Management of Vaginismus
Vaginismus should be managed with a multimodal approach combining vaginal dilators, cognitive behavioral therapy (CBT), and pelvic floor physiotherapy, with this combination showing the highest success rates (86%) for achieving pain-free vaginal penetration. 1, 2
First-Line Treatment Strategy
Begin immediately with graduated vaginal dilators as the cornerstone of therapy, regardless of the patient's sexual activity or orientation. 3, 1 Start with the smallest size and progress systematically to achieve desensitization—early initiation yields the greatest benefit. 3, 1
Concurrently initiate pelvic floor physiotherapy within the first 2 weeks of diagnosis. 3, 1 Physiotherapy addresses the underlying involuntary pelvic floor muscle contraction and has demonstrated an 85% success rate. 2 Functional electrical stimulation-biofeedback combined with pelvic floor muscle relaxation can help patients learn voluntary muscle control. 4
Start CBT simultaneously with dilator therapy, particularly for lifelong vaginismus. 3, 1 CBT is efficacious for addressing the fear and anxiety components that perpetuate the condition. 3, 1 The eight-stage gradual desensitization protocol using vaginal self-dilation should be incorporated into the behavioral therapy program. 4
Adjunctive Pharmacologic Management
Apply vaginal moisturizers 3-5 times weekly to the vagina, vaginal opening, and external vulva for tissue quality improvement. 3, 1 Use water-, oil-, or silicone-based lubricants with all sexual activity or touch. 3, 1
For persistent introital pain and dyspareunia that does not respond to conservative measures, offer topical lidocaine. 3, 1 This can be applied directly to the affected area for symptomatic relief. 3
If severe vaginal atrophy is contributing to symptoms, consider low-dose vaginal estrogen (pills, rings, or creams) after conservative measures have been tried. 3, 1 For women on aromatase inhibitors who have not responded to previous treatment, vaginal DHEA (prasterone) may be offered. 3, 1
Treatment Timeline and Expectations
Most women can achieve satisfactory vaginal intercourse within 2-6 weeks of commencing rapid desensitization therapy with vaginal moulds. 5 Combined interventions demonstrate the highest pooled therapeutic success rate at 86%, compared to 82% for CBT alone, 85% for physiotherapy alone, and 78% for dilator therapy alone. 2
Critical Pitfalls to Avoid
Never recommend surgical correction for vaginismus—it is almost never required and may be detrimental to achieving success. 1, 5 Surgery has no role in the management of this condition. 5
Do not delay treatment initiation, as early intervention with dilators yields the greatest benefit. 3, 1 Avoid recommending dilators based solely on sexual activity; offer them to all women at risk for vaginal changes to be proactive in sexual and vulvovaginal health. 3, 1
Do not use PDE5 inhibitors (sildenafil) for female vaginismus, as evidence shows contradictory results and lack of efficacy in women. 3, 1 These medications have not demonstrated effectiveness for female sexual dysfunction. 3
Referral Considerations
Refer to specialized professionals including gynecologists with experience in sexual health, pelvic floor physiotherapists, sexual counselors, psychologists, or psychiatrists as needed. 3 In some countries, dedicated multidisciplinary onco-sexology clinics with sexuality group counseling are available and can be offered. 3
Ensure ongoing partner communication is encouraged throughout treatment, and consider couples counseling when appropriate. 3 Educational interventions should be provided for both patients and their partners, either separately or together. 3