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GENEVIEVE: A Painful Case

Genevieve and Paul, a couple in their early twenties complain that they have not
consummated their marriage so far, despite being married for 2 years.

This is because Genevieve experiences severe pain in the lower vagina when penetrative
intercourse is attempted.

The medical, surgical, family and drug histories of both partners are unremarkable. Nor is
there a history of past sexual abuse or psychological or social difficulties.

Both parties drink only socially and do not smoke or use recreational drugs.

On examinatiom Genevieve looks well with stable vital parameters. Her heart, lungs,
abdomen and CNS evaluation show no abnormalities. Pelvic examination reveals: (a) the vulvar
region appears normal; (b) no abnormal discharges; (c) insertion of the examining finger results
in severe pain spasms of the outer one-third of the vagina.

1. Salient features

(+) severe pain in the lower vagina when penetrative intercourse is attempted

(+) insertion of examining finger results in severe painand spasms of the outer one-third of the
vagina

(-) unremarkable medical, surgical, famly and drug history

(-) no previous history of sexual abuse, psychological, social difficulties

(-) patient’s religious/cultural belief

2). What are the relevant laboratory investigations, should there be, that can aid the
diagnosis?

Answer: Assessment of sexual dysfunction is best approcached using a biopsychosocial model,


and should include a sexual history and physical examination. “Laboratory testing is usually not
needed to identify causes of sexual dysfunction”.
DIAGNOSIS CLUES ETIOLOGY PHYSICAL FINDINGS EVALUATION*

Vulvodynia Well-defined entry Frequently Unremarkable or Visual


pain; vulvar pain, unknown; mild erythema; inspection;
burning, irritation; possibly markedly tender; colposcopy and
poor response to infections or leukoplakia, biopsy of
prior treatments, irritants ulcerations, suspicious area;
symptoms with pigmented lesions or apply acetic acid
activities that put nodules are to highlight
pressure on vulva suspicious areas.
(sitting or bicycle
riding)

RULE IN: Well defined entry pain

RULE OUT: Grossly normal vulvar area, no lesions, no discharge

Atrophic Well-delineated Estrogen Visual inspection Based on physical


tissue or entry pain; deficiency; of pubic hair, examination;
impaired vaginal pain; arousal-phase labial fullness, discussion of
lubrication vaginal dryness, difficulty; integrity of foreplay, arousal-
friction, decreased vaginal mucosa, phase mechanics
irritation; lubrication and vaginal depth; and expected
difficulty and impaired vaginal vaginal mucosal sensations
pain with barrel distention; friability, fissures
penetration surgery

RULE IN: Entry pain

RULE OUT: cannot be totally ruled out


4. What is the diagnosis of this case, management and treatment (pharmacologic and
psychotherapeutic)

DIAGNOSIS: PRIMARY VAGINISMUS / Genito-Pelvic Pain/Penetration Disorder

Genito-Pelvic Pain/Penetration Disorder

Diagnostic Criteria (DSM-5) 302.76


(F52.6)

A. Persistent or recurrent difficulties with one (or more) of the following:


1. Vaginal penetration during intercourse.
2. Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration
attempts.
3. Marked fear or anxiety about vulvovaginal or pelvic 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.
B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6
months.
C. The symptoms in Criterion A cause clinically significant distress in the individual.
D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a
consequence of a severe relationship distress (e.g., partner violence) or other significant
stressors and is not attributable to the effects of a substance/medication or an other
medical condition.

Specify whether:

Lifelong: The disturbance has been present since the individual became sexually active.

Acquired: The disturbance began after a period of relatively normal sexual function

Specify current severity:

Mild: Evidence of mild distress over the symptoms in Criterion A.

Moderate: Evidence of moderate distress over the symptoms in Criterion A.

Severe: Evidence of severe or extreme distress over the symptoms in Criterion A


MANAGEMENT AND TREATMENT:

Current treatments for vaginismus can be divided into four main categories: pelvic floor
physiotherapy, pharmacological treatments, general psychotherapy and sex/cognitive behavioral
therapy.

 Pelvic floor physiotherapy,


 Pharmacological treatments
 General psychotherapy
 Sex/cognitive behavioral therapy.

Pelvic floor physiotherapy

The rationale for the use of pelvic floor physiotherapy in the treatment of vaginismus is that it
will aid in developing awareness and control of the vaginal musculature as well as restore
function, improve mobility, relieve pain and overcome vaginal penetration anxiety.

Physical therapists use a variety of techniques to achieve these goals, such as breathing and
relaxation, local tissue desensitization, vaginal dilators, pelvic floor biofeedback and manual
therapy techniques

Pharmacological treatment

Three main types of pharmacological treatment have been proposed for vaginismus: local
anesthetics (e.g., lidocaine), muscle relaxants (e.g., nitroglycerin ointment and botulinum toxin)
and anxiolytic medication

Local anesthetics, such as lidocaine gel, have been proposed based on the rationale that
vaginismic muscle spasms are due to repeated pain experienced with vaginal penetration and,
hence, the use of a topical anesthetic aimed at reducing the pain is hypothesized to resolve the
spasm . A 5% lidocaine gel was applied on the hyperesthetic areas of the vaginal and topical
nitroglycerin ointment, hypothesized to treat the muscle spasm by relaxing the vaginal muscles,
was also discussed only in a case study.

