Recent Research On The Treatment Of Vaginismus

A common problem clinicians will see is vaginismus. 

Vaginismus is defined as a genito-pelvic pain/penetration disorder along with dyspareunia under the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders; Fifth Edition) in which penetration is often impossible due to pain and fear. Vaginismus is both a physical and psychological disorder as it exhibits both muscle spasms and fear/anxiety of penetration. Symptoms vary by severity. Common presentation is an inability or discomfort to insert/remove a tampon, pain with penetration, and complaints of “hitting a wall” in attempted penetration; and inability to participate in gynecological exams.1

Although it was described more than a century ago2, it is rarely taught or focused on in medical school, resident training or medical conferences or meetings.3  Vaginismus treatments include the widespread use of vaginal dilators, physical therapy with or without biofeedback, biofeedback, sex and relationship counseling, psychotherapy, cognitive behavioral therapy, therapist-aided exposure, hypnotherapy, and lubricants. 

A recent study aimed to present a large cohort of patients based on prior published studies approved by an institutional review board and the Food and Drug Administration using a comprehensive multimodal vaginismus treatment program to treat the physical and psychologic manifestations of women with vaginismus and to record successes, failures, and untoward effects of this treatment approach.4

The authors of this study evaluated the severity of vaginismus. The penetrative history was used in addition to presentation at pelvic exam, and then given a level. There are 2 grading systems, Lamont and Pacik, that indicate the level of fear and anxiety about being touched. They found that those with severe vaginismus were Lamont levels 3 and 4, and Pacik level 5. For example, a Pacik Level 5 includes Lamont grade 4 “generalized retreat: buttocks lift up; thighs close, patient retreats” plus a visceral reaction such as “palpitations, hyperventilation, sweating, severe trembling, uncontrollable shaking, screaming, hysteria, wanting to jump off the table, a feeling of going unconscious, nausea, vomiting and even a desire to attack the doctor”.

241 patients participated in this study, with a mean duration of 7.8 years. 70% of participants were a Lamont level 4 or Pacik level 5 at baseline. The authors looked at previous treatments tried and coping strategies; 74% had tried lube, 73% had tried dilators, 50% had tried Kegels, 28% had tried physical therapy, 3% had tried a surgical vestibulectomy. Most participants had a mean of at least 4 failed treatments.

The goal of treatment was for the subjects to achieve pain free intercourse. In order to tolerate the treatment many were sedated with midazolam before the Q-tip test, and increased sedation given as needed. The duration of treatment was 30 minutes and consisted of:

• Q-tip test with as minimal sedation as possible to rule out vulvodynia and provoked vestibulodynia
• Digital exam of tolerance in order to assess the level of spasm in introitus. Graded 0 (no spasm) to 4 (severe spasm where digital insertion was difficult)
• Botox 50 U injections to right and left submucosal space near the bulbospongiosus muscle administered with a pediatric speculum placed. Additional Botox was injected submucosally into levator ani muscles if also in spasm/tight
• Injections 0.25% bupivacaine (a numbing agent) 1 mL increments along right and left lateral vaginal walls (9 mL per side) from cervix to introitus
• Progressive dilation; circumference 3 inches (#4), 4 inches (#5), 5 inches (#6)
• Reassessed with digital examination
• Re-insert #5 or #6 dilator and patient was awakened and taken to recovery

In the recovery room a nurse educated the participants on use of the dilator. Patients were discharged with the #4 dilator in place and asked to keep in until the next day. They were given Ibuprofen and sleeping aids as needed. 

The next day participants returned (with partners) and progressed to larger sized dilators (sizes #5 and #6). They participated in group counseling with the primary researcher, discussing dilator progression, returning to intercourse and lubricants. Participants were allowed to defer to have private counseling if they desired. They were all encouraged to continue seeing their healthcare clinicians as indicated; sex therapists, physical therapists, psychologists.

