If you’ve ever said the following:
“It feels like there’s a wall there.”
“I can’t insert a tampon.”
“I can’t have penetrative sex with my husband.”
“I was told I need to drink a glass of wine right before sex, but that still doesn’t help.”
You might be experiencing vaginismus symptoms.
DEFINITION
What exactly is vaginismus? Vaginismus, pronounced vaj-uh-niz-muhs, is characterized by involuntary contractions of the pelvic floor muscles, particularly the muscles surrounding the vaginal opening, interfering with vaginal penetration. While these muscle spasms cause unexplained sexual pain and penetration difficulties, they are not to be confused with dyspareunia, which is simply pain with sex. Vaginismus is often revealed during penetration attempts such as those made by inserting a finger, a tampon, or a speculum during a gynecological exam. Women report a feeling of having a “wall” at their vaginal opening, and are unable to go past this “wall”. Research has shown that around 5-17% of women are affected by vaginismus (1).
There are 2 main classifications of vaginismus, primary and secondary. Primary vaginismus is when a woman has never been able to have pain-free penetration. It is commonly discovered during her first attempt at inserting a tampon or with her first attempt at sexual intercourse. Women with primary vaginismus tend to report they have never been able to use a tampon or have a pain-free PAP test. They may also report never having been able to have sex with their partners.
Secondary vaginismus is when a woman used to be comfortable with penetration, but then something happened to cause the vaginal muscles to go into involuntary contraction, causing painful penetration. An example would be hypersensitivity along the vestibule (an area at the vaginal opening) due to frequent yeast infections. The hypersensitivity and pain felt along the vestibule with penetration can lead towards involuntary muscle contractions and eventually an inability to allow any penetration at all: vaginismus. Another example of a cause of secondary vaginismus could be some sort of traumatic event, such as childbirth. Childbirth can be quite traumatic due to natural tearing of the vaginal opening, an episiotomy, and/or bruising around the vagina. The pain and discomfort associated with a traumatic birth can cause muscle guarding and involuntary muscle spasms to protect the area. These involuntary pelvic floor muscle spasms can develop into vaginismus.
There are different severities of vaginismus: “situational” and “complete.” Situational vaginismus is an ability to tolerate certain forms of penetration, such as using a tampon, and an inability to tolerate other forms of penetration, such as sexual intercourse. Complete vaginismus is an inability to tolerate any form of penetration.
The cause of vaginismus varies. It may be due to an emotional response, such as rigid upbringing, sexual assault/rape, or negative feelings. It can be brought on as a physical response too (for example, yeast/urinary infections, childbirth, or hormonal changes, such as those occurring during menopause). There may also be no identifiable cause at all.
Fear and anxiety are commonly associated with vaginismus, as they feed into the pain cycle. The pain cycle, in this case, starts with a woman anticipating pain with penetration. When this happens, the body involuntarily contracts the pelvic floor muscles to guard from potential pain, which tightens the muscles making penetration painful. The pain felt during penetration further induces the pelvic floor to guard and spasm, which actually creates more pain. The woman may start to avoid sexual intimacy and develop fear and anxiety around it. The fear and anxiety feed into the anticipation of pain, and the whole cycle starts all over again.
DIAGNOSIS
Vaginismus is typically diagnosed from a patient’s medical and psycho-sexual history and a gynecological exam to rule out other conditions, such as vulvodynia. Some medical practitioners use questionnaires, such as the Female Sexual Function Index or the Vaginal Penetration Cognition Questionnaire (1), to help diagnose vaginismus. It is important for practitioners to rule out other conditions and to understand the severity of the pain and anxiety associated with vaginismus. This will help determine the prognosis and the treatment plan.
TERMINOLOGY CONTROVERSY
The field of pelvic floor dysfunction is in its adolescence. As a result, many pelvic pain diagnoses have undergone change as our understanding of the disorder improves. For example, “Interstitial Cystitis” has become “Painful Bladder Syndrome” and “Chronic Prostatitis” has become “Chronic Pelvic Pain Syndrome”. The term “vaginismus” is being debated and may be replaced with more specific terminology in the near future. To read more about this, please read our blog post “Is Vaginismus an outdated, useless, term?”
TREATMENT
Treatment does not consist of a glass of wine right before sex… despite the number of practitioners offering this advice! However, pelvic floor physical therapy is very effective. Physical therapy consists of manual therapy to release the muscle spasms throughout the pelvic floor, abdomen, buttocks, lower back and legs; training on how to voluntarily relax the pelvic floor muscles (fondly known as the pelvic floor drop); and initiation of an individualized home program involving stretches and dilators. We see the best results when the patient is treated by a multidisciplinary team including( as well as a physical therapist): a psychologist, a sex therapist, and/or a medical doctor (who can administer trigger point or Botox injections, if necessary). The psychologist and/or sex therapist will help with addressing fear and anxiety, as well as any emotional disturbances associated with the pain of vaginismus. Trigger point injections and dry needling can be helpful with releasing trigger points throughout the pelvic floor and larger muscle groups contributing towards pelvic floor tightness. Botox injections can also be helpful with relaxing muscle tightness in the pelvic floor, particularly the muscles surrounding the vaginal opening. To read about one woman’s successful treatment, click here.
Relaxation of the pelvic floor musculature is key to treating vaginismus. This means that kegel exercises are not appropriate! Kegels contract the pelvic floor and when you have something already tight, you do not want to tighten it even further and cause more spasming. It is best to hold off on kegel exercises and to seek an evaluation with a pelvic floor physical therapist.
Vaginismus is not a sentence to life behind a wall. It is a common impairment affecting millions of women worldwide. If you or a loved one has been diagnosed with vaginismus, please know that treatment is available. To find a pelvic floor physical therapist near you click here. To read Jackie’s story on vaginismus please click here.
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Are you unable to come see us in person? We offer virtual appointments!
Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online.
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. The cost for this service is $75.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
Reference:
1. Pacik, Peter. Understand and treating vaginismus: a multimodal approach. Int. Urogynecol J. 2014; 25:1613-1620.
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
I had a hysterectomy and now my vagina feels tight and like something stuck in there. My OB/GYN suggested Pelvic Floor Therapy and I have had about 6 sessions. So far no progress. I am not happy with the slowness of things. One session will help a little then the next will make things worse! The last session was concentrating on my upper body shoulders and neck. Now I am so sore and bruised I do not want to go back. Are there exercises I can just do at home at my own pace?
Thank you for any assistance you can provide.
Hello Julie,
Please read our blog for more information. I hope it helps!
https://pelvicpainrehab.com/pelvic-floor-physical-therapy/1964/what-is-a-good-pelvic-pain-pt-session-like-2/
Best,
Malinda
I appreciate your description of vaginismus. It is one one the conditions like vulvar pain syndrome, pudendal neuralgia (primary and secondary), endometriosis and other conditions resulting in pelvic pain that are overlooked and not understood.
Thank you for your article.
Hello Judith,
Thank-you for your feedback!
All my best,
Malinda
Nice Malinda! I recently gave a presentation on a similar subject!
Hello Muirna,
Thank-you!
Kind Regards,
Malinda
Thank you for sharing this. It’s definitely a bit relieving. However, because my vaginismus is caused by severe anxiety it’s hard for me to come to terms with physical therapy. The possibility of touching and “internal electrodes” has me freaking out. Could you explain more about what physical therapy for vaginismus looks like? Thanks!
Hi Kate,
Please read our blog on what a good pelvic pain PT session is like : https://pelvicpainrehab.com/female-pelvic-pain/1964/what-is-a-good-pelvic-pain-pt-session-like-2/
Regards,
Admin