330 Part 1

The Diagnosis and Treatment of
KCNPNM Annual Conference
April 2014
By Jean D. Koehler, Ph.D.
And Susan Dunn, P.T.
Koehler Disclosures
• Proctor and Gamble – Consultant and
interviewer for Stage 3 clinical trials on
testosterone patch for women – 2003-2004
• Proctor and Gamble- Regional Consultant’s
Board- 2004- 2005
• Ortho-McNeil- Pharmaceuticals- Advisory
Board of Female Sexual Dysfunction expertsNovember 2004
• Boeringer Ingleheim- Speaker’s Bureau-2010
Vaginismus Definition
Proposed by Rosemary Basson, M.D.
The persistent or recurrent difficulties of the
woman to allow vaginal entry of the penis, a
finger, and/or any object despite the woman’s
expressed desire to do so.
There is often phobic avoidance, involuntary pelvic
floor muscle contraction, and the
anticipation/fear/experience of pain.
Structural abnormalities must be ruled
Basson et al, 2004
DSM V- 302.76 (Women’s) Genito-Pelvic
Pain/Penetration Disorders
• Marked vulvovaginal pain in penetration
attempts (dyspareunia)
• Marked anxiety about penetration or
anticipated penetration
• Marked tightening of pelvic floor muscles
during attempted penetration
(was called Vaginismus in prior manuals)
Types of Vaginismus
• Primary- never achieved attempted coitus
• Secondary- onset after pain free coitus
• Total- penetration not possible through the PC
• Partial- penetration achieved, but painful
• Situational- only with some penetrants
– with penis but not speculum or visa versa
– with larger sized partner but not smaller sized
– with gyn exam, but not with coitus
Incidence of Sexual Pain Disorders
US general population data- Michael et al, 1994
• Consistent coital pain in females-10-15%
International general population data- Lewis et al, 2004
• Vaginismus- 6%
• Coital pain- 2-20%
The Cochrane Database of Systemic Reviews- McGuire and
Hawton, 2002
Vaginismus in medical settings- 4-12%
Vaginismus in sexual Dysfunction Clinics- 5-17%
Women of childbearing age- est. .5-1%
Graziottin, A. 2008
Factors Impacting Changes in Female Sexual Function Variables from Mid Aged Woman’s Sexual Functioning Study
Europe and Australia (Graziottin & Dennerstein in press,2005)
Partner status
Sexual Function
Throughout a Woman’s
c. J Alexander ‘05
Age Health
Medical Conditions That May Lead to Vaginismus
• PVD- provoked vestibulodynia- one of most common causes of
dyspareunia in pre-menopausal women (Smith 2014)
• Estrogen, testosterone deficiency
– OC use before 16, and for up to 2-4 years (Davis 2013)
– Vulvovaginal atrophy in menopausal women (Hope 2010)
• Pelvic floor disorders
• Vaginal infection- i.e. recurrent yeast, herpes, bacterial vaginosis,
• Vulvar dermatoses, i.e. lichens sclerosis
• Allergy to condoms, semen
• Endometriosis
• Radiation therapy
• Injury from force –rape
• Prior painful vaginal/urological medical interventions- especially in
childhood/teen years- iatrogenic?
• Female Genital Mutilation
• Genetic abnormalities- i.e. septate hyman
Psycho-social Conditions Correlating
to Vaginismus- Research Results
• Pre-existing General Anxiety Disorder1
• Personality features- fear of new experiences,
catastrophizing thoughts about pain, disgust
propensity, low self-esteem2, 3
• Specific fear of penile vaginal penetration
• Less self stimulation
• Increased prevalence of desire and arousal
• 1- Watts and Nettle, 2010
• 2- van Lankveld et al., 2010
• 3- Borg, C. et al. 2012
Possible Psychosocial CausesClinical Observations
• Strict religious proscriptions against sexual
interaction/especially coitus
• Body Myths
• Phobia to vaginal penetration, sometimes of any orifice
• Sexual abuse or assault history• Poor or unsure relationship with sexual partner
• Fear of unplanned pregnancy, delivery pain
• Secretly unwanted pregnancy
• Stuck developmentally as a “good little girl”, not
wanting to grow up sexually and disappoint parents
The New Treatment Team for
Sexual Pain Disorders
• Pelvic Pain MD/NP
• Pelvic Floor Physical
• Certified Sex
Case Example of the team
Role of the Gyn Provider • When the patient presents painful
penetration as the reason for the office visit
• When the providers notices an inability to
perform a speculum exam
Sexual History for Vaginismus
• Is she in a sexually active relationship?
