Prof. Aboubakr Elnashar

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??When woman's body says no to sex Vaginismus
Prof. Aboubakr Elnashar
Benha University Hospital, EGYPT E-mail
elnashar53_at_hotmail.com
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• Recurrent or persistent involuntary contraction
  of the outer third of the vagina interfering with
  sexual intercourse
• It is involuntary reflex precipitated by real or
  imagined attempts at vaginal penetration

Define
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• It consists of
• Phobia of penetration of the vagina
• Involuntary spasm of the lower third of the vagina

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In general population The exact prevalence
rate is not known. Rare(1) In family planning
clinic in Iran 12 In sexual dysfunction
clinics 5-40
Prevalence
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1. Primary (never able to have intercourse) or
secondary (past history of vaginal penetration
without problems). Secondary vaginismus is often
associated with dysparunia
Types
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2.Global (unable to place any thing in the
vagina) or situational (able to use a tampon
can tolerate a pelvic examination but cannot have
intercourse)
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• Cycle of vaginismus
• Fear of vaginal penetration
  Involuntary muscle spasm
  
•  
• Relationship breakdown
  Pain
•  
• Avoidance of intercourse
• gynecological examination
  Humiliation
•  
• 
  Anxiety distress

Effects

• Infertility

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                 I. Psychological 1.  An
unpleasant experience Past sexual abuse,
painful first attempt of coitus or vaginal
examination 2.  Extreme fear of penetration
because of wrong belief that her vagina is too
small to accommodate an erect penis, fear of
pregnancy or intimacy 3.  Unexpressed negative
feelings towards her husband 4. Religious
orthodoxy 5. Pain-tension-pain cycle
Causes
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                 II. Physical Rare.
PID endometriosis tender scar partially
imperforate hymen vaginal stenosis
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• Aim
• To break the vicious cycle replacing pain by
  pleasure spasm by relaxation
• To make the women feels that she owns her own
  vagina can share it for sexual activity should
  she wish.
• Requirements
• Warm, empathetic attitude great patience
• 1.     

Treatment
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• Lines of treatment
• 1.Exploration of phobia
• 2.Sex education
• 3.Guided tour
• 4.Control of muscles Adductor muscles
  
• P
  coccygeus

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• 5. Systematic vaginal desensitization
• Step 1Insertion of a trainers under controlled
  relaxation
• Step 2 Sharing of control with husband
• Step 3 Insertion of penis with the woman in
  control
• Step 4 Transfer control of insertion of penis to
  husband
• 6. Drugs
• 7. Surgical treatment

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 1. Exploration of phobia. It is the most
difficult part of the treatment. Psychological
causes should be addressed. If there is a
history of childhood traumatic experience, this
has to be recalled the emotions which
accompanied it relived in order to help the woman
to come to terms with them  
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• 2. Sex education
• How their genital organs are put together how
  they both function.
• Genital anatomy
• Sexual physiology behavior  

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3.  Self exploration of sexual anatomy (guided
tour) Patient in semi-sitting position legs
apart mirror placed in front of her vulva, she
explores her genitalia with the doctor explaining
the anatomy physiology.  
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• 4. Control of muscles
• Relaxation exercises to the adductor muscles
• To help her to relax when anticipates vaginal
  penetration.
• The doctor hold the woman s knees together
  firmly while she attempts to separate them, then
  slowly she is allowed to succeed.
• During these maneuvers she learns muscle
  relaxation eventually allows access to the
  vagina.    

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b. Contraction /relaxation exercise (Kegel s
exercise) to gain control over the muscles
surrounding her introits . The patient must
learn first how to identify the muscle for
herself. She is advised to sit on the toilet with
her legs spread as far apart as possible. If she
then starts stops the flow of urine, she
becomes aware of the pubococcygeus action.
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Once the muscle is identified, the woman can
practice contracting it repeatedly whenever she
has time. She simply flexes this muscle 20 times
in a row 3 to 5 times every day till it is firm.

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• 5. Systematic vaginal desensitization of the fear
  of vaginal penetration
• Vaginal dilatation exercises are a misnomer
  because the vagina is not physically stretched
• Trainers fingers, commercial dilators, tampons,
  of gradually increasing diameter, specifically
  designed specula such as Simms, Amiell, Stanley.
• The choice depend on the patient preference
  comfort level.

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Approaches 1.  Gradual using vaginal
self-dilatation or  Rapid using vaginal mould
insertion. Duration 2-6 weeks Rapid
desensitization is preferred (Biswas
Ratnam,1995) 2. In-vitro The dilator is
introduced by the doctor or In-vivo the dilator
is introduced by the patient According to
Cochrane library, 2002, No discernable
differences between the 2 forms of systematic
desensitization Success rate 90  
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• Program
• Step 1 Insertion of a trainers under controlled
  relaxation
• In private, in a relaxed nonsexual setting. The
  protocol for use of dilators is explained to the
  patient while she is in the office, but the
  actual placement of the dilators is done by the
  patient when she is at home.
• The dilators should be covered with a warm, water
  soluble lubricant. If she is unable to relax
  enough to place the smallest dilator in her
  vagina propranolol, or alprazolam may also help
  reduce anxiety. Once the patient has been able to
  place the smallest dilator in her vagina, she can
  progressively insert the largest dilators,
  practicing Kegel s exercises while dilator in
  place.

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Step 2 Sharing of control with husband. When she
is comfortable inserting the larger dilators, she
can instruct her husband how to place the dilator
in her vagina while she maintains control how
quickly the dilator are placed. The husband
becomes active in the vaginal dilatation
exercises only when the patient is emotionally
physically ready after anxiety of being touched
is extinguished.   
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Step 3 Insertion of penis with the woman in
control. Sitting or kneeling over her husband,
female superior position inserting his penis
herself.  
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Step 4 Transfer control of insertion of penis to
husband During sex therapy the patient are
advised to refrain from coitus. The patient is
told to perform the exercise for 10 to 15
minutes, 5 times per week. Therapy sessions are
conducted every 2 weeks to follow support the
progress made in the treatment, to reduce
resistance to provide large dilator according
to progress made.
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 6. Drugs Anxiolytics antispasmodics have
nothing to offer (Guirguis,1984). The only
indication for drugs when vaginismus is a part of
a more generalized syndrome of sexual phobia. A
trial of imipramine 30-75 mg daily
Benzodiazepines to aid both relaxation
interviews (Mikhail, 1976)
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7. Surgical treatment Almost never required may
be detrimental to achieving success. The
resulting scar may aggravate the
condition. Indications to remove an organic
cause septum, stricture, partially imperforate
hymen .        
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Conclusions

• Vaginismus is recurrent or persistent involuntary
  contraction of the outer third of the vagina
  interfering with sexual intercourse.
• Vaginismus causes marked stress, anxiety, break
  down of marital relationship infertility
• Vaginismus is caused mainly by psychological
  factors

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. Lines of treatment of vaginismus are
Exploration of phobia, sex education, guided
tour, control of the adductors P coccygeus
muscles, systematic vaginal desensitization
drugs . Surgical treatment is almost never
required may be detrimental to achieving success
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Thank you
Prof. Aboubakr Elnashar
Benha University Hospital, EGYPT E-mail
elnashar53_at_hotmail.com