Dilator progression was as follows:

Month 1

– 2 hours of dilator per day. Participants could opt to perform this one time per day for two hours, or twice per day for an hour each session.

– They were instructed to progress to larger sizes until size five or six was comfortable.

Month 2

– One hour of dilator use per day (with continued progression toward larger sizes)

Month 3

– 15-30 minutes of dilator use per day

Months 4-12

– 10-15 minutes of dilator use per day or every other day

Post-procedure intercourse recommendations were:

• Delaying intercourse until #5 dilator was able to be easily inserted
• 1 hour of dilator work before attempting intercourse for the first time
• If partner’s penis is larger progress to larger dilators
• Goal of the first few attempts is to insert tip of dilator only
• Once tip can be inserted easily then progress to full penetration; restrain from thrusting
• Try “spooning position” if ‘leg lock’ occurs
• Try different positions with dilator work and intercourse to see what works best

The results of this study were that 71% of participants achieved pain-free intercourse five weeks after the procedure. 2.5% (6 participants) could not achieve this goal within a one-year period, however they were able to use size #5 or #6 dilators. 

Minor adverse effects occurred in six patients: three patients developed mild temporary stress incontinence, two patients had mild temporary blurred vision that cleared within days to weeks, and one patient noted excessive vaginal dryness. All adverse effects were resolved within four months, and none were no major or permanent. 

The authors hypothesized that the insertion of dilators under conscious sedation at the time of Botox and bupivacaine injections, counseling, and post-treatment support provided the initial breakthrough that allowed the patient to realize that pain-free penetration is possible and that her anatomy is normal.5

In everyday clinical practice vaginal dilators are often used for this (as well as other) vaginal pain conditions. Use of the dilator has been supported by medical associations, such as the American Cancer Society and the National Forum of Gynecological Oncology Nurses, for its benefits offered to women’s genitalia. Regardless of the reported benefits of this treatment, the low level of compliance of women has remained a problem. Previous studies have shown that women experience undesirable emotions while using the dilator, including embarrassment, anxiety, and fear; they also anticipate pain, loss of modesty, and experience a recollection of bad memories ranging from painful cancer treatments to sexual violence. Other reasons that women hesitate to undergo to utilize thistherapy include various types and levels of pain, lack of information about its use, and a misunderstanding of its potential benefits. Studies such as the one reviewed in this article may be of benefit to those patients who display low compliance to this treatment method.

Kristen Digwood, DPT, CLT

Elite Pelvic Rehab

182 Butler Street

Wilkes-Barre, PA 18702

Phone: 570-970-0402

https://www.elitesportspt.com/

https://www.facebook.com/Elite-Pelvic-Rehab-1483300151931870/

References

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: Amer- ican Psychiatric Association; 2013. 
2. ims JS. On vaginismus. Trans Obstet Soc Lond 1861;3: 356-367. 
3. Pacik P.T. Understanding and treating vaginismus: a multimodal approach. Int Urogynecol J. 2014;25:1613–1620.
4. Pacik, P., Geletta, S. Vaginismus Treatment: Clinical Trials Follow Up 241 Patients. Sex Med 2017;5:e114-e123
5. Ter Kuile MM, Van Lankveld JJ, De Groot E, et al. Cognitive- behavioral therapy for women with lifelong vaginismus: process and prognostic factors. Behav Res Ther 2007; 45:359-373. 
6.  Can an educational intervention improve compliance with vaginal dilator use in patients treated with radiation for a gynecological malignancy? Brand AH, Do V, Stenlake A Int J Gynecol Cancer. 2012 Jun; 22(5):897-904.
7. Punt L. Patient compliance with the use of vaginal dilators following pelvic radiotherapy for a gynaecological cancer. J Radiother Pract. 2011;10(1):13–25.
8.  Lee Y. Patients’ perception and adherence to vaginal dilator therapy: a systematic review and synthesis employing symbolic interactionism. Patient Prefer Adherence. 2018;12:551-560. Published 2018 Apr 12. doi:10.2147/PPA.S163273