Introduction

The symptoms of vaginismus were first described in 1861. Nevertheless, for years, women endured painful intercourse or the inability to have sexual relations. This topic was recently overlooked in media and popular science publications. Additionally, nonspecific symptoms often led to misdiagnosis or trivialization of the problem.

Women often fear to speak about this due to shame or the belief that their problem might be dismissed as trivial. However, vaginismus is a common disorder and can affect 2% of Polish women. In the United Kingdom, it is estimated that 1 in 500 women suffers from this problem. According to the British Medical Journal, it occurs more frequently in cultures where virginity holds very high value. However, the problem of vaginismus affects women and girls of reproductive age regardless of origin or race. Incidences of vaginismus are thought to be between 1 and 17% per year worldwide. 12 to 21% of North American women report some type of genito-pelvic pain to healthcare providers, and approximately 15% of North American women in report that they experience dyspareunia (painful sex) regularly.

Today, women increasingly seek accurate diagnosis and effective therapy. Cooperation between specialists guarantees comprehensive treatment of every aspect of the problem. The application of modern treatment methods improves health and well-being, which, combined with the possibilities of medicine, can lead to complete recovery.

Pochwica pierwotna

By definition, vaginismus is a disorder characterized by involuntary contraction of the vaginal muscles and part of the pelvic floor muscles (PFM). It can be persistent or recurring. It affects the muscles surrounding the outer third of the vagina (perineal muscle, levator ani muscle), adductor muscles of the thighs, abdominal rectus muscles, and gluteal muscles.

The first description of this disease was made by the American physician Marion Sims, hence it is often called the Marion-Sims syndrome. Based on the symptoms observed in five patients, he presented this disease as a "syndrome of symptoms, forming a separate disease, terrible in terms of the extent of misery it is the source of, a misfortune not only physical but also social and moral."

It is difficult to find clear sources concerning the prevalence of vaginismus. Estimates range from 3 to 17%. These differences result from the difficulties that occur during diagnosis. Women usually seek help from a gynecologist. The diagnosis made is not always accurate. This may suggest that the problem of vaginismus is more common than it seems. However, diagnosing vaginismus is very difficult. A detailed medical interview is extremely important, which based on the collected information about symptoms, can lead to the exclusion of other diseases pointing to vaginismus.

The causes of vaginismus can vary. Based on these, two types of vaginismus are distinguished.

Primary Vaginismus

Primary vaginismus most often occurs in teenagers and young women. Its causes can arise even before the initiation of sexual intercourse. These include: fear of losing virginity, which may be accompanied by pain, bleeding, unsuccessful sexual initiation, fear of engaging in sexual intercourse, fear of sexually transmitted diseases, and unwanted pregnancy.

A factor that increases the likelihood of primary vaginismus is also a negative attitude towards one's own sexuality. Growing up in orthodox or very conservative communities, family or religious rigorism, influence the perception of one's own sexuality. A misguided view of intercourse can also result from early sexual experience that was traumatic. Often this is early contact with pornography, especially brutal, watching a sexual act, for example, parents, or being a victim of rape or molestation.

In the case of primary vaginismus, there is often a distorted image of one's own body. It is associated with the belief of unattractiveness and the opinion that the genital organs are ugly, and body secretions are disgusting.

Primary vaginismus is often associated with the occurrence of congenital developmental defects of the female sexual organs. Just the awareness of organic causes can be a reason for the occurrence of the disease. The mentioned developmental defects appear at an early stage of intrauterine development. Disorders of the development of the Müller ducts and the urinary-sex sinus lead to abnormal development of the uterus and fallopian tubes, and consequently to the occurrence of defects that form the basis of vaginismus. These include: congenital overgrowths of the genital organs, septa, total or partial convolution of the genital organs, rudimentary organs, the complete absence of genital organs.

Secondary Vaginismus

Secondary vaginismus occurs in conjunction with organic causes such as endometriosis, recurring inflammatory states of the vagina and vulva, mucous membrane atrophy resulting from a decrease in sex hormone levels (hypoestrogenism), and age.

