There has been much controversy over the treatment of choice for vaginismus. Sims recommended a surgical intervention that consisted of the removal of the hymen, the incision of the vaginal orifice and subsequent dilatation. Soon thereafter, the need for a surgical procedure was questioned given that dilatation alone appeared to result in favorable outcomes.[5,73,74] Walthard, who conceptualized vaginismus as a phobic reaction to an excessive fear of pain, was one of the first to recommend psychotherapy. Throughout the early 20th century, psychoanalysis was often prescribed following the notion that vaginismus was a hysterical or conversion symptom.[76,77] In the 1970s, Masters and Johnson greatly influenced the treatment of sexual dysfunction, in general, and reported that vaginismus could be easily treated with behaviorally oriented sex therapy, which included vaginal dilatation. The success rates for the various treatments, ranging from vaginal dilatation to psychoanalysis to behaviorally oriented sex therapy were always reported to be excellent. Current treatments for vaginismus can be divided into four main categories: pelvic floor physiotherapy, pharmacological treatments, general psychotherapy and sex/cognitive behavioral therapy. Table 1 summarizes the treatment outcome studies of vaginismus.
Pelvic Floor Physiotherapy
The rationale for the use of pelvic floor physiotherapy in the treatment of vaginismus is that it will aid in developing awareness and control of the vaginal musculature as well as restore function, improve mobility, relieve pain and overcome vaginal penetration anxiety.[39,72,78] Physical therapists use a variety of techniques to achieve these goals, such as breathing and relaxation, local tissue desensitization, vaginal dilators, pelvic floor biofeedback and manual therapy techniques.[39,72,78] To date, there are two studies with 100% success rates that have investigated the efficacy of biofeedback in the treatment of vaginismus.[72,79] Unfortunately, they have very small sample sizes (<12) and lack appropriate control groups.[72,79] In addition, one study had only 6-month follow-up with the success rate dropping to 60%.[66,72] Considering the importance accorded to the vaginal muscle spasm component in vaginismus, it is surprising that pelvic floor physiotherapy has not been investigated more extensively.
Three main types of pharmacological treatment have been proposed for vaginismus: local anesthetics (e.g., lidocaine), muscle relaxants (e.g., nitroglycerin ointment and botulinum toxin) and anxiolytic medication.[80–87] Local anesthetics, such as lidocaine gel, have been proposed based on the rationale that vaginismic muscle spasms are due to repeated pain experienced with vaginal penetration and, hence, the use of a topical anesthetic aimed at reducing the pain is hypothesized to resolve the spasm. Its efficacy has only been reported in a case study in which a 5% lidocaine gel was applied on the hyperesthetic areas of the vaginal introitus of a 17-year-old women suffering from primary vaginismus. A topical nitroglycerin ointment, hypothesized to treat the muscle spasm by relaxing the vaginal muscles, was also discussed only in a case study. A Muslim Bedouin couple presenting with primary vaginismus were able to engage in a satisfactory sexual relationship following the application of a topical nitroglycerine ointment. Given that all the available information is in the form of case studies, no firm conclusion can be reached.
Botulinum toxin, a temporary muscle paralytic, has been recommended in the treatment of vaginismus with the aim of decreasing the hypertonicity of the pelvic floor muscles. In Shafik and El-Sibai's treatment study (n = 13), women with vaginismus who received an injection of botulinum toxin were able to engage in 'satisfactory intercourse' as compared with no improvement in a control group receiving saline injections. The successful outcome persisted for an average follow-up of 10.2 months. Nonetheless, there are a number of limitations to this promising study, such as the small sample size, lack of information on how vaginismus was diagnosed and lack of independent determination of treatment outcome. A recent treatment outcome study (n = 39) demonstrated that women with vaginismus secondary to PVD, who received repeated injections of botulinum neurotoxin type A into the levator ani, displayed improvements on standardized measurements of sexual activity (i.e., the Female Sexual Functioning Index), on possibility of having sexual intercourse, on levator ani EMG hyperactivity and on bowel–bladder symptoms. After a 39 month follow-up, 63.2% of their participants had completely recovered from vaginismus and PVD, 15.4% still needed some injections, 15.4% had dropped out and the remaining had not completed the treatment protocol. Another pharmacological treatment that has been proposed is the use of anxiolytics, such as diazepam, in conjunction with psychotherapy based on the hypothesis that vaginismus is a psychosomatic condition resulting from past trauma and, thus, anxiety-reducing medication will resolve the symptoms. Mikhail's uncontrolled study found that the administration of intravenous diazepam during psychological interviews in four women with vaginismus resulted in successful intercourse. Unfortunately, conclusions concerning the pharmacological treatment of vaginismus are limited because most studies lack appropriate placebo control groups and do not randomly assign patients to treatment, are based on small samples or do not use standardized outcome instruments.
