vulvar Vestibulitis Syndrome • A subset of vulvodynia, is the most frequent cause of dyspareunia in premenopausal women. (Mena et al, J Nerv Ment. Dis 1997: 185:561-69) • Prevalence 9.8 – 15% in general gynecologic practice • Diagnoses by severe pain to pressure or touch on the vulvar vestibule or introitus and vulvar erythema of varying degrees. • The ISSVD 2003 classification is under vulvodynia

36. Dysfunctions/Common Diagnoses • Dyspareunia • Muscle Atrophy • Interstitial Cystitis • Constipation • Abdominal pain • Vaginal Stenosis • Incontinence • Pubic Symphysis Pain • Pelvic Organ Prolapse • Piriformis Syndrome • Diastasis Recti • Vestibulodynia • Vulvar Vestibulitis • Vaginismus/anismus • Levatorani syndrome • Pudendal Neuralgia • Iliopsoas Syndrome • Episiotomy pain • Coccydynia • ObturatorInternus Syndrome • Post Operative pain • Sciatica

37. Role of the Physical Therapist • Team approach with other health care providers. • Physical Therapist focuses on neuromuscular/orthopedic/myofascial contribution to symptoms

38. What to Expect • Many patients perceive physical therapy for these diagnoses to be different than physical therapy for other orthopedic/spine rehabilitation. Same therapy…….different body part • Patient should expect a complete musculoskeletal evaluation of the symptomatic area.

39. Patient Profile • Teen through adult life span • Male and female • Sedentary and high end athlete • Varying socio-economic • Various cultural backgrounds

40. Questionnaire will include: • Pain with activity • Bowel movements/Urination • Sitting vs. standing vs. supine vs. prone • Intercourse pain (with superficial and/or deep penetration/orgasm/positional dependent) • Urologic changes with intercourse/orgasm • Patient should fill out questionnaire that addresses sexual history i.e. abuse/pregnancies/pathology/psychiatric

41. PT Treatment • Address Structure and Biomechanics • Mobilize/Stabilize Thoracic spine, Lumbar spine and SI Joints • LLD, Postural abnormalities • Muscle imbalance • Address Connective Tissue Restrictions and MTrPs • Connective Tissue Mobilization, Dry Needling • Surrounding the bony pelvis • Anterior, medial, lateral and posterior thighs • Abdomen, low back, buttocks • Nerve Mobilization • Seating Adaptations/Work Modifications

42. Pudendal Nerve Nerve Roots: S2, S3, S4 50% sensory, 20% motor and 30% autonomic

43. Course of the Pudendal Nerve

44. Iliopsoas

46. Pelvic Floor Muscles

47. Abdominal WallSuperficial Layers

48. Mechanism of Injury • Traction • Constipation, Childbirth, strenuous squatting • Compression • Cycling, Horseback riding, prolonged sitting • Surgical • Hysterectomies, corrective sx for prolapse • Common etiology for nerve entrapment • Visceral-Somatic Interaction • Chronic bladder infections, yeast infections, bacterial prostatitis

49. Traction Injury Childbirth, Constipation, Strenuous Squatting

50. Compression injury “Cyclist’s Syndrome”