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Case History

image A 23-year-old woman presents with the inability to have intercourse. She had no problems with her first partner when she was 16 years old, although this relationship ended six months later. Because she was sexually active her general practitioner performed a cervical smear for her when she was 17 years old. She found this excruciatingly painful. It was suggested that the pain was due to a retroverted uterus and she has not attended for a smear since, despite numerous reminders. She has been unable to have intercourse with two partners subsequently, despite feeling aroused, and is concerned that her current relationship will end.

What physical conditions need to be considered before a diagnosis of vaginismus can be made?

What factors are associated with vaginismus?

What are the aims of treatment?

How are these aims achieved?


image The term 'vaginismus' was first used in the nineteenth century1 and is now thought to be one of the commonest female sexual problems. The true prevalence is unknown; however, it is identified in 10%–20% of women requesting help for sexual dysfunction.2 Definitions vary as to whether or not spasm of the muscles surrounding the lower third of the vagina is included or whether it is difficulty in allowing vaginal entry, often associated with involuntary pelvic muscle contraction.3 Although it occurs when the woman anticipates intercourse, there is often fear of any object being placed in the vagina, thus tampons are not used and gynaecological examinations are not well tolerated. The condition may be primary, where non-painful penetrative intercourse has never occurred, or secondary, where previously the woman has experienced non-painful penetrative vaginal intercourse.3

What physical conditions need to be considered before a diagnosis of vaginismus can be made?

Vaginismus is thought to occur as a conditioned response secondary to adverse physical or psychological stimuli. Thus, any pathology which causes dyspareunia, either superficial or deep, can set up a cycle whereby fear of pain causes involuntary spasm which causes further pain, reinforcing the conditioned response (Figure 33.1).4 Specific conditions which should be looked for and excluded are shown in Table 33.1.

Figure 33.1

Cycle of vaginismus. Source: Butcher 2005.4

Table 33.1Causes of dyspareunia

What factors are associated with vaginismus?

Early traumatic experiences are thought to predispose to vaginismus. Thus, traumatic sexual experiences, unsympathetic gynaecological examinations and assault are all associated factors.3 However, it has also been reported that, unlike women ...

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