Principles of Vaginismus Treatment

• The cycle of attempted penetration being associated with pain is broken.
• The vaginal muscles are retrained such that tone is lower and reflex increase in tone no longer occurs.

Details
The woman puts aside ten minutes twice daily to be private, preferably after 5 to 10 minutes with a bath, shower, or music, etc.  During the ten minutes, she experiences introital touch initially and then begins insertion of the vaginal inserts.  Many women with repeated pain from attempted penetration recognize simple introital touch or pressure as pain and, for them:

Stage 1
Simply be in control of self-touch with a finger, or with the insert, touching at the introitus confirming that, with herself in control, she can perceive simply touch and not pain.

Stage 2
Pass the insert into and through the introitus and leaving it in for 5 to 10 minutes, confident the sensation experienced is not pain, just pressure and awareness that there is something in the vagina and in the introitus.

Stage 3
On other successive days, the woman gradually inserts more of the first insert and then moves through the rest of the series of 5 to 7 inserts at her own pace, never allowing pain, always withdrawing the insert slightly if true pain is perceived,such that a narrower diameter is present in the in the introitus and pain is absent. Sometimes it is necessary to go back to the previous size of insert and then progress again more slowly.

Sexual Activity
As she progresses through stages 1 to 3, if the patient has a partner, all non-penetrative sex is encouraged. Finally free of the threaat of subsequent pain, many women feel perhaps for the first time sexual enjoyment, arousal, and climax that is without risk.  Women who, as a consequence of the pain of vaginismus, have secondarily lost desire need to begin with very low-key sexual activity at their own pace, knowing nothing else is expected and that they are in control of everything that happens. If there is a partner, seeing him (or her) to explain the vaginismus and the concept of continuing with non-intercourse sex, or re-introducing non-intercourse sex, is very necessary.

Stage 4 
Once insert #5 or #6 is reached, the phenomenon of vaginismus in the presence of inserts is clearly over. So that vaginismus does not recur with penile penetration, it is important to encourage the couple to allow some penile/vulval contact without penetration and then, later, penile insertion only without thrusting.  The vital pre-requisite is that the woman is aroused to the point of wanting penetration before she invites it and that she remain in control such that in these early stages she should decide on position, timing of insertion, slowness of insertion, and any movement that occurs. If penetration is attempted somewhat clinically “because it’s the next stage now we’ve got to insert #6” the actual penetration may well be painless but later there would likely be discomfort from rubbing the non-aroused vagina.

Problems

• The woman cannot insert even the smallest insert.  We would  suggest that, in the examining room, she, with your guidance, or you, with her full permission, at each stage gently show how the insert can enter the introitus. This may take more than one visit, that is maybe just at the introitus on one visit but not through. We suggest she would be sitting up, in control, with her partner present if she wishes, with your nurse present if the patient wishes, and that you night use diagrams or models to explain anatomy. In about 50% of women, this is the way the first insertion is done and, the other 50% are more comfortable with making that first insertion on their own at home.

• The woman gets “stuck”, for example at insert #2 or #3. Again, going back to the examining room one more time, and actually guiding the woman with her own insert, is necessary.

• The woman develops cystitis. This is rarely reported from the first few insertions, very similiar to the mechanism of “honeymoon” cystitis and is treated similiarly.  In our experience, it is always short lived and a few prophylactic nitrofurantoin or one course of anti biotics will suffice.

If you need more information please email the pharmacist.