Abstract
Vaginismus is currently defined as an involuntary vaginal muscle spasm interfering with sexual intercourse that is relatively easy to diagnose and treat. As a result, there has been a lack of research interest with very few well-controlled diagnostic, etiological or treatment outcome studies. Interestingly, the few empirical studies that have been conducted on vaginismus do not support the view that it is easily diagnosed or treated and have shed little light on potential etiology. A review of the literature on the classification/diagnosis, etiology and treatment of vaginismus will be presented with a focus on the latest empirical findings. This article suggests that vaginismus cannot be easily differentiated from dyspareunia and should be treated from a multidisciplinary point of view.
Keywords
Vaginismus is described as an involuntary vaginal muscle spasm interfering with sexual intercourse [1]. Since the term was first coined in the 19th Century, vaginismus has been conceptualized as a relatively infrequent but well understood and easily treatable female sexual dysfunction. In 1859, gynecologist Sims wrote that ‘from personal experience, I can confidently assert that I know of no disease capable of producing so much unhappiness to both parties of the marriage contract, and I am happy to state that I know of no serious trouble that can be cured so easily, so safely and so certainly’ [2]. This conceptualization was perpetuated by Masters and Johnson who reported a treatment outcome success rate of 100% [3]. It seems likely that this presumed high cure rate and lack of diagnostic controversy deterred new research. In fact, Beck described vaginismus as ‘an interesting illustration of scientific neglect’ [4]. Since Reissing et al.'s review of the vaginismus literature, a few important empirical studies on the diagnosis and treatment of vaginismus have been published [5]. Interestingly, their results challenge the validity of the current definition of vaginismus as well as the notion that it is an easily diagnosable and treatable condition. The current article will examine the literature on the classification/diagnosis, etiology and treatment of vaginismus with a focus on the latest empirical findings.
Prevalence
There are no epidemiological studies examining the population prevalence of vaginismus. This may be true since such a study would probably require a stressful gynecological examination that sufferers might often prefer to avoid. As a result, there have been dramatically varying estimates regarding the prevalence of this problem. Some such as Masters and Johnson claim that it is a relatively rare condition [3,6], while others suggest that it is one of the most common female psychosexual dysfunctions [7–10]. Although the population prevalence remains unknown, the prevalence rates in clinical settings have been reported to range between 5–17% [11].
In a British study, Ogden and Ward examined the help-seeking behaviours of women suffering from vaginismus and found that the professional most frequently consulted was the general practitioner [12]. Unfortunately, their respondents reported that general practitioners were the least helpful health professional they consulted. Overall, there was general dissatisfaction with available help, which may reinforce many vaginismic women's pre-existing avoidance in seeking help. This is consistent with Shifren et al.'s findings in the USA that only a third of women with ‘any distressing sexual problem’ consult [13]. According to their sample, the barriers for receiving professional help were poor self perceived health and embarrassment in discussing sexual problems.
Classification & diagnosis
Vaginal muscle spasm
In her 1547 treatise on ‘The Diseases of Women’, Trotula of Salerno is thought to have provided the earliest description of what we today call vaginismus: ‘a tightening of the vulva so that even a woman who has been seduced may appear a virgin’ [14]. Much later, Huguier gave the first medical description of the syndrome; however, it appears that Sims first coined the term ‘vaginismus’ in 1862 while addressing the Obstetrical Society of London [15]. Sims described vaginismus as ‘an involuntary spasmodic closure of the mouth of the vagina, attended with such excessive supersensitiveness as to form a complete barrier to coition’ [2]. To date, the involuntary muscle spasm remains the core element of the definition of vaginismus suggested by the American College of Obstetrics and Gynecology (ACOG) and by the Diagnostic and Statistical Manual of Mental Disorders-IV-TR (DSM-IV-TR) [1,16]. The International Classification of Diseases (ICD)-10 categorizes vaginismus either as a ‘pain disorder’ or as a ‘sexual dysfunction comprised of a spasm of the pelvic floor muscles that surround the vagina, causing the occlusion of the vaginal opening with penile entry being either impossible or painful’ [17].
