Eur J Surg Sci 2011;2(3):73-79
ORIGINAL ARTICLE
Treatment Outcome of 460 Women with Vaginismus
Süleyman ESERDAĞ1, Ebru ZÜLFİKAROĞLU1, Süleyman AKARSU1, Saygın MİCOZKADIOĞLU1
1 Department
of Obstetrics and Gynecology, Ankara Dr. Zekai Tahir Burak Women's Teaching and Research Hospital,
Ankara, Turkey
ABSTRACT
Introduction: We aimed to emphasize the importance of the gynecological examination in the treatment of vaginismus.
Materials and Methods: From January 2005 to October 2008, 460 sexual partners who had been treated at the tertiary
Vaginismus Therapy Clinic (HERA) for vaginismus were studied via examination of treatment charts. The patients enrolled in this
prospective study had vaginismus according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders Fourth
Revision, Turkey (DSM-IV-TR). Patients participated in a face-to-face interview and were assessed with a gynecologic examination before and after the treatment and also at 3- and 12-months follow-up. Cognitive behavioral sex therapies and medical
hypnotherapy were used in the management.
Results: We developed our classification system based on the gynecological examination, and classified all the patients at the
first visit. Among 460 women, we classified 152 (33.04%) as first- degree, 180 (39.1%) as second-degree, 108 (23.4%) as thirddegree, and 20 (4.34%) as fourth-degree. All of the therapies were individualized for the patients based on the first gynecological
assessment. After the treatment and at the 3-month follow-up, 460 (100%) women had had successful sexual intercourse. The
mean number of treatment sessions was 4.2. At the 1-year follow-up after treatment, 392 (85.2%) not only had regular intercourse but orgasm as well. Forty (8.69%) did not have orgasm but felt that intercourse was pleasurable. Twenty-eight (6.08%)
women had regular intercourse but no interest.
Conclusion: Our study showed that conducting a non-traumatic gynecologic examination is very important for definite diagnosis,
classification of severity and establishment of a therapy modality for higher success rates in the management of vaginismus.
Key words: Vaginismus, Treatment outcome, Gynecological examination
Received: October 24, 2011 • Accepted: November 04, 2011
ÖZET
Vajinismuslu 460 Hastanın Tedavi Sonuçları
Giriş: Vajinismus tedavisinde jinekolojik muayenenin önemini vurgulamak amaçlanmıştır.
Materyal ve Metod: Ocak 2005-Ekim 2008 yılları arasında Vajinismus Tedavi Merkezinde (HERA) tedavi almış 460 vajinismuslu çift çalışmaya dahil edildi. Bu prospektif çalışmada hastalar "Diagnostic and Statistical Manual of Mental Disorders Fourth
Revision, Turkey (DSM-IV-TR)" kriterlerine göre vajinismus tanısı konarak çalışmaya kabul edildi. Hastalarla yüzyüze yapılan
73
Treatment Outcome of 460 Women with Vaginismus
görüşmeler sonrası tedavi öncesi, sonrası ve tedavi sonrası 3. ve 12. aylarda jinekolojik muayeneleri yapılmıştır. Hastaların
tedavilerinde kognitif davranışsal terapiler ve medikal hipnoterapi uygulanmıştır.
Bulgular: Hastaların ilk görüşmesinde yapılan jinekolojik muayenesi üzerinden vajinismus dereceleri belirlendi. Toplam 460
hastanın 152 (%33.04)'sinde 1. derece, 180 (%39.1)'inde 2. derece, 108 (%23.4)'inde 3. derece, 20 (%4.34)'sinde 4. derece
vajinismus olarak tespit edildi. Yapılan ilk jinekolojik değerlendirme sonrası kişiye özel tedavi programı oluşturuldu. Tedavi sonrası ve takiplerin 3. ayında 460 hastanın tümü başarılı bir şekilde cinsel birliktelik yaşadılar. Ortalama tedavi süresi 4.2 bulundu.
Takiplerin 1. yılında 392 (%85.2) hasta birlikteliğin yanı sıra orgazmı yaşadılar. Kırk (%8.69) hasta orgazm olamadı ancak keyif
aldıklarını belirttiler. Yirmi sekiz (%6.08) hasta ise ilişkiye girmeyi başarsalar da çok fazla keyif alamadıklarını belirttiler.
