Secondary vaginismus can occur even after years of satisfying sexual activity when a woman undergoes pelvic reconstructive surgery or develops vulvar dystrophy or vulvovaginal atrophy. Pain or the fear of pain can trigger a powerful reflex spasm of the levator ani musculature. Also keep in mind that secondary vaginismus may not be reproducible during the pelvic examination.
Treatment of both primary and secondary vaginismus includes physical therapy of the pelvic floor using biofeedback. The patient’s partner also needs to attend at least one session to learn techniques to prevent levator spasm and disable the reflex.
In the early phase of treatment, it may be helpful for the couple to agree to participate in a pact to avoid penetration during sexual activity. This approach may help reawaken sexual desire and arousal by eliminating the fear of pain.
The nature of the patient’s relationship with her partner is a powerful determinant of outcome. For example, intimacy and good communication are more likely to resolve the problem, whereas a difficult relationship may inhibit success. Depending on the scenario, counseling and psychological assessment may be necessary in the treatment of vaginismus, especially when a patient has a history of abuse.
Deep dyspareunia may be linked to pelvic pathology
This pain disorder may be associated with poor arousal or with fixation of the pelvic organs as a result of endometriosis, adhesions, or posthysterectomy scarring.
In a “normal” scenario, when arousal is unimpeded, the vagina lengthens by about 30%, and the uterus and cervix lift out of the cul-de-sac. This helps explain why not all women who have retroverted uteri or an obliterated cul-de-sac experience deep dyspareunia.
The patient’s history is a critical component of diagnosis. Ask her about foreplay, lubrication, and arousal prior to penetration. During the physical examination, be vigilant for point tenderness along the vaginal cuff and painful nodularity along the uterosacral ligaments.
To successfully treat deep dyspareunia, you must address any pelvic pathology as well as arousal problems. If penetration occurs prior to adequate arousal, the vagina remains shorter and the uterus has not yet engorged and lifted out of the cul-de-sac, resulting in “bump” dyspareunia. Surgery can elevate and alter any uterine retroversion that is present, but it is very rarely needed when adequate arousal can be achieved.
Pain with orgasm may arise from uterine pathology
At the time of orgasm, the levator ani musculature and myometrium contract strongly. When adenomyosis or degenerating uterine fibroids are present, pain may occur during or after orgasm. Women who have pelvic floor tension myalgia also may experience pelvic pain and aching after orgasm.
To tease out the cause of orgasm-related pain, perform a careful physical examination. To distinguish uterine pain from pain at the pelvic floor, perform a single-digit examination of each pelvic floor muscle before touching the cervix and uterus. Compression applied to a tender uterus often triggers a muscle spasm at the pelvic floor, so it is important to evaluate the pelvic floor muscles for tone and discomfort before performing a bimanual exam.
Treatment of uterine pathology usually entails medical or surgical intervention, whereas pelvic floor tension myalgia is treated with physical therapy and biofeedback.
Female orgasmic disorder may indicate a need for basic education
When a woman reports a persistent delay in or absence of orgasm after an otherwise satisfying episode of sexual activity and excitement, female orgasmic disorder is the likely cause. It may be primary or secondary.
Primary anorgasmia is often related to sexual inexperience and ignorance. Management may require education, use of a vibrator, and permission to engage in self-exploration—or it may necessitate evaluation and management by a trained sexual therapist. Resources for the patient, including educational materials and video, can be found at www.bettersex.com.
Secondary anorgasmia occurs in women who have a history of regular orgasm; the cause is generally drug-related. Among the usual culprits are selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants. Anorgasmia can be difficult to treat in these cases because discontinuation of the antidepressant can worsen depression—and depression is often associated with disorders of desire. One option is switching the class of the antidepressant to one less likely to disrupt orgasm, such as buproprion or trazodone. Off-label use of low-dose sildenafil may reverse the effect of SSRIs on orgasmic function, according to recent evidence.8
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