Vaginismus is defined as recurrent or persistent involuntary spasm of the muscu- lature of the outer third of the vagina that interferes with vaginal penetration, which causes personal distress (1). Vaginistic women vary widely in their sexual behavior repertoire: from very limited to very extensive. In some cases, the desire to have children is first and foremost, without there being any real motivation to work on the sexual relationship. The complaint can be situational or generalized. Vaginismus is not part of the sexual response cycle.
Prevalence rates for vaginismus are scant, without the benefit of multiple studies on specific populations. Prevalence estimates for vaginismus range from 1% to 6% (2). Vaginismus is a supreme example of the mandatory blending of mind and body. The precise etiology is often unclear. There are various theories on the causes of vaginismus, each with its own therapeutic approach. In this chapter, first, the literature on the concept of vaginismus is reviewed; secondly, the different views on the origination of vaginismus are discussed, followed by the various treatments. The chapter is concluded with a diagnostic and treatment protocol.
The assumption that dyspareunia and vaginismus are distinct types of sexual pain disorders has recently been challenged (3 – 8). Research has demonstrated persist- ent problems with the sensitivity and specificity of the differential diagnosis of these two phenomena. Both complaints may comprise, to a smaller or larger extent: (1) problems with muscle tension (voluntary, involuntary, limited to vaginal sphincter, or extending to pelvic floor, adductor muscles, back, jaws, or entire body), (2) fear of sexual pain (either specifically associated with genital touching/intercourse or more generalized fear of pain, or fear of sex), and (3) propensity for behavioral approach or avoidance. All these three phenomena are typical of vaginismus, but may also be present in dyspareunia.
Also, differentiation between vaginismus and dyspareunia using clinical tools is difficult, or nearly impossible (3,7,8), and vaginal spasms cannot be diagnosed reliably (3). Only physical therapists can differentiate vaginismic women from matched controls on the basis of muscle tone or strength differences (3,9,10). In addition, for the treatment of vaginismus, despite strong clinical support, vaginal “dilatation” plus psycho-education, desensitization, and so on is not to date supported by scientific study (5,10 – 13). Finally, there is accumulating basic research to support the idea that the pelvic floor musculature, like other muscle groups, is indirectly innervated by the limbic system and there- fore highly reactive to emotional stimuli and states (14 – 16). On the basis of this emerging knowledge of the underlying pathophysiologic mechanisms, it is obvious that current diagnostic categories of vaginismus and dyspareunia may overlap, and need to be reconceptualized. The same goes for the spasm-based definition of vaginismus despite the absence of research confirming this spasm criterion.
At the 2nd International Consultation on Erectile and Sexual Dysfunctions in July 2003 in Paris, a multidisciplinary group of experts in the field has proposed new definitions of vaginismus and dyspareunia (2,17). Vaginismus is defined as: The persistent or recurrent difficulties of the woman to allow vaginal entry of a penis, a finger, and/or any object, despite the woman’s expressed wish to do so. There is often (phobic) avoidance and anticipation/ fear of pain. Structural or physical abnormalities must be ruled out/addressed. It is emphasized that reflexive involuntary contraction of the pelvic muscles as well as thigh adduction, contraction of the abdominal muscles, muscles in the back and limbs, associated with varying degrees of fear of pain and of the unknown, typically precludes full entry of a penis, tampon, speculum, or finger. However, discomforting or painful vaginal entry may occur.
Dyspareunia is defined as: Persistent or recurrent pain with attempted or complete vaginal entry and/or penile vaginal intercourse. The authors clarify that the experience of women who cannot tolerate full penile entry and the movements of intercourse because of pain needs to be included in the definition of dyspareunia. Clearly, they state, it depends on the woman’s pain tolerance and her partner’s hesitance or insistence. A decision to desist the attempt at full entry of the penis or its movement, within the vagina, should not change the diagnosis. Finally, they recommend that the diagnoses be accompanied by descriptors relating to associated contextual factors and to the degree of distress.
VIEWS ON THE CAUSES OF VAGINISMUS
Vaginismus is treated in various ways. Interventions vary from surgery to rela- tional therapy. There are various theories on the causes of vaginismus and each has its own therapeutic approach. We elaborate on the psychoanalytical view, the psychological view, the behavioristic view, the interactional view, the sociocultural view, the pain view, the overactive pelvic floor muscle view, the somatic view, and the multidimensional view.
The Psychoanalytical View
Musaph defined vaginismus as a hysterical symptom, or a conversion symptom (18). In other words, a psychological complaint (anxiety) is changed into a phys- ical symptom (a vaginistic reaction). According to Musaph, why some women are vaginistic whereas other are not depends on whether they have a primary disposition towards suppression as a defense mechanism; this might be towards a disrupted mother – child relationship, or other stressful situations that occurred in the oral and oedipal phase of emotional development.
