Genito-Pelvic Pain/Penetration Disorder (Vaginismus)

BASICS

Previously known as vaginismus and dyspareunia
Defined by persistent/recurrent difficulties ≥6 months with at least one:
Inability to have vaginal penetration ≥50% of attempts
Marked genito-pelvic pain during penetration ≥50% attempts
Marked fear of penetration or pain ≥50% attempts
Marked pelvic floor muscle tensing/tightening during penetration attempts ≥50%
Causes marked distress or interpersonal difficulty
Not due to nonsexual mental disorder, severe relationship stress, substance effects

Multifactorial; primary and secondary forms
Primary: psychological/psychosocial factors, negative sexual messaging, poor body image, sexual trauma, hymenal abnormalities, painful gynecologic exams
Secondary: situational; linked to dyspareunia from vaginal infection, dermatitis, scarring, endometriosis, lubrication deficiency, pelvic radiation, estrogen deficiency, conditioned pain response

No labs unless infection suspected
Consider factors: partner, relationship, individual vulnerability, cultural, medical
Testing directed at secondary causes

Generally successful outpatient treatment (80% cases respond)
Treat physical conditions first (infections, scarring, lubrication)
Pelvic floor physical therapy and myofascial release as initial step
Cognitive-behavioral therapy (CBT) and gradual desensitization effective
Sex therapy beneficial
Vaginal dilation exercises, progressing from self to partner-directed, focusing on control and comfort
Topical anesthetics or anxiolytics may aid desensitization
Medications:
Low-dose tricyclic antidepressants (e.g., amitriptyline 10 mg) for pain/anxiety
Botulinum toxin type A injections (20-400 U) for refractory cases; may be combined with bupivacaine
Surgery contraindicated

Teach pelvic anatomy, normal sexual function
Explain involuntary nature of muscle spasms
Use mirrors for muscle control awareness
Educate partner about nonvolitional spasms and reassure regarding relationship impact
Instruction on vaginal dilation techniques

Landry T, Bergeron S. How young does vulvovaginal pain begin? Prevalence and characteristics of dyspareunia in adolescents. J Sex Med. 2009;6(4):927-935.
Maseroli E, Scavello I, Rastrelli G, et al. Outcome of medical and psychosexual interventions for vaginismus: a systematic review and meta-analysis. J Sex Med. 2018;15(12):1752-1764.
Weinberger JM, Houman J, Caron AT, et al. Female sexual dysfunction and the placebo effect: a metaanalysis. Obstet Gynecol. 2018;132(2):453-458.
Crowley T, Goldmeier D, Hiller J. Diagnosing and managing vaginismus. BMJ. 2009;338:b2284.
Melnik T, Hawton K, McGuire H. Interventions for vaginismus. Cochrane Database Syst Rev. 2012;12(12):CD001760.
Pacik PT. Vaginismus: review of current concepts and treatment using Botox injections, bupivacaine injections, and progressive dilation with the patient under anesthesia. Aesthetic Plast Surg. 2011;35(6):1160-1164.

Conduct comprehensive medical, psychosocial, and sexual history with patient-controlled pelvic exam
Condition is treatable with multidisciplinary approach
CBT and desensitization exercises are effective therapies
Botulinum toxin injection therapy is promising in refractory vaginismus
Surgery is contraindicated and rarely needed