When is Painful Intercourse Secondary Vaginismus?

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Outline steps that should be taken during the pelvic exam to diagnose secondary vaginismus
2. Describe protocols for use of vaginal dilators

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Genoox, Inc., and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2020, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

Vaginismus is the involuntary tightening of the vaginal muscles, which can cause painful intercourse. History and physical examination are important to make the correct diagnosis and direct appropriate therapy

Consider secondary vaginismus in a situation where a woman who previously did not have pain during intercourse now describes pain on penetration in the following scenarios
- When there is no improvement after patient’s regular use of estrogen creams for the treatment of postmenopausal symptoms related to vaginal atrophy/atrophic vaginitis
- Postpartum patients who complain of sexual pain but no obvious clinical source can be visualized
During the pelvic exam
- The practitioner should attempt to insert a medium vaginal dilator
- If unable to do so, the provider should work with patient on inserting the largest size vaginal dilator possible with minimal pain, gradually increasing size of dilators until she is able to insert a dilator approximate to the size of partner’s penis
- In both cases, vaginal dilators should be used in addition to local estrogen treatments

SYNOPSIS:

Women with postmenopausal atrophy are most commonly treated with topical estrogen. Practitioners may also consider whether the muscles have concomitantly tightened, causing pain during intercourse. This can be true of post-partum women as well. The use of vaginal dilators to re-stretch the muscles which have tightened can significantly help to alleviate the pain experienced by the patient.

KEY POINTS:

Tight vaginal muscles often accompany postmenopausal atrophy and postpartum pain and this is generally not tested nor detected
Introduction of vaginal dilators of the appropriate size is a simple treatment option that should accompany treatment with local, topical estrogen or estrogen/testosterone
Initial attempt can be made by using a size medium dilator
- If this is not successful, practitioner can introduce a smaller one
Patient can use the dilators at home for 10 minutes a day, increasing the size each week until they can insert a dilator which is approximately the size of their partner’s penis with no pain
ICD10 DIAGNOSIS CODE: N94.2