Vaginismus is involuntary contraction of muscles around the opening of the vagina in women with no abnormalities in the genital organs. The tight muscle contraction makes sexual intercourse or any sexual activity that involves penetration painful or impossible.
In vaginismus, vaginal muscles tighten involuntarily despite women's desire for sexual intercourse. Vaginismus usually begins when women first attempt to have sexual intercourse. However, it sometimes develops later, for example, when another factor makes intercourse painful for the first time or when women attempt intercourse while they are emotionally distressed. Because intercourse may be painful, women fear it. This fear makes muscles even tighter and causes or increases pain when sexual intercourse is attempted. A reflex reaction develops so that when the vagina is pressed or sometimes even just touched, the vaginal muscles automatically (reflexively) tighten. Most women thus cannot tolerate sexual intercourse or any sexual activity that involves penetration. Some women cannot tolerate the insertion of a tampon or have never wanted to try. However, most women with vaginismus enjoy sexual activity that does not involve penetration.
The diagnosis is based on the woman's description of the problem and her medical and sexual history, including childhood and adolescence, and a subsequent pelvic examination.
To make the examination as tolerable as possible, doctors often move slowly and gently while they explain what they are doing in detail. They may offer women a mirror to see their genitals, and in some cases, doctors may suggest that women guide the doctor's hand or instruments into the vagina. Usually, women need to be treated before a pelvic examination can be done. Doctors look for scars, infections, or other abnormalities to determine whether they could be causing the symptoms. When vaginismus is the problem, no such abnormalities are found.
Treatment aims to lessen the reflexive tightening of vaginal muscles and the fear of pain that occurs when the vagina and surrounding area are touched. To weaken this reflex, women are instructed to do certain touching exercises.
At first, women touch an area as close to the vaginal opening as they can without causing pain. Each day, they should move a little closer to the opening, slowly increasing how close they can come to the vagina without causing pain. When they can touch the tissues around the opening (called labia), they can practice opening the labia. Women are encouraged to use a mirror to see their genitals. They are taught to bear down (as when having a bowel movement), which makes the vaginal opening larger, so that it can be seen more easily. Eventually, women can touch the vaginal opening without causing pain. They are then instructed to insert their finger into the vagina, pushing or bearing down while inserting the finger to enlarge the opening and make insertion easier.
When they can do these exercises and experience no pain, they can start to use cone-shaped inserts, which are placed in the vagina. An insert is left in for 10 to 15 minutes. Then the vaginal muscles become used to pressure. As women become comfortable with an insert, they use progressively larger inserts, which gradually increase the pressure in the vagina. Eventually, women invite their partner to place an insert in the vagina. Thus, women learn to relax the vaginal muscles and override the reflexive tightening.
Once the partner can insert the cone without causing pain, the couple's sexual activity can include touching the woman's genital area with the partner's penis, but without its entering the vagina.
Only after completing these steps should the couple try intercourse again. Doctors usually recommend that women hold their partner's penis and place it partly or completely in their vagina in the same way that they placed the insert. Some women are more comfortable being on top during intercourse at this point. This process may make some men be overly cautious and too reluctant to push, or they may lose their erection. They may benefit from a phosphodiesterase inhibitor (such as sildenafil, tadalafil, or vardenafil).
Last full review/revision July 2013 by Rosemary Basson, MD, FRCP (UK)