Another cause of secondary vaginismus can be allergies. An example may be hypersensitivity to latex. It manifests as pain initially only during intercourse, which occurs using a latex condom. A long-lasting such situation will lead to painful intercourse, and consequently the development of a disease that prevents penetration.

Injuries that occurred during childbirth are also considered a cause of secondary vaginismus. These include vaginal tears, ruptures, improper suturing, effects of forceps, vacuum delivery, or consequences of applying the Kristeller maneuver.

There is also another classification of vaginismus based on the cause of occurrence. It divides it into organic and psychoemotional vaginismus. Organic vaginismus occurs as a result of organic causes, that is, the coexistence of gynecological diseases. In such a case, treatment is limited to gynecological treatment. On the other hand, psychoemotional vaginismus is associated with the occurrence of psychosomatic and psychogenic causes. Therapy must include both gynecological and psychological treatment. It is recommended to supplement treatment with sexology therapy.

Due to the occurrence of symptoms, vaginismus is divided into preludial and paroxysmal. The former refers to pain and spasms that occur before the initiation of intercourse. In the latter case, these symptoms appear with an attempt at penetration. These criteria also allow vaginismus to be divided into actual and imaginative.

Symptoms of Vaginismus

The most common symptoms of vaginismus include pain, reflexive spasm of the muscles at the entrance to the vagina and the muscles of the pelvic floor in a defensive manner, squeezing of the thighs, lordosis, and fear of intercourse. The pain is associated with penetration, but may also occur during a gynecological examination or the application of a tampon. Although vaginismus is a disease mainly associated with pain, its sensation is not necessary to make a diagnosis. According to the latest research, the muscle spasms appearing in the definition occur only in 28% of subjects (Reissing et al.). This complicates the process of diagnosis and increases the risk of qualifying the problem as another disease. Therefore, an extremely important aspect in the diagnostic process is an interview, which allows a better understanding of the problem. Depending on the stage, different intensities of the disease can be observed. Based on this factor, we distinguish vaginismus:

First degree - intercourse takes place with sensations of pain, but there is no sexual response or pleasure associated with intercourse;
Second degree - penetration is only possible using a small speculum or finger;
Third degree - initial lack of possibility of penetration using a speculum or finger, which subsides after the application of persuasion and/or anesthetic gel;
Fourth degree - complete inability to penetrate, gynecological examinations or other medical procedures can only take place under full anesthesia.

Vaginismus is a sexual dysfunction often confused with dyspareunia. It belongs to the group of provoked vulvodynia and is associated with pain experienced before, during, and after sexual intercourse. This pain is characterized by burning, chronic itching, and hypersensitivity in the area of the vulva, perineum, anus, or urethral opening.

Dyspareunia may result from organic, psychogenic, or multifactorial causes. It can be divided based on:

pain location:
- superficial - pain in the vestibule of the vagina,
- deep - pain in the vault of the vagina,
- generalized - pain covering the entire vagina;
chronology:
- primary - occurring from the beginning of sexual intercourse,
- secondary - occurring due to a causative factor,
- revealed during the medical interview;
time of occurrence:
- early - pain appears with the onset of intercourse,
- late - pain appears towards the end of intercourse.

Until recently, these two conditions were differentiated based on the belief that there was no pelvic muscle spasm in dyspareunia. However, research shows that both spasm and pain are not necessary conditions for a diagnosis of vaginismus. A key difference is that penetration is possible in the case of dyspareunia. Moreover, vaginismus manifests as a fear of pain, which does not occur in dyspareunia or vulvodynia. This factor occurs in 74-88% of patients and leads to avoidance of sexual intercourse, but also gynecological examinations. In addition, in patients suffering from vaginismus, the attempt at penetration triggers negative emotions. These include:

feelings of guilt,
emotional numbness,
fear of commitment,
distrust,
feelings of weakness and helplessness,
the feeling of losing control during sexual contact,
shyness

Aspekt psychologiczny

The psychological aspect is an integral part of vaginismus and its impact on mental health. According to 90% of respondents, their mental health has deteriorated.

