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Vaginismus: Pathophysiology, Etiology and New Treatment


Vaginismus: Pathophysiology, Etiology and New Treatment

When the muscles around the vagina tighten involuntarily when penetration of the vagina is attempted, vaginismus occurs. It can be painful; it also makes sexual intercourse difficult or impossible because the vagina can completely close up.

The two types of vaginismus are:

 

  • Primary vaginismus, which is when a woman has never been able to have sex because of this condition.
  • Secondary vaginismus, which is when a woman has previously been able to have sex but now it is difficult or impossible.

 

Symptoms of vaginismus vary between women. vaginismus can cause distress and relationship problems and may prevent a woman from starting a family because it disrupts or completely stops her sex life. Gynecological and pelvic examinations could also become difficult or impossible due to this condition. Before a doctor can examine a woman who has vaginismus, she may need an anesthetic.

 

PATHYPHYSIOLOGY:

Before being correctly identified as a conditioned response, vaginismus was considered to constitute a hysterical or conversion symptom, and was conceptualized as a symbolic expression of a specific unconscious intrapsychic conflict. Some still believe that women with vaginismus harbor an unconscious desire to castrate men because they are envious of and hostile toward them. These clinical formulations postulate that penis envy is a universal phenomenon that emerges during the phallic phase of a young girl’s development. According to this theory, a girl is likely to develop vaginismus later in her life if she doesn’t resolve her “penis envy”.

 

Vaginismus is explained as the physical expression of a woman’s unconscious wish to frustrate the man’s sexual desires or more specifically, of her wish to “castrate” him in revenge for her own “castration”. Fear of pain and fear of intercourse cause vaginismus, making coitus extremely difficult or even impossible. This problem is present in many unconsummated marriages. Vaginismus is like an eye blink response when a threat of touch occurs. The symptom is ego-syntonic; before some other motivation such as a desire for childbearing brings the woman or couple in for treatment, their marriage may go on for several years.

 

It seems that recently there’s an agreement that vaginismus is a psychophysiologic disorder with phobic elements that result from actual or imagined negative experiences with sexuality/penetration, and/or organic pathology. Fear and anxiety regarding penetration is expressed physiologically through involuntary vaginal muscle spasm, which is the characteristic of vaginismus. Vaginismus may occur to a minimal degree in many women; it’s not a common problem, but it isn’t a rare one either. Due to vaginismus, the women and their partners are unable to enjoy intercourse, and their self-esteem becomes affected by the repeated failures or by avoidance of intimate relations entirely, making vaginismus a troublesome condition. However, women who have vaginismus can be capable of pleasure and orgasm by other sexual methods, so they don’t necessarily have other sexual inhibitions.

 

ETIOLOGY:

Important causes of vaginismus include various etiologic factors. Reissing et al has sorted it in an excellent critical review, which is modified as below:

 

Misinformation, ignorance, and guilt about sexuality:

About 90% of patients with vaginismus have shown a high degree of ignorance and misinformation about their sexuality. For instance, some women thought that they have to have an orgasm in order to reproduce, or that menstruation was unclean.

 

Fear of pain:

Some researchers have suggested that fear of pain isn’t a cause of vaginismus, rather a symptom. On the other hand, others have stressed its possible causal and maintaining role in the disorder. Fear of pain was the primary reason for abstinence in an interview study of 476 women with vaginismus. New experiments supported this theory more recently, in which 74% of women with vaginismus reported that the primary reason underlying their condition was fear of pain. Childhood physical trauma, such as enemas and suppositories, fear of a violent father, and negative maternal conditioning are some of the childhood experiences that have been implicated in the development of this fear of pain. But in vaginismus, the cause-effect relationship of pain has to be considered: Is the pain secondary to some factors other than the putative vaginismic muscle response (e.g. vulvar vestibulitis syndrome, infections, sexually transmitted diseases, etc.), or is it the result of the spasmodic muscle activity?

 

Until now, the nature, severity, or causal mechanism of vaginismic pain isn’t understood. Women with vaginismus frequently have or have had other phobias. They saw their mothers as ineffectual (in that they would not protect themselves or their children) and, at times, helplessly dependent, though not usually passive. Although without success, their mothers often fought hard against their fathers’ dominance. Thus, having intercourse represents a dreaded role, which is identification with the mother.