Sonuç: Çalışmamız göstermiştir ki, vajinismuslu hastanın ilk görüşmesinde yapılan bir jinekolojik muayenenin vajinismusun tam
tanısını koymak, derecelendirmek ve tedavinin optimal planlanması için son derece önemlidir.
Anahtar kelimeler: Vajinismus, Tedavi sonucu, Jinekolojik muayene
Geliş Tarihi: 24 Ekim 2011 • Kabul Ediliş Tarihi: 04 Kasım 2011
INTRODUCTION
Vaginismus is the presence of persistent difficulty
to allow vaginal entry of a penis, finger, and/or any
object, despite the woman’s expressed desire to do so,
with involuntary pelvic muscle contraction[1]. In fact,
it is included in the subcategory of sexual pain disorders and is classified as a sexual dysfunction[2].
Similar to other types of sexual dysfunctions, it may
cause marital and interpersonal problems or infertility. The predisposing factors of vaginismus are primarily sexual trauma, religious background, and cultural and environmental factors[3].
In severe cases of vaginismus, the rectus abdominis, the adductors of the thighs and the gluteus muscles may also contract involuntarily as opposed to the
rhythmic contraction during orgasm. This contraction is a general defensive reaction against a threatening
situation. Increased muscle tension that precludes
vaginal entry may cause the sexual pain[4].
Vaginismus may be classified as either primary or
secondary. Primary or lifelong vaginismus presents
from the first attempt at penetration. In secondary or
acquired vaginismus, a woman loses the ability to
have intercourse following physical or psychological
trauma, gynecological intervention (abortion, difficult
delivery, etc.), menopausal atrophic changes, or pelvic
pathology[5].
In this prospective study, we evaluated the characteristics of 460 women with vaginismus and reported
the efficacy of our vaginismus therapy.
MATERIALS and METHODS
In this prospective study, 460 sexual partners who
had been treated at the Vaginismus Therapy Clinic
(HERA) from January 2005 to October 2008 for vagi-
74
nismus were studied via the examination of treatment
charts. Forty-four patients with organic problems
(pathologic or anatomic) were treated with some surgical interventions or medical treatments and were
excluded from the study. All patients enrolled in this
prospective study signed an informed consent form.
The Medical Ethics Committee of Dr. Zekai Tahir
Burak Women’s Health Teaching and Research
Hospital, Ankara, Turkey approved this work.
Vaginismus was defined according to the criteria
of the Diagnostic and Statistical Manual of Mental
Disorders Fourth Revision, Turkey (DSM-IV-TR)[2].
The diagnostic criteria for vaginismus is a recurrent
or persistent involuntary contraction of perineal
muscles surrounding the outer third of the vagina at
an attempt of penetration with a penis, finger, tampon
or speculum and marked distress or interpersonal
difficulty owing to vaginal reactions. The couples who
refused diagnostic and treatment procedures or were
lost to follow-up before a definite result were excluded from the study. In addition, those couples with
severe family problems were referred to a psychologist specialist before starting the treatment. Thus, we
included a total of 460 couples. The duration of
unconsummated coitus of couples ranged from 1
week to 18 years.
A team comprised of a sex therapist, gynecologist,
psychiatrist, and psychologist was organized for the
therapy. As the first step, history was obtained and
then a physical and gentle gynecologic examination
with reassurance was done for absolute diagnosis. We
used our classification system of four degrees of severity by means of the gynecological examination, with
patients in lithotomy position (Table 1). The gynecological examination and classification permitted us to
evaluate the existence of any organic problem (vaginal
Eur J Surg Sci 2011;2(3):73-79
Eserdağ S, Zülfikaroğlu E, Akarsu S, Micozkadıoğlu S.
Table 1. The classification system of vaginismus based on gynecological examination “Eserdag Classification”
First degree
Patient tolerates insertion of examiner’s index finger into the vaginal canal and involuntary vaginospasm is felt by the examiner.
Second degree
Patient tolerates insertion of examiner’s little finger to vaginal entry with difficulty and some anxiety.