Firstly, the occurrence of vaginismus is associated with the presence of anxiety. This results in a decrease in the frequency of sexual intercourse due to the high rate of emotional stress that occurs during vaginal penetration. As mentioned above, the feeling of anxiety also arises in relation to gynecological examinations.

This anxiety may constitute a kind of specific phobia. It is unclear whether the avoidance of intercourse is aimed at combating the phobia (reducing the feeling of anxiety) or avoiding pain. However, in patients suffering from vaginismus, actions aimed at reducing sexual intercourse can be clearly observed.

Anxiety may also be related to a lack of understanding and a feeling of shame. Many patients who come to us with this problem emphasize that it is a very embarrassing problem for them. They often feel that they cannot discuss it with their family or friends, and even their partner. They feel alone. Often, they do not address this issue for fear of trivializing the symptoms. The result of a lack of partner support can be sexual frigidity or a reduction in intercourse. As they confirm, this, in turn, affects relationships, weakening them. For some partners, the lack of sexual intercourse may cast doubt on the success of the relationship. In addition, the lack of ability to penetrate results in the inability to become pregnant. This can again reflect on the relationship between the partners and has a particularly negative impact on the patient.

The relationship itself is equally important. When it is based on violence or conflict, it can only exacerbate the problem. Aggressive relationships distort the image of proper intercourse, guaranteeing satisfaction to both partners. Often, a lack of sexual interest on the part of the partner leads to a decrease in self-esteem, also in terms of physical attractiveness. This affects the incorrect perception of one's body.

Vaginismus is such an embarrassing problem for many patients that they do not attempt to enter into a relationship. For many of them, this disease is too embarrassing to talk about with their loved ones. They are even more afraid to trust someone with whom a relationship would only be created. Such a situation can again have a negative impact on the perception of one's person and one's body. It generates stress and tension, which only deepens the problem.

Due to the lack of clear criteria, the process of diagnosing vaginismus takes a very long time. Often, patients also encounter trivialization of the problem, and the proposed treatment is limited to recommending relaxation techniques or a "glass of wine to relax". Lack of information and awareness of the problem discourages women from seeking help from specialists. The prevailing belief in society about stigmatizing women with gynecological (reproductive) problems means that they often close in on themselves. Their self-esteem and mood drop. This can lead to the onset of psychological disorders, including depression or generalized anxiety disorder. In some cases, it may also affect the identification of sexual orientation or identity.

The psychological aspect is also important due to the causes of vaginismus. Bad sexual experiences, too early initiation, rape, exploitation, or witnessing sexual violence or the act itself (especially in childhood) can result in the emergence of fear of intercourse.

Treatment methods for vaginismus

It is essential in the treatment process to understand that the probability of recovery is 100%. Well-conducted therapy, composed of several elements, is able to quickly remove the causes of the problem and forget about its occurrence.

Lack of knowledge among primary care physicians and often trivialization of the problem by gynecologists can effectively discourage treatment. However, the diagnosis of vaginismus can be made not only by a gynecologist, but also by a sexologist and psychologist, but only a physician can make the diagnosis. A psychologist can only identify symptoms and refer to a doctor for a final diagnosis, but they can treat diagnosed vaginismus with psychological methods. There are many treatment methods, and their combination can only speed up the healing process.

Doctor and vaginismus diagnosis

The first stage is an effective diagnosis. This includes a medical interview and a gynecological examination. It is important to get answers to questions: under what circumstances do the symptoms occur, do they appear from the first sexual intercourse, is the muscle contraction involuntary and independent of will. It is also recommended to perform a blood picture, cytological examination, ultrasound of the small uterus, and if necessary, colposcopic examination. This allows to diagnose the problem and determine the type of vaginismus. This facilitates the planning of effective therapy.

Pharmacotherapy is used in the treatment of vaginismus, which includes the administration of anti-anxiety drugs. Anesthetic gels and analgesic ointments are also used. A significant group of drugs for vaginismus are also drugs that relax the muscles surrounding the vagina or pelvic muscles or drugs reducing tension.

