Significations et usages de Vaginismus

This article needs additional citations for verification. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (May 2007)

Vaginismus, sometimes anglicized vaginism, is the German name for a condition that affects a woman's ability to engage in any form of vaginal penetration, including sexual intercourse, insertion of tampons and/or menstrual cups, and the penetration involved in gynecological examinations. This is the result of a reflex of the pubococcygeus muscle, which is sometimes referred to as the "PC muscle". The reflex causes the muscles in the vagina to tense suddenly, which makes any kind of vaginal penetration—including sexual intercourse—painful or impossible.

A woman suffering from vaginismus does not consciously control the spasm. The vaginismic reflex can be compared to the response of the eye shutting when an object comes towards it. The severity of vaginismus, as well as the pain during penetration (including sexual penetration), varies from woman to woman.

Spasm may be due to muscles around the pelvis being tight from the frequent tension. This also limits blood flow through the whole vaginal area. This makes the mucous membranes sensitive and prone to tearing. This is painful to different degrees and means that some women experience pain in their daily lives and can in some cases mean that they are unable to ride a bicycle or even wear jeans. Local anaesthesia in the form of gels or creams may help control the problem.

  Primary vaginismus

A woman is said to have primary vaginismus when she has never been able to have penetrative sex or experience vaginal penetration without pain. It is commonly discovered in teenagers and women in their early twenties, as this is when many young women in the Western world first attempt to use tampons, have penetrative sex, or undergo a Pap smear. Women with vaginismus may be unaware of the condition until they attempt vaginal penetration. A woman may be unaware of the reasons for her condition.^[1]

A few of the main factors that may contribute to primary vaginismus include:

• a condition called vulvar vestibulitis syndrome, more or less synonymous with focal vaginitis, a so-called sub-clinical inflammation, in which no pain is perceived until some form of penetration is attempted
• urinary tract infections
• vaginal yeast infections
• sexual abuse, rape, other sexual assault, or attempted sexual abuse or assault
• knowledge of (or witnessing) sexual or physical abuse of others, without being personally abused
• domestic violence or similar conflict in the early home environment
• fear of pain associated with penetration, particularly the popular misconception of "breaking" the hymen upon the first attempt at penetration, or the idea that vaginal penetration will inevitably hurt the first time it occurs
• personality traits such as pain-catastrophizing cognitions^{[clarification needed]} and harm-avoidance behaviour^[2]
• any physically invasive trauma (not necessarily involving or even near the genitals)
• generalized anxiety
• stress
• negative emotional reaction towards sexual stimulation, e.g. disgust both at a deliberate level and also at a more implicit level^[3]
• strict conservative moral standards with low liberal moral standards^{[clarification needed]} — a general difficulty at doing 'wrong' or behaving in ways perceived as transgressive, which also can elicit negative emotions^[4]

Occasionally, primary vaginismus is idiopathic.^[5]

Vaginismus has been classified by Lamont^[6] according to the severity of the condition. He describes four degrees of vaginismus: In first degree vaginismus, the patient has spasm of the pelvic floor that can be relieved with reassurance. In second degree, the spasm is present but maintained throughout the pelvis even with reassurance. In third degree, the patient elevates the buttocks to avoid being examined. In fourth degree vaginismus (also known as grade 4 vaginismus), the most severe form of vaginismus, the patient elevates the buttocks, retreats and tightly closes the thighs to avoid examination. Pacik expanded the Lamont classification to include a fifth degree in which the patient experiences a visceral reaction such as sweating, hyperventilation, palpitations, trembling, shaking, nausea, vomiting, losing consciousness, wanting to jump off the table, or attacking the doctor.^[7] The Lamont classification continues to be used to the present and allows for a common language among researchers and therapists.

However, it does not provide for a language with which a woman might best be able to verbalise her concerns, pain or problems. A woman with a lot of trust in the doctor might be classified as 1 but experience severe pain. A woman with less trust, or a woman who is or has been subjected to harsh examination, might be classified as 4 or 5 even if the physical discomfort she experiences with attempts at penetration in non-clinical settings is comparatively mild.

