Updated: 11/30/2021

Vaginismus

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  • Snapshot
    • A 40-year-old, recently divorced, woman presents with pain upon sexual intercourse. When attempting intercourse after her divorce, there was severe pain upon penetration, forcing her to end sexual intercourse. Upon further questioning, she reveals that she is a sexual assault survivor. On physical exam, there is involuntary vaginal muscle contractions during pelvic examination.
  • INTRODUCTION
    • Vaginismus is a sexual pain disorder
      • note, dyspareunia is also a sexual pain disorder but distinct from vaginismus
        • dyspareunia results from medical or psychological issues and cannot be diagnosed on physical exam
      • vaginismus results in physical difficulty allowing vaginal penetration, despite willingness
    • Vaginismus is the only type of sexual dysfunction that can be diagnosed with physical exam
    • Risk factors
      • generalized anxiety disorder
      • depression
      • history of sexual trauma
      • strict religious upbringing
    • Associated conditions
      • dyspareunia
        • even after dyspareunia is resolved, memory of dyspareunia may cause vaginismus
  • ETIOLOGY
    • Pathogenesis
      • involuntary, painful reflex spasm of the paravaginal thigh adductor muscles
      • results from anxiety about sex or pelvic exam
        • results from a bad experience with either in the past
  • Presentation
    • Symptoms
      • pain during intercourse
      • difficulty with vaginal penetration
    • Physical exam
      • pain with pelvic exam
  • Differential Diagnosis
    • Dyspareunia
    • Psychological (e.g. performance anxiety)
  • DIAGNOSIS
    • Diagnosis confirmed if vaginal muscles contract involuntarily with pelvic exam
  • Treatment
    • Gradual vaginal dilators
    • Physical therapy to relax the tight muscles
    • Counseling
  • Prognosis
    • Vaginal dilators are typically very successful
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(M2.GN.17.4733) A 21-year-old female presents to her first gynecology visit. She states that six months ago, she tried to have sexual intercourse but experienced severe pain in her genital region when penetration was attempted. This has continued until now, and she has been unable to have intercourse with her partner. The pain is not present at any other times aside from attempts at penetration. The patient is distressed that she will never be able to have sex, even though she wishes to do so. She does not recall ever having a urinary tract infection and has never been sexually active due to her religious upbringing. In addition, she has never tried to use tampons or had a Pap smear before. She denies alcohol, illicit drugs, and smoking. The patient is 5 feet 6 inches and weighs 146 pounds (BMI 23.6 kg/m^2). On pelvic exam, there are no vulvar skin changes, signs of atrophy, or evidence of abnormal discharge. The hymen is not intact. Placement of a lubricated speculum at the introitus elicits intense pain and further exam is deferred for patient comfort. Office urinalysis is negative. Which of the following is a risk factor for this patient’s condition?

QID: 108621
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Low estrogen state

14%

(6/43)

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Endometriosis

9%

(4/43)

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Generalized anxiety disorder

63%

(27/43)

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Squamous cell carcinoma of the vulva

0%

(0/43)

5

Body dysmorphic disorder

12%

(5/43)

M 6 E

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