Psychotherapy and vaginismus

Psychotherapy is a component of treatment that is particularly effective when other methods do not yield results, or when the patient does not accept other methods, or best in combination with other methods. It is also used in patients with severe anxiety disorders. Psychological treatment is especially important in the case of psychoemotional vaginismus. Often, fear of intercourse is dependent on other mental disorders. Personality issues, relationship problems, lack of understanding or support amplify negative feelings. This, in turn, makes the problem of vaginismus bigger. Feelings of loneliness and pessimism limit the desire to seek help from specialists, reducing the chances of recovery.

Among the treatment methods, sexology also plays a significant role, as it is related to the causes of the disease. Often, the fear of intercourse stems from a lack of self-confidence and the belief in a lack of attractiveness. A mistaken view of the body, its intimate parts, lack of sexual knowledge, wrong perceptions about intercourse are some of the causes of vaginismus. Systematizing knowledge and improving the perception of one's own sexuality can influence the reduction of fear and greater courage in undertaking treatment attempts.

Urogynecological physiotherapy

A very effective, though still rarely used, treatment method is urogynecological physiotherapy. It's a young field, which is increasingly becoming known among women. It deals with muscle-fascial therapy in the area of the small pelvis. It is characterized by a holistic approach to the patient and great empathy. In the case of vaginismus, it employs: exercises of the pelvic floor muscles and related structures, manual relaxation of tensioned tissues, relaxation techniques, and breathing exercises. An advantage of urogynecological physiotherapists' work is the proposal of exercises that the patient can perform independently at home.

Dilators

One of the tools proposed by urogynecological physiotherapists for home therapy are dilators - of course, if minimal penetration is possible. These are so-called vaginal expanders. They are made of soft and safe silicone. Their task is, among others, to reduce tensions and accustom the tissues to touch. This influences the partial or complete elimination of pain, and the improvement of elasticity, shape, and flexibility of tissues. The therapy is gradual, and the patient decides at what pace it is conducted. The set consists of five dilators of different sizes, where the smallest is the size of a little finger, and the largest is the size of a large erection. The patient starts the therapy with vaginal application of the smallest dilator, and gradually chooses a larger size. This change occurs when the patient is ready, and there is no pain. Dilators with a tapering tip are often easier to use. The application should be done with a water-based lubricant, in a comfortable position and without hurry. It is not recommended to use a dilator in too large a size. It is extremely important to adjust the size and force to the body's capabilities. The application of a dilator or another object of too large a size, using force, or against the patient's conscious will, can only harm, not only physically but also psychologically. The result of such actions can be mechanical damage to the vaginal tissues, and consequently an increased risk of bacterial and viral infections. Aggressive actions can also strengthen the fear of penetration, further attempts to use the tool, negatively affecting the patient's psyche.

Another tool used in the range of exercises related to urogynecological physiotherapy can be a vibrator. Although it is a device that will not work for everyone. The action of vibrations can have a relaxing effect on the muscles. However, for some patients, it may constitute too large a stimulus. It is worth noting that some patients, instead of muscle relaxation, experience even greater muscle tension due to vibrations. It is therefore important to test its action and use this method only after consulting with a urogynecological physiotherapist or a trusted manual therapist.

Alternative treatment methods

Alternative treatment methods in the fight against vaginismus make up a fairly wide group. They include: osteopathy, yoga and meditation, visualization practices, relaxation, and others.

Alternative therapies in healing vaginismus

Osteopathy

Osteopathy is concerned with the removal of somatic effects of long-term tensions. This means that the application of manual therapy reduces physical symptoms such as headaches, joint pain, spinal pain, abdominal pain, and many others. This type of therapy is one of the tasks of osteopaths, who also demonstrate a holistic approach to the patient.

Relaxation Techniques and Vaginismus

Relaxation techniques are a method that supports the traditional route of treatment. They pose no danger, as they do not induce unwanted reactions while generating low costs. These include:

autogenic training,
progressive muscle relaxation,
breath control,
behavioral relaxation training.

The effects of relaxation techniques include a reduction in pain perception, reduced anxiety and fear, reduced tension, reduced fatigue, improved quality and quantity of sleep, normalization of arterial blood pressure, improved control over perceived stress, and reduced emotional tension. To achieve this effect, four conditions must be met:

a comfortable position,
a calm environment,
additionally, but optionally, regular repetition of a word, thought, sound,
a state of mental concentration.

