Vaginismus is a condition where a woman's body involuntarily contracts the muscles surrounding the vaginal opening when penetration is attempted. It is considered both a physical and psychological problem caused by factors like anxiety, past trauma, or misinformation about female anatomy. Treatment involves gradual vaginal dilation exercises to relax the muscles, as well as sex education, pelvic floor exercises, and in severe cases, Botox injections into the muscles surrounding the vagina. The goal is to help the woman gain control of her vaginal muscles and feel comfortable with penetration through a systematic desensitization process. Success rates of different treatment methods range from 72-100%, with Botox allowing more rapid treatment in refractory cases.

1. Aboubakr Elnashar
Benha University Hospital, EGYPT
Vaginismus
When a Woman's Body says
No to Sex
ABOUBAKR ELNASHAR

2. FEMALE SEXUAL RESPONSE
 Master & Johonson (1966):
 Excitement,
 Plateau
 Orgasm &
 Resolution.
 Completely mechanistic
 ignores feelings
 Distinction between Excitement & Plateau is
imprecise

3.  Kaplan (1979):
 Desire
 Excitement (Plateau is a part of Excitement).
 Orgasm &
 Resolution.
This fits better with FSD

4. FSD
1. Sexual desire disorders:
Hypoactive sexual desire & sexual aversion
2. Sexual arousal disorders
3. Orgasmic disorders
4. Penetration disorders:
Dysparunia
Vaginismus
5. Other sexual disorders:
Sexual phobias,
Anesthesia with arousal & orgasm,
Genital pain during non-coital activities.

5. 1. DEFINITION
1862
Dr. Marion Sims
Introduced the term “vaginismus”
Reflex-like contraction of the circumvaginal
musculature, resulting in non-consummation of
marriage.
ABOUBAKR ELNASHAR

6. Old:
Recurrent or persistent involuntary contraction of
the outer 1/3 of the vagina interfering with sexual
intercourse
Vaginal spasm has been considered the
defining diagnostic characteristic of vaginismus
for150 y.
This remarkable consensus, based primarily on expert
clinical opinion, is preserved in the DSMIVTR.
ABOUBAKR ELNASHAR

7. Studies:
1. Vaginal muscle spasm
 has never been validated
 EMG: 28% of the vaginismus
(Reissing et al, 1999)
2. Vaginismus cannot be reliably dd from superficial
dyspareunia
(Basson, 1996; Har-Toov et al., 2001; Kaneko, 2001; de Kruiff et al., 2000; van
Lankveld et al., 1996; Wijma et al., 2000 ; Ng, 2001; Okawa, 2001; Pukall et al.,
2000; Reissing et al., 1999, 2004; Lahaie et al, 2015)
ABOUBAKR ELNASHAR

8. Recent:
International Definitions Committee”, 2005
Persistent or recurrent difficulties of the women to
allow vaginal entry (penis, finger, and/or object…).
despite her expressed wish to do so..
ABOUBAKR ELNASHAR

9. 3. TYPES
1. Primary
lifelong, never able to have
intercourse
Secondary
acquired, past history of vaginal
penetration without problems.
2.Global
unable to place any thing in the
vagina
situational
able to use a tampon, tolerate a
pelvic examination but cannot
have intercourse
1. Spasmodic
[Leiblum, 2000]
spasm of the vagina
2. Non spasmodic.
ABOUBAKR ELNASHAR

10. 4. CAUSES
Most often, never delineated.
Multidimensional condition
Physical and a psychological condition
[Rosenbaum, 2013].
ABOUBAKR ELNASHAR

11. Precipitating
factors
Painful SI
Painful Pelvic EX
Sexual assault
Childhood abuse
PID
Gyn surgery
Urogenital atrophy
Predisposing
factors:
Anxiety disorders
Maintaining
factors
When a couple
continue trying to have
intercourse despite the
pain: reinforce spasm
of the musculature.
ABOUBAKR ELNASHAR

