Vaginismus ( Pain with spasm at time of entry)

Vaginismus ( Pain with spasm at time of entry)

Vaginismus In vaginismus involuntary painful contraction of vaginal entry muscles (i.e. vaginal opening) is so painful that entry is virtually impossible. So that due to spasm of introitus muscles there occurs virtual closure of the vaginal opening with significant pain. Vaginismus is one of the causes of Dyspareunia. This is one of the common cause of coital pain & even this one of the important cause for non-consummation of marriage. This can be classified as lifelong or situational. Similarly it may be classified as primary from beginning or secondary means started later in life. It is found in approximately one percent of women. In some women there may be mild degree of vaginismus in which sexual intercourse is possible but with pain. In one study approximately 10% housewife had some degree of vaginismus pain. In vaginismus pain felt by girl or female is so much that next time she starts avoiding the sexual contact of any kind because of fear that it will give her pain. Thus in most cases husband is unable to penetrate her successfully also called as non-consummation of marriage. But the fore play & sexual desire excitation & lubrication may be absolutely normal in vaginismus women. In many women they do sex between their abducted thighies. With this technique even many vaginismic women may get enough arousal & even orgasm. Due to any of the various below-mentioned causes the vaginal penetration or intercourse may be painful. This leads to development of a conditioned response in the body, so that the moment penis or even finger comes closure to vagina for penetration there occurs painful spasm of all the pelvic muscles at vaginal opening with associated fear of penetration. Thus nothing can enter. In future She starts avoiding sex. The causes of vaginismus are 1)Disorder of sex centre: So that vagina & muscles around it goes into painful spasm at the point of penis entry rather than relaxing. 1.) It may also occur following any previous painful penetration of penis i.e. painful sexual intercourse or painful entry of some other object as painful examination of vagina by doctor with some instrument or by some traumatic experience in the past. 2.) Sexual aversion disorder & female sexual arousal disorder 3.) Hormone disorder:In which female hormones are less some other sex stimulating hormone are disturbed. These hormone disorders may be due to any of the following causes: Hypothalmic idiopathic hypogonadotropic hypogonadism, Prolactinomas, Empty sella, Sheehan syndrome, Panhypopituitarism, Inflammatory /infiltrative Ovarian lesions : Granulosa-theca cell, Brenner, mucinous/serous cystadenomas, Krukenberg. mumps oophoritis, Resistant ovary (Savage syndrome), Autoimmune disease 1.) Defect in uterus or vagina : Narrow vaginal openings or small vagina,Labial agglutination/fusion, transverse vaginal septum, Complete androgen resistance (testicular feminization), 2.) Infections: in genital tract or vulvae vestibule, vulvo-vaginitis 3.) Less lubrication due to various reasons as hormone deficiency 4.) Connective tissue diseases leading to dryness 5.) Psychological problems: as depression & other psychiatry disorders 6.) Sicca syndrome 7.) Idiopathic 8.) Any ulcerative lesions of vagina as chronic lichen planus, herpese genitals, Pemphigus vulgaris of vagina 9.) Decreased blood supply to vagina due to various medical conditions can lead to diminish vaginal lubrication, pain during intercourse 10.) Vulvar vestibulitis 11.) Restrictive upbringing, Inadequate sexual information, early insecurity in psychosexual role, 12.) Obstructive vaginal lesions: Vaginal stenosis, vaginal scarring, post surgical problems, retroverted uterus, organic diseases of uterus, endometriosis, adenomyosis, tubes or ovaries, chronic pelvic inflammatory diseases, urethral diverticulum 13.) Idiopathic vulvodynia DIAGNOSIS OF CAUSE Of PAIN DURING SEX First step in proper treatment of pain during sex is accurate diagnosis of cause of her pain during sex. So we first try to find out cause. We take detailed history, thorough sex counseling and physical examination by female doctor, examination genitals. After that depending on likelihood of particular, cause relevant tests are done at our centre. Thus you may consult us at our centre & at same time you may get all test done also. The time taken in getting all the reports ready is 36 hours. So if you are from out of Delhi, you may come here for two days. DETAILED HISTORY Onset: We take detailed history, as for quality