Vaginismus: A Review of the Literature on the Classification/Diagnosis, Etiology and Treatment

Marie-Andrée Lahaie; Stéphanie C Boyer; Rhonda Amsel; Samir Khalifé; Yitzchak M Binik

Women's Health. 2010;6(5):705-719.

Evaluation of Treatment Research

Vaginismus has traditionally been considered as an easily treatable sexual dysfunction. The elevated success rates, reported in the literature must, however, be considered in light of uncontrolled designs, small sample sizes, elevated or unreported drop-out rates, which are not evaluated with intent-to-treat statistics, as well as a lack of long-term follow-up data. In fact, the only randomized controlled treatment trial does not support the notion that vaginismus is an easily treatable condition.^[70]

A basic issue in treatment evaluation is how a successful treatment outcome is defined. The great majority of studies have defined success as the ability to achieve vaginal penetration through sexual intercourse. While successful penetration is clearly a crucial first step, if it is not accompanied by pleasurable feelings, then treatment success is questionable. For instance, Schnyder et al. found that although 98% of the women in their sample were able to have intercourse by the end of treatment with vaginal dilators, 50% were still experiencing pain during penetration.^[105] Similarly, although nine out of ten participants in the Ter Kuile et al. fear reduction study were able to experience penetration, none of the measures of sexual enjoyment or pleasure significantly improved. While it appears that high success rates in vaginal penetration may soon be achievable, the therapeutic challenge of increasing vaginismic women's pleasure has not even been approximated.^[108]