Third degree
Patient demonstrates fear, cannot tolerate examiner’s finger in her vagina, and allows examiner
only to touch her vestibulum and vulva.
Fourth degree
Patient demonstrates tremendous fear, anxiety and embarrassment, sometimes cries and elevates her buttocks, constricts her thighs, withdraws herself, contracts all her muscles (sometimes even her chin and toes), and does not allow the examiner to even touch her vulva or allows
it with difficulty.
septum, rigid hymen, vaginitis, vulvar vestibulitis,
etc.) as well as to determine the modality of therapy,
and patients were also informed about the therapy
and its estimated duration.
If the male partner had problems, a urologic examination was performed by a urologist. If there was
no organic problem in the male partners, cognitive
and behavioral sex therapies were also given to them
to prepare them for the intercourse[6-8].
We used cognitive and behavioral therapies in all
patients with first-, second-and third-degree severity.
Cognitive and behavioral therapies were used after the
medical hypnotherapy in all patients with fourth-degree severity.
After obtaining a medical history, patients were
instructed about the reasons for vaginismus, the
conscious/subconscious mechanisms and sexual
myths. We provided a wide explanation for the patient
about the common psychodynamics of vaginismus
and assured her that she is not alone, that the condition can be cured, and that her genital anatomy was
normal, etc. We used various therapeutic metaphors,
verbal suggestions and encouragement to support
patient self-esteem during the therapies.
We also showed the patient the genital anatomy in
a pelvic model and described the functions of the
genital organs (especially the clitoris, vagina, hymen).
Then, systematic desensitization and dilatation techniques with behavioral approaches like mirror exercises, external genital massage, Kegel exercises, and
firstly finger and then mechanic vaginal dilator insertions were used. We did not use finger dilatation
except for discovering the vaginal structure for a period, as these exercises were not found attractive or
hygienic by the patients.
Eur J Surg Sci 2011;2(3):73-79
We used our specially developed smooth plastic
vaginal dilators, “Eserdag dilators”, in these exercises.
These four graduated dilators started from 16 mm
front-19 mm back and finish with 33 mm front-36
mm back in diameter. After an instruction and
demonstration, patients were asked to insert these
gradually expanding vaginal dilators into their vaginal
canal, using breath techniques and lubricating agents.
We gave the patients a private room to conduct their
exercises alone or with their partners for a period of
time ranging from 1 hour to 3 hours, and then advised
them to repeat the exercises at home as home tasks.
The patients were encouraged to come to the clinic
every day and most of them agreed to this arrangement. Thus, the treatment duration was quite short
(generally concluded in one week). Some of the patients came to the sessions alone, while others were
joined by their partners.
We also conducted “sexual pleasure studies”, including clitoral and vaginal stimulation, focusing the brain
on orgasmic responses and discovering the body’s erogenous zones, to encourage sexual excitement.
After insertion of the fourth vaginal dilator was
achieved, information was given to the couple about
sexual intercourse. The easiest positions were shown
using educational CDs and on a pelvic model for
illustration for a comfortable penetration, and then
intercourse trials were started.
The cognitive and behavioral therapies that we use
in our clinic are shown in (Table 2)[6-8].
Statistical analyses were performed using the
Statistical Package for the Social Sciences (SPSS)
Software (SPSS, Chicago, IL, USA) version 9.0 for
Windows. Statistical evaluation was performed with
Student’s t-test and chi-square test. The one-way
75
Treatment Outcome of 460 Women with Vaginismus
Table 2. The cognitive and behavioral therapies
used in our clinic
Verbal suggestions and encouragement
Information about genital anatomy and physiology
Mirror exercises
Breathing techniques
Relaxing and positive thinking methods
Kegel exercises
Genital massage (Alone and with her husband)
Feeling inside the vagina with finger
Progressive dilator exercises (Alone and with her
husband)
Sensation focus exercises
Sexual awareness exercises
Information about coitus, reproduction and contraception using models and DVDs (alone and with her
husband)
ANOVA and logistic regression test were performed
to compare means among groups. Results were considered statistically significant if p< 0.05.