Botulinum toxin, a temporary muscle paralytic, has been recommended in the treatment
of vaginismus with the aim of decreasing the hypertonicity of the pelvic floor muscles.

Another pharmacological treatment that has been proposed is the use of anxiolytics, such
as IV diazepam, in conjunction with psychotherapy based on the hypothesis that vaginismus is a
psychosomatic condition resulting from past trauma and, thus, anxiety reducing medication will
resolve the symptoms.

General psychotherapy

A variety of psychological treatments for vaginismus have been investigated, including


marital, interactional, existential–experiential, relationship enhancement and hypnosis. The
psychological treatments are often based on the notion that vaginismus results from marital
problems, negative sexual experiences in childhood or a lack of sexual education.

The therapy can be conducted in an individual or couple format. Generally, in individual


therapy, the treatment is to identify and resolve underlying psychological problems that could be
causing the disorder.

In couples therapy, vaginismus is conceptualized as a problem for the couple and the treatment
tends to focus on the couple’s sexual history and any other problems that may be occurring in the
relationship.

Sex/cognitive behavioral therapy

In the 1970s, Masters and Johnson reported that vaginismus could be easily treated with
behaviorally oriented sex therapy that included vaginal dilatation.

The first step of their treatment consists of the physical demonstration of the vaginal
muscle spasm to the patient (and her partner) during a gynecological examination. The couple is
then instructed to insert a series of dilators of graduated sizes at home guided by both the patient
and her partner with the aim of desensitizing the patient to vaginal penetration. Masters and
Johnson’s treatment regimen also emphasized the importance of education regarding sexual
function and the development and maintenance of vaginismus in order to relieve the
psychological impact of the condition.

As a result of the influence of Masters and Johnson, several studies were conducted on
the efficacy of sex therapy in the treatment of vaginismus with excellent success rates reported
resulting in continued utilization of this treatment for vaginismus.

The first ever randomized controlled therapy outcome study for vaginismus was recently
published. This study investigated a cognitive behavioral sex therapy for the treatment of
vaginismus. The treatment included the sexual education and vaginal dilatation technique as in
Masters and Johnson’s treatment protocol. It was also comprised of cognitive therapy, relaxation
and sensate focus exercises.

Participants received the treatment for 3 months either in group therapy or in bibliotherapy
format. At

post-treatment, 18% (14% group therapy; 9% bibliotherapy) of participants in the treatment


group reported successful attempted penile– vaginal intercourse while none of the women in the
waiting list control group reported having had successful intercourse. Interestingly, there was no
significant difference in efficacy between the group therapy and bibliotherapy treatment format.
Van Lankveld’s group reformulated their conceptualization of vaginismus from a sexual
disorder to a vaginal penetration phobia. A recent study carried out by the same group
investigated a treatment for vaginismus focusing more explicitly and systematically on the fear
of coitus through the use of prolonged, therapist-aided exposure therapy.

The treatment was comprised of education on the fear and avoidance model of vaginal
penetration as well as of a maximum of three 2 h sessions of in vivo exposure to the stimuli
feared during vaginal penetration. A replicated (n = 10) randomized single-case A–B phase
design was used. The results showed that nine out of ten participants were able to engage in
intercourse following treatment and these findings persisted at a 1-year follow-up. In addition,
the exposure treatment was successful in decreasing fear and negative penetration beliefs.

The 10-Step Vaginismus Resolution Process

To aid women in getting proper treatment direction, we have assembled a comprehensive


program in book/kit form as outlined below. The self-help program is a straight-forward, step-
by-step approach used by many treatment professionals to successfully guide women through the
complete process of overcoming vaginismus. Treatment steps can usually be completed at home
using a self-help approach, allowing a woman to work at her own pace in privacy, or in
cooperation with her health care provider or specialist. Easy-to-follow instructions,
supplemented with descriptive illustrations and helpful strategies, make the process a positive,
successful experience. At the completion of the steps, pain and penetration problems due to
vaginismus are typically fully resolved.

Step 1 – Understanding Vaginismus

Step 1 provides an overview of vaginismus and how sexual pain, tightness, burning sensations or
penetration difficulties may result from it. This approach helps women to get started by being
proactive about their sexual health as understanding vaginismus is fundamental to the process of
overcoming it. Topics also include how to obtain a solid diagnosis, treatment methods,
relationship issues, pelvic/relaxation techniques, conditioned responses and muscle memories.

Step 2 – Sexual History Review & Treatment Strategies

A balanced approach is taken to help women review and analyze their history. Exercises help
identify and evaluate any events, emotions, or triggers contributing to vaginismus sexual pain or
penetration problems. Checklists and detailed exercises map out a woman’s sexual history and
pelvic pain events, working toward appropriate treatment strategies. Emotional reviews help
detail any negative events, feelings, or memories that may collectively contribute to involuntary
pelvic responses. Topics also include blocked or hidden memories and how to move forward
when there have been traumatic events in a woman’s past.