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Table 1. Review of treatment outcome studies for vaginismus.
Author (year)	Study type	Diagnostic method	Sample (n)	Treatment (n)	Definition of success	Drop-out rate	Result	Follow-up	Ref.
*Pelvic floor physiotherapy*
Barnes et al. (1984)	Uncontrolled clinical study	Pelvic exam Self report	5	Biofeedback, psychotherapy and dilators	Intercourse	Not reported	100% success	6-month FU: success <60%	[72]
Seo et al. (2005)	Uncontrolled clinical study	Pelvic exam Self report	12	Functional electrical stimulation-biofeedback and CBT	'Satisfactory intercourse'	Not reported	100% success	Not reported	[79]
*Pharmacological treatment*
Hassel (1997)	Case study	Not stated	1	5% lignocaine gel	Ability to undergo a pelvic exam Intercourse	NA	Success	Not reported	[80]
Peleg et al. (2001)	Case study	Pelvic exam	1	Nitroglycerin ointment	'Satisfactory intercourse'	NA	Success	12.5-month FU: success maintained	[81]
Mikhail (1976)	Uncontrolled clinical study	Referral with diagnosis	4	iv. diazepam and marital and psychotherapy	Disappearance of symptoms	Not reported	100% success	2- to 6-month FU: success maintained (ongoing psychotherapy)	[82]
Plaut et al. (1997)	Case study	Referral by gynecologist	1	Anxiolytic medication and psychotherapy	Intercourse	NA	Success	FU (time unspecified): success maintained	[83]
Brin et al. (1997)	Case study	Pelvic exam	1	Botulinum toxin injections	Intercourse	NA	Success	2-year FU: success maintained	[84]
Ghazizadeh et al. (2004)	Uncontrolled clinical study	Referral with diagnosis	24	Botulinum toxin injections	Painless pelvic exam	Not reported	96% no symptoms during pelvic exam 'Satisfactory intercourse'	2- to 24-month FU: success maintained 75% satisfactory intercourse; 17% mild pain	[85]
Shafik et al. (2000)	Uncontrolled clinical study	Not reported	13	Botulinum toxin (8) Saline (5)	'Satisfactory intercourse'	Not reported	100% success No improvement	8- to 14-month FU: success maintained	[86]
Bertolasi et al. (2009)	Uncontrolled clinical study	EMG recordings	39	Botulinum toxin type A injections	Intercourse EMG Psychometrics	15.4%	63.2% success	Not reported	[87]
*Psychological treatments: general psychotherapy*
Barnes (1986)	Uncontrolled clinical study	Pelvic exam Self-report	55	Brief psychotherapy, education and dilators (50) Biofeedback (5)	Intercourse	Not reported	84% success	6-month (four couples lost at FU), three couples no longer having intercourse	[66]
Kennedy et al. (1995)	Uncontrolled clinical study	Pelvic exam Self-report No local pathology	18	Individual psychotherapy for both partners, education, in vivo desensitization and retraining of sexual behavior	Intercourse	Not reported	78% success	Not reported	[52]
Elkins et al. (1986)	Case study	Unconsummated marriage	1	Interactional therapy	Intercourse	NA	Success	12- and 15-month FU: children born, but no information on sexual function	[88]
Gottesfeld (1978)	Case study	Unconsummated marriage Self-report	1	3 years of psychotherapy with hypnosis	Intercourse with orgasm	NA	Success	2-year FU: success maintained	[89]
Harman et al. (1994)	Case study	Diagnosed by physician	1	Relationship enhancement therapy and sexual education	'Improvement of relationship'	NA	Success	6-week FU: success maintained	[90]
Kleinplatz (1998)	Case study	Referral by gynecologist	1	Psychotherapy (existential–experiential)	Disappearance of vaginismus 'Sexual well-being'	NA	Success	6-month FU: success maintained	[91]
Pridal et al. (1993)	Case study	Referral	1	Brief psychotherapy, relaxation, Kegels and dilators	'Satisfactory intercourse'	NA	Success	3-month FU: success maintained	[93]
Ben-Zion et al. (2007)	Controlled clinical trial	DSM-IV criteria	32	Couple therapy and other treatments (16) Surrogate therapy and other treatments (16)	Intercourse	Not reported	100% success 75% success	Not reported	[94]
Delmonte (1988)	Case study	Referral	1	Psychotherapy, marital therapy, relaxation–hypnosis	Painless intercourse	NA	Success	6-month FU: success maintained	[95]
*Sex/cognitive-behavioral therapy*
Hawton et al. (1990)	Controlled clinical trial	Referral	Vaginismus (30) Other female sexual dysfunctions (76)	Sex therapy and Kegels	Vaginismus resolved or largely resolved	10% in vaginismus group	80% success 51% success	3-month FU: success rate <76 (67%)	[62]
Van Lankveld et al. (2006)	Randomized controlled treatment outcome study	Pelvic exam Self-report	117	CBT group therapy (43)	Intercourse	21%	9% success	3-month and 1-year FU: success rate >21%	[70]
				CBT bibliotherapy (38)			18% success	3-month and 1-year FU: success rate <15%
				Wait-list control (36)			No success
Chakrabarti et al. (2002)	Case study	Self-report	1	Sex education and psychotherapy	Intercourse	NA	Success	Maintained (time unspecified)	[96]
Grillo et al. (1980)	Uncontrolled clinical study	Pelvic exam Painful hymenal rings/rigid remnants	17 Dyspareunia with comorbid vaginismus	Surgical removal of hymenal remnants and sex therapy and dilators and Kegel	Intercourse with orgasm Painless pelvic exam	Not reported	100% success	Not reported	[97]
Jeng et al. (2006)	Retrospective study	Pelvic exam Self-report	120	Sex therapy and xylocaine and oral analgesics and relaxation and dilation	Intercourse	Not reported	93% success	3-month and 1-year FU: 83% intercourse with orgasm	[98]
O'Sullivan et al. (1978)	Uncontrolled clinical study	Pelvic exam	46	Short-term sex therapy and dilators	'Normal sexual function'	48%	52% success	Not reported	[99]
Oystragh (1988)	Case study	Unconsummated marriage	1	Sex therapy and hypnosis and dilators	Painless intercourse	NA	Success	Maintained (time unspecified)	[100]
Ng (1993)	Case study	Unconsummated marriage	1	Mien-Ling dilators	'Pleasurable intercourse'	NA	Success	2-month FU: success maintained	[101]
Fuchs (1980)	Uncontrolled clinical study	Not stated	71	Systematic desensitization in vitro (18) Systematic desensitization in vivo (54)	Intercourse	(in vivo 2% group)	89% success 98% success	2- to 5-year FU for 65 patients: 'normal sexual adjustment' maintained	[102]
Wijma et al. (1997)	Case study	Self-report		CBT following in vivo systematic desensitization and phobia counter-conditioning	Intercourse free of pain/fear No recurrence of vaginismus	NA	Success	6-month and 1.5-year FU: success maintained	[103]
Wijma et al. (2000)	Case study	VVS diagnosis and penetration not possible	1	Systematic desensitization	Disappearance of burning pain	NA	Success	Not reported	[104]
Schnyder et al. (1998)	Randomized clinical study	DSM-III-R criteria	44	In vivo dilation and relaxation and education (25) In vitro dilation (23)	Painless intercourse Increased sexual desire and orgasm capacity	5%	98% success 50% still having intercourse pain	6- to 22-month FU: (8 lost) 50% disappearance, 47.7% improvement	[105]
Biswas et al. (1995)	Uncontrolled clinical study	Not stated	19	Rapid desensitization under anesthesia	'Satisfying intercourse'	Not reported	100% success	Not reported	[106]
Scholl (1998)	Uncontrolled clinical study	Pelvic exam Self-report	23	Sex therapy and dilators and Kegel exercises	Intercourse	13%	87% success	1- to 4-year FU: 95% continue intercourse	[107]
Ter Kuile et al. (2009)	Replicated single-case design	Pelvic exam Self-report	10	Exposure therapy	Intercourse Psychometrics	0%	90% success and significantly less fear	3-month and 1-year FU: success maintained	[108]