RESULTS
Table 1 shows the classification of vaginismus severity among patients in our study. We classified 152
(33.04%) patients as first-degree, 180 (39.1%) as seconddegree, 108 (23.4%) as third-degree, and 20 (4.34%) as
fourth-degree. While 23 (5%) patients were diagnosed
as secondary vaginismus, 437 (95%) of them were primary vaginismus and 128 (27.8%) had perforated
hymen showing at least one coitus.
Among 152 women with first-degree severity, the
number of treatment sessions ranged from 2-4, with a
mean of 3.4, and all were successfully cured. Among
180 women with the second-degree severity, the number of treatment sessions ranged from 2-5, with a
mean of 4.2. Among 108 women with third-degree
severity, the number of treatment sessions ranged
from 4-7, with a mean of 5.1. Among 20 women with
the fourth-degree severity, the number of treatment
sessions ranged from 4-10, with a mean of 6.8. The
success rate among all women in our study was 100%
(Table 3).
In our study, the number of treatment sessions
and duration of unconsummated intercourse were not
found to be positively related (Table 4). One hundred
sixty-seven couples having a duration of unconsummated intercourse of less than 1 year had 2-10 treatment sessions with a mean of 4.3; 128 couples having
a duration of unconsummated intercourse of 1.1-3
years had 2-8 treatment sessions with a mean of 3.9;
92 couples having a duration of unconsummated
intercourse between 3.1-5 years had 2-7 treatment
sessions with a mean of 4.3; 49 couples having a duration of unconsummated intercourse of 5.1-10 years
had 3-9 treatment sessions with a mean of 4.2; and 24
couples having a duration of unconsummated intercourse of more than 10 years had 3-10 treatment
sessions with a mean of 4.8 (Table 3).
Among 460 women with vaginismus, 460 (100%)
had successful sexual intercourse after treatment and
at the 3-month follow-up. At the 1-year follow-up
after treatment, 392 (85.2%) not only had regular
intercourse but orgasm as well. Forty (8.69%) did not
have orgasm but felt that intercourse was pleasurable.
Twenty-eight (6.08%) women had regular intercourse
but no interest. One year after treatment, 351 (76.3%)
Table 3. Comparison of severity of vaginismus, treatment sessions and successful outcome
Degree of vaginismus
First degree (Mild)
Number of
patients
Treatment
sessions
Treatment modalities
Success rate
152
3.4 (2-4)*
CB Therapies
100%
Second degree (Moderate)
180
4.2 (2-5)*
CB Therapies
100%
Third degree (Moderate-Severe)
108
5.1 (4-7)*
CB Therapies
100%
Fourth degree (Severe)
20
6.8 (4-10)*
CB + Hypnotherapies
100%
Total
460
4.2 (2-10)*
CB + Hypnotherapies
100%
* p< 0.05 between first, second degree and third, fourth degree, ANOVA.
CB: Cognitive-Behavioral.
76
Eur J Surg Sci 2011;2(3):73-79
Eserdağ S, Zülfikaroğlu E, Akarsu S, Micozkadıoğlu S.
Table 4. Comparison of duration of unconsummated intercourse and treatment sessions
Duration of unconsummated
intercourse (years)
Number of vaginismic women
Treatment sessions
≤1
167*
4.3 (2-10)**
1.1-3
128*
3.9 (2-8)**
3.1-5
92*
4.3 (2-7)**
5.1-10
49*
4.2 (3-9)**
> 10
24*
4.8 (3-10)**
* p < 0.05 between ≤ 1, 1.1-3, 3.1-5, 5.1-10 and > 10 years, ANOVA.
** p > 0.05 between ≤ 1, 1.1-3, 3.1-5, 5.1-10 and > 10 years, logistic regression.
women were pregnant. Most of the other patients
stated they currently had no plans to get pregnant.
No recurrence was reported by the patients as
feedback.
DISCUSSION
Psychological, social, cultural, personal, or physical factors may cause vaginismus[6]. For the treatment
of vaginismus, different methods, from psychoanalysis to surgical interventions, have been developed[7-13].
Recently, combined therapies have been preferred for
vaginismus treatment, as progressive muscle relaxation, vaginal dilatation, or psychological counseling.
Why was a new classification system needed?
