Information About Vaginismus
Categorically, information is given about what vaginismus is, the types of vagi- nismus (complete, situational, primary, secondary), the difference from dyspar- eunia, the vicious circle, how often it occurs, the reaction of the partner, the consequences on sexual satisfaction, the wish to have children, pregnancy, delivery, possible causes (psychological, relational, social, physical), the role of the pelvic floor muscles, the relationship between vaginismus and complaints related to micturition and/or defecation, and treatment methods (education, psychological approach, relational therapy, group therapy, treatment with artifi- cial aids, physical treatment). In addition, the aim of treatment is discussed; this could be the realization of pregnancy without coitus, or making coitus possible.
Explanation of the Treatment
Explain that the treatment protocol depends on the aim of treatment. If the aim solely concerns the wish to have children, then treatment can comprise learning to insert a 1 cc syringe into the vagina, filled with semen obtained by masturba- tion (artificial insemination). This technique can be applied at home at a time during the menstrual cycle that gives the best chance of conception. For every woman with vaginismus, but particularly for a woman who chooses solely for artificial insemination, it is important to realize that vaginismus does not have any predictive value regarding the course of possible childbirth. They have just as much chance as any other woman of an easy or difficult delivery with or without the aid of technical gadgetry. However, it is of great importance that the person who is supervising the delivery is well informed about the problems and takes them into consideration, that is, as little internal examination as pos- sible and, if necessary, as carefully as possible whereby the patient is given control of the situation.
If the aim is coitus, or to be able to insert a tampon or speculum, then treat- ment will comprise various elements: information about vaginismus, a physical examination, behavioral therapy, self-exploration, pelvic floor muscle exercises, systematic desensitization, and cognitive therapy. Explain precisely what these elements entail. Make it clear to the patient that she must now do things that she will find very unpleasant and would rather avoid. There is going to be hard work, especially at home with the homework assignments. Explain the import- ance of the homework assignments. Make it clear to the patient that you are trying to teach her to come to terms with her fear of penetration, but that over- coming the fear will not necessarily mean a more satisfactory sex life. Coitus can be very nice, but it is not of overriding importance for the quality of the sexual interaction. As part of the first consultation, a written report may be very helpful.
In order to detect or exclude physical causes, the nonphysician and physician will have to work together. Especially in the case of vaginismus, it is not always desir- able or practical to perform a medical examination straight away. The patient and care provider must make the decision together and also agree when it will take place and who will be there. The medical examination can best be described as an “educative gynecological sexological examination.” In a nutshell, it can be described as an examination with “accessories.” Although the doctor is gathering information (where do the patient’s boundaries lie), he or she also tells the patient about the anatomy of the external genitals and points out what is normal, or shows the patient possible abnormalities. In this way, the examination can some- times correct a negative self-image, or the doctor can explain to the patient and ideally also to her partner how physical changes and reactions are correlated with sexual problems.
It is extremely important that the patient knows in advance that she has total control over the situation, knows exactly what is going to happen and that she is the one who decides who is going to be there and who is not, and that she knows that during the examination, her boundaries will be respected and safe-guarded. Through this examination, the foundations are laid for a meaningful discussion afterwards, in which all the findings are repeated and it often happens that sexual complaints come to light that the patient has been concealing.