Although psychoanalysis has paid a great deal of attention to the develop- ment of sexuality, very few analysts have written about treatment for vaginismus. Musaph distinguished between two forms of psychoanalytical therapy: dynamic- oriented therapy and classical psychoanalysis. The dynamic-oriented therapy form is a method to heal the symptoms, that is, the aim of therapy is to cure the neurotic reaction, in this case the vaginistic reaction. Some analysts use other resources besides the usual psychoanalytical methods, such as psychophar- maceuticals and hypnosis. Important elements in classical psychoanalysis are regression and reliving the traumatic experiences that are related to the sexual problem.
More recent research revealed that women with vaginismus have signifi- cantly increased comorbid anxiety disorders, whereas depression rates are not found to be increased (4,19,20). The role of childhood sexual trauma is unclear, since different frequency rates are found (3,4), and the presence of increased rates of posttraumatic stress disorder has not been investigated as yet. Psychological characteristics, measured with self-report instruments, do not unequivocally corroborate the presence of anxiety disorders. Personality traits found to be more often present in this group suggest the presence of self- focused attention and negative self-evaluation in the etiology or maintenance of vaginismus (3,20). Sexual functioning may be impaired with regard to sexual desire and arousal response during sexual activity. Psychopathology and impaired psychological functioning may be caused as well as effect of vaginis- mus. Experimental evidence thus far documented the role of experienced threat in increased pelvic floor muscle tension, but did not discriminate between women with and without vaginismus (10,21,22). The causation and maintenance of vaginismus by psychological factors thus remain unresolved although fear of penetration and associated attentional bias may play a role. So far, no randomized controlled trials of psychological treatment for vaginismus have been published.
The Behavioristic View
Another view on the origination of vaginistic reaction comes from the behavior- istic angle. Although the majority of authors with this point of view agree that vaginismus is a conditioned anxiety reaction that results in spasm of the entrance to the vagina (23 – 26), only a small minority give an explanation for the origination of this behavior. Brinkman, for instance, gave an explanation model (27). He assumed that vaginismus is the end result of a classic conditioning process in which painful sexual intercourse took place. As a consequence of this process, the penis is conditioned into an aversion stimulus that when an approach is made, gives rise to tension and avoidance behavior, which once again leads to painful spasm of, in particular, the vaginal and anal sphincter muscles. Brinkman assumed that conditioning of the vaginistic reaction can occur in various ways. Sometimes one negative experience is enough, particu- larly in the case of incest or rape. Often, conditioning takes place over several experiences and such influences are far more difficult to establish.
Treatment according to the behavioristic view, which has been gaining popularity over the past 20 years, is based on the learning principle. In other words, a reaction that has been learned can also be unlearned. To resolve vaginis- tic complaints, various therapy forms have been developed within behavioral therapy: systematic desensitization, muscle exercises, and counter-conditioning. These therapy forms are not mutually exclusive and are often used in combination.
Systematic desensitization was originally developed by Wolpe and it appears to be effective in reducing various forms of tension (28). Wolpe made two basic assumptions:
1. A certain stimulus (e.g., an approaching penis) causes anxiety (response).
2. When a response can be generated that is antagonistic to anxiety (e.g., relaxation in the presence of an anxiety-invoking stimulus), then the relationship between the stimulus (the approaching penis) and the anxiety response will diminish.
There are two forms of systematic desensitization: in vitro and in vivo. In vitro means that the desensitization takes place in a fantasy situation, whereas in vivo means that it takes place in the real situation. Systematic desensitization in vivo is the more commonly used method for the treatment of women with vaginistic complaints. First, the woman learns to relax. Then she learns to gradu- ally accept objects of increasing diameter in her vagina, such as fingers or vaginal rods. She starts with the smallest size and finishes with the largest size that matches the size of the partner’s penis in erection. Many therapists employ systematic desensitization (23,25,27,29 – 33). It is often combined with other techniques, such as muscle exercises (23,34 – 36), stroking exercises (29,34 – 37), discussing difficult relational aspects (34), and cognitive therapy (33). Some therapists exchange the relaxation exercises for tranquillizers or hypnosis. The aim of muscle exercises is to teach women to become conscious of their vaginal muscles and to practice contracting and relaxing them. Consciousness is important, because vaginistic women contract their pelvic floor muscles con- vulsively, without being aware of doing so.
An often used method to gain control of the vaginal muscles was described by Luyens (34). According to this author, a woman can become conscious of her vaginal muscles by looking at her genitals using a hand-mirror and then making squeezing and bearing-down motions with the vagina. Often, first attempts are unsuccessful, because many women are unable to localize these muscle groups and pull in their stomach instead. However, this can be learned by means of pelvic floor muscle exercises. An additional advantage of pelvic floor muscle exercises is that these exercises have a positive effect on the intensity with which genital sensations are experienced during sexual arousal.