Vaginismus is truly and easily diagnosed by a gynecologic examination[14]. The gynecologist specialized for
sexual therapies should be trustworthy, gentle, tender,
and understanding of the patient during the first gynecologic evaluation because of the risk of causing unnecessary pain and discomfort, which may cause avoidance
of the therapies in these patients.
Frequently, vaginismus patients are classified into
the four degrees of severity as firstly defined by
Lamont in 1978. According to the Lamont classification, first degree is perineal and levator spasm relieved with reassurance, second degree is perineal spasm
maintained throughout the pelvic examination, third
degree is levator spasm and elevation of buttocks, and
fourth degree is levator and perineal spasm, buttocks
elevation, adduction, and retreat. Our classification
system that we have used for 10 years, the “Eserdag
classification”, is based on a gentle digital gynecologic
evaluation after the genital inspection (Table 1). Thus,
it is quite easy and objective for differentiation of the
four classes, which will guide the therapy.
Eur J Surg Sci 2011;2(3):73-79
Interestingly, in our experience, we found severe
vaginismic patients not capable of vaginal sex, who
tended toward anal penetration with their partners.
Thus, perineal spasm was not an essential factor in
severe-degree vaginismus, as mentioned in the
Lamont classification.
According to our observation, the most important
factor that led to a high success rate in our patient
group was the patient’s trust of her therapist. Other
essential factors were performing home exercises
regularly, being patient, being in love with their partner, and receiving psychological support from him.
Unconsummated intercourse can also occur due
to some organic genital problems[15,16]. Forty-four
patients (11.45% of the total 504 patients) were excluded from this study and managed by some surgical
operations or medical treatments. Most of the organic
problems of patients in our study were rigid and thick
hymen, vulvar vestibulitis, vaginitis, Bartholin abscess, and vertical and horizontal vaginal septum.
Thus, this finding also emphasizes the importance of
a thorough gynecological evaluation for the patients
with sexual problems at the beginning of the therapy.
Reissing et al. reported that vaginismus may be
classified as "vaginal penetration phobia" or "genital
pain disorder", or both[17]. For the patients with
fourth-degree vaginismus, we used medical hypnotherapy, which was quite effective to diminish anxiety
and phobia, resolve fear and facilitate relaxation and
loosening of the muscles. After the hypnotherapy,
desensitization and dilatation exercises were also easy
to perform. We generally did a single hypnotherapy in
the second interview after providing some relevant
information. However, some patients may need multiple hypnotherapy sessions. We sometimes used
hypnosis including sexual imagination in the last treatment session before the intercourse.
77
Treatment Outcome of 460 Women with Vaginismus
The therapy durations were quite short in our
clinic. Most of the patients were cured in one week
perhaps because patients presented for the treatment
every day for sessions as long as 1-3 hours. Our study
showed that daily treatment sessions were positively
related with the success rate and a fast response.
According to our experience, hypnotherapy quickens
the therapy as well. This may explain why treatment
duration among the severe vaginismus patients was
not significantly different from that of the mild- and
moderate-in-severity patients.
In this study, the number of treatment sessions
was not found to be positively correlated with the
duration of unconsummated intercourse. We believe
this is because the most important factor in the management of vaginismus is to first make the definite
diagnosis with a gynecologic examination. The duration of unconsummated intercourse did not affect the
number of treatment sessions. At this point, our
results did not support the findings of Jeng et al.,
which suggest that couples with a duration of unconsummated intercourse of up to 2 years have a better
success rate[14]. Friedman also reported results similar to those of Jeng et al.[18].
Several studies have suggested that successful
penetration alone in the treatment of vaginismus is
not enough for the success, since pleasure is also an
important factor[17,19]. In our study, at the 1-year
follow-up after treatment, we asked patients whether
sexual pleasure or pregnancy was achieved.
According to the results, 392 (85.2%) women not
only had regular intercourse but orgasm as well.
Forty (8.69%) did not have orgasm but felt that intercourse was pleasurable. Twenty-eight (6. 08%)
women had regular intercourse but no interest. No
recurrence of the problem after the therapy was
reported in the long-term.