CBT: Cognitive behavioral therapy; EMG: Electromyography; FU: Follow-up; iv.: Intravenous; NA: Not applicable; VVS: Vulvar vestibulitis syndrome.

Sidebar

Executive Summary

Vaginismus continues to be perceived by clinicians as a well-understood and easily treatable female sexual dysfunction despite the lack of research supporting these claims.

Prevalence

Although the population prevalence of vaginismus remains unknown, it has been reported to range between 5 and 17% in clinical settings.

Classification & diagnosis

There has been a 150-year consensus concerning the definition of vaginismus as an involuntary vaginal muscle spasm despite the lack of research supporting the vaginal muscle spasm criterion.
Women with vaginismus may demonstrate high pelvic floor muscle tension and/or experience genital pain and/or report fearing vaginal penetration or pain.
Vaginismus and dyspareunia are currently considered two mutually exclusive disorders despite empirical findings demonstrating that health practitioners have a great difficulty reliably differentiating both conditions.
Recently, new definitions of vaginismus integrating pelvic floor muscle tension, genital pain and fear have been proposed.

Etiology

Most psychological factors that have been proposed to play a role in the etiology of vaginismus (i.e., abuse, relationship factors, negative sexual attitudes and lack of sexual education) have not received empirical support.
Although organic pathologies and pelvic floor dysfunction have often been implicated in the development of vaginismus, they have not been empirically investigated.

Treatment

Current treatment options for vaginismus include pelvic floor physiotherapy, pharmacological treatments, general psychotherapy and sex/cognitive behavioral therapy.
The success rates for the various treatments have generally been reported to be excellent despite the lack of randomized controlled treatment outcome studies validating this claim.
To date the only randomized controlled treatment outcome study that investigated the efficacy of cognitive behavioral sex therapy for vaginismus does not support the notion that vaginismus is an easily treatable condition.
A recent exposure treatment focusing more extensively on the fear component of vaginismus has demonstrated promising results.

Future perspective

A new conceptualization of vaginismus as a 'genito–pelvic pain/penetration disorder', characterized by the inability to have vaginal intercourse/penetration, genito–pelvic pain, fear of vaginal intercourse/penetration, and tension of the pelvic floor muscles, has recently been proposed.
A multidisciplinary diagnostic and adequate treatment approach for vaginismus addressing fear, genital pain, pelvic floor muscle tension and sexual pleasure is recommended. This set of skills is not easily accomplished by individual practitioners and should probably be addressed by a multidisciplinary team.