Vaginismus and Sexual Pain Disorders
The existence of vaginismus is obviously associated with the history of humanity, but was first described in the 19th century. The contractile muscle group is only in the 1/3 outer part of the vagina. It may not be possible for the penis to enter the vagina only because of the involuntary rhythmic or continuous contraction of these muscles, due to the spasm of the vagina. After the patients started to talk with difficulty and anxiety with difficulty and relaxed a little during the application, the expression “as if there is a door or a wall and I cannot continue after that point in sexual intercourse” is actually the way I define it the most. In vulvar vestibulitis, the vagina often loosens enough to allow intercourse, but due to inflammation at the entrance of the vulva, its severity is burning and pain. There is a word of hypersensitivity at the entrance to the vagina, which makes sexual intercourse very uncomfortable.
If the state of spasm at the vaginal entrance is not in contact with the woman since the beginning of her sexual life, this condition is called “primary vaginismus”. If the woman is able to have sexual intercourse before, and this occurred later, it is less frequently called ‘secondary vaginismus’. The treatment strategy in both cases may differ in secondary vaginismus. If a woman’s partner or other psychological problem is detected, turning to the cause may completely change the treatment approach of vaginismus.
It is often very difficult to identify a risk factor for vaginismus. Obtaining a detailed history while interviewing the woman, determining the origin of the cause and trying to deal with these factors during behaviour therapy, of course, increase the success of the treatment in many ways. However, it is not possible to identify a cause in most women with vaginismus. In other words, it may not be possible to find reasons such as pressure and taboo, hymen fears as we thought, sexual abuse in childhood, experiencing violence between parents or domestic, and seeing parents during sexual intercourse. Many women can sincerely state that they do not have any of these or other stories and had a good childhood. Sociocultural, racial or economic differences do not seem to have much statistical difference either.
In this case, while doing research on the causes, I think it is not meaningful to drown in this matter. Of course, if we can determine the cause, it can be continued with multidimensional and psychiatric support. Of course, the multidisciplinary approach can produce a much better result. If everything is so usual by getting help to solve the main problem or why it cannot be determined, what needs to be done after all is to ensure that the woman can accept something painlessly and without fear. The way to this is through pelvic rehabilitation.
‘Finger exercises’ have been used in pelvic rehabilitation for a long time in the psychiatric approach. In this treatment approach, the woman tries to move her finger from the vagina entrance by taking a certain time every day and continues the treatment by increasing the dose of the exercise by evaluating one or two conditions a week with her psychiatrist. Meanwhile, there is a time share between the psychiatrist and her client, which also allows for speech therapy.
In the gynecological approach, the woman learns to use the pelvic floor muscles and relax the muscles by using some apparatus with her doctor three days a week. In this approach, I have been experiencing the patient’s participation and continuation of treatment for many years and I see that the problem can be solved in a much shorter time. It must be repeated that the joint approach of psychiatry-gynecology can be much more effective in a group of patients due to additional psychological factors.
The most important issue that should not be forgotten during these approaches is the defence reaction triggered by the fear reaction felt by the woman. The phobic reaction, called fear reaction, can go up to panic attacks. The woman experiences this feeling in decreasing episodes during the treatment sessions. Meanwhile, the basic feeling of trust in the physician-patient relationship should be the most important factor that will prevent him from losing his faith.
In any case, the most important factor of the success of the treatment is that the woman wants to be treated and continues the treatment without interruption. The second important factor is that the partner or spouse also supports the treatment. Here, the patience and support of the spouse and partner are as basic and important as the patient-physician cooperation.
The woman’s pain in sexual intercourse is defined as dyspareunia. Although dyspareunia has organic causes such as vaginal infection, pelvic infection, endometriosis, it can occur without any reason.
The area called vulvar vestibule refers to the vaginal entrance where labium major (large lips), labium minus (small lips), the area where the origin of the urinary tract reflects on the vagina, refers to the hymen and the surrounding tissue.
Vulvar is the cause of about half of vestibulitis dyspareunia. Diagnosing vulvar vestibulitis is quite difficult and requires experience. Because the diagnostic criteria are very relative.
The main complaint of the woman is that she feels pain with hypersensitivity and burning after a stimulus at the entrance to the vagina, that is, the vulvar vestibule, and sexuality accompanies the pain. Stimuli can range from the pressure of the penis, to the pressure of the pants he wears. Normally these stimuli are not expected to stimulate burning or pain, but an immunological mechanism with an unknown cause creates an increase in nerve endings and an extremely sensitive area appears.
In the examination findings; varying degrees of redness in the vulva, sensitivity caused by pressure on the vulva, and pressure on the vaginal entrance or pain in sexual intercourse.
In the examination, certain points of the vagina entrance are touched with a cotton swab with a certain pressure and the sensitive points and the severity of the sensitivity are determined. However, it should be ensured that the patient has no history of vaginal infection and surgery for at least 6 months.
In the treatment of vulvar vestibulitis, pelvic rehabilitation is often effective in experienced hands and rarely, it is necessary to remove the vulvar vestibule. It is a very complicated surgery and should be done in experienced hands.