Vag

1. Physiotherapy Interventions for
Lifelong Vaginismus
Presentation given at the 36th Annual Meeting of
the Society for Sex Therapy and Research
Elke D. Reissing, Ph.D., C.Psych.
Heather Armstrong, Ph.D. (cand.)

2. Acknowledgment
Caroline Allen, M.A., P.T.
Staff and patients
at Pelvic Support Physiotherapy

3. Why lifelong vaginismus?
 To avoid diagnostic confusion with women who
suffer from dyspareunia and who are no longer engaging
in intercourse.
 To focus on women who experience severe vaginal
penetration problems and have NEVER been able to
experience vaginal penetration.
 No research on effectiveness of PT

4. PT for dyspareunia
 Pelvic floor pathology has been consistently associated as a
causal, maintaining and/or exacerbating factor in women with
vulvodynia (e.g., Reissing et al., 2005).
 The physiotherapy approach for treating vulvodynia has been
well described in the literature (e.g., Rosenbaum & Owens, 2008).
 Outcome for PVD is excellent but more variable for generalized
vulvodynia (e.g., Bergeron et al., 2010; Gentilcore-Saulnier et al., 2010).

5. Pelvic floor pathology in vaginismus
 Historical origin of vaginal spasm interfering with intercourse is
not useful as the sole diagnostic criterion - but suggests pelvic floor
involvement in vaginal penetration problems.
 Comparative study b/w women with vaginismus and PVD found
no significant differences in pelvic floor pathology between groups
(as assessed by 2 PT, EMG, and 2 gynecologists; Reissing et al., 2004).
 Online survey of women with vaginismus: PT interventions were
reported as most helpful (Reissing, man in prep.)
 Anecdotally in our city, first line intervention as per physician/OBGYN referral.

6. Retrospective chart review and interview
 Sample: Consecutively treated women with vaginismus at one PT
clinic.
(Defined as: never having experienced vaginal penetration;
partial penetration without thrusting; partial attempts).
 Measure: Had to rely on what was in PT files.
 Recruitment (letter/email from PT to former patients):
- Chart review: tacit; had to state they want to be excluded
(3 participants excluded: acquired vag (1), moved (1), discontinued early (1))
- Phone Interview: Had to rely on patients taking the initiative to
contact us for participation in interview.
N=46
N=12

7. Sample characteristics – chart review
AGE: M=38, R= 24 - 58
68% ~ never had vaginal penetration (remainder: partial/no thrusting)
58% ~ never used tampon
33% ~ never had gyne exam with speculum;
of those who did, 71% only with pediatric speculum.
Diagnoses
Physical Therapist
Vaginismus Vaginismus + PVD
77% 19%
Referring Physician
Vaginismus Vaginismus + PVD Vaginismus + GVD PVD
49% 12% 2% 7%

8. Assessment information
Pelvic floor assessment:
Notable anxiety (as observed by PT): 62%
M-tone
-3 to +3
M-contract
0-5
M-relax
0-4
Pain – rest
0-10
Pain – ins.
0-10
Pain- move
0-10
Pain- after
0-10
Mean 2.7 2.1 1.9 .3 6 6 2
Range 1-3 2-4 2-4 0-3 1-10 0-10 0-6
Mode 3 2 2 0 7 8 0

9. Assessment information
Pelvic floor assessment:
 significant hypertonicity, poor voluntary control, poor ability to
relax muscles post-contraction.
M-tone
-3 to +3
M-contract
0-5
M-relax
0-4
Pain – rest
0-10
Pain – ins.
0-10
Pain- move
0-10
Pain- after
0-10
Mean 2.7 2.1 1.9 .3 6 6 2
Range 1-3 2-4 2-4 0-3 1-10 0-10 0-6
Mode 3 2 2 0 7 8 0

10. Assessment information
Pelvic floor assessment:
 High degree of self-reported pain with insertion; relatively low pain
post-insertion.
M-tone
-3 to +3
M-contract
0-5
M-relax
0-4
Pain – rest
0-10
Pain – ins.
0-10
Pain- move
0-10
Pain- after
0-10
Mean 2.7 2.1 1.9 .3 6 6 2
Range 1-3 2-4 2-4 0-3 1-10 0-10 0-6
Mode 3 2 2 0 7 8 0

11. Physiotherapy interventions
INTERVENTION Applied/patient
Patient education (100%)
Internal manual therapy (100%)
Modified Kegel exercises* (94%)
Home exercises (client) (98%)
Use of dilators (83%)
Home exercises (partner) (71%)
Biofeedback (educational) (78%)
Electrical stimulation (37%)
*with resistance/contact, focusing on conscious “dropping” of pelvic floor.

