Scott G Chudnoff, MD

Disclosures

October 18, 2005

Question

What causes vaginal noises with position changes during intercourse? A patient who had a TAHBSO [total-abdominal hysterectomy and bilateral salpingo-oophorectomy] in 2000 and is moderately fit has a small cystocele and rectocele. She is on hormone therapy and has no problem with vaginal dryness. Apparently vaginal noises ("gassy/snuffling sounds") are very loud and have affected her sexual functioning adversely. She came to the office for answers, and I need some help on this one.

Response from Scott G Chudnoff, MD

The production of vaginal noises during intercourse is not uncommon for many couples and typically is related to the physics of penetration during intercourse. The sounds are primarily related to air being forced out of the vagina during thrusting of the penis into the vaginal vault. Air can get trapped in the back of the vagina behind the penis during penetration. As the penis is thrust deeper, the pressure builds and vaginal compliance will reach a peak, causing the air to escape around the penis. The sound created is from the slapping of the vaginal walls (think whoopee cushion).

Typically, the vaginal walls are in relatively close approximation to each other with minimal to no air present in the vault. However, several circumstances can arise that introduce air into the vagina. If the introitus is gaping, as may be the case in a multiparous patient or one with vaginal vault prolapse and defects, then the normal anatomic relationship of the vaginal walls will be distorted and permit a larger quantity of air into the vagina than is typical.

Additionally, normal physiologic changes of the vagina during intercourse predispose to this condition. As excitement is achieved, there is swelling of the labia and uncovering of the introitus with a less compliant tissue (imagine trying to place an item [penis] into a plastic bag [vagina] without holding the edges [introitus] of the bag vs placing the bag in a can [labia] and having the can maintain the opening [introitus] of the bag). Additionally, the vagina typically shortens with a bulging of the deep vagina and a narrowing of the external vagina. As engorgement proceeds throughout excitement, vaginal compliance is also reduced. This creates an ideal environment for air to get trapped and subsequently forced out during penetration.

Position changes during intercourse can help to accentuate this condition in several ways. First, during position changes the penis is often removed from the vagina and reinserted in the new position. The more times the penis is completely removed from the vagina and reinserted, the more likely air will be trapped inside and forced out. Also, when the position is changed, particularly after the woman is fully excited, the vagina has already undergone the physiologic changes described above. At the initiation of intercourse, the vaginal walls are in close proximity with minimal air in the vaginal vault; the vagina is subsequently open (the bag being held open by the can) so that when the penis is reinserted, there is already a significant amount of air present in the vault. Additionally, different positions can affect the dimensions of the vaginal vault, with certain positions creating a greater predisposition for this effect.

I have several suggestions for counseling this patient. The first is for the patient to try to modify sexual activity with her partner. If they are able to change positions with the penis still in the vagina, this may decrease air entry during intercourse. Along this same line, any lessening of the degree of removal of the penis and reinsertion will serve to reduce this effect. Additionally, by inserting the penis slowly, the overall volume of the sound will likely be greatly if not completely diminished, as it will allow for a slow leak of the air. Shallower penetration will also help by not creating as great a pressure differential in the air trapped behind the penis.

You may also suggest to the patient that she and her partner try to determine whether there are positions that are more problematic and perhaps not use those positions at the beginning of intercourse or perhaps avoid a particular position if they find the noise too disruptive.

For the patient with significant vault abnormalities, surgical correction of the vault may be an option to consider if all other measures fail and her quality of life is being significantly affected by the condition. Obviously, a thorough exam of the vault and introitus should be undertaken to determine whether any major defects exist. However, it is very difficult to truly assess a defect in relation to this condition, as there are 2 factors involved, ie, male and female. It is impossible to make a standard judgment on appropriate introital/vaginal caliber by physical exam, as much depends on the size of the penis. Also, surgery is not guaranteed to alleviate the situation and would be an aggressive and invasive approach.

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