12. 5. DIAGNOSIS
A. History
• Medical
• Psychosocial
• Sexual history, including any episodes of traumatic
sexual experience
(Crowley et al, 2009).
A clear description of the pain, fear, and avoidance
responses.
The woman’s ability to tolerate genital exploration by
herself or another.
History of
severe pain during intercourse or
intercourse being impossible.
ABOUBAKR ELNASHAR

13.  Sexual history
(Crowley, 2009)
1. Is penetration possible?
2. If so, is it painful?
3. Is it painful only at penetration?
4. How anxious does she feel at the thought of
penetration?
5. Can she insert tampons or fingers?
ABOUBAKR ELNASHAR

14. B. Genital examination
To exclude organic pathology:
herpes virus, lichen sclerosis, and others
[Crowley, 2009)
Several consultations may be needed before the
woman is ready to be examined
ABOUBAKR ELNASHAR

15. 6. CLASSIFICATION
Lamont and Pacik
Stratifying the severity of vaginismus
{success in tt is related to the severity}
depends on:
1. Degree of vaginal spasm
2. Degree of fear and anxiety
ABOUBAKR ELNASHAR

16. ABOUBAKR ELNASHAR

17. 7. TREATMENT
Aim:
•Exercise her mind:
•Make the women feels that she owns her vagina and can
share it for sexual activity should she wish. : sexual
counseling
•Exercise her body:
•prove that something can go into the vaginal without pain:
Dilator.
•Break the vicious cycle (Fear – ms spams – pain):
•Botox
ABOUBAKR ELNASHAR

18. •Requirements:
Warm, sympathetic attitude
Great patience
ABOUBAKR ELNASHAR

19.  Lines of treatment: PS MD BO
1. Phobia: Exploration
History
False beliefs
2. Sex: Education
Anatomy
Physiology
3. Muscle: Control
Adductors: Relaxation exercise
P coccygeus: Kegel s exerciseABOUBAKR ELNASHAR

20. 4. Desensitization: Systematic vaginal
Step 1:Insertion of a trainers under controlled
relaxation
Step 2: Sharing of control with husband
Step 3: Insertion of penis with the woman in
control
Step 4: Transfer control of insertion of penis to
husband
5. BOTOX= Botulinum toxin
6. Other modalities
ABOUBAKR ELNASHAR

21. 1. PHOBIA: EXPLORATION
Difficult
1. History of psychological causes should be
addressed.
History of childhood traumatic experience:
recalled & the emotions which accompanied it relived
in order to help the woman to come to terms with them
ABOUBAKR ELNASHAR

22. 2. Dealing with false beliefs: (common myths):
1. Vagina is too small to allow penetration
In fact:
vagina is a “potential space”.
At rest, the walls of the vagina lie touching each other, but
separates to make room for something entering it
Baby is able to travel through the vaginal canal during
childbirth
Vagina lengthens by 50% during sexual arousal:
accommodating almost any penis size.
ABOUBAKR ELNASHAR

23. 2. Fear of tearing of the hymen: pain, bleeding.
In fact
most women:
 minor and temporary discomfort
± happen without her awareness
ABOUBAKR ELNASHAR

24. 2. SEX EDUCATION
Woman and her husband
More effective than
condescending remarks in
decreasing patient anxiety
[Huber et al,2009].
1. Genital anatomy
PC (pubococcygeus)
muscles, that tightens
involuntarily when
vaginismus is experienced.
ABOUBAKR ELNASHAR

25. Self exploration of sexual anatomy (guided tour)
Semi-sitting position
legs apart
mirror placed in front of her vulva, she explores her
genitalia (with the doctor) explaining the anatomy &
physiology.
ABOUBAKR ELNASHAR

26. 2. Sexual physiology & behavior
How their genital organs are put together
how they both function.
The vagina muscles
do not contract on their own,
the reasons of their contraction are the negative
thoughts and beliefs about sexuality and sexual
intercourse.
Brain
responsible of vaginismus,not vagina:
name of this sexual dysfunction must be
brainismus, not vaginismus.
ABOUBAKR ELNASHAR

