By Malinda Wright
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.
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.
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.
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 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.
Malinda Wright, MPT
Malinda received her undergraduate degree from Dominican University of California in International Management. She attended graduate school for physical therapy at Royal College of Surgeons Ireland, and has been fortunate to travel to some wonderful countries including Scotland, Egypt, and Brazil. Malinda has always had a flair for adventure so when she isnt treating patients in our Los Gatos office, she enjoys snow skiing and hiking. However, Malinda believes that there is nothing like spending time with family in beautiful California.
1. Pacik, Peter. Understand and treating vaginismus: a multimodal approach. Int. Urogynecol J. 2014; 25:1613-1620.