In conclusion, our study showed that in the management of vaginismus patients, the duration of unconsummated intercourse does not affect the treatment
outcome. Further, a non-traumatic gynecologic evaluation is very important for definite diagnosis, determination of the degree severity and establishment of
an individualized treatment modality.
Acknowledgements
The authors appreciate the assistance from all staff
in Hera Clinic.
78
REFERENCES
1. Basson R, Leiblum S, Brotto L, Derogatis L, Fourcroy J,
Fugl-Meyer K, et al. Definitions of women’s sexual
dysfunction reconsidered: advocating expansion and
revision. J Psychosom Obstet Gyneacol 2003; 24: 221-9.
2.American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders. 4th ed. Text
Revised.
Washington,
DC:
American
Psychiatric
Association; 2000.
3. Fertel NS. Vaginismus: a review. J Sex Marital Ther 1977;
3: 113-21.
4. van der Felde J, Laan E, Everaerd W. Vaginismus, a
component of a general defensive reaction: an investigation of pelvic floor muscle activity during exposure to
emotion-inducing film excerpts in women with and without vaginismus. Int Urogynecol J Pelvic Floor Dysfunct
2001; 12: 328-31.
5. Tulla ME, Dunn ME, Antilus R, Mueyyirci-Delale O.
Vaginismus and failed in vitro fertilization. Sex Relat Ther
2006; 21: 439-43.
6. Hawton K, Catalan J. Sex therapy for vaginismus: characteristics of couples and treatment outcome. Sex
Marital Ther 1990; 5: 39-48.
7. Rosen RC, Leiblum SR. Treatment of sexual disorders in
the 1990s: an integrated approach. J Consult Clin
Psychol 1995; 63: 877-90.
8. Kabakci E, Batur S. Who benefits from cognitive behavioral therapy for vaginismus? J Sex Marital Ther 2003; 29:
277-88.
9. Ter Kuile MM, Bulté I, Weijenborg PT, Beekman A, Melles
R, Onghena P. Therapist-aided exposure for women with
lifelong vaginismus: a replicated single-case design. J
Consult Clin Psychol 2009; 77: 149-59.
10. Ter Kuile MM, van Lankveld JJ, de Groot E, Melles R,
Neffs J, Zandbergen M. Cognitive-behavioral therapy for
women with lifelong vaginismus: process and prognostic
factors. Behav Res Ther 2007; 45: 359-73.
11. Praharaj SK, Verma P, Arora M. Topical lignocaine for vaginismus: a case report. Int J Impot Res 2006; 18: 568-69.
12. Ben-Zion I, Rothschild S, Chudakov B, Aloni R. Surrogate
versus couple therapy in vaginismus. J Sex Med 2007; 4:
728-33.
13. Seo JT, Choe JH, Lee WS, Kım KH. Efficacy of functional
electrical stimulation - biofeedback with sexual cognitivebehavioral therapy as treatment of vaginismus. Urology
2005; 66: 77-81.
Eur J Surg Sci 2011;2(3):73-79
Eserdağ S, Zülfikaroğlu E, Akarsu S, Micozkadıoğlu S.
14. Jeng CJ, Wang LR, Chou CS, Shen J, Tzeng CR.
Management and outcome of primary vaginismus. J Sex
Marital Ther 2006; 32: 379-87.
15. Dogan S. Vaginismus and accompanying sexual dysfunctions in a Turkish clinical sample. J Sex Med 2009; 6:
184-92.
16. Tugrul C, Kabakci E. Predictor variables of vaginismus
(Vaginismus olgularında yordayıcı değişkenler). Türk
Psikiyatri Dergisi 1996; 7: 201-7.
17. Reissing ED, Binik YM, Khalife S. Does vaginismus
exist? A critical review of the literature. J Nerv Ment Dis
1999; 187: 261-74.
Eur J Surg Sci 2011;2(3):73-79
18. Friedman IJ. Virgin wives. London: Tavistock; 1962.
19. Whipple B. Women’s pleasure and satisfaction: consideration of new diagnosis criterion. Proceedings of 7th Asian
Congress of Sexology, 5.
Address for Correspondence
Ebru ZÜLFİKAROĞLU, MD
Bilkent 2 E 1 Blok No: 23
Bilkent, Ankara-Turkey
E-mail: [email protected]
79