27. 3. MUSCLES CONTROL
a. Relaxation exercises
 to the adductor muscles
To help her to relax when anticipates vaginal
penetration.
The doctor hold the woman ‘s knees together
firmly while she attempts to separate them,
then slowly she is allowed to succeed.
ABOUBAKR ELNASHAR

28. b. Contraction /relaxation exercise
(Kegel ‘s exercise)
To gain control over the muscles surrounding her
introits .
1. The patient must learn first how to identify the
muscle for herself.
2. She is advised to sit on the toilet with her legs
spread as far apart as possible.
3. If she then starts & stops the flow of urine, she
becomes aware of the pubococcygeus action.
ABOUBAKR ELNASHAR

29. 4. Once the muscle is identified, the woman can
practice contracting it repeatedly whenever she has
time or 10-15 times a day
ABOUBAKR ELNASHAR

30. Recommended for every woman especially
• To strengthen or restore pelvic floor muscle tone.
• To increase sexual health and sexual confidence with her partner.
• To avoid incontinence or are currently experiencing urinary stress/urge
incontinence.
•Giving or has given birth.
• Going through menopause. ABOUBAKR ELNASHAR

31. ABOUBAKR ELNASHAR

32. 4. DESENSITIZATION:
SYSTEMATIC VAGINAL DESENSITIZATION OF THE
FEAR OF VAGINAL PENETRATION
Vaginal dilatation exercises are a misnomer
{vagina is not physically stretched}
Behavioural therapy to treat phobias and other
behavioural problems that involve anxiety.
ABOUBAKR ELNASHAR

33. Trainers:
Fingers
commercial dilators
Tampons
specifically designed specula
Simms, Amiell, Stanley.
•The choice depend on the patient preference &
comfort level.
•Fingers are preferred
{allow to feel the muscles contracting.
easy to remove if she starts to feel any discomfort}.

34. ABOUBAKR ELNASHAR

35. Approaches
1. Gradual
using vaginal self-dilatation Starting with the
smallest one she inserts larger vaginal trainers
over time until one the size of a penis can be
inserted comfortably.
Rapid using vaginal mould insertion.
Duration: 2-6 weeks (2-15 sessions)
Rapid desensitization is preferred
(Biswas & Ratnam,1995)
ABOUBAKR ELNASHAR

36. 2. In-vitro: The dilator is introduced by the doctor or
In-vivo: the dilator is introduced by the patient
No differences between the 2 forms of systematic
desensitization
(Cochrane SR, 2002)
ABOUBAKR ELNASHAR

37. Success rate:
72-100% success in uncontrolled trials and case
series.
limited evidence to recommend the use of systematic
desensitisation
(Cochrane SR, 2001)
ABOUBAKR ELNASHAR

38.  Program
Step 1: Insertion of a trainers under controlled
relaxation:
In private, in a relaxed & nonsexual setting at
home. do the exercises with a finger inside the
vagina.
clip your fingernails and use a lubricating jelly. Or
do the exercises in a bathtub, where water can be a natural lubricant.
Your finger needs to be inserted 5-6 cm. That's up
to about the first knuckle joint.
Start with one finger and work your way up to 3
The insertion of digits is a slow and graduated
process and can take weeks of nightly exercises.
ABOUBAKR ELNASHAR

39. ABOUBAKR ELNASHAR

40. Step 2: Sharing of control with husband.
When she has become comfortable with this
process, her partner’s fingers are introduced.
while she maintains control how quickly the
fingers are placed.
The husband becomes active in the vaginal dilatation
exercises only when the patient is emotionally &
physically ready & after anxiety of being touched is
extinguished.
When she is comfortable inserting the larger dilators, she can instruct her husband how to place the dilator in her vagina
ABOUBAKR ELNASHAR

41. Step 3: Insertion of penis with the woman
in control.
Sitting or
kneeling over her husband,
female superior position
& inserting his penis herself.
ABOUBAKR ELNASHAR