In concrete terms: Seat yourself comfortably and have the examination couch adjusted for the woman to be sitting. Give the patient a hand-mirror. Also give her the freedom not to look if she does not want to. Allow her partner to look over your shoulder. Take a moistened cotton bud and tell the patient (and her partner if he is present) what you see, what details you are paying close attention to, what is normal, what is abnormal and whether you consider this is playing a role in the patient’s complaints. By conducting the examination in this way, you force yourself to make a thorough inspection. In the case of vaginismus, exam- ining the patient using a speculum or the fingers do not form part of the phys- ical examination. Tell the patient before you start that you are not going to do these things. This will save her from anticipatory anxiety and the examination will go more smoothly, which will promote better results. It is also important to ask the patient about her actual experience of the examination while you are busy and not to just assume that she is picking up your reassuring words and signals. An important aspect of the examination is the nonverbal communi- cation: the patient’s behavior and that of her partner during the examination often say much more than words can express. Obviously, the nonverbal communication works in both directions—the doctor also constantly sends out signal
In order to achieve a good view, you should ask the patient’s permission to spread the vulva and then ask her to bear-down. The physician might also ask her to spread her vulva herself with her fingers. Adequate spreading is of great import- ance, otherwise, for example, you might not be able to see hyperaemic foci at the base of the hymen, which form a symptom of the most common cause of dyspar- eunia in young women, the vulvar vestibulitis syndrome. Adequate spreading also enables the patient to experience the consequences of pelvic floor muscle activity: by bearing-down or coughing, she will be able to see that the entrance to her vagina becomes larger.
Subsequently, you can ask the patient’s permission to insert the cotton bud through the hymen while she is bearing-down and assure her that you will stop the procedure immediately if she wishes. If the cotton bud can be inserted easily without any problem (which is very often an eye-opener!), the procedure can be repeated with a finger or with a smooth metal rod that is the slightly thicker than the cotton bud. Hegar rods are extremely useful for this purpose because they are available in many small diameters. If it is possible to proceed to larger diameters during the procedure, you can switch over to vaginal rods. These are plastic rods with different diameters to match the natural situation, that is, the size of the partner’s penis.
Measuring of Pain
To measure vulvar pain, the cotton-swab test is widely used (57,58). Pain is diagnosed by palpating different sites around the vulvar vestibule in a clock- wise fashion and noting the patient’s verbal and physical reactions. However, the cotton-swab test is prone to measurement error when used for experimental purposes or to measure treatment outcome (59). Ideally, the degree of pain should be documented with a diagnostic tool, for example, the vulvalgesiometer (60). It can be used as a diagnostic tool capable of differ- entiating among women with different types of genital pain, and because of its large range of exertable pressures, it may aid in quantifying the severity of pain (mild, moderate, and severe) experienced by these women. This device also has applications in quantifying changes in vestibular sensitivity as a result of treatment.
The Pelvic Floor
The sheet of pelvic floor muscles can be easily translated for the patient by describing it as a sort of trampoline: an elastic sheet that closes off the lower pelvis and has two openings, the anus and the vagina. The pelvic floor muscles contain both these openings in loops and they determine the discharge diameter of the anus and access diameter of the vagina. Women with dyspareunia or vagi- nismus contract these muscles in order to voluntarily or involuntarily control the accessibility of the vagina. This results in an inability to relax at times when this would be desirable, for example, during love-making or when being examined on the gynecology couch. Involuntary contraction on the gynecology couch does not infer that this also happens at home.
Inversely, some women can undergo a gynecological examination without any problem, but have vaginistic reactions in other circumstances, depending on what they find threatening. In many cases, the pelvic floor muscles are chroni- cally contracted and feel like “steel cables.” Muscles that are constantly con- tracted will start to cause pain, especially if pressure is also exerted from the other side, such as during an attempt at coitus.
In order to find out pelvic floor muscle problems, the physician places his or her finger between the woman’s labia just in front of the vaginal opening and see how that feels. At the same time, she can be advised to reduce the tension in her pelvic floor muscles by repeatedly contracting or relaxing them and giving reversed pressure. This reversed pressure creates room to continue pushing or contracting the muscles, which is followed by relaxation. At the moment of relax- ation, the physician moves the finger slowly inside. As the finger moves, keep it dorsally curved to feel the pelvic floor muscle without touching any painful areas at the vestibulum. In the end of the examination, the finger is slowly withdrawn. The use of a lubricant will facilitate the examination and also prevent tissue damage (Sensilube, Sonogel).