This 150-year consensus concerning the definition of vaginismus is striking given the lack of empirical findings validating the vaginal muscle spasm criterion [5]. In fact, Reissing et al. (n = 87) found that although vaginismic women demonstrated a greater frequency of vaginal muscle spasm while undergoing a gynecological examination than did age, relationship and parity matched healthy controls or women suffering from dyspareunia associated with provoked vestibulodynia (PVD), only 28% of the vaginismus group actually displayed a vaginal muscle spasm. Moreover, only 24% reported experiencing spasms with attempted intercourse. Even more puzzling was the finding that two independent gynecologists agreed only 4% of the time on the diagnosis of vaginismus [18]. These findings call into question the primary diagnostic criterion of vaginismus.
Another method of evaluating the validity of the vaginal muscle spasm criterion is via the electrical recording of muscle activity, which can be done through surface electromyography (sEMG) or needle electromyography. Recent sEMG and needle EMG studies have investigated the activity of the pelvic floor muscles in women diagnosed with vaginismus. Reissing et al. found that women with vaginismus displayed lower pelvic floor muscle strength and greater vaginal/pelvic muscle tone compared with matched controls but no significant differences at all between the vaginismus and PVD group [18,19]. Shafik and El-Sibai (n = 14) also demonstrated through needle EMG, a higher EMG activity at rest and on induction of the vaginismus reflex in the levator ani, puborectalis and bulbocavernosus muscles in women with vaginismus compared with age-matched controls [20]. Consistent with the findings above, Frasson et al. (n = 30) found significant needle EMG basal and reactive hyperexcitability in primary lifelong vaginismus and in women with PVD accompanied by vaginismus as compared with controls [21]. On the other hand, three well-controlled sEMG (ranging from 29 to 224) studies did not confirm a significant difference in ability to contract and relax the pelvic floor muscles between women with and without vaginismus [22–24].
These contradictory results may be partially explained by the lack of an operationalized definition of the term ‘muscle spasm’ as well as the lack of consensus regarding which muscles are involved in vaginismus. Some authors refer to broad groups of muscles such as the muscles of the outer third of the vagina, the pelvic muscles or the circumvaginal and perivaginal muscles [25–29], while others refer to more specific ones, such as the bulbocavernosus, the levator ani and puboccoccygeus [30,31]. None of these studies indicate how they concluded which muscles are involved [5]. The term spasm itself is also controversial as there is no agreement on whether spasm refers to an involuntary muscle cramp, a defensive mechanism or a hypertonicity of the pelvic floor muscles.
In addition to the lack of agreement regarding the term muscle spasm and the muscles involved in vaginismus, there is no empirically standardized diagnostic protocol for vaginal muscle spasm. Although Masters and Johnson claimed that a pelvic exam was necessary to diagnose vaginismus, researchers and clinicians have frequently relied on self report of difficulties with vaginal penetration [2,32]. The lack of a standardized diagnostic protocol is not a trivial problem since studies concerning vaginismus may well include highly diverse samples. The fact that studies using the vaginal muscle spasm DSM-IV-TR definition of vaginismus failed to find a vaginal spasm suggests that vaginal muscle spasm is not a reliable diagnosis and as a result diverse patient populations might have been included [21–24].
Pain
Even though vaginismus is classified as a sexual pain disorder in the DSM-IV-TR, pain is not mentioned in the diagnostic criteria. Other definitions of vaginismus such as those published by the ACOG [16], the International Association for the Study of Pain (IASP), the WHO and Lamont do mention pain in their definitions [17,33,34]. However, no description of the pain characteristics, such as location, quality, intensity and duration are provided [32]. There is also a lack of information regarding whether the pain is a cause or consequence of the vaginal muscle spasm [32]. While most clinical reports and research concerning vaginismus do not make reference to the pain element in vaginismus [35], some authors believe that pain is one of its core components [10,18,36–40]. In fact, several studies have found that a large percentage of women suffering from vaginismus experience pain with attempted vaginal penetration [18,25,35,37,40–43]. The pain experienced by women with vaginismus has been found to be very similar to the pain reported by women with PVD [18,40,42].
