Vaginismus usually results from fear that intercourse will be painful; it usually begins with the first attempt at sexual intercourse but may develop later after periods of stress. Women may develop a phobia-like avoidance of penetration. Most women with vaginismus thus cannot tolerate full or often even partial penetration. Some cannot tolerate insertion of a tampon or have never wanted to try. However, most women with vaginismus enjoy nonpenetrative sexual activity.
Reflex muscle tightening can also accompany dyspareunia of any cause, thereby adding to the pain and difficulty with entry. Women anticipate a recurrence of pain when intercourse is initiated, and muscles tighten, making attempts at sexual intercourse even more painful.
Diagnosis is suspected based on symptoms. Physical abnormalities that cause pain, such as those that cause dyspareunia should be excluded by physical examination. However, the condition itself makes examination difficult. One strategy is to initiate treatment as described below and defer the confirmatory examination. When the examination is done, the physician can give the patient a sense of control by having her sit up and view her genitals using a mirror. The woman then spreads her labia and inserts her or the examiner’s gloved finger past the hymen as she bears down. This simple digital examination can simultaneously confirm a normal vagina and the presumed diagnosis of vaginismus.
In progressive desensitization, women progressively accustom themselves to self-touch near, on, and then through the introitus.
The woman first touches herself daily as close to the introitus as possible, separating the labia with her fingers.
Once her fear and anxiety due to introital self-touch has diminished, the woman will be more able to tolerate the physical examination.
The next stage is to insert her finger past her hymen; pushing or bearing down during insertion enlarges the opening and eases entry.
Once finger insertion causes no discomfort, vaginal cones in gradually increasing sizes are inserted progressively; leaving a cone inside for 10 to 15 min helps perivaginal muscles become accustomed to gently increasing pressure without reflex contraction. The woman first inserts a cone herself; when comfortable with the cone, she then allows her partner to help her insert one during a sexual encounter to confirm that it can go in comfortably when she is sexually excited.
Once insertion in this context is comfortable, the couple should include penile vulvar stimulation during sexual play so that the woman becomes accustomed to feeling the penis on her vulva.
Ultimately, the woman inserts her partner’s penis partially or fully, holding it like an insert. She may feel more confident in the woman superior position.
Some men experience situational erectile dysfunction in this process and may benefit from a phosphodiesterase inhibitor.