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Dyspareunia versus Vaginismus

In this blog post, I am going to cover dyspareunia and vaginismus. I will discuss what the definition of each is and how each one is treated.

This is a bit complicated, so I’m going to super simplify this and give you a synopsis on this, based on the literature I have read. I am not going to go over all the literature with you. See below for references if you want that information.

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Definitions

Genito-Pelvic Pain/Penetration Disorder

Recently, with the DSM V, these two diagnoses have been categorized into one diagnosis called genito-pelvic pain/penetration disorder. The DSM-5 criteria for Genito-Pelvic Pain/Penetration Disorder include one or more of the following:

  • Tightening of the vaginal muscles resulting in the inability to penetrate
  • A feeling of tension, pain, or a burning sensation felt when penetration is attempted
  • A decrease in or no desire to have intercourse
  • Voluntary avoidance of sexual activity
  • An intense phobia or fear of pain with penetrative vaginal intercourse

I learned in my training that these conditions are different. And I treat them differently. The definitions of dyspareunia and vaginismus depend on who you ask. And I think that the definitions in the literature are debatable. Additionally, dyspareunia is a broad term to describe pain with sex and can include vaginismus.

For instance, vaginismus is a diagnosis listed in the DSM. But the way that I define vaginismus is different than a mental health professional. mental health professionals do not perform internal vaginal exams.

Dyspareunia

Dyspareunia means pain with sex. It is an umbrella term and can include vaginismus in the definition. In other words, vaginismus can be a type of dyspareunia.

The following findings would lead me to a diagnosis of dyspareunia: If the patient has pain, but I am able to successfully perform an exam.

There is sometimes an underlying medical reason for dyspareunia. This can also be the case for vaginismus. Some of thee underlying medical issues can include:

  • Endometriosis
  • Interstitial cystitis
  • Lack of estrogen such as with menopause or during the post-partum period if you’re breastfeeding
  • Vestibulodynia

Vaginismus

The definition of vaginismus is that you have pain and also a spasm of the pelvic floor muscles with attempted penetration. This can be with a penis, a tampon, or a gynecologic exam. Vaginismus can also be broken down into primary and secondary types. Primary means that you have never been able to have penetrative vaginal intercourse. And secondary means that you have, at one point been able to have sex but now you can’t anymore. 

I usually attempt a vaginal exam on the first visit when I see a patient for a sexual concern. However, I will not perform an internal vaginal exam on the first visit if the patient is hesitant, has a history of sexual trauma, or does not want one on the first visit. 

The following findings would lead me to a diagnosis of vaginismus: If I feel a spasm of the muscles that prevents me from performing an exam, and the patient has a history of not being able to tolerate a gynecologic speculum exam or wear tampons.

Additionally, it is typically thought that the cause of vaginismus is pain combined with fear and anxiety. This could be due to a number of factors, including those medical issues listed above, as well as: 

  • Physical abuse, 
  • Lack of correct knowledge about sex
  • Relationship difficulties or just what I have found is a partner who is quite fearful of your pain as well

How is each treated?

So no we have the question of does it really matter which diagnosis you get? I would not say one is necessarily worse than the other. But it does matter to me in terms of how I treat and what I think the prognosis is, and also how quickly I think the patient can get better. 

For instance, I would start with the attempted insertion of a q-tip versus my finger for someone who has never been able to use a tampon, have a gynecologic exam, or have sex. My prognosis for this patient is that it would take 6 months or longer to treat (though not always). I have had a patient with primary vaginismus who had complete resolution in 2 months (8 sessions). But those with dyspareunia, especially if it’s just superficial, tend to get better in about 1 to 2 months. 

As is the case with any person seeking physical therapy, I would start with a thorough exam. This includes taking a very detailed history of the problem. I then proceed to the physical exam, which would include assessment of:

  • soft tissue mobility
  • posture
  • muscle strength and coordination
  • internal vaginal pelvic exam

Based on these findings, possible treatment options would include postural corrective exercises, tissue mobility manual therapy and stretches, and muscle coordination exercises.

I also recommend the use of a dilator or vaginal trainer for almost all of my patients presenting with pain or difficulty with penetrative vaginal intercourse. Here are two examples: the Milli Vaginal Trainer ($50 off with code SHA50) or Intimate Rose dilators ($5 off if you follow the link).

Questions

Q: I have been diagnosed with vaginismus. I am 57 and have gone through menopause. I am just getting married. My husband and I used to be able to have sex when we first met and now my muscles just lock up and he cannot enter his penis inside even a ilttle bit. I do have some sexual trauma from my past husband. But it’s weird that I was able to have sex with my current husband before. Is this all in my head? Am I crazy?

A: Absolutely not. While fear, anxiety, or a history of trauma may be relevant, there is absolutely a physical component that needs to be resolved that cannot be resolved with mental health treatment alone (I don’t think please correct me if I’m wrong).

Q: What if penetration happens with a finger for examination? But penal penetration was never achieved? Is that vaginismus?

A: Vaginismus includes a spasm of the pelvic floor muscles combined with fear and anxiety. I would call this vaginismus. It could be that with the finger exam, there was no fear and anxiety and so no spasm occurred. However, a penis is a lot less innocuous than a finger, so is likely to induce more fear and anxiety.

Are you experiencing either dyspareunia or vaginismus? Book a free consultation or an appointment with me to find out how I can help.

References

Binik Y. The DSM diagnostic criteria for vaginismus. Arch Sex Behav 2010; 39:278-291.

Ergani S, Bolat N, Ergani H, Tekin O, Unlubilgin E, Cendek B. A vaginismus study: really need surgery? Eur J Obstet Gynecol Reprod Biol 2019;234:e1-e131.

Genito-Pelvic Pain or Penetration Disorder DSM-5 302.76 (F52.6). Theravive website. Accessed July 20, 2021. https://www.theravive.com/therapedia/genito–pelvic-pain-or-penetration-disorder-dsm–5-302.76-(f52.6).

Lamont J. Dyspareunia and vaginismus. Global Library of Women’s Medicine website. Updated November 2011. Accessed July 20, 2021. https://www.glowm.com/section-view/heading/dyspareunia-and-vaginismus/item/429#

Reissing E, Armstrong H, Allen C. Pelvic floor physical therapy for lifelong vaginismus: a retrospective chart review and interview study. J Sex Marital Ther 2013; 39:306-320.

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