The Interactional View
The interactional view assumes that vaginistic complaints have a function in maintaining the balance between partners, or in the emotional functioning of the woman herself. In this sense, the complaint can form a solution! There are very few authors who explain the phenomenon of vaginismus fully on the basis of this view. However, much of the literature mentions the behavior and the personality structure of the male partner. He comes forward as a low self- confidence, anxious, passive, dependent person who is afraid of failure and for whom sex is a loaded subject (27,38,39). The partners of vaginistic women are believed to often suffer from sexual problems themselves, such as impotence and premature ejaculation (29,35,39,40). Despite these problems, the couple usually look very harmonic on the outside. They give the impression of being very well suited (18,37). In a recent study, rates of parital discord were equal to the general population (3). It speaks for itself that within the interactional view, partner-relational therapy and sexual therapy are not considered to be two clearly distinguishable specialties. Both concern the same system of two persons. Although the majority of therapists agree that the partner can play a major role in maintaining the complaints, very few actually involve the male partner in the therapeutic process. This is where we pay the price for the fact that in vivo observation is missing from the sexual anamnesis.
The Sociocultural View
Sjenitzer believes that vaginismus is caused by the social position of women in our society and their dissatisfaction with their role (41). According to this author, vaginismus is a protest against the patriarchal norms that reduce women to either a lust object or a mother. In addition, she makes a stand against sexist ideas in the treatment of vaginismus, particularly against placing coitus in the central position in the sexual relationship. The feminist view states clearly that women often seek something in sexuality that is completely different from what men seek. In women, the experience of emotional intimacy is generally a prerequisite for them to enjoy sex. Bezemer developed group therapy for women with vaginistic complaints (42). At the same time, group therapy was organized for the male partners of these patients, led by male therapists. The aim of this therapy was to restore the woman’s power over her body and her physical reactions. Thus, a therapy aim such as “coitus” was totally taboo! When a woman has power over her body, she can decide equally well not to have sex. A clear example of this view is given in the study by Van Ree who sometimes regards vaginismus as an adequate reaction to an inadequate way of life (43).
The Pain View
In a recent review article, Reissing et al. have raised the question as to the extent to which the existing concept of vaginismus is correct (5). Is the increased pelvic floor muscle tension actually characteristic of vaginismus? In their view, the role of the pelvic floor muscles in vaginismus is identical to the role of the muscles in chronic tension headaches: an important symptom, but not of decisive import- ance to the diagnosis. Does this apply to the experience of pain? They believe that in vaginistic patients, until now the pain or the changed sensations (dysesthe- sia) have been unjustly bypassed. Is vaginismus therefore a phobic reaction to penetration? This is indeed the case in some vaginistic women, but it is not clear whether this fear is cause or consequence. In their view, women with vagi- nismus are suffering from an aversion/phobia for vaginal penetration, or from a genital pain problem, or both. If the aversion/phobia lies in the forefront, then cognitive behavioral therapy and pharmacological intervention are the obvious choice. In contrast, a genital pain problem requires a multidisciplinary approach, such as is also the case with other chronic pain syndromes.
The Overactive Pelvic Floor Muscle View
More than half of the women with vaginismus also report complaints related to urination and/or defecation (44). According to Van de Velde, vaginismus should be regarded as a pelvic floor muscle problem (hyperactivity) and not primarily as a sexual problem. She considers that conditioning is the most likely mechanism behind the involuntary contractions of the pelvic floor muscles, which makes pelvic floor muscle physiotherapy an important part of the treatment.
The Somatic View
From a purely somatic point of view, constriction or an obstruction can be solved by using a scalpel. Although Walthard rejected surgical intervention for the treat- ment of vaginismus as early as in 1909 (45), and Sikkel-Bufinga (46), who per- formed a follow-up study found that only one vaginistic patient had benefitted from the surgical knife, until recently a few doctors could still be found who opted for such a surgical approach (47). The least vigorous method is dilatation plasty, in contrast with the far more drastic perineal plasty or levator plasty, in which part of the pelvic floor muscles are also cleaved through the midline. The emotional consequences of such an operation can be enormous. The most important consequence is that the woman loses control of her pelvic floor muscles, together with the control over her body and her right to self-determination. This is even more painful when the phenomenon vaginismus is used as a solution for relationship problems. It is remarkable that although this form of therapy was commonplace until recently, very little has been published on it. Treat- ment with pharmacotherapy including benzodiazepines and Botulinum toxin injections has been mentioned in the literature but no controlled trials are available (48,49).
