When is Painful Intercourse Secondary Vaginismus?

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

 Learn More – Primary Sources:

Interventions for vaginismus

Women’s experiences of using vaginal trainers (dilators) to treat vaginal penetration difficulties diagnosed as vaginismus: a qualitative interview study