Step 3 – Sexual Pain Anatomy

Women often lack complete information about their body’s sexual anatomy, function, and the
causes of pelvic pain and penetration problems. Confusion regarding problems with inner
vaginal areas and vaginal muscles frequently lead to misdiagnosis and frustration. Step 3
educates about these sexual body parts with emphasis on their role in sexual pain and penetration
issues. Topics include how to distinguish what kind of pain or discomfort is normal with first-
time or ongoing sex and what physical changes take place during arousal to orgasm cycles in the
context of sexual pain or penetration problems. Anatomy areas such as the hymen and inner
vulva are explained and demystified (for example there are six diagrams of hymen varieties to
help distinguish hymen problems).

Step 4 – Vaginal Tightness & The Role Of Pelvic Floor

Muscles Female sexual pain and penetration difficulties typically involve some degree of
involuntary tightening of the pelvic floor. This step focuses on the role of pelvic floor muscles,
especially the pubococcygeus (PC) muscle group, explaining in great detail how once they are
triggered they continue to cause involuntary tightness with attempts at intercourse. Effective
vaginismus treatment focuses on retraining the pelvic floor to eliminate involuntary muscle
reactions that produce tightness or pain. Learning how to identify, selectively control, exercise
and retrain the pelvic muscles to reduce pain and alleviate penetration tightness and difficulties is
an important step in vaginismus treatment.

Step 5 – Insertion Techniques

For women with penetration difficulties or pain, techniques must be learned to allow initial entry
without pain. In this step, women practice pubococcygeus (PC) muscle control techniques as
they allow the entry of a small object (cotton swab, tampon, or finger) into their vagina, working
completely under their control and pace. Any involuntary muscle contractions that had
previously closed the entrance to the vagina and prevented penetration are overridden. Women
begin to take full control over their pelvic floor and learn how to flex and relax the pelvic floor at
will, eliminating unwanted tightness and allowing entry.

Step 6 – Graduated Vaginal Insertions

When used properly, vaginal dilators are effective tools to further help eliminate pelvic tightness
due to vaginismus. Dilators provide a substitute means to trigger pelvic muscle reactions. The
effective dilator exercises in Step 6 teach women how to override involuntary contractions,
relaxing the pelvic floor so it responds correctly to sexual penetration. Graduated vaginal
insertion exercises allow women to comfortably transition to the stage where they are ready for
intercourse without pain or discomfort.

Step 7 – Sensate Focus & Techniques For Couples To Reduce Pelvic Floor Tension

Helping with the transition to pain-free intercourse, this step explains sensate focus techniques
for couples to use to reduce pelvic floor tension and increase intimacy. Couples begin to work
together during this step as exercises teach how to successfully practice sensate focus (controlled
sensual touch) and prepare for pain-free intercourse using techniques from earlier steps. The
exercises are designed to build trust and understanding and assist in the process to adjust to
controlled intercourse without pain.
Step 8 – Pre-Intercourse Readiness Exercises

Finalizing preparations for couples to transition to fully pain-free intercourse, this step completes
pre-intercourse readiness. Couples review and practice techniques that eliminate pelvic floor
tension and prepare to transition to full intercourse. Preparing ahead of time to be able to
manage, control and eliminate pain or penetration difficulties, the exercises assist with the final
transition to pain-free intercourse.

Step 9 – Making The Transition To Intercourse

Step 9 explains the techniques used to eliminate pain and penetration difficulties while
transitioning to normal intercourse. Many troubleshooting topics are covered (with supporting
diagrams) such as positions to use to maximize control and minimize pain, tips to ensure more
comfortable intercourse, etc.

Step 10 – Full Pain-Free Intercourse & Pleasure Restoration

The final step toward overcoming vaginismus includes penis entry with movement and freedom
from any pain or tightness. Step 10 exercises are designed to educate, build sexual trust and
intimacy, and complete the transition to full sexual intercourse free of pain. Couples can begin to
enjoy pleasure with intercourse, initiate family planning, and move forward to live life free from
vaginismus.

Genito-Pelvic Pain/Penetration Disorder

Diagnostic Criteria 302.76 (F52.6)

E. Persistent or recurrent difficulties with one (or more) of the following:


5. Vaginal penetration during intercourse.
6. Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration
attempts.
7. Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or
as a result of vaginal penetration.
8. Marked tensing or tightening of the pelvic floor muscles during attempted vaginal
penetration.
F. The symptoms in Criterion A have persisted for a minimum duration of approximately 6
months.
G. The symptoms in Criterion A cause clinically significant distress in the individual.
H. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a
consequence of a severe relationship distress (e.g., partner violence) or other significant
stressors and is not attributable to the effects of a substance/medication or an other
medical condition.
Specify whether:

Lifelong: The disturbance has been present since the individual became sexually active.

Acquired: The disturbance began after a period of relatively normal sexual function

Specify current severity:

Mild: Evidence of mild distress over the symptoms in Criterion A.

Moderate: Evidence of moderate distress over the symptoms in Criterion A.

Severe: Evidence of severe or extreme distress over the symptoms in Criterion A.