• Is penetration possible? If so, is it painful?
• Is it painful only at penetration? When else?
• Describe the pain? Locations, intensity, sharp/dull, etc.
• How anxious does she feel at the thought of penetration?
• Can she insert a tampon or finger without pain?
• How long has this been a problem?
• Was the onset sudden or gradual? Is it present all the time?
• Is pain experienced at times other than with intercourse?
• Is she able to become aroused and climax at all with self or partner?
• How anxious does she feel about the thought of a genital
examination? If so, what about it makes her anxious?
• Has she ever had a traumatic sexual experience or history of
physical/emotional/sexual abuse?
• What does she believe is causing her penetration pain?
– Koehler adapted from Crowley T,2009 & Kingsberg SA,2007
Preparing for the Initial Exam with a
Primary Vaginismus Patient
LISTEN-to your patient if she expresses fear
WATCH - for fearful body language
–Let her decide who will be present
–Let her decide the extent of the initial
–Ask her if she can think of anything to
facilitate the exam
–First show a film to all new pelvic exam
patients if you can or
–Describe each step in advance as you
–Offer sedation(Valium 5mg.) if needed
–Let her know she can interrupt the
exam at any time without being a
REASSURE HER that you will let her
have control of the exam
– Pacing of insertion
– Inserting speculum herself
– Using a pediatric speculum
– Starting with your finger only while the
patient bears down
– Or postponing internal exam pending
completion of physical therapyor sex therapy
• Give her a mirror to see her vulva
• Explain her anatomy/correct misinformation
• Clarify what structures are normal or
• Ask her how she’s coping during the exam
• If exam is normal, explain how her fear and
pelvic floor hypertonus tricks her into
believing she’s too small for penetration
What if you still can’t examine her?
• Have her practice the Rosenbaum Mindfulness
• In case that doesn’t work, in the same visit:
– Give her contact info of either a pelvic floor P.T. or
– Sex therapist or
– Both
– Let her choose which approach appeals to her
Rosenbaum Mindfulness Protocol
• Uses mindfulness accompanied by systematic
desensitization to reduce anxiety
• Can be first practiced at home
• Can be practiced in the provider’s exam room
ahead of the examination or on a prior day
• See handout for protocol
• Rosenbaum and Padoa- 2012
• Rosenbaum- 2011
Further At-home steps when no sex
therapist or pelvic floor physical
therapist available
• Once she has proceeded through these steps, she may
continue to utilize the anxiety reduction techniques as
they apply to self-touch of the genitals, self-touch of
the vulvar vestibule and vaginal finger insertion.
• She may further apply these techniques for gradual
dilator use with the practitioner and with her partner.
This progression includes self-insertion of the dilator,
self-insertion with her partner holding dilator as well,
her partner inserting the dilator with the client holding
it as well, and finally, her partner inserting the dilator.
The Role of the Gyn Provider in
Secondary Vaginismus
Case example of Secondary
vaginismus originating with medical
What Other Office-Based Treatments
Can Medical Providers Try?
Provider- led Modified Sensate Focus
• Good for couples seeking infertility treatment
– diagnosed with primary vaginismus
– no sex therapist or pelvic floor physical therapist
in the area
– Results:
Most resolved vaginismus
Half became pregnant
Nonpregnant evaluated for other sources of infertility
See handout
• Jindal and Jindal, 2010
Botulinum Toxin (Botox)
• Botox for treatment resistant cases
– No good controlled studies and adverse events
need to be documented
– But pre vs. post treatment show it’s effectiveness
• Ferreira and Souza 2012 Meta-Analysis
• Adverse events
– two cases of mild stress incontinence
– one case of excessive vaginal dryness of 82
patients in one study
Pacik,P. Aesth Plast Surg (2011) 35:1160–1164
What predicts successful treatment?
• Reducing penetration fears
• Attributing the problem to psychological
• Positive attitude toward one’s genitalia
• Strong wish to become pregnant
• Better sexual knowledge
• Homework compliance
• Pretreatment martial satisfaction
van Lankveld et al., 2010
What predicts longer treatment?