Though spasm of the pubococcygeus muscle is commonly thought to be the primary muscle involved in vaginismus, Pacik identified two additionally-involved spastic muscles in treated patients under sedation. These include the entry muscle (bulbocavernosum) and the mid-vaginal muscle (puborectalis). This accounts for the common complaint that patients often report when trying to have intercourse: "It's like hitting a brick wall".^[1]

  Secondary vaginismus

Secondary vaginismus occurs when a woman who has previously been able to achieve penetration develops vaginismus. This may be due to physical causes such as a yeast infection or trauma during childbirth, while in some cases it may be due to psychological causes, or to a combination of causes. The treatment for secondary vaginismus is the same as for primary vaginismus, although, in these cases, previous experience with successful penetration can assist in a more rapid resolution of the condition. Peri-menopausal and menopausal vaginismus, often due to a drying of the vulvar and vaginal tissues as a result of reduced estrogen, may occur as a result of "micro-tears" first causing sexual pain then leading to vaginismus.^[8]

  Prevalence

The prevalence of vaginismus has been reported to be 6% in two widely divergent cultures, Morocco and Sweden. The prevalence of manifest dyspareunia has been reported as low as 2% in elderly British women, yet as high as 18–20% in British and Australian studies.^[9]

Another study documented vaginismus rates of between 12% and 17% being reported in women presenting to sex therapy clinics (Spector and Carey 1990). The National Health and Sexual Life Survey, which used random sampling and structured interviewing, found that between 10% and 15% of women reported having experienced pain during intercourse during the previous 6 months (Laumann et al. 1994).^[5]

The most recent study-based estimates of vaginismus incidence range from 5% to 47% of people presenting for sex therapy or complaining of sexual problems, with significant differences across cultures (see Reissing et al. 1999; Nusbaum 2000; Oktay 2003). It seems likely that a society's expectations of women's sexuality may particularly impact on these sufferers.^[10]

  Treatment

There are a variety of factors that can contribute to vaginismus. These may be physical or physiological, and the treatment required can depend on the reason that the woman has developed the condition. As each case is different, an individualized approach to treatment is useful. The condition will not necessarily become more severe if left untreated, unless the woman is continuing to attempt penetration, despite feeling pain. Some women may choose to refrain from seeking treatment for their condition, or be unaware that treatment might be available or even that their difficulties constitute a medical condition.

According to the Cochrane Collaboration review of the scientific literature, "In spite of encouraging results reported from uncontrolled case series there is very limited evidence from controlled trials concerning the effectiveness of treatments for vaginismus. Further trials are needed to compare therapies with waiting list control and with other therapies."^[11] Although few controlled trials have been carried out, many serious scientific studies have tested and supported the efficacy of the treatment of vaginismus. In all cases where the systematic desensitization method was used, success rates were approximately 90% or better. For an example of one of these studies, see Nasab, M., & Farnoosh, Z.; or for a basic review, see Reissing's literature review (links below). A Dutch study showed that many women were subsequently able to be penetrated, but far fewer women actually enjoyed being penetrated.^[12]

One treatment that is employed is the use of vaginal probes. Vaginal probes are graduated or tapered blunt-ended probes. They come in different sizes, usually no larger than the size in length and diameter of a tampon. Here, the woman can work with a trusted nurse practitioner, doctor, specialized physical therapist, or other person trained in sexual dysfunction and disorder, to help her organize a therapeutic program to (slowly and gradually) assist her in overcoming her fear of penetration. Vaginal probes are introduced into the woman's vagina, usually with her own hand so that she can maintain control both physically and psychologically over the rate of insertion. This procedure requires a great amount of trust and compassion to take place between the patient and the practitioner for the outcome to be successful.^{[citation needed]}

It is also possible for the patient to use vaginal probes without a doctor present.

  Psychological

According to Ward and Ogden's qualitative study on the experience of vaginismus for women (1994), the three most common contributing factors to vaginismus are fear of painful sex; the belief that sex is wrong or shameful (often the case with patients who had a strict religious upbringing); and traumatic early childhood experiences (not necessarily sexual in nature).

Vaginismus patients are twice as likely to have a history of childhood sexual interference and held less positive attitudes about their sexuality, whereas no correlation was noted for lack of sexual knowledge or (non-sexual) physical abuse.^[13]

For some women, especially those with primary vaginismus, it is important to address the psychological aspects of the problem as well as the actual muscle spasm. A woman may choose to address the issue on her own terms, or she may seek the help of a therapist. Some women, especially those with secondary vaginismus, may rely on a physical rather than psychological treatment and also be successful. There are emotional difficulties associated with vaginismus, even for women whose vaginismus has a purely physical cause, which can include low self-esteem, relationship issues, continuing fear of penetration, and depression.

