Vaginismus occasionally develops in women with clinical symptoms of severe dyspareunia (painful intercourse). When dyspareunia has a firm basis in pelvic pathology, the existence of which escapes examining physicians, and over the months or years coition becomes increasingly painful, vaginismus may result. The patient is not reassured by the statement that “it’s all in your head” or equally unsupportive pronouncements when she knows that it is always severely painful for her when her husband thrusts deeply into the vagina during coital connection.
As an example of this situation, vaginismus has been demonstrated as a secondary complication in two cases, of severe laceration of the broad ligaments. Also recorded are two classic examples of onset of vaginismus, the first in a young woman with pelvic endometriosis, the second in a 62 years old postmenopausal widow who without sex-steroid replacement therapy went through remarriage sought a return to sexual functioning after seven years of abstinence.
The two women developing a syndrome of vaginismus subsequent to childbirth laceration of the broad ligaments supporting the uterus (universal-joint syndrome) have similar histories. A composite history will suffice to demonstrate the pathology involved.
Marital Couple D was seen with the complaint of increasing difficulty in accomplishing vaginal penetration developing after 6 years of marriage. There were two children in the marriage, with the onset of severe dyspareunia oriented specifically to the delivery of the second child. The second child, a postmature baby of 8 pounds 14 ounces, had a precipitous delivery.
There is a positive history of nurses’ holding, the patient’s legs together to postpone delivery while waiting for the obstetrician. As soon as sexual activity was reconstituted after the delivery the patient experienced severe pain with deep penile thrusting.
During the next year, the pain became so acute that the wife sought subterfuge to avoid sexual exposure. The coital frequency decreased from two to three times a week to the same level per month. On numerous occasions, the patient was assured, during medical consultation, that there was nothing anatomically disoriented in the pelvis and that pain with intercourse was “purely her imagination.”
Supported by these authoritative statements, the husband demanded an increased frequency of sexual function. When the wife refused, the couple separated for a few months. During this period, the woman assayed intercourse on two separate occasions with two different men, but with each experience, the pelvic pain with deep penile thrusting was so severe that her obvious physical distress terminated sexual experimentation.
The marital couple was reunited with the help of their religious adviser, but with attempted intercourse vaginal penetration was impossible. After 8 months of repeatedly unsuccessful attempts to reestablish coital function, the couple was referred for therapy.
Family Couple E had been married 8 years when seen in the Clinic. They mutually agreed that a coital connection had not been possible more than once or twice a month in the first two years of marriage. Each time, the wife had moaned or screamed in pain as her husband was thrusting deeply into her pelvis.
After the first two years of marriage, every attempt at vaginal penetration had been unsuccessful. Both Mr. and Mrs. E had been under intensive psychotherapy, the husband for three and the wife for four years, when referred to the Foundation.
During the routine physical examinations, advanced endometriosis was discovered, and severe vaginismus was demonstrated. In due course, the wife underwent surgery for correction of the pelvic pathology. After recovery from the surgery, she returned with her husband for therapeutic relief of the vaginismus which, as would be expected, still existed despite successful surgical correction of the endometriosis.
Marital Couple F, a 66 years old husband, and his 62 years old wife, were seen in consultation. When the wife was 54 years old, her first husband died after a three-year illness during which sexual activity was discontinued.
She remarried at 61 years of age, having had no overt sexual activity in the interim period. She had never been given hormone replacement therapy to counteract the natural involution of pelvic structures.
First attempts at the coital connection in the present marriage produced a great deal of pain and only partial vaginal penetration. With reluctance, the wife sought medical consultation. Her physician instituted hormone replacement techniques.
After a 6-week respite, further episodes of coital activity also resulted in pain and distress. Despite the fact that by this time the vaginal walls were well stimulated by effective steroid replacement, the new husband found it impossible to attain vaginal intromission.
The wife had developed obvious psychosocial resistance to the concept of sexual activity in the 60 plus age group based on
- the pain that had been experienced attempting to consummate her new marriage.
- a real sense of embarrassment created by the need for medical consultation and the necessity of admitting that she had been indulging in coital activity at her age.
As a result of the trauma that developed with attempts to renew sexual function subsequent to almost ten years of continence, she developed involuntary spastic contraction of the vaginal outlet. Judicious use of Hegar dilators and a detailed, thorough, and authoritative refutation of the taboo of aging sexual function (based on the belief that sexual activity in the 60, 70, or even 80 year age groups represents some form of perversion) were quite sufficient to relax and relieve the vaginal spasm.
Sex with Female Homosexual
Two case histories illustrate the occasional effect of homosexual orientation upon the female partner.
Marital Couple G
was composed of a 26 years old woman married to a man 37 years old. The wife had been actively homosexual since seduction by an elder sister when she was 12 years old. There had been no history of heterosexual function before meeting her husband. He was a successful professional man and offered the woman much in the form of social status and financial security. He had been previously married and divorced.
Sexual exposure during the short engagement had been restricted, by female edict, to multiple manipulative approaches. There was a total inability to penetrate on the wedding night or to consummate the marriage thereafter. When the couple was seen after 18 months of marriage, the wife’s hymen was not intact but there was evidence of severe vaginismus.
Once all of her pertinent histories were obtained and shared with her marital partner, there was little further resistance to penile penetration. She was orgasmic with intercourse within two weeks after termination of the acute phase of therapy.
Marital Couple H
had been married for 7 years. There were two children. The husband became an alcoholic, lost his job, and left his family without warning. He was out of the home for 3 years before he could be persuaded to seek professional help. There was another year spent in treatment before he could return to family and social position.
Fortunately, there was sufficient financial resource, so no great financial hardship was suffered by his family. The wife, distraught at first, sought support from her best friend, also married and living in the neighborhood.
Within a year an overt homosexual relationship developed. Mrs. H had no prior history of homophile orientation. Two years after her husband left the home, Mrs. H attempted sexual intercourse on several different occasions with two different men, but neither man could penetrate.
There was no further heterosexual exposure after these failures until her husband was released from institutional control to return to normal activity. When attempting intercourse, Mr. H could not penetrate, nor was he able to during the subsequent two years before the marital couple was seen in therapy.
The vaginismus was obvious at physical examination. The probable cause of her involuntary rejection of coitus was explained and accepted by both partners. Dilators were used effectively and coital functioning was reestablished quickly.
One marriage had existed in a sexual successful state for almost 10 years when the husband was detected in an extramarital affair. There was a 4-month period of continence while marital fences were mended with help from clergy.
Although verbally forgiving his transgressions, the wife evidenced vaginal spasm during subsequent attempts at coital connection. The marital couple’s inability to reestablish a successful coital pattern continued for almost 18 months until, consumed with fears for performance, feelings of guilt, and finally of personal rejection, the husband became secondarily impotent. When seen in therapy, both vaginismus and impotence were presenting systems.
There have been 7 more instances of vaginismus treated by Foundation clinic personnel. Onset of symptoms has ranged from evidence of involuntary vaginal spasm with a first coital opportunity to dysfunction secondary to physiological or psychological trauma. There seems little need for further illustration of the onset of the syndrome.
Regardless of onset, an effective therapeutic approach is to establish the etiological influences by careful history-taking, and then to approach treatment confidently. With adequate dissemination of information so that full appreciation of onset of the sexual dysfunction is acquired by marital couple involved, and the sexual partners’ mutual cooperation in therapy, reversal of the syndrome of vaginismus is accomplished with relative ease.