Pretreatment sexual desire problems
Fear of STI’s
Negative parental attitudes towards sex
Previous operations for vaginismus
History of physical abnormality- like septum
• van Lankveld et al., 2010
What doesn’t predict treatment
• Sexual abuse history– Higher rate among vaginismus patients, but sexual
abuse history doesn’t predict future vaginisimus
• Other sexual dysfunctions in either partner
vanLankveld, Jacques et al. 2010 ;
Pregnancy Considerations
Sexual pain patients wishing to conceive should
avoid these topical or intravaginal agents:
• Gabapentin
• Baclofen
• Diazepam
• Amitriptyline
» Rosenbaum TY and Padoa. ACME Information: Managing Pregnancy
and Delivery in Women with Sexual Pain Disorders. Review. J Sex.
Med., Vol. 9, Issue 7, Article first published online: 3 JUL 2012
To a Pelvic Floor PT and/or Certified Sex
– Before proceeding with the exam if she prefers
– If she is unable to complete the exam
– For treatment of nonmedical causes of her
– If there are mixed psychogenic and medical causes
• Defined by the International Society for the Study
of Vulvovaginal Diseases (ISSVD) as vulval
discomfort, most often described as burning pain,
occurring in the absence of relevant visible
findings or a specific, clinically identifiable,
neurological disorder.
• Patients can be further categorized by anatomical
region (i.e. generalized vuvlodynia,
hemivulvodynia, clitorodynia) and also by
whether the pain is provoked or unprovoked.
Vulvar Vestibulitis Syndrome
• A subset of vulvodynia, is the most frequent
cause of dyspareunia in premenopausal women.
(Mena et al, J Nerv Ment. Dis 1997: 185:561-69)
• Prevalence 9.8 – 15% in general gynecologic
• Diagnoses by severe pain to pressure or touch on
the vulvar vestibule or introitus and vulvar
erythema of varying degrees.
• The ISSVD 2003 classification is under vulvodynia
Muscle Atrophy
Interstitial Cystitis
Abdominal pain
Vaginal Stenosis
Pubic Symphysis Pain
Pelvic Organ Prolapse
Piriformis Syndrome
Diastasis Recti
Vulvar Vestibulitis
Levator ani syndrome
Pudendal Neuralgia
Iliopsoas Syndrome
Episiotomy pain
Obturator Internus
Post Operative pain
Role of the Physical Therapist
• Team approach with other health care
• Physical Therapist focuses on
contribution to symptoms
What to Expect
Many patients perceive physical therapy for
these diagnoses to be different than physical
therapy for other orthopedic/spine
rehabilitation. Same therapy…….different
body part
Patient should expect a complete
musculoskeletal evaluation of the
symptomatic area.
Patient Profile
Teen through adult life span
Male and female
Sedentary and high end athlete
Varying socio-economic
Various cultural backgrounds
Questionnaire will include:
Pain with activity
Bowel movements/Urination
Sitting vs. standing vs. supine vs. prone
Intercourse pain (with superficial and/or deep
penetration/orgasm/positional dependent)
Urologic changes with intercourse/orgasm
Patient should fill out questionnaire that addresses
sexual history i.e.
Address Structure and Biomechanics
 Mobilize/Stabilize Thoracic spine, Lumbar spine and
SI Joints
 LLD, Postural abnormalities
 Muscle imbalance
Address Connective Tissue Restrictions and
 Connective Tissue Mobilization, Dry Needling
Surrounding the bony pelvis
Anterior, medial, lateral and posterior thighs
Abdomen, low back, buttocks
Nerve Mobilization
Seating Adaptations/Work Modifications
• Nerve Roots: S2, S3,
• 50% sensory, 20%
motor and 30%
Pelvic Floor Muscles
Abdominal Wall
Superficial Layers
• Traction
– Constipation, Childbirth, strenuous squatting
• Compression
– Cycling, Horseback riding, prolonged sitting
• Surgical
– Hysterectomies, corrective sx for prolapse
– Common etiology for nerve entrapment
• Visceral-Somatic Interaction
– Chronic bladder infections, yeast infections,
bacterial prostatitis
• Childbirth, Constipation, Strenuous
• “Cyclist’s Syndrome”
• Hysterectomy, Correction of prolapse,
Gynecological surgeries requiring lithotomy
Jackknife position
Risk of muscle damage/scarring/adhesions
with surgeries
Total Hip arthroplasty – muscle stays intact but
may be damaged when the femur is elevated
and exposed
Ito et al – “…short ER’s, especially conjoined
tendon, are at high risk of being damaged and
their detachment might be inevitable during
the superior and/or posterior capsular release
that is necessary to mobilize the femur during
DAA in certain cases”
• Chronic bladder infections, yeast
infections, bacterial prostatitis
Modalities for Pelvic Pain
• Biofeedback/Pressure perionometry/surface
• Ultrasound
• Vaginal Dilators
• Electrical Stimulation
• Weight Training for the pelvic floor
Perineal Ultrasound
Decrease soft tissue
Increase blood flow
hypertrophy/scar tissue
Not appropriate for all
patient types and
contra-indicated for
some diagnoses.
