Female pain during sexual intercourse is common and affects at least 30 % of the world population. It can range from discomfort (dyspareunia) to severe pain or intercourse being impossible (vaginismus). It can be due to medical conditions such as herpes and menopause (secondary vaginismus) or the reasons may be unknown such as in primary vaginismus. Sexual pain may be due to a very tight entry muscle (“intercourse is like hitting a wall”) as in severe vaginismus, or may involve the vulva as in vulvodynia or vestibulodynia. Associated conditions may co-exist such as irritable bowel syndrome and interstitial cystitis.
Treatment is available for most forms of sexual pain. It is important to have the correct diagnosis first. Many patients treated by Dr. Pacik have had numerous failed treatments because either the diagnosis of vaginismus was not made, or the severity of the problem was not appreciated. Although classification systems exist, many clinicians do not stratify the severity of the vaginismus. Patients may continue for years getting frustrated as their relationships continue to be compromised. Depression and anxiety are common as these women continue to lose hope that they will ever be normal.
Mild vaginismus can be treated by a variety of means. These patients are often able to co-operate so that vaginal muscles can be stretched with dilators in conjunction with sex counseling, psychotherapy, physical therapy, hypnotherapy, etc. to lessen the amount of associated anxiety. As vaginismus becomes more severe, the patient is able to relax less well and increasingly avoids different forms of penetration. The patients understand what is being told to them but are unable to incorporate the suggestions as a result of heightened anxiety. Most of our patients fall into this category who have been frustrated by years of inability to respond to treatment.
As the condition of vaginismus becomes more severe, different methods can be employed to solve this. For patients able to tolerate some forms of penetration (“situational vaginismus“) dilation techniques started under anesthesia have been helpful. For those who are unable to tolerate any form of penetration comfortably (“complete vaginismus“) it has been found that the entry muscle is in spasm and these patients respond to the Botox program which consists of Botox injections, progressive dilation under anesthesia and post procedure counseling including the use of dilators and progressing to intercourse.
The FDA approved pilot study of 30 patients is now complete with at least one year follow up of patients. It was found that 29 of 30 patients (97%) were able to achieve intercourse and none required re-treatment. In this study none of the patients had associated vulvodynia or vestibulodynia.
Summary: It is important to distinguish between the many different causes of sexual pain. Given the proper information we have found that patients are able to self diagnose vaginismus as a cause of sexual pain. A high percentage of vaginismus patients respond to the Botox program giving permanent relief to their condition.
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