oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.
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".
This can occur even when there is adequate arousal but is often related to other sexual problems, as vaginismus is part of a spectrum of female sexual dysfunction. These problems are common and may be related to numerous factors in the woman's life:
- Unrelated disease
- Relationship problems
- Drug abuse
- Alcohol problems
- Hormonal changes
- Prescribed drugs
Although this is a subject many women find difficult to bring to their doctor, and therefore figures are likely to be underestimates, studies suggest that as many as 40% of all women have some problem with their sex lives. Figures suggest up to 24% women do not reach orgasm.
Community estimates of the prevalence of vaginismus are 0.5-1%. This increases to 4.2-42% in specialist and clinical settings.
Research methodology is flawed in this area and there is a lack of meaningful data on psychological causes. Negative perceptions of the woman's own sexuality are common. Events such as an early adverse sexual experience (though not necessarily assault or rape) or unsympathetic genital examination are thought to contribute.
An organic factor may be a vestibulodynia - a tender area at the entrance to the vagina. This may be caused by postmenopausal oestrogen deficiency, trauma associated with genital surgery, abnormalities of the hymen, genital tract infections or pelvic radiotherapy.
Most women are very reluctant to discuss their sexual problems and so, for them to consult their GP, the patient must view the problem as being serious. Alternatively, their partner may have forced them to consult their GP.
It may be necessary to ask a number of questions to ascertain the exact nature of the problem.
As well as the problem of inability to achieve penetration associated with vaginismus, the woman may complain of:
- Lack of interest in sex when their partner wants it.
- Inability to become aroused.
- Dryness and lack of lubrication.
- Inability to achieve orgasm (anorgasmia).
- Dyspareunia - this may be due to lack of arousal and/or poor lubrication but may indicate other disorders, such as pelvic inflammatory disease (PID) and endometriosis or disorders causing irritation of the vestibule.
- The clinician should take a careful gynaecological, obstetric and urological history to determine if there is any obvious likely cause.
- Examination of the external genitalia and vagina is essential, looking for any congenital urogenital anomalies, ulceration and inflammation. Pelvic examination may be difficult with vaginismus and require patience, and maybe a second visit. Anecdotal evidence suggests warm lubricant gel may help relax muscles.
- Exclude vulvar vestibulitis; in one series of women with lifelong vaginismus and vulvar vestibulitis, erythema was found in 77%, and pain 'on touch' in 69%. Erythema and pain on the same location were seen in 56% of the patients.
Having excluded any obvious physical cause, treatment consists of education, counselling, and behavioural exercises. Treatment should be tailored to the needs of the woman and her partner, if she is in a relationship. The woman's objectives should be explored. These may be penetrative painless intercourse, tampon use, or painless vaginal examination:
- When the main goal is conception, information about assisted conception should be given.
- Where the goal is for the woman to be more comfortable with her genitals, relaxation techniques and self-exploration of the genitals and insertion of 'vaginal trainers' can be used. These are smooth plastic rods that are graduated in size and length; they have a handle and lubrication gel to use when inserting them. A Cochrane systematic review reported 72-100% success but these were in uncontrolled trials and case series. It concluded that there is limited good-quality evidence to recommend their use.
- If she is in a relationship, a sensate focus programme may be offered to the couple. This is a series of structured touching activities which help couples overcome anxiety and increase comfort with physical intimacy. The focus is on touch rather than performance and intercourse is initially 'banned'.
- Lidocaine has been successfully used where pain is a principal problem.
- Consider hormone replacement therapy in post-hysterectomy and perimenopausal women.
- In refractory cases, injections of botulinum toxin have been effective
There is little good-quality evidence to inform this. The willingness of the woman to come forward with the problem and participate in treatment may be a significant factor, although spontaneous improvement has been noted in up to 10% of women with vaginismus.
The woman may be unable to participate in the cervical screening programme, although if penetrative intercourse has never occurred, she would fall into a lower-risk group for cervical carcinoma anyway.
Further reading & references
- Reed BD, Haefner HK, Edwards L; A survey on diagnosis and treatment of vulvodynia among vulvodynia researchers and members of the International Society for the Study of Vulvovaginal Disease. J Reprod Med. 2008 Dec;53(12):921-9.
- Crowley T, Goldmeier D, Hiller J; Diagnosing and managing vaginismus. BMJ. 2009 Jun 18;338:b2284. doi: 10.1136/bmj.b2284.
- Elnashar AM, El-Dien Ibrahim M, El-Desoky MM, et al; Female sexual dysfunction in Lower Egypt. BJOG. 2007 Feb;114(2):201-6.
- Meston CM, Hull E, Levin RJ, et al; Disorders of orgasm in women. J Sex Med. 2004 Jul;1(1):66-8.
- Lewis RW, Fugl-Meyer KS, Corona G, et al; Definitions/epidemiology/risk factors for sexual dysfunction. J Sex Med. 2010 Apr;7(4 Pt 2):1598-607.
- Ter Kuile MM, Van Lankveld JJ, Vlieland CV, et al; Vulvar vestibulitis syndrome: an important factor in the evaluation of lifelong vaginismus? J Psychosom Obstet Gynaecol. 2005 Dec;26(4):245-9.
- McGuire H, Hawton K; Interventions for vaginismus. Cochrane Database Syst Rev. 2003;(1):CD001760.
- Cacchioni T, Wolkowitz C; Treating women's sexual difficulties: the body work of sexual therapy. Sociol Health Illn. 2011 Feb;33(2):266-79. doi: 10.1111/j.1467-9566.2010.01288.x.
- Praharaj SK, Verma P, Arora M; Topical lignocaine for vaginismus: a case report. Int J Impot Res. 2006 Nov-Dec;18(6):568-9. Epub 2006 Mar 30.
- Long CY, Liu CM, Hsu SC, et al; A randomized comparative study of the effects of oral and topical estrogen therapy on the vaginal vascularization and sexual function in hysterectomized postmenopausal women. Menopause. 2006 Sep-Oct;13(5):737-43.
- Ghazizadeh S, Nikzad M; Botulinum toxin in the treatment of refractory vaginismus. Obstet Gynecol. 2004 Nov;104(5 Pt 1):922-5.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Hayley Willacy
Dr Hayley Willacy
Prof Cathy Jackson