of pain whether is at the introitus, superficial or deep inside, whether it is mild, moderate or severe pain. Then we decide whether it occurs all the time only during sexual activity. How is the response of previous treatment? Response to previous therapy, Libido, Stress (physical or mental), History of precipitation by some drugs any past history of sexual abuse or painful sex. EXAMINATION OF GENITALS We examine whether any Sexual Development defect is present or not. For this vaginal size is measured by vaginometer or Genitometer (if patient is outstation then by radiological tests). The vagina is examined for some local problem. In many cases vaginal examination may or may not elicit the spasm & pain. If the vaginal examination is very painful with accompanied spasm is another proof of the diagnosis as vaginismus. Status of female hormone is assessed by examination of various estrogenic signs. Galactorrhoeas & features of other hormones disorders are checked up. Blood supply of vagina is assessed, by assessing the texture of vaginal wall. Nerves supplying the female genitals examined by sensation testing & Deep Tendon reflexes. Then other systems of body are also examined. INVESTIGATIONS i.e. DIAGNOSTIC TESTS At our centre we have all the facility for complete investigation of cause of pain during coitus & other difficulties. So we perform following tests, step by step depending on their need based on history & examination. The various diagnostic tests needed/performed are as follows: - Step I : Hormone Testing: Various Female sex hormones & other associated Hormones are tested by latest-immunoassay techniques. These hormones includes total Estradiol, Estriol, Prolactin, LH, FSH, T3, T4, TSH others as Cortical, E2, Free testosterone SHBG etc. Among above tests relevant hormones are tested in that particular patient. Results are available in 36 hours. When we find out any of above hormones disorder correction of these hormone disorder helps a lot in eliminating pain. Blood glucose & other relevant tests are also done. Step II : ULTRASOUND SCANNING : Ultrasound scanning is done to decide whether any type of local problem is present or not, accordingly treatment is prescribed. Step III :. SEX COUNSELING : After detail discussion with our female sex therapist, we try to finds out the root cause of pain problem then we treat accordingly. For counseling we take detail history of sexual development, her thoughts, her misconception about sex, her old experience in sex, her unconscious fears about sex. This counseling session unravels all the hidden psychological causes of sexual pain disorder. Step IV : OTHER TESTS (If required) 1) Pelvic Nerve Testing: By conduction and sensory testing (NCV, EMG). 2) Psychoanalysis: To find different factor leading to psychogenic pain disorder. 3) Detailed Sex Counseling TREATMENT OF VAGINISMUS Once the diagnosis of vaginismus is confirmed after detailed history, examination, relevant investigations, we start the treatment. It involves giving the sex therapy session, which is focused on eliminating the painful vasospasm of pelvic muscles & associated fear of entry of penis into vagina. The various treatment options are: 1) Sex Therapy 2) Hormone Therapy 3) Treatment of any secondary cause found as infection, or local cause or any psychiatric disorder. 1) Sex Therapy: The various sex therapy is offered by sex therapist leading to elimination of the pelvi-vaginal muscular spasm & fear of penis entering vagina. Sex therapy begins with detail sex education about the anatomy of male & female genitals. Then we give the patients specific exercises, which, the couple has to do at their home. After every exercise session fear of penetration decreases. Along with these exercise vaginal dilators of increasing sizes are given. These vaginal dilators, along with S focus exercise sex therapy is designed to gradually expose the women to vaginal penetration with increasing sizes. With these exercises along with behavioural therapy,hypnotherapy,& couple's therapy leads to cure in few months. 2) Anti-in-effective drugs: The anti-microbial treatment is indicated whenever the infection is found. 3) Hormones Therapy: Hormones therapy is given to cure the hormone problem whenever hormone disorder is found. Estrogen treatment is given when deficiency of hormones are found. Hormones therapy helps n fast cure of this problem & do not have any adverse effects as they given to only those patients in whom some hormone disorder is found. 4) Other drugs found effective are anti-inflammatory, serotonin reuptake inhibitors.