A variety of psychological treatments for vaginismus have been investigated, including marital, interactional, existential–experiential, relationship enhancement and hypnosis.[52,88–95] The psychological treatments are often based on the notion that vaginismus results from marital problems, negative sexual experiences in childhood or a lack of sexual education. The therapy can be conducted in an individual or couple format. Generally, in individual therapy, the treatment is to identify and resolve underlying psychological problems that could be causing the disorder. In couples therapy, vaginismus is conceptualized as a problem for the couple and the treatment tends to focus on the couple's sexual history and any other problems that may be occurring in the relationship. Although the reported success rates are high (78–100%), all except two are case studies with poorly designed and described treatment interventions as well as a lack of information on how vaginismus was diagnosed. The two reports that are not case studies lack appropriate control groups and have no follow-up data [52,94]
Sex/Cognitive Behavioral Therapy
In the 1970s, Masters and Johnson reported that vaginismus could be easily treated with behaviorally oriented sex therapy that included vaginal dilatation. The first step of their treatment consists of the physical demonstration of the vaginal muscle spasm to the patient (and her partner) during a gynecological examination. The couple is then instructed to insert a series of dilators of graduated sizes at home guided by both the patient and her partner with the aim of desensitizing the patient to vaginal penetration. Masters and Johnson's treatment regimen also emphasized the importance of education regarding sexual function and the development and maintenance of vaginismus in order to relieve the psychological impact of the condition. As a result of the influence of Masters and Johnson, several studies were conducted on the efficacy of sex therapy in the treatment of vaginismus with excellent success rates reported resulting in continued utilization of this treatment for vaginismus.[62,96–107] These studies were, however, uncontrolled[62,97–99,102,106,108] or case studies[96,100,101,103,104] and all presented important methodological flaws, such as the lack of a waiting list control group and of standardized measurements to evaluate treatment outcome as well as elevated or unreported drop-out rates.
The first ever randomized controlled therapy outcome study for vaginismus was recently published. This study investigated a cognitive-behavioral sex therapy for the treatment of vaginismus. The treatment included the sexual education and vaginal dilatation technique as in Masters and Johnson's treatment protocol. It was also comprised of cognitive therapy, relaxation and sensate focus exercises. Participants received the treatment for 3 months either in group therapy or in bibliotherapy format. At post-treatment, 18% (14% group therapy; 9% bibliotherapy) of participants in the treatment group reported successful attempted penile–vaginal intercourse while none of the women in the waiting list control group reported having had successful intercourse. Interestingly, there was no significant difference in efficacy between the group therapy and bibliotherapy treatment format. At 3 month and 1-year follow-ups, 19% of the participants in the cognitive behavioral sex therapy group and 18% in the bibliotherapy group had achieved intercourse.
Although the rate of successful outcome was far below what was expected based on previous nonrandomized controlled treatment outcome studies, internal analyses of the data suggested that successful outcome was mediated by changes in fear of coitus and avoidance behavior. Van Lankveld's group reformulated their conceptualization of vaginismus from a sexual disorder to a vaginal penetration phobia.[70,108] A recent study carried out by the same group investigated a treatment for vaginismus focusing more explicitly and systematically on the fear of coitus through the use of prolonged, therapist-aided exposure therapy. The treatment was comprised of education on the fear and avoidance model of vaginal penetration as well as of a maximum of three 2 h sessions of in vivo exposure to the stimuli feared during vaginal penetration. A replicated (n = 10) randomized single-case A–B phase design was used. The results showed that nine out of ten participants were able to engage in intercourse following treatment and these findings persisted at a 1-year follow-up. In addition, the exposure treatment was successful in decreasing fear and negative penetration beliefs.
Women's Health. 2010;6(5):705-719. © 2010
Future Medicine Ltd.