Vaginismus is a complex and often misunderstood condition characterized by involuntary contractions of the pelvic floor muscles, which can hinder vaginal penetration and cause significant distress for affected women.

The DSM-5 defines vaginismus as part of the broader category of Genito-Pelvic Pain/Penetration Disorder (GPPPD). This disorder encompasses difficulties with vaginal penetration, often accompanied by pain, fear, or marked tightening of the pelvic floor muscles.

DSM-5 Definition of Vaginismus (as part of Genito-Pelvic Pain/Penetration Disorder)

Genito-Pelvic Pain/Penetration Disorder includes persistent or recurrent difficulties in one (or more) of the following areas:

1. Vaginal penetration during intercourse.
2. Marked vulvovaginal or pelvic pain during vaginal intercourse or attempted penetration.
3. Marked fear or anxiety about pain in anticipation of, during, or as a result of vaginal penetration.
4. Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.
5. 
   

Diagnostic Criteria:

• The symptoms must cause significant distress or interpersonal difficulty.
• The symptoms must be present for at least 6 months.
• The symptoms cannot be better explained by a nonsexual mental disorder, a medical condition, or the effects of a substance or medication.

Epidemiology

• Prevalence is estimated at 1-7% of women worldwide, though exact figures are challenging to determine due to underreporting.
• Most commonly affects women in their late teens to early 30s.
• Women seeking Tx for sexual dysfunction: 21-48% (Eserdağ et al., 2021; Ferreira & Souza, 2012)

Risk Factors

Presentation

Management requires a holistic, multidisciplinary approach targeting both psychological and physical factors. Clinicians must adopt a compassionate, sensitive method, recognizing the emotional and physiological aspects influencing patient comfort and cooperation in treatment.

Broad Principles of Management

1. Comprehensive Evaluation

   • Obtain detailed Hx: gynecological, obstetric, sexual, and urological.
   • Conduct genital exam (external/internal), assessing for anomalies, scarring, or inflammation.
   • Approach pelvic exams gradually, prioritize patient comfort and consent, and be prepared to pause or reschedule as needed.
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2. Tailored, Multidisciplinary Approach

   • Behavioral Therapies: CBT for addressing anxiety, fear, and negative associations with intimacy.
   • Pelvic Floor Physical Therapy: Gradual muscle relaxation and control techniques.
   • Systematic Desensitization: Progressive vaginal dilator use, focusing on patient’s tolerance and goals.
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3. Patient Education & Communication

   • Provide open, stigma-free information on sexual health, normalizing discussion around vaginismus to reduce shame and embarrassment.
   • Support patient’s own goals (e.g., pain-free intercourse, tampon use, or comfortable exams).
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4. Partner Involvement & Sensate Focus

   • Involve partner (if applicable) in structured intimacy exercises to build trust, focusing on non-penetrative touch and reducing performance anxiety.
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5. Pharmacological Interventions (if indicated)

   • Topical Anesthetics (e.g., lidocaine) or Botulinum Toxin Injections in select cases to alleviate pain and muscle spasm.
   • Topical Estrogen: Beneficial in cases with vulvovaginal atrophy or dryness (especially peri-/postmenopausal).
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6. Consideration for Pregnant Patients

   • Recognize unique challenges in pregnant patients with vaginismus, ensuring supportive obstetric care to prevent avoidance due to past negative experiences or lack of provider understanding.
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7. Assisted Reproduction Options

   • For patients aiming for conception, provide information on assisted reproductive options where vaginismus hinders natural conception efforts.

Women with vaginismus generally have a favorable prognosis, especially with appropriate treatment, which often leads to significant symptom improvement and greater sexual satisfaction. Success can depend on factors such as the condition’s duration, any coexisting psychological issues, and support from partners and healthcare providers. GPs play a key role in creating a supportive environment for open discussions on sexual health, helping to ensure timely diagnosis and effective treatment.

**References:**

1. Eserdağ et al. "Insights into the Vaginismus Treatment by Cognitive Behavioral Therapies: Correlation with Sexual Dysfunction Identified in Male Spouses of the Patients." *Journal of Family & Reproductive Health* (2021). doi:10.18502/jfrh.v15i1.6079
2. Ferreira and Souza. "Botulinum Toxin for Vaginismus Treatment." *Pharmacology* (2012). doi:10.1159/000337383
3. Marthasari et al. "Vaginismus and Infertility." *Indonesian Andrology and Biomedical Journal* (2020). doi:10.20473/iabj.v1i2.33
4. Banaei et al. "Bio-Psychosocial Factor of Vaginismus in Iranian Women." *Reproductive Health* (2021). doi:10.1186/s12978-021-01260-2
5. Muammar et al. "Management of Vaginal Penetration Phobia in Arab Women: A Retrospective Study." *Annals of Saudi Medicine* (2015). doi:10.5144/0256-4947.2015.120
6. Ramanathan et al. "Common Pitfalls in the Management of Vaginismus in Couples With Subfertility in India." *Journal of Psychosexual Health* (2022). doi:10.1177/26318318221089600
7. Demirci and Kabukçuoğlu. "‘Being a Woman’ in the Shadow of Vaginismus: The Implications of Vaginismus for Women." *Current Psychiatry Research and Reviews* (2020). doi:10.2174/2666082215666190917153811
8. Çankaya and Aslantaş. "Determination of Sexual Attitude, Sexual Self-Consciousness, and Sociocultural Status in Women With and Without Lifelong Vaginismus: A Case-Control Study." *Clinical Nursing Research* (2022). doi:10.1177/10547738221103334
9. Pereira et al. "Physiotherapy Protocol with Interferential Current in the Treatment of Vaginismus."
10. Pacik et al. "Case Series: Redefining Severe Grade 5 Vaginismus." *Sexual Medicine* (2019). doi:10.1016/j.esxm.2019.07.006
11. Çankaya and Aslantaş. "Determination of Dyadic Adjustment, Marriage and Sexual Satisfaction as Risk Factors for Women with Lifelong Vaginismus: A Case Control Study." *Clinical Nursing Research* (2021). doi:10.1177/10547738211046136
12. Pacik and Geletta. "Vaginismus Treatment: Clinical Trials Follow-Up on 241 Patients." *Sexual Medicine* (2017). doi:10.1016/j.esxm.2017.02.002
13. Zarski et al. "Efficacy of Internet-Based Guided Treatment for Genito-Pelvic Pain/Penetration Disorder: Rationale, Treatment Protocol, and Design of a Randomized Controlled Trial." *Frontiers in Psychiatry* (2018). doi:10.3389/fpsyt.2017.00260
14. Pacik. "Vaginismus: Review of Current Concepts and Treatment Using Botox Injections, Bupivacaine Injections, and Progressive Dilation with the Patient Under Anesthesia." *Aesthetic Plastic Surgery* (2011). doi:10.1007/s00266-011-9737-5
15. Achour et al. "Vaginismus and Pregnancy: Epidemiological Profile and Management Difficulties." *Psychology Research and Behavior Management* (2019). doi:10.2147/prbm.s186950