According to the DSM-IV-TR, vaginismus can be classified as either lifelong (primary) or acquired (secondary). It has often been suggested that PVD may result in acquired vaginismus [31,34,44]. Although lifelong and acquired vaginismus are generally considered to differ in their etiology and response to treatment, there are no empirical data validating these claims.
Differential diagnosis of vaginismus from dyspareunia
According to the DSM-IV-TR, there are two mutually exclusive sexual pain disorders: vaginismus and dyspareunia. Dyspareunia is defined as ‘recurrent genital pain associated with sexual intercourse’ [1]. PVD is reported to be the most frequent subtype of dyspareunia in premenopausal women with a prevalence of 7% in the general population [45,46]. Women with PVD typically experience a severe, sharp, burning pain upon vestibular touch or attempted vaginal entry [45,47,48]. It is diagnosed through the cotton-swab test, which consists of the application of a cotton swab to various areas of the vulvar vestibule and surrounding tissue [47].
Despite the fact that vaginismus and dyspareunia associated with PVD have been portrayed as two distinct clinical entities, they have many overlapping characteristics, such as the elevated vulvar pain and vaginal/pelvic muscle tone [18,42]. In fact, a number of studies have demonstrated that a large percentage (range between 42 and 100%) of women with vaginismus also meet the criteria for PVD [18,24,41,42]. This may explain, in part, why health practitioners (i.e., gynecologists, physical therapists and psychologists) show significant difficulties reliably differentiating vaginismus from PVD [18]. It should be noted, however, that PVD is characterized superficial dyspareunia. The pain of deeper dyspareunia is usually easily differentiable from that associated with vaginismus. Women with vaginismus, however, were found to display significantly higher levels of emotional distress while undergoing a gynecological examination and to avoid significantly more sexual and nonsexual vaginal penetration attempts as compared with women with PVD [18,37,42].
Fear
Clinical reports have long suggested that fear plays an important role in vaginismus [3,16,47–50]. Only a few studies have investigated this further [50–53]. For example, fear of pain was the primary reason reported by women with vaginismus for their abstinence as well as the core motive underlying their avoidance of sexual intercourse [18,53]. Moreover, a large percentage (range between 74 and 88%) of women with vaginismus report significant fear of pain during coitus [50,53]. Women suffering from vaginismus share a number of characteristics with individuals suffering from a ‘specific phobia’. Specific phobias are defined as ‘marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation’ [1]. Individuals with a specific phobia will experience feelings of anxiety, fear or panic upon encountering the feared object or situation. As a result, they will tend to actively avoid direct contact with the phobic stimulus [1]. Women with vaginismus report fear of vaginal penetration and associated pain and display high levels of emotional distress during vaginal penetration situations, such as during gynecological examinations [18,50]. Women with vaginismus also tend to avoid situations involving vaginal penetration (i.e., gynecological examination, tampon insertion and sexual intercourse) [18].
It still remains unknown, however, whether vaginismic women avoid these particular situations in order to diminish their anxiety level similar to individuals suffering from a specific phobia, or in response to their pain experience, or both. Nonetheless, the avoidance of vaginal penetration cannot be solely explained by the experience of pain since women with dyspareunia, who also experience severe pain during vaginal penetration, have not been shown to avoid vaginal penetration situations as much as women suffering from vaginismus [18,42].
Although fear appears to be a promising factor that characterizes women with vaginismus, the existing empirical studies lack appropriate control groups, standardized instruments to measure fear and appropriate statistical analysis [50–53].