  Physical

  Velvi Dilators for Treating Vaginismus

Physical treatment of the internal spasms may include sensate focus exercises, exploring the vagina through touch, and desensitization with vaginal dilators. Dilation therapy involves inserting objects into the vagina. When treating the spasms through dilation, the dilators, or probes, used are replaced with gradually larger sizes as the woman progresses.

The treatment for the limited blood flow to the vaginal region includes training the muscles around the pelvis and thus enabling them to relax and increase blood flow. This would include using inserting probes and flexing the internal muscles as well as general fitness to the abdomen, lower back, butt and thighs. Stretching the muscles is also important.

  Paralytics

In cases of vaginismus where more traditional treatments have not been successful, a paralytic agent such as Botox may be used. Botox offers an option that allows women who deeply fear penetration to the point where dilators are "too scary" to move ahead despite this fear.^[1] The use of Botox relaxes the muscle spasm for about four months. Optionally, if the procedure is carried out under sedation or general anesthesia, the patient may awaken having already achieved what is usually the hardest first step: the insertion of a dilator. The anesthesia works in concert with the Botox injection(s) to ensure that her first experience with the dilator is not painful.^[1]

  Sexuality

If a woman suspects she has vaginismus, sexual penetration is likely to remain painful or truly impossible until her vaginismus is addressed. This is a highly frustrating condition, as other people, including doctors, may speculate negatively on the origin or existence of her difficulties. Vaginismus does not mean that a woman is frigid, does not want intercourse or does not love her partner. Women with vaginismus may be able to engage in a variety of other sexual activities, as long as penetration is avoided. Sexual partners of vaginismic women may come to believe that vaginismic women do not want to engage in penetrative sex at all, though this may not be true for most such women. There is currently no indication that vaginismus reduces the sexual drive or arousal of affected women, and as such it is likely that many vaginismic women wish to engage in penetrative sex to the same degree as unaffected women, but are deterred by the pain and emotional distress that accompanies each attempt. Psychological pressure to "perform" sexually or become aroused quickly with a partner can deter the sufferer from future attempts and/or cause her vaginismus to become more severe.

  Masturbation

Many people do not realize that even women without vaginismus commonly experience pain or discomfort upon attempting sexual penetration without being sufficiently aroused.^{[citation needed]} Most women acknowledge sexual arousal as vital to achieving comfortable penetration.^{[citation needed]}

One of the problems which may accompany vaginismus is that a woman may be extremely hesitant to engage in penetrative sexual activity with others, due to a fear of pain associated with any kind of vaginal penetration. Solo masturbation, with penetration, can alleviate this fear.

Orgasm need not be the only goal of masturbation. It may also serve to increase comfort with the genital area, to explore various sensations through genital and clitoral touch, and to become aware of those sensations which are relaxing and pleasurable. Sexual arousal causes changes in the shape and color of the vulva, as well as in the vaginal lubrication produced. As a woman becomes more aware of her individual sexual response, she can learn which sensations are best for bringing her to a state of arousal. She will then be better equipped to teach her partner which sensations feel best for her.

  Emotional experiences

A woman who is interested in having (or, at minimum, willing to have) intercourse, and finds that her vagina responds with a reflex that makes intercourse impossible, is likely to experience a wide range of emotions, from amazement to grief to embarrassment. Some women may already have negative associations with their genitals, including fears that their genitals are ugly, dirty, or sinful.

These associations can lead to negative emotions arising during any kind of sexual expression, including masturbation, and these emotions can take time to process. Feelings of shame, inadequacy or a fear of being "defective" can be deeply troubling. If multiple attempts at penetration are made before treating vaginismus, it may lead to fear of sexual intercourse, and worsen the amount of pain experienced with each subsequent attempt. Relaxation, patience and self-acceptance are vital to a pleasurable experience.^{[citation needed]}

  See also

• Penis captivus
• Hymen

  References

  External links

• [1] Detailed information on the understanding, diagnosis and treatment of vaginismus.

http://www.vaginismusmd.com/

• [2] Resource articles about vaginismus and treatment using Botox injections. http://www.plasticsurgerypa.com/
• Vaginismus Research at University of Groningen, Netherlands (Females needed for recruitment)