What are the management options for vaginismus?

Management of Vaginismus

Vaginismus should be managed with a multimodal approach combining vaginal dilators, cognitive behavioral therapy, and pelvic floor physiotherapy, with this combination showing the highest success rates for achieving pain-free vaginal penetration. 1

First-Line Treatment Approach

Vaginal Dilators (Progressive Desensitization)

• Vaginal dilators are the cornerstone of vaginismus management and should be offered to all patients experiencing pain with vaginal penetration, regardless of sexual activity or orientation 1
• Start early for greatest benefit, using graduated sizes to achieve systematic desensitization 1
• Two approaches exist: gradual self-dilation (preferred in most settings) or rapid desensitization with vaginal mould insertion under clinical supervision 2
• Rapid desensitization programs can achieve satisfactory vaginal intercourse within 2-6 weeks in motivated patients 2

Cognitive Behavioral Therapy (CBT)

• CBT is efficacious for lifelong vaginismus and should be initiated concurrently with dilator therapy 1
• Components include sexual education, relaxation exercises, gradual exposure, cognitive restructuring, and sensate focus therapy 3
• Can be delivered as group therapy (ten 2-hour sessions) or bibliotherapy with minimal telephone contact 3
• At 12-month follow-up, 21% of group therapy participants and 15% of bibliotherapy participants achieve successful intercourse 3

Pelvic Floor Physiotherapy

• Pelvic floor physiotherapy should be offered to all women with vaginismus to address underlying pelvic floor dysfunction 1
• Pelvic floor muscle training improves sexual pain, arousal, lubrication, orgasm, and satisfaction 1
• Functional electrical stimulation (FES)-biofeedback combined with sexual cognitive-behavioral therapy achieves 100% success in small studies, with all patients tolerating vaginal intercourse after 8 weeks 4

Adjunctive Pharmacologic Management

For Vaginal Dryness and Atrophy

• Begin with vaginal lubricants for sexual activity and vaginal moisturizers applied 3-5 times weekly to the vagina, vaginal opening, and external vulva 1, 5
• Water-, oil-, or silicone-based lubricants reduce friction and irritation 1
• Hyaluronic acid preparations effectively reduce vaginal mucosal inflammation, dryness, and fibrosis 5

For Persistent Introital Pain

• Topical lidocaine can be offered for persistent introital pain and dyspareunia that does not respond to conservative measures 1, 6, 5
• Apply directly to affected areas as needed before sexual activity or examinations 6

For Severe Symptoms Not Responding to Conservative Measures

• Low-dose vaginal estrogen (pills, rings, or creams) can be used for severe vaginal atrophy contributing to vaginismus 1
• For women with hormone-positive breast cancer, low-dose vaginal estrogen requires thorough discussion of risks and benefits 1
• Vaginal DHEA (prasterone) may be offered to women on aromatase inhibitors who have not responded to previous treatment 1, 5

For Anxiety Component

• Anti-anxiety medication can be used as an adjunct when significant anxiety or phobia of vaginal penetration is present 7
• Address underlying sexual ignorance, previous traumatic experiences, or religious orthodoxy that may contribute to the phobia 2

Treatment Algorithm

1. Initial assessment: Perform gynecologic examination noting points of tenderness, vaginal atrophy, and anatomic changes; exclude other causes like vulvodynia 1

2. Start conservative measures immediately:

   • Vaginal moisturizers 3-5 times weekly 1, 5
   • Lubricants for any sexual activity or touch 1
   • Begin graduated vaginal dilator program 1

3. Initiate behavioral therapy within first 2 weeks:

   • Refer for CBT (group or bibliotherapy format) 3
   • Refer to pelvic floor physiotherapist 1
   • Consider FES-biofeedback if available 4

4. Add pharmacologic interventions as needed:

   • Topical lidocaine for persistent pain 1, 6
   • Low-dose vaginal estrogen if severe atrophy present 1
   • Anti-anxiety medication if significant phobia component 7

5. Refer to sexual health specialist or gynecologist if symptoms persist despite 8-12 weeks of multimodal therapy 6, 8

Critical Pitfalls to Avoid

• Never recommend surgical correction for vaginismus, as it is almost never required and may be detrimental to achieving success 2
• Do not delay treatment—early intervention with dilators yields greatest benefit 1
• Avoid recommending dilators based solely on sexual activity; offer to all women at risk for vaginal changes to be proactive in sexual and vulvovaginal health 1
• Do not use PDE5 inhibitors (sildenafil) for female vaginismus, as evidence shows contradictory results and lack of efficacy 1

Expected Outcomes

• Treatment requires patience and a warm, empathetic attitude from the physician 2
• Rapid desensitization programs achieve success in 2-6 weeks 2
• Standard multimodal therapy shows 14-21% success at achieving intercourse by 12 months, though effect sizes remain modest and warrant continued treatment optimization 3
• FES-biofeedback combined with SCBT achieves 100% success in achieving satisfactory vaginal intercourse after 8 weeks in small studies 4
• Management can be time-consuming and require trial and error, but multidisciplinary care with multimodal therapy often results in positive patient outcomes 8