Summary
The current definition of vaginismus is problematic. First, the vaginal muscle spasm criterion has never been empirically validated and it appears that vulvar pain and the fear of pain or of vaginal penetration characterizes most women currently diagnosed with vaginismus. Moreover, vaginismus cannot be reliably differentiated from superficial dyspareunia. A recent consensus definition reflects these conclusions and defines vaginismus as: ‘persistent or recurrent difficulties of the woman to allow vaginal entry of a penis, finger and/or any object, despite her expressed wish to do so. There is variable (phobic) avoidance, involuntary pelvic muscle contraction and anticipation/fear/experience of pain. Structural or other physical abnormalities must be ruled out or addressed’ [54]. Binik has also recently proposed a new conceptualization that combines vaginismus and dyspareunia into a single genito–pelvic pain/penetration disorder characterized by persistent or recurrent difficulties for 6 months or more with at least one of the following [32]:
Inability to have vaginal intercourse/penetration on at least 50% of attempts;
Marked genito–pelvic pain during at least 50% of vaginal intercourse/penetration attempts;
Marked fear of vaginal intercourse/penetration or of genito–pelvic pain during intercourse/penetration on at least 50% of vaginal intercourse/penetration attempts;
Marked tensing or tightening of the pelvic floor muscles during attempted vaginal intercourse/penetration on at least 50% of occasions.
Etiological factors
Psychological factors
Although the definition, diagnosis and treatment of vaginismus have focused largely on the organic symptom of vaginal muscle spasm, the proposed etiological factors have primarily been psychogenic. The most frequently proposed include negative sexual attitudes, psychological and/or physical trauma, and relationship difficulties.
Negative sexual attitudes & lack of sexual education
The associations between negative sexual attitudes, sexual ignorance and vaginismus have been frequently mentioned in the vaginismus literature [1,51,55]. For example, Ellison claimed that vaginismus primarily resulted from: a lack of sexual knowledge and the presence of sexual guilt both leading to a fear of engaging in intercourse [56,57]. These are consistent with Silverstein, Ward et al. and Basson's conclusion that women suffering from vaginismus hold negative views about sexuality in general and about sex before marriage [41,51,53]. However, all these studies suffer from a number of important methodological limitations such as small sample sizes (n = 22–89), lack of appropriate statistical analyses and control groups, as well as absence of standardized measurement instruments and a standardized protocol to diagnose vaginismus [41,51,53,56,57]. There are only two etiological studies of vaginismus that have included a standard statistical analysis or a control group [58,59] and only one that used a standardized measurement instrument [60]; their results do not support the notions that women with vaginismus hold negative sexual attitudes and/or have lower levels of sexual knowledge and education.
Relationship factors
Vaginismus has frequently been reported to result from a dysfunctional couple relationship [60,61]. The available empirical evidence is controversial. For example, Tugrul and Kabakçi's (n = 40) uncontrolled study demonstrated that 85% of vaginismic women who applied for the treatment of vaginismus and 90% of their husbands evaluated their marriages as satisfactory [50]. Hawton and Catalan (n = 30) found that couples suffering from vaginismus have a significantly better relationship and communication when compared with 76 couples presenting other types of female sexual dysfunctions [62]. Although relationship factors have not been empirically demonstrated to play a significant role in the etiology of vaginismus, women who suffer from vaginismus do have fewer sexual relations and avoid more sexual contact when compared with healthy controls [50,59]. It remains unclear, however, whether these are causes or consequences of vaginismus.
Partners of women with vaginismus have been reported in clinical reports to suffer from sexual dysfunction as well as to display passive and unassertive personalities [3,26,51,57,63–65].
Controlled empirical findings using standardized instruments evaluating type of personalities and male sexual dysfunction, however, have not supported this view [26,52,58]. For example, when the personality characteristics of male partners of women with vaginismus are compared with controls or norms, no differences were demonstrated. Moreover, the few studies that investigated the chronology of sexual dysfunction in partners of women with vaginismus concluded that sexual dysfunction such as erectile and premature ejaculation are generally the result rather than the cause of vaginismus [30,64,66,67].