Confirmation of the positive influence of relaxation techniques are the results of an analysis by Orme-Johnson. Their studies on a group of 1,000 people insured in one of the insurance companies confirmed the benefits arising from practicing these techniques. They unequivocally stated that people practicing relaxation techniques used medical services less frequently. We conduct some of these relaxation techniques in Warsaw.

Breathing

An essential relaxation technique is breathing. It is the basis for other relaxation methods. It is characterized by simplicity and effectiveness. It involves diaphragmatic breathing, which guarantees a larger amount of fresh air and indirectly affects the vagus nerve, thereby influencing its regulation. There are many types of breathing exercises. To perform the simplest breathing exercises, just sit with a straight back and start inhaling air through your nose. It is worth placing one hand on the chest and the other on the stomach. It is important to observe a significant lifting of the abdomen with a slight lifting of the chest during inhalation. Exhalation should be calm and done through the mouth. BTTRS - Biodynamic Breath and Trauma Release System - is a breathing practice that we conduct, although from experience, a true tantric massage with the proper breath gives quicker and more lasting beneficial effects on the relaxation of the pelvic floor muscles.

MBSR as Support in Vaginismus Treatment

Mindfulness (MBSR) is a meditation technique that originated in the late 70s. At that time, it was a medical and psychological program used for people suffering from chronic pain. Today, it has greatly evolved and is essentially a lifestyle. It involves striving for acceptance and focusing on the present time. It affects neuronal activity and re-evaluates sensory information. This means that the body re-analyzes external stimuli and plans reactions anew. This can lead to a decrease in pain responses. Moreover, mindfulness meditation helps better organize work and gain more energy for action. It is a way to calm down and achieve balance. It is a simple secular technique, devoid of elements of spirituality, so it is accessible to everyone of any faith or lack thereof. Mindfulness can be practiced at any time of the day, during a break between daily duties. Contrary to popular belief, mindfulness is not about sitting and thinking about nothing. It is intended to strengthen the sense of presence in the present time, and hence capture the thoughts and emotions that accompany us without dwelling on each of them. It is extremely important in relation to mindfulness meditation that it is confirmed by research. It has been proven to affect the brain structures responsible for the stress response. The therapy itself improved the mental state of the subjects. Analysis of the results showed that this change can occur in a short time (the program lasted 8 weeks). This is evidence of the effectiveness of this therapy as a supplement to the effects of conventional medicine. Its costs are minimal and the occurrence of side effects is impossible. Read more about different types of meditation and its effect on the body in the book "The Power of Spiritual Development".

Visualization

A practice that is gaining more and more supporters is health visualization. It is a type of relaxation that involves imagining what we want to achieve. Its aim is to consciously evoke a positive image of oneself, one's body, and future events. The visualization process involves imagining what brings the greatest relaxation.

It doesn't matter what it is: a landscape, a place, a character, a state, a situation. However, it is important to imagine as many details as possible, such as sound, smell, or color. This will facilitate returning to the imagined place without much effort. The advantage of visualization is the stimulation of the nervous and muscular systems without actual physical activity. This means that the brain receives information about the performed action, which the body did not actually perform. The effectiveness of visualization mainly depends on the frequency of its use. Regular practice based on detailing the environment guarantees stronger and more real sensations.

Yoga and Vaginismus

Yoga, in the simplest but not entirely correct understanding, is an activity composed of passive poses. It has a positive effect on eliminating tension, stress, and anxiety. It helps to keep the body in very good physical condition, as it improves its flexibility and endurance. Yoga is often seen as a sport, stretching. It also has a beneficial effect on the body, but it is not recommended as a practice supporting the treatment of vaginismus. To truly relax the muscles that tense involuntarily, it is extremely important to introduce meditation during the performance of asanas – poses. Only such a conscious approach to the yoga position can initiate the processes of deep psychological relaxation, which directly affects the physical body. This, in turn, improves the functioning of the entire body and has a positive effect on mental health. Thus, with small financial outlays, it can realistically accelerate the treatment process.