If physical abnormalities are found that can cause pain, for example, a stiff hymen or epithelial defects, then the patient may have dyspareunia with second- ary pelvic floor muscle hypertonia that contributes to maintaining the complaints. All forms of physical illness or abnormality that cause vaginismus or pain during coitus require medical treatment by a doctor. If the patient has general pelvic floor muscle problems with impaired micturition or defecation, then attention must also be paid to these aspects by means of learning to adopt a correct toilet position and micturition frequency, and breaking the habit of bearing- down during micturition. In the case of the irritable bowel syndrome, dietary measures can be discussed.
The aim of group or individual behavioral therapy is to break the stimulus – response pattern and regain optimal control over the situation. For the group therapy protocol, the reader is referred to centers where group therapy is given. The protocol described below is for individual behavioral therapy.
Treatment comprises self-exploration, relaxation of the pelvic floor muscles, and systematic desensitization. This can be achieved in a step-by-step exercise program that consists of self-exploration, muscle relaxation exercises, and gradually learning to accept penetration in situations where it is the woman’s own expressed wish to do so. Each step requires a great deal of practice; the next step cannot be taken until the previous one has been successfully com- pleted. Every new step can trigger resistance, which manifests itself as anxiety, tension, or pain. Intrapsychological and interpsychological aspects can come to light that require referral to a psychotherapist or relational therapist. It is import- ant to warn the patient right from the start that further referral may be necessary, in order to alert her “not to feel dumped” in a later phase of treatment.
Step 1: Self-exploration
The patient is given the following assignment to do at home in her own peaceful and quiet environment: examine her genitals with a hand-mirror (exposure in vivo). A second step is for her to touch her genitals. It is expressly not the aim to experience sexual arousal, but to become accustomed to her genitals. Next she is given the assignment to manipulate her pelvic floor muscles at various intervals, by systematically contracting and relaxing them. In order for her to recognize the feeling, she can be told that the muscles are the same ones that prevent her from inadvertently breaking wind. In this way, assignments are combined with relaxation exercises.
Step 2: Systematic Desensitization
After the successful completion of step 1, the next assignment is for the patient to place her finger between her labia just in front of the vaginal opening and to see how that feels. At the same time, she can be advised to reduce the tension in her pelvic floor muscles by repeatedly contracting or relaxing them and giving reversed pressure. This reversed pressure creates room to continue pushing or contracting the muscles, which is followed by relaxation. At the moment of relax- ation, she can push her finger inside, or a cotton bud, hegar rod, vaginal rod, or a vibrator. Disadvantages of cotton buds, hegar rods, vaginal rods, and vibrators are that they are alien to the body and they give an awfully mechanical and coitus- oriented impression. Thus, if the patient has a history of indecent assault, rape, or incest, old fears can be rekindled. Advantages are the variety of diameters that enable gradual habituation. All the advantages and disadvantages of whether or not to use artificial aids in the exercises should be discussed fully prior to any decision-making about this issue. Ultimately, it is the patient’s decision. In addition, there is nothing against exercising in a variety of ways, or first with the fingers and if that is unsuccessful, with artificial aids or vice versa.
The patient can do the exercises on her own, in the presence of her partner or together with her partner. She is asked to make time to do the exercises at least two or three times per week. However, a prerequisite is that when she decides to try the exercises, she is feeling relaxed, at peace with herself and is certainly not thinking “I will just do them quickly to get them over with”.
Once she has managed to accept penetration of her finger or an artificial aid, she can keep it in place for a period of time and experience what feelings arise on a conscious level and how the tissues feel. Careful movement of the pelvic floor muscles, fingers, or artificial aid will increase the sensations. Then it is the end of the exercise for the moment and the fingers or artificial aid are slowly withdrawn. Short exercise sessions prevent the patient from becoming obsessively preoccu- pied and also prevent tissue irritation. The use of a lubricant will facilitate the exercises and also prevent tissue damage. Quite apart from this, there is no change in the advice to continue love-making with the partner, albeit with a strict ban on coitus or attempts at coitus.