42. Step 4: Transfer control of insertion of
penis to husband
ABOUBAKR ELNASHAR

43. 5. BOTULINUM NEUROTOXIN A (BOTOX)
Produced by:
Clostridium botulinum,
Mechanism:
Prevention of acetylcholine release: prevents
neuromuscular transmission: muscle weakness
Temporary muscle paralysis
Onset:
3-7 d after injection
Duration:
3-4 months.
ABOUBAKR ELNASHAR

44. First described by
Brin and Vapnek
[Brin, Vapnek, 1997]
although it is not licensed for this condition
(Eccleston , Woolley, 2008)
Other indications:
Treating a number of clinical conditions
associated with neuromuscular dysfunction, such as focal dystonias, upper
motor neuron syndromes, and muscle hyperactivity.
ABOUBAKR ELNASHAR

45. Technique:
150-400 mIU injected into the
puborectalis muscles in 3 sites on
each side of the vagina
1. A vial of 500 U botulinum toxin type A
(Dysport; Ipsen Ltd, UK) is diluted with 1.5 mL
of normal saline solution.
2. A total dose of 150–400 U equally injected in
puborectalis muscles. 3 points on each side
with a 23-gauge needle.
3. Light sedation of 1–5 mg midazolam and 50–
150 mg fentanyl. Oxygen (6–8 L/min) given
via face mask. Monitoring of SpO2 via pulse
oximetry. The sedation was not deep; some
extent of muscular contraction was required to
be visible to find the exact location of muscles
for injection.
4. Patients were discharged on the same day.
They were followed up after 1 w to check the
vaginal muscle resistance, and were thenABOUBAKR ELNASHAR

46. it covers the vestibular bulb it is innervated by the
deep/muscular branch of the perineal nerve, which is a branch
of the pudendal nerve
ABOUBAKR ELNASHAR

47. Indications
Severe or refractory cases.
?Mild and severe cases of vaginismus
Contraindications
Hypersensitivity to albumin, botulinum toxin, or any
component of the formulation
Infection at the proposed injection site(s)
Pregnancy
Diseases of neuromuscular transmission
Coagulopathy or therapeutic anticoagulation.
ABOUBAKR ELNASHAR

48. Side effects:
No major
1. Fecal and urinary incontinence lasting 3 to 4
months
2. Unusual pressure pain in the vagina separate
from the vaginismus pain.
ABOUBAKR ELNASHAR

49. Results:
No RCT
More rapid effect
Most of the success after 1 tt, but occasionally
repeat tts were required.
Success: 75%
(Pacik, 2011)
ABOUBAKR ELNASHAR

50. Ineffective treatments
Hymenectomy
doesn’t solve the problem but makes it worse:
avoidance of sex completely
Kegel exercises alone
ABOUBAKR ELNASHAR

51. Drugs:
Lubricants, topical anesthetics, anti-depressants,
sedatives, excess alcohol, hallucinogenic drugs,
muscle relaxants, antispasmodics
The only indication:
when vaginismus is a part of a more generalized
syndrome of sexual phobia.
imipramine 30-75 mg daily
Benzodiazepines to aid both relaxation & interviews
ABOUBAKR ELNASHAR

52. What can be done to prevent Vaginismus
 Sexual education
 Pre-marital sexual counseling and guidance
ABOUBAKR ELNASHAR

53.  Vaginismus, and superficial dyspareunia overlap
 Vaginal muscle spasm is not a valid or reliable
diagnostic criterion for vaginismus.
 Clinical syndrome that consists of overlapping
elements of
hypertonic pelvic floor muscles
Pain
Anxiety, and
Difficulty in penetration.
ABOUBAKR ELNASHAR

54.  Lines of treatment of vaginismus:
1. Phobia Exploration
2. Sex education
3. Muscle Control
4. Desensitization: Systematic vaginal desensitization
5. Botox Injection
ABOUBAKR ELNASHAR

55. ABOUBAKR ELNASHAR
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