Vaginismus and Orgasmic Problems in Women

Vaginismus is an inability or difficulty in achieving vaginal penetration during sexual intercourse associated with spasm of the muscles around the entrance to the vagina.

This can occur even when there is adequate arousal but is often related to other sexual problems. It can result from:

• Being worried about becoming pregnant
• Sexual abuse as a child
• An earlier rape
• A lack of interest in sexual activity
• Pain around the vestibule¹

Vaginismus is just part of a spectrum of female dysfunction which involves loss of sexual desire and/or arousal. These are common problems and may be related to numerous factors in the woman's life:

• Overwork
• Depression
• 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 approximately 40% of all women have some problem with their sex lives. Figures suggest up to 24% women do not reach orgasm.^2,3

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 - 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

• 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.
• Exclude vulvar vestibulitis; in one series of women with lifelong vaginismus and vulvar vestibulitis, erythema was found in 77%, pain "on touch" in 69%. Erythema and pain on the same location were seen in 56% of the patients.¹

Having excluded any obvious physical cause, it is necessary to devote time to educating the patient as to how her anatomy works and how common the problem is.

Education is often best done with a mirror during the examination. The woman needs to be encouraged to tell you her problems (reassure as to confidentiality within legal boundaries) especially in regard to her partner and his problems. Very few sexual difficulties are one-sided.

There are also several practical steps that can be taken:

• Advise on the use of lubricants, reducing alcohol consumption and lowering stress
• Suggest pelvic floor exercise
• Lignocaine has been successfully used where pain is a principle problem⁴
• Consider hormone replacement therapy in post-hysterectomy and peri-menopausal women⁵
• Review and change prescribed drugs especially antidepressants, oral contraceptives and IUCDs
• Refer for marriage counselling, cognitive behavioural therapy^6,7or psychosexual therapy.⁸ (Sex therapy may be based on the Masters and Johnson research)
• In refractory case, injections of botulin toxin have been effective⁹

This has been shown to be related to:¹⁰

• Duration of the dysfunction
• Patient's perception of the cause of the problem
• History of previous attempts at operative treatment
• Motivational factors
• Partner's degree of acceptance of the unconsummated relationship
• Previous organic abnormalities
• Extent of sexual knowledge
• Fear of sexually-transmitted diseases
• Parental attitudes regarding sex
• Patient's attitude toward her genitalia