12. Therapy Process - Outcome
MILESTONES AVERAGE SESSION
Small dilator 6
Medium dilator 8
Tampons 10
Large dilator 13
Dildo (option) 20
Speculum 22
Gyne exam 22
Intercourse 18

13. Termination
Number of sessions:
M = 20 (R=1-126)
(minus 1-10 sessions: M-29)
1-10 ~ 35% …(able to have intercourse (n=2); early termination (n=12))
11-20 ~ 22%
21-30 ~ 30%
31-40 ~ 7%
41-126 ~ 7%

14. Interview data (N=12)
Relationship status: Married (58%), Dating (25%), Single (17%)
Number of sessions: M=31; (R=14-51)
Time since termination: M=25 month (R=9-44 months)
Satisfaction with PT: 9/10 (R=8-10)
Success with PT: 9/10 (R=6-10)
N.B. ↓ satisfaction and ↓ success associated with early termination due to lack of
resources to pay PT.

15. Therapy gains
GAIN ACHIEVED (Y/N)
Intercourse 100%
Enjoy sex 100%
↓ Anxiety 86%
Gynecological exam 100%
Use tampons 100%
↑ Understanding 100%
Hope 92%

16. Therapy gains (FSFI – healthy controls*)
Cronbach’s alpha: .88; *Rosen et al., 2000
FSFI Scales Post-treatment
Vaginismus
Healthy
controls*
P-value
Desire 5.3 6.9 .013
Arousal 15.4 16.8 ns
Lubrication 16 18.6 .03
Orgasm 11.8 12.7 ns
Satisfaction 10.8 12.8 .009
Pain 10.8 13.9 .03
Full Scale 25.9 30.5 .005

17. Therapy gains (FSFI – patient controls*)
Cronbach’s alpha: .88; *Rosen et al., 2000
FSFI Scales Post-treatment
Vaginismus
FSAD* P-value
Desire 5.3 4.7 ns
Arousal 15.4 9.7 .000
Lubrication 16 10.9 .001
Orgasm 11.8 7.1 .001
Satisfaction 10.8 8.2 .002
Pain 10.8 10.6 ns
Full Scale 25.9 19.2 .000

18. Therapy gains (Female Sexual Distress Scale, FSDS)
 Overall: M=17 (R=2-37)
 58% 15 42%
 The lower the scores on the FSFI, the higher the FSDS, (p<.01)
 High sexual distress not related to self-reported PT course,
outcome, or satisfaction.

19. Summary – PT1
 Women with lifelong vaginismus present with significant pelvic
floor pathology, pain, and anxiety.
 Progress in PT is variable with some women needing many more
sessions - but most women needing 30 sessions or less
(more sessions/longer treatment time compared to vulvodynia).
 PT interventions are similar to interventions used in the treatment
of vulvodynia.
(Less focus on pain desensitization, more focus on conscious awareness on
relaxing/dropping the pelvic floor).

20. Summary – PT2
 Women reach therapy goals of intercourse, pleasure with sexual
activity, reproductive hygiene and health care, and overall
understanding and hope.
 Patient satisfaction with PT intervention and outcome is very
high.

21. BUT….Summary - Sexuality
 Formal measures indicate that post-treatment, a significant number
of women have not experienced full sexual rehabilitation.
 Almost half of the women still were sexually distressed.
 Higher distress was noted in women with lower sexual function
(FSFI scores).

22. Conclusions
 PT is an excellent treatment option for lifelong vaginismus and
merits further evaluation.
 BUT, much like in women with PVD there appears to be no linear
relationship between symptom reduction and healthy sexual function.
 This suggests that PT interventions need to be integrated with
interventions that specifically target sexual rehabilitation.