Once the patient is successfully able to insert one finger or an artificial aid (i.e., without anxiety, tension, or pain), the next step is to insert two fingers (at the moment of insertion, one above the other, then moved next to each other) or an artificial aid with a slightly larger diameter. This procedure is repeated until the fingers or artificial aid can be inserted in a relaxed manner and, once inserted, can be moved without anxiety, tension, or pain. If artificial aids are being used and the patient has a male partner, then if she so desires, the procedure can be continued until she can successfully (i.e., in a relaxed manner) insert and move an artificial aid with a diameter that matches the partner’s penis. If the patient has a female partner, then being able to insert a finger or dildo in a relaxed manner will suffice. Sometimes when a patient is using vaginal rods, she experi- ences the progression from one rod to another as being too big. In such cases it is useful to wrap the rod in more and more condoms during each exercise session, in order to make the transition more gradual. In addition, this makes the rod more user-friendly.
During treatment, the partner can gradually become more involved in the exer- cises. All the steps are repeated, starting with the discussion about genital anatomy. In some cases, it is necessary to start with genital “look and feel exer- cises.” Each new step is always discussed thoroughly and tailored to incorporate attention to the thoughts and feelings that arise. Between steps, this usually requires a number of individual and/or relationship-oriented interventions. Sometimes the exercises prove to be a bridge too far and it is necessary to refer the patient to a psychotherapist, relational therapist, or physiotherapist (electrofeedback).
It is the patient herself who indicates when she feels the time is right to exper- iment with her partner. She can choose a moment within or outside the context of love-making, or choose a moment in extension of an exercise session with fingers or artificial aids. In order to prevent the male partner from insisting on penetration while the patient is not yet ready, it can be worthwhile only to tell her that the coitus ban has been lifted. When the patient is ready, she takes the leading role (i.e., determines the timing and position) and he makes himself totally subservient. The penis is inserted in exactly the same manner as that employed in the penetration exercises. Both partners should be warned that in the initial stages, love-making will seem rather technical or mechanical, but that gradually the technicalities will sink into the background.
The cognitive therapeutic approach is based on the notion that between stimulus and response, there are factors within the individual that determine the nature and intensity of the response. Interventions in this field aim to change the behavior and feelings of the woman by teaching her to think and behave differently. To achieve this, the doctor as primary treating physician of vaginistic patients, will probably require the assistance of a psychologist/sexologist, psychothera- pist, or relational therapist.
Owing to the fact that vaginismus is often a conditioned response, the role of cognitive therapy is small. The active ingredient in cognitive therapy is there- fore to break the conditioned response, that is, “just get on with things” (exposure in vivo). Women with vaginismus will undoubtedly have irrational thoughts of “too thick,” “does not fit,” and so on, especially when the complaints have been present for some time. Although such thoughts can be removed cognitively by means of good patient education, in principle, this will have little or no effect on the occurrence of the complaints. Many patients have followed this path of little success. The most important aspect of cognitive therapy therefore is not so much removing the complaint, but instead motivating the patient, offering insight into the origination of the complaint, and further tackling the problem if it appears to contain a strong rational component. Particularly if the woman’s body is expressing what she cannot put into words, cognitive therapy is suitable in the form of:
cognitive restructuring; whether or not with the aid of RET techniques, detecting, and changing dysfunctional thought patterns;
increasing the patient’s ability to solve problems, for example, in the form of social expertise training in which she learns to better express her sexual feelings and motives towards her partner, particularly the dicta- tion of her boundaries.
In summary we can say that in the treatment of vaginismus, diverse interventions can play a role at any time in the treatment process.
Generally, areas for special focus are:
increasing sexual knowledge; reformulating (aspects of ) the complaint; decreasing inhibiting thoughts;
increasing positive thoughts;
learning to tune into positive physical feelings;
learning to use one’s imagination for sexual fantasies.
In relationship-oriented sexual counseling, attention can also be paid to:
increasing mutual assertiveness;
improving communicative expertise.