The Multidimensional View
According to this vision the two categories of sexual pain disorders, dyspareunia and vaginismus, are heterogenous, multisystemic, and multifactorial dis- orders that should not be characterized as simply a “disorder of the pelvic floor” or as a “pain problems” or as a “vestibulum problem” or as a “psychologi- cal problem.” From this point of view for treatment, an integrated approach is recommended (2).
Specific attention is needed for six areas: the mucous membrane, the pelvic floor, the experienced pain, sex and partner therapy, the emotional profile, and the genital mutilation/sexual abuse.
In this vision, there is no “one size fits all” approach and no or – or approach but an and – and approach. The treatment should be individualized to each women, after carefully listening to her story and after she has been well informed about the disease and its natural course and about possible treatments or ways of handling it: care made to measure. It is up to the woman and her partner to decide which treatment they wish to embark on.
TREATMENT FOR VAGINISMUS
The above-described views and treatment models show that there is wide vari- ation in the causal attributes of vaginismus and that this “diagnostic” variety leads to an even wider variety of therapeutic interventions. In itself this is not par- ticularly surprising when we consider that in order to have sexual intercourse in a satisfactory manner, obviously apart from the physical conditions that have to be met, there must also be special knowledge, expertise, attitudes and, last but not least, emotional moods. All this is overruled by motivation: Do I really want to?
A thorough diagnostic procedure in which an inventory is made of somatic, psychological, and social aspects, therefore seems vital in order to choose the best approach. During such a procedure, it is often difficult to say when the diagnostics end and the therapy begins.
The literature shows that it is impossible to make a direct comparison of the effectiveness of the different treatment methods (5,11 – 13). It is also striking that no studies have appeared that used a pre – post design or a between-groups design, in which for example, a treatment was compared to a waiting list condition (50).
Prediction of treatment by means of psychological variables has thus far been investigated in noncontrolled studies only (51 – 53). Irrespective of the type of treatment and the specific therapeutic aims, an average success rate of 60 – 80% is reported. However, if we only look at the examinations that more or less pass the methodological criticism test then the success rate would be about 60% or less (54,55).
These rates suggest that all treatment forms achieve results and as far as this aspect is concerned, they vary very little. This indicates a nonspecific treatment effect. In terms of attention, validation of her complaint, and the patient’s feeling of control and competence, the active constituents seem to be effective on a meta level than on a content level. Cost/effectiveness ratios of the diverse treatment forms then become interesting. Behavioral therapy, in comparison with other psychotherapeutic approaches, can be regarded as relatively efficient (56). This finding in combination with the fact that behavioral therapeutic techniques can also be transferred to non-psychotherapists, make the behavioral therapeutic treatment of vaginismus interesting in more than one respect. Each care provider will choose a therapeutic strategy for vaginistic couples on the basis of his or her training. For example, for gynecologists and urologists, in most cases without any specific sexological training, the behavioral therapeutic approach will be the most obvious choice. It works and it is efficient too! However, its application requires more intense effort than just the acquisition of a set of vaginal rods. It is a treat- ment that is very time-consuming, requires great patience, great empathy, sensi- tivity to nonverbal signals, and insight into relational interactions. A care provider who intends to treat vaginismus has to be able to take a good sexual history. He or she must be able to signal or interweave ambivalent feelings regarding coitus, sex, the partner, their own body, the desire to have children. He or she must be able to bring to light serious relational problems or severe trau- matic experiences (sexual violence!) and he or she has to realize that being able to have sex does not automatically mean that the coitus is enjoyed. Thus in brief, the same applies to every care provider who intends to treat vaginismus as it applies to the patient: Do I really want to?
If the answer is no, then it is better to refer the patient elsewhere. If the answer is yes, then it is highly recommended to follow a suitable training course first.
Treatment according to protocol comprises an, at the start, unknown number of sessions. The first session takes 45 – 60 min. Subsequent sessions take 20 min. Sessions are held once every 2 – 4 weeks. Major components of the treatment include information about vaginismus, a physical examination, expla- nation of the treatment, behavioral therapy, sensation focus exercises, pelvic floor muscle exercises, systematic desensitization, and cognitive therapy. These components do not have a fixed order; they are applied electively. During the exercises and during the consultations, underlying factors (causes and/or problems) can become clear.
It is worthwhile to administer a measurement instrument before and after treatment. With the aid of a measurement instrument, possible comorbidity can be detected and the effect of the intervention can be evaluated. Questionnaires in the English language have the advantage that they are well known in the inter- national literature, which facilitates comparisons of international publications, and that they have been used often in research, which facilitates comparisons between results and populations. However, for local use these questionnaires have to be translated and validated again but this is recommended because of cultural differences. A simple but effective instrument to obtain measurement data is the Visual Analogue Scale. From time to time during the treatment, the woman marks a score on a sliding scale to represent the amount of progress that has been made.