Women with vaginismus experience shame and embarrassment A patient

Women with vaginismus experience shame and embarrassment. A patient with 12 years of attempted and failed treatments noted how this was among the “darkest and most embarrassing periods of my life causing me to live with vaginismus in silence and shame” (personal communication). Other women have noted how they think about their vaginismus during the entire day and before they go to sleep. Vaginismus frequently leads to marital problems and depression and to feelings of isolation, is a major cause of unconsummated marriages, is an inability to tolerate GYN examinations, and is not tolerated in cultures with arranged marriages, often resulting in an annulment.
Vaginismus treatments include the widespread use of vaginal dilators, physical therapy with or without biofeedback, biofeedback, sex and relationship counseling, psychotherapy, cognitive behavioral therapy, therapist-aided exposure, hypnotherapy, and lubricants.
The successful use of Botox (onabotulinumtoxinA; Allergan, Irvine, CA, USA) injections to treat secondary vaginismus was first described as a case report in 1997 and later developed by different investigators. Abbott et al using a placebo-controlled study of onabotulinumtoxinA showed that all eight women who had onabotulinumtoxinA 25 U injected into the bulbospongiosum achieved intercourse compared with none of the five women in the placebo group, with no recurrence or reinjection in the follow-up stat 3 inhibitor of 8 to 14 months. Ghazizadeh and Nikzad used Dysport (abobotulinumtoxinA; Galderma Laboratories, Fort Worth, TX, USA) to treat 23 women with Lamont grade 3 and 4 refractory vaginismus and reported a 75% success rate of pain-free intercourse in these women were followed for a mean of 12.3 months (range = 2–24).
The purpose of this report was to discuss a large cohort of women, many with failed prior treatments, who were treated using a program approved by an institutional review board (IRB) and the Food and Drug Administration (FDA) for continued research, which included a multimodal program of intravaginal injections of Botox and bupivacaine, progressive dilation under conscious sedation, use of an indwelling dilator, and postprocedure counseling, support, and follow up.



Main outcome measures

There were several important outcomes of this study. (i) Although severe vaginismus can be difficult to treat and treatment failures are common, this group of women had a rapid response to treatment. (ii) Stratifying the severity of vaginismus allowed us to properly support these women, many who had multiple prior failed treatments and had high levels of fear and anxiety. (iii) The multimodal nature of this program treated the psychologic fear and anxiety and the physical vaginal spasm. (iv) Giving these patients our personal contact information helped support them. (v) Some patients who showed no improvement after Botox injections elsewhere did not have counseling or support. Some had multiple attempts at Botox injections with continued failure. (vi) Vaginismus is not a surgical problem. Hymenectomy and episiotomy are inappropriate treatments for this condition. (vii) The clinician needs to be aware of the many secondary challenges these women face and to be prepared for ongoing treatment or referrals. These include residual fear and anxiety for penetration, inability to progress to intercourse despite using dilators, low libido (sometimes of both partners), heightened harm avoidance and pain catastrophizing, disgust issues, anorgasmia, partner solicitousness and hostility, infidelity, and erectile dysfunction.
We hypothesize that the insertion of dilators under conscious sedation at the time of Botox and bupivacaine injections, counseling, and post-treatment support provide the initial breakthrough that allows the patient to realize that pain-free penetration is possible and that her anatomy is normal. The chemodenervation of Botox injections takes effect approximately 2 to 7 days after injection and lasts for approximately 4 months. This gives these women adequate time to advance with their dilators and progress to intercourse. Women are not aware when the Botox is no longer active. Some women do not achieve intercourse for at least 1 year yet can be successful if they continue dilating.