Authentic Tantric Massages and Vaginismus

Authentic tantric massages are massages during which a person actively participates in the process of diaphragmatic mouth breathing. A tantric massage, correctly performed by a person with psychological experience and experience in working with trauma, and also with medical knowledge, can contribute to a significant acceleration of treatment, including vaginismus and other neurological disorders.

Tantric massage, through breath and the action of touch in the skin-visceral space through the vertebral arches, in accordance with the Polyvagal Theory, directly affects the restoration of the homeostasis of the tenth cranial nerve (i.e., exiting the fight/flight state, and consequently restoring the homeostasis of the 3 paths of the nervous system: the social engagement system, the sympathetic trunk, and the dorsal pathway of the vagus nerve) and other nerves, which are responsible not only for regulating the work of internal organs, but also improve well-being, psychological and physical relaxation. A woman, after a positive experience of a tantric massage, gains more confidence in her body, her life, and towards men. Tantric massage is particularly beneficial for women who have been hurt and lost trust in men. Before the massage, there is time for a long conversation, during which, among other things, boundaries are discussed that are to be respected during the massage.

During the massage, the masseur will respect these boundaries - this element of tantric massage allows to experience that what a woman says is important, and her boundaries are respected. Thanks to this, she increases her sense of agency and trust in others. During a tantric massage, yoni mapping (yoni massage) may also be performed but it is not mandatory. We perform tantric massages in Warsaw.

Lifestyle

Vaginismus therapy also involves a lifestyle change. This refers to actions that have a beneficial impact on health in a general sense. These include combating overweight, physical activity, healthy eating, limiting the consumption of stimulants, adequate amount of sleep, and others. A healthy lifestyle has a positive effect on the entire body, improves the functioning of organs, increases immunity, and contributes to the elimination of tension. It can also improve appearance. This, in turn, can result in an improved self-perception, and consequently, can significantly enhance mental health condition.

Combined Therapy - Vaginismus Treatment

It is extremely important to combine the work of many specialists due to the complexity of the problem. It relates to female sexual organs, so it is important to consult with the appropriate specialist, in this case, a gynecologist. The doctor, after taking a history, will be able to make an accurate diagnosis and exclude other diseases. If necessary, he or she will propose pharmacotherapy. This will help to reduce the problem of negative feelings associated with sexual intercourse.

Psychology plays a huge role in vaginismus therapy. Even though the problem is associated with physical pain, its source often constitutes fear. This could suggest disorders related to trauma or difficult childhood experiences, but not necessarily. It can originate from upbringing, beliefs, convictions, or wounds from breakups, rejections, etc. Psychotherapy will help to get rid of the fear of intercourse. It will also influence the perception of one's self in a mental and physical sense.

A sexologist plays a similar role in the therapy process. His or her help may influence the perception of one's body in the context of one's own sexuality. In addition, he or she will supplement knowledge about intercourse and normalize the topic.

Actions leading to an improvement in lifestyle can also facilitate the healing process. The systematic use of relaxation techniques can also yield positive results. Reduction of tension and better stress management can minimize vaginismus symptoms or weaken its causes. The work with the body, including massages, urogynecological physiotherapy, tantric massage, is crucial.

Combining the above methods increases the certainty of complete healing and can accelerate this process. The mentioned methods complement each other, guaranteeing a holistic approach to the patient.

However, probably the most important element of vaginismus therapy is the patient's work. Without her commitment and faith in successful treatment, the effectiveness of the therapy cannot be expected. Forceful actions can have negative effects, so it is worth trusting specialists and taking advantage of the combination of all possibilities. Vaginismus can be completely cured, but action is necessary. Although it is a rarely discussed problem, it is quite common. Therefore, rapid specialist intervention and patient commitment are the prescription for saying goodbye to the problem. If you have any questions, feel free to contact.

Bibliography:

https://www.vuvatech.com/blogs/vuvagirlblog/how-common-is-vaginismus-according-to-statistics
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Medicine

November 30, 2022

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Vaginismus, what is it, symptoms, treatment methods, therapy

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