Sexual &/or physical abuse
Although the experience of sexual and/or physical abuse is generally considered an important etiological factor in vaginismus, the empirical evidence is less conclusive [1,60,68]. Five out of six studies [62,65,66,69,70] found no evidence of a higher prevalence of sexual and physical abuse. The sixth study found only weak evidence since women with vaginismus were twice as likely to report a history of childhood sexual interference (attempts at sexual abuse and sexual abuse involving touching) as compared with a ‘no pain’ group [59]. Larger studies with matched control groups and well-validated definitions of abuse are required to resolve this issue.
Biological factors
Organic pathology
A number of organic pathologies (e.g., hymeneal and congenital abnormalities, infections, vestibulodynia, trauma associated with genital surgery or radiotherapy, vaginal atrophy, pelvic congestion, endometriosis, vaginal lesions and tumors, scars in the vagina from injury, childbirth or surgery, and irritation caused by douches, spermicides or latex in condoms) resulting in painful/difficult/impossible vaginal penetration have been suggested as etiological factors [5,8,16,68,71]. There have been no controlled studies evaluating this possibility.
Pelvic floor dysfunction
Pelvic floor muscle dysfunction (e.g., hypertonicity and reduced muscle control) has been suggested as a predisposing factor in the development of vaginismus [39,45]. Barnes et al.'s uncontrolled study (n = 5) argued that vaginismic women had difficulty evaluating vaginal muscle tone and as a result experienced problems distinguishing between a relaxed state and a spasm [72]. It remains unclear, however, whether pelvic floor dysfunction is a predisposing factor or the defining symptom. To date, no controlled longitudinal studies have investigated the role of pelvic floor muscle dysfunction in the etiology of vaginismus.
Summary
Although a long list of psychological factors have been proposed as playing a role in the etiology of vaginismus, very few have been supported by empirical research. In addition, no biological factors hypothesized to be involved in the development of vaginismus have been adequately investigated.
Treatment
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 [2]. 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 [75]. 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 [2]. 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.
Review of treatment outcome studies for vaginismus.
CBT: Cognitive behavioral therapy; EMG: Electromyography; FU: Follow-up; iv.: Intravenous; NA: Not applicable; VVS: Vulvar vestibulitis syndrome.
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.
Pharmacological treatment
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 [80]. 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 [81]. 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 [81]. 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 [84]. 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 [86]. 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 [87]. 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 [82]. 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.
General psychotherapy
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 [3]. 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 [70]. 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 [108]. 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.
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].
Conclusion
Although most research concerning vaginismus presents significant methodological limitations, certain conclusions can be made from the few well-controlled studies. First, vaginal muscle spasm is not a valid or reliable diagnostic criterion for vaginismus. Second, vulvar pain is an important characteristic of most women suffering from vaginismus and should be always evaluated. Third, although vaginismus and dyspareunia are presently considered two mutually exclusive disorders, they share many characteristics and are very difficult to differentiate using our current clinical tools. Fourth, fear and avoidance of vaginal penetration situations have been mentioned to be an integral part of vaginismus; interestingly, there are no controlled published studies examining its role. Finally, the present conceptualization of vaginismus as an easily treatable sexual dysfunction has not been supported by empirical research. Unfortunately, it is very difficult to conduct research when inherent problems exist with the definition of vaginismus.
Future perspective
Unlike the current DSM-IV-TR definition of vaginismus, Binik's new conceptualization of vaginismus as a genito–pelvic pain/penetration disorder takes into consideration existing empirical findings as it incorporates pain, muscle tension and fear. Binik's diagnostic criteria are easily translatable into dimensional terms and do not categorically separate vaginismus from provoked vestibulodynia. This new conceptualization also has significant diagnostic and therapeutic implications in that it suggests that a multidisciplinary approach taking into account muscle tension, genital pain and fear will be necessary to attain a high success rate. It is unlikely that a lone professional will be able to provide such a treatment. A multidisciplinary team, including a gynecologist, physical therapist and psychologist/sex therapist, should be involved in the assessment and treatment of vaginismus to address its different dimensions.
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.
Although the population prevalence of vaginismus remains unknown, it has been reported to range between 5 and 17% in clinical settings.
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.
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.
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.
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.
Footnotes
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.