 

Organic pathology:

Some of the possible organic causes of vaginismus are:

 

  • Congenital abnormalities
  • Hymeneal abnormalities
  • Vulvar vestibulitis syndrome
  • Sexually transmitted diseases
  • Vaginal atrophy and adhesions due to vaginal surgery or intravaginal radiation
  • Pelvic congestion
  • Prolapsed uterus
  • Infections
  • Endometriosis
  • Vaginal lesions and tumors

 

When any medical problem that causes dyspareunia persists, vaginismus will probably be the result.

 

Sexual violation:

Some people have argued that vaginismus may be the result of experiencing or witnessing sexual trauma.

 

Religious orthodoxy:

Some researchers believe that vaginismus is characterized by an excessively severe form of control stemming from religious orthodoxy, a history of sexual trauma, or, with previous homosexual identification after attempted heterosexual activity by a woman. Even though religiosity as a causal factor has failed to receive consistent support, but some authors have thought that high moral expectations instilled by the mother or sexual guilt resulting from a strict, religious up-bringing can result in vaginismus.

 

Personality:

One of the possible causes of vaginismus is personality. Based on a clinical sample of 100 vagnismic women, a study hypothesized that women in unconsummated marriages use a variety of defenses to deal with their conflicting emotions about sexuality; subsequently, these defenses become a part of their personality. However, when investigators used standard personality inventories, attempts to confirm these clinical hypotheses have failed.

 

Parents’ relationship and the father-daughter relationship:

The fathers of vaginismic women tended to be extremely critical, domineering, moralistic and threatening when these women were children, according to a study of 22 patients. More than 90% of the women with vaginismus reported feeling afraid of their fathers. The fathers were alcoholics in 45.5% of the cases, and 22.7% of the fathers had mental or nervous breakdowns that required hospitalization. The relationship of the parents was poor, and in about 55% of the cases, actual violence or physical abuse occurred between parents. Many of those women had witnessed or heard their mothers being forced to have sex. Although the mothers sometimes resisted their husbands, but they usually tended to oblige.

 

Male partner's personality:

By arguing that the problem is emotionally infectious, a study implicated the male partners in the etiology of vaginismus. For instance, by being “undercompetent, over-anxious, or too forbearing”, the male partner can potentially cause or exacerbate vaginismus in the female partner. The most common assertion is that the male partner has been chosen because he is passive and unassertive, and the couple is involved in an unconscious collusion to avoid intercourse.

 

Male partner’s sexual dysfunction:

The most frequent etiologic factor is male sexual dysfunction, where the vaginismus serves to protect the couple from confronting the problem of the male partner.

 

The couple’s relationship:

Vaginismus may be caused by various types of difficulties in the relationship of the couple, including conflict and/or infidelity.

 

TREATMENT OF VAGINISMUS:

Whether the root cause can be identified or not is what treatment of vaginismus depends on. For instance, appropriate medication can be used to treat obvious physical causes, such as an injury or infection.

 

Sex therapy:

The woman may be taught some self-help techniques to try to resolve the problem in case the cause is less obvious. The specialist may advise the woman on self-help techniques, as well as offering:

 

  • Counseling to address any underlying psychological issues such as fear or anxiety
  • Cognitive behavioral therapy to change any irrational or incorrect beliefs about sex, and if necessary, to educate the woman about sex.

 

Vaginal trainers:

Gradually widening or dilating the vagina with a set of vaginal trainers is involved in one of the techniques to relax the muscles in the vagina. These trainers can be used at home; they are four smooth, penis-shaped cones of gradually increasing size and length. First of all, the smallest one is used; a lubricant can be used if needed. The woman can move on to the second size once she feels comfortable inserting the smallest one, and so on.

 

Relaxation and touching:

Exercises of relaxation and exploration may be of help in case the cone method doesn’t work. While getting to know her body, the woman can have a bath, massage and breathing techniques, which are good ways to relax. She can try inserting a tampon while using lubricant if necessary, once she reaches the stage where she can put her fingers inside her vagina.

