Although the term “vaginismus” is often loosely used to refer to reﬂex tightening secondary to dyspareunia (e.g., from PVD or vaginal atrophy), strictly speaking, the term should only be used when no such pathology is present. Thus, the diagnosis of vaginismus is provisional until a very careful introital and vaginal examination can be done. This is not possible until the woman learns to be able to abduct her thighs, open the labia with her fingers or permit the examiner to do so, and to tolerate introital touch. The therapy for vaginismus must begin before the diagnosis is confirmed: 1.
Encourage the couple to engage in sexual activities that exclude any attempt at intercourse. They may need to have “dates” and deliberately provide sexual contexts.
2.
Explain to the patient the reﬂex contraction of pelvic muscles around the vagina to touch, especially when touch was associated only with negative emotions and physical pain. These women rarely use tampons and avoid the introitus and vagina in sexual play and have not experienced any neutral or positive sensations from this area of their bodies.
3.
Institute self-touch on a daily basis for a few minutes as close to the vaginal opening as possible. This may be done while the woman is in the bathtub or relaxing by herself on the bed. This is not sexual, and at first it will be highly anxiety provoking. Providing she does this daily, the anxiety will quickly decrease.
4.
Suggest adding visual imagery to the previous exercise so that she imagines being able to have a limited vaginal examination, sitting up on the examination couch at about a 70-degree angle to, with the aid of a mirror, view the vaginal opening and separate her labia, and be in control of what happens.
5. As soon as she is ready, perform the partial vulvovaginal examination as in step 4. If possible, encourage her to touch the vagina, moving her finger past the hymen, possibly afterward doing the same with the physician’s gloved finger.
6.
Once the vagina is adequately examined, prescribe a series of vaginal inserts of gradually increasing diameter. When symptoms suggestive of PVD are present— especially burning with semen ejaculation, dysuria, or vulvodynia after intercourse attempts—she should use only the smallest insert before a repeat examination takes place.
7.
When it is necessary to exclude PVD, repeat the examination with the woman checking for allodynia with a cotton swab. Sometimes the physician can do this; it depends entirely on the amount of anxiety and apprehension the woman retains. The number of false-positive findings for allodynia can be limited if the patient touches the rim of the vaginal opening. Provoked vestibulodynia or other gynecologic findings should be treated.
8.
Once the patient is able to use larger inserts, the following steps can be undertaken: a.
Encourage the woman to allow her partner to assist her in placing the insert in her vagina.
b.
Encourage the couple during their sexual times to brieﬂy use the insert—to prove to her that the insert will still go in when her body is physiologically aroused.
c.
Once she has used the insert on a number of occasions during sexual play, encourage her to follow it immediately with insertion of her partner’s penis. It is usually preferable for the woman to hold her partner’s penis in the same position she used with the insert and to insert the penis herself. He must allow his pelvis to move forward with gentle pressure as she tries to insert it. The use of external lubrication is advised in these first attempts at penile entry.
Phosphodiesterase type 5 inhibitors may be used to treat temporary situational partner erectile dysfunction that occurs at the crucial moment when the woman is finally able to accommodate her partner’s penis.