Vaginal Dilators
• Protocol varies
depending on diagnosis
• Common diagnoses that
are appropriate for
vaginal dilators:
constipation, vaginal
stenosis, muscle
Therapeutic exercise
How to find and utilize a pelvic pain
Physical Therapist
State organizations (KPTA)
National Organizations (APTA)
National Pelvic Pain Organizations
Talk to local P.T.’s and they can normally refer
you to the appropriate office.
• Insurance – these diagnoses are usually
Case Examples of patients successfully
treated with only pelvic floor PT
• Thorough psycho-social evaluation
• Individual therapy for anxiety and depression
• Relationship therapy or involving partner in supporting
her treatment
• Insight therapy for negative/shameful sexual attitudes
• Education on sexual anatomy and function to reduce
penetration fears
• Sexual Abuse/Trauma treatment
• Cognitive therapy, insight therapy, hypnosis, EMDR,
educational videos, bibliotherapy, exposure therapy
ter Kuile 2013
• At-home patient-led dilator therapy
(No touching or live sexual demonstrations are ever done
in the sex therapist’s office!)
Case Example of Vaginismus
Patients successfully treated with
sex therapy alone
Preparing the patient to return to gyn
• Cognitive therapy to decatastrophize
• Positive imaging
• Giving her control of the exam by educating
her gyn
• Using an anxiolytic ahead if wanted
• Giving her permission not to complete the
exam the first time back
• Preparing her for vaginal delivery
Who Are Sex Therapists and How Do I
Find One?
• licensed psychotherapists from any
psychotherapy discipline with additional
training in sexual health and illness
• Certification or Diplomate by AASECT –
– CST or DST after their names
• (The American Association of Sexuality
Educators, Counselors and Therapists)
• Licensure in FL
• www.aasect.org- find a therapist by state
Treatment Success Rates
Independent Study Cited
Biswas & Ratnam, 1995
Butcher, 1999
Masters & Johnson, 1970
Schnyder, Schnyder-Luthi,et. al., 1998
Katz & Tabisel, 2002
Nasab & Faroosh, 2003
Scholl, 1988
Studies cited in Heiman, 2002
- www.vaginismus.com
Resources for Becoming an Effective
Female Sexual Medicine Provider
Establish a team of related FSD
– Pelvic Floor Physical Therapist:
– Certified Sex Therapist-www.aasect.org
– Sexual Medicine Specialist• AASECT certified sexuality counselors in medical field
• Training from ISSWSH
– Urologists, Internists, and Endocrinologists
who are interested in sexual medicine
References Books for Providers
• Textbook of Sexual Medicine
William Maurice, M.D.
• Sexual Pharmacology- Fast Facts
R.T. Segraves, M.D.
• Sex In America: A Definitive Survey
Michael et al
• The Journal of Sexual Medicine
Vaginal Dilators
Syracuse Medical Devices
(315) 637-9275
Individually sold and inexpensive
Provider Education in Female Sexual
Medicine and Psychology
1- “Women’s Sexual Health Course for N.P.’s”
June 27-29, 2014- Dallas
Sponsored by The International Society for the Study of
Women’s Sexual Medicine
2-ISSWSH annual meetings, membership and list serve
3-The American Association of Sexuality Educators,
Counselors, and Therapists annual meetings and trainingswww.aasect.org
Resources for Patients
Private Pain- It’s about life not just sex
by Ditza Katz and Ross Lynn Tabisel -2005
www.vaginismus.com–self-help books, online
forums, and other resources
Internet Chat rooms
– Google “Vaginismus support groups”
[email protected]
Dunn Physical Therapy, PLLC
Louisville, Kentucky
[email protected]
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Thank you for your attention!
Questions and Comments?

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