 

NEW TREATMENT: BOTULINUM TOXIN IN THE TREATMENT OF REFRACTORY VAGINISMUS

Extinguishing the conditioned involuntary vaginal spasm is the goal of treating vaginismus. Medications including lubricants, anesthetic creams, propranolol, or alprazolam have been used effectively to reduce anxiety, but about 10% of the patients don’t respond. A wide range of muscle disorders such as blepharospasm, cervical dystonia, and strabismus have been successfully treated with botulinum toxin type A. Botulinum toxin type A has also been used to reduce wrinkles and facial lines.

 

New studies in patients with severe and refractory vaginismus have investigated the effect of this drug on vaginal spasms. The edge of the puborectalis or pubococcygeus muscle impinges on the lateral wall of the vagina about 1.5-2 inches above the hymen. Patients characteristically describe the involuntary spasm of these muscles during attempts at insertion of the penis.

 

Vaginismus has been recently described as an involuntary spasm of the pelvic floor muscles and perineal muscles that surround the outer third of the vagina, making intercourse impossible or uncomfortable. This involuntary spastic contraction is a reflex response stimulated by imagined, anticipated, or real attempts at vaginal penetration. The abductors of the thighs, the rectus abdominis, and the gluteus muscles may also be involved in severe cases of vaginismus. If vaginismus is global, the woman won’t be able to place anything inside her vagina, or it could be situational, in which case she can’t have intercourse but can use a tampon and tolerate a pelvic examination.

 

Botulinum toxin type A is a neurotoxin that is produced by Clostridium botulinum, a spore-forming anaerobic Bacillus, which appears to affect only the presynaptic membrane of the neuromuscular junction in humans, where it prevents calcium-dependent release of acetylcholine and produces a state of denervation. Until new fibrils grow from the nerve and form junction plates on new areas of the muscle-cell walls, the muscle inactivation persists.

 

By preventing the release of acetylcholine, botulinum toxin paralyzes muscles. The amount of toxin to which there is exposure relative to muscle bulk will determine the extent of paralysis. The neuromuscular blockade is permanent, and the establishment of new neuromuscular junctions causes recovery of function by a process of terminal axonal and nodal sprouting. The distribution or binding of botulinum toxin isn’t affected in any way by renal, hepatic, or other diseases. It is thought that this toxin is metabolized locally.

 

The minimum dose of toxin that is necessary to produce systemic toxicity is still not known. However, it is estimated that 160 vials of the drug would be needed to produce systemic symptoms of toxicity, according to extrapolation of animal experiments. A number of clinical conditions associated with neuromuscular dysfunction, such as focal dystonias, upper motor neuron syndromes, and muscle hyperactivity have been treated successfully with botulinum toxin. Many of these conditions are associated with significant pain. It has also been observed that not only did botulinum toxin treat neuromuscular disorders, but that it also improved the pain that was associated with them. Botulinum toxin type A injections proved to be significantly better than placebo in a randomized trial of 31 patients with chronic low back pain.

 

The amount injected per muscle, the total amount injected, the number of sites injected, and selection of appropriate areas to inject are some of the important considerations that should be taken into account when administering botulinum toxin. To avoid development of antibodies, the total dose and frequency should be minimized, despite the fact that the incidence of antibody development is low, about 4%.

 

The effectiveness of botulinum toxin type A injection have been demonstrated by new studies in the treatment of moderate and severe cases of vaginismus. Complete response to botulinum toxin injection was reported by Shafik et al in a placebo-controlled study of 13 patients. Additionally, a case of dyspareunia complicated with interstitial cystitis that was managed with injected of botulinum toxin at 2 consecutive sessions was reported by Brin and Vapnek; the patient’s symptoms resolved after a few days, and she had intercourse for the first time in 8 years.

 

In conclusion, patients with vaginismus who have failed to respond to conventional therapies can benefit from botulinum toxin. However, treatment with botulinum toxin should be ideally administered as part of clinical trials, and should be considered experimental.

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Prepared By: Dr. Mehyar Al-khashroum
Edited By: Miss Araz Kahvedjian




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