Botox Treatment for Vaginismus

YouTube Video by Dr. Pacik
Rachel: The Blessing of Botox
Rachel: The Blessing of Botox Part 2
Khadija's story
Wendy: Another Woman of Courage
Kelsie: You Tube
Achieving Intercourse with Botox
Advancing to Intercourse
Anonymous Testimonials
Anxiety and Vaginismus
Botox for Vaginismus: Controlled study
Botox for Vaginismus. Fear of treatment
Botox for Vaginismus Internet Confusion
Botox for Vaginismus: Pacik Study
Botox for Vaginismus: Publication
Botox for Vaginismus: References
Botox Treatment for Vaginismus
Botox, Vaginismus & Burning
British Connections
Burning and Itch in Vaginismus
Causes of Vaginismus
Dilator Advancement, Getting Unstuck
Dilators for Vaginismus, Correct Use
Dysparuenia (Painful Intercourse)
Incidence of painful intercourse
Insurance coverage for Vaginismus
Lamont classification of vaginismus
Organization: AASECT
Organization: SSSS
Painful intercourse: Medical Reasons
Pelvic Floor Anatomy
Summary: International Study
Team Approach for Vaginismus
Too Much Talk
Unable to have Intercourse
Vaginal Dilation during Anesthesia
Vaginal Dilation under Anesthesia
Vaginal Spasm treated with Botox
Vaginismus and Libido
Vaginismus, Botox, Dilators
Vaginismus, Botox, General
Vaginismus, Botox, Skype
Vaginismus Post Botox Instructions
Vaginismus Pre & Post Questionnaires
Vaginismus: The Tyra Banks Show
Vulvodynia (vulvar pain) & Botox

by Peter T. Pacik, MD, FACS

Additional information written by Dr. Peter T. Pacik on vaginismus can be found under Botox for Vaginismus.

What is Vaginismus?

Vaginismus is an uncontrolled, involuntary painful spasm involving the muscles surrounding the vagina which can be triggered by any stimulation near the vagina or even the thought of any form of vaginal penetration such as tampon, finger, GYN speculum exam, and intercourse. Fear of penetration is the overriding emotion, and often gives rise to considerable reactions such as sweating, nausea and vomiting.

What causes Vaginismus?

The cause(s) of vaginismus is generally unknown. Numerous theories exist, and at times there may be a specific cause of vaginismus such as being sexually molested as a child or young adult. This is true in a small percentage of women. Strict home values regarding sexual involvement and the fear of getting pregnant has been linked to vaginismus.  Girls are often told that the first time they have sex is very painful and this may set the stage for fear of intercourse. Thinking that their vagina is too small to accommodate the penis, they are frightened that the vagina will be ripped or stretched too far. At times, there are infections or medical problems that can be treated, but for the most part the cause of vaginismus is unknown.

Who suffers from Vaginismus?

Any woman from any culture in the world can suffer from vaginismus. Women can come from any background, any level of education, and any level of sexual awareness and sexual education. 

When is Vaginismus first diagnosed?

As a youngster, the girl may note difficulty in using a tampon. Later, women may become aware that something is wrong during their first GYN examination. The thought of a speculum entering them causes an unexpected physiologic response which may start as fear, and progress to shaking, and sometimes nausea and vomiting. The unsuspecting patient and her doctor are surprised by this dramatic reaction, and often the doctor will unknowingly ask the patient to relax, when in actual fact the patient has no control over this response. Even at this point, a diagnosis of vaginismus may not be made because many physicians are not sensitive to the diagnosis of vaginismus. The patient feels terrible, the doctor is confused, and the patient may be told to come back another time. This is usually the beginning of a long and painful journey that is emotionally upsetting to the patient. The fear of not being able to consummate a marriage begins to take hold, and this may be the beginning of numerous trials of therapy to overcome the vaginismus.

Worse yet, the patient may discover her vaginismus on her honeymoon. Here too, she is totally unprepared for this turn of events, as is the new husband who has no clue as to what is going on.

Classification of Vaginismus:

In primary vaginismus, the woman has never been able to have intercourse, and often has not been able to tolerate any form of penetration including a small tampon.

In secondary vaginismus, the patient may have been able to have intercourse, and may have given birth to a child, but something happens (again usually unknown) and intercourse is no longer possible. Any attempt at this causes considerable pain, withdrawal and fear.

Vaginismus is further classified according to severity using the Lamont classification

• First degree vaginismus:  the muscles of the vagina are noted to be tight, but the patient is able to relax with reassurance.
• Second degree vaginismus: the muscles are in a state of contraction and the patient is unable to relax.
• Third degree vaginismus:  There is spasm of the vaginal muscles and the patient elevates her buttocks to avoid being examined.
• Fourth degree vaginismus (also currently known as Grade 4 vaginismus): Is the most severe form of vaginismus described, with severe spasm of the vaginal muscles combined with considerable fear. This results in an involuntary reaction that causes the patient to elevate her buttocks, retreat, and close her thighs. Examination is impossible.

Many of our patients exhibit a ” Fifth degree vaginismus” in that the retreat is so severe that they are ready to jump off the examining table, and they note a major physiologic reaction of  sweating, nausea and even vomiting. This sometimes takes place just knowing they are going in for an examination.

The duration of vaginismus varies according to the severity of the condition. First and second degree vaginismus patients may respond to conservative therapy and this can takes months to years. More severe forms of vaginismus usually do not respond to dilators, physiotherapy, psychotherapy, hypnotherapy, biofeedback, drugs, hymenectomy or sex counseling and are often shunted from one therapist to another. Often the diagnosis of vaginismus is not made and the patient may spend years involved with unsuccessful treatments. This takes a major toll on the patient and her relationship.

Painful intercourse (known as dyspareunia) ranges from mild to severe and may progress to vaginismus.

Another term associated with vaginismus is vulvodynia (pain around the area of the vulva formerly known as vulvar vestibulitis syndrome). This condition may or may not be associated with vaginismus and again unless there are specific medical conditions, the cause of vulvodynia is for the most part unknown.

Treatment of Vaginismus:

Numerous conservative therapies exist for the treatment of dyspareunia (painful intercourse) and vaginismus, yet none of them have withstood well controlled scientific studies. Severe cases of painful intercourse and vaginismus often involve years of treatment at considerable time and expense, associated with frustration on the part of the patient and continued disruption of their relationship. Conservative therapy often consists of Kegal exercises, psychotherapy, sex counseling, lubricants, topical anesthetics, muscle relaxants, anti-anxiety medications, anti-depressants, physical therapy and therapy with dilators. Some patients drink themselves into a stupor or use excessive amounts of anti-depressants to be able to achieve intercourse. Others are unable to have any form of penetration no matter what they try. Hymenectomy may be performed but vaginismus due to an intact hymen is rare. Surgery (vestibulectomy) may be successful, but pain due to scar formation may result. Conservative measures generally take years to accomplish the goal of being able to have painless intercourse. More severe cases are resistant to these measures resulting in a great deal of frustration and upheaval in relationships and marriage. Numerous scientific publications are critical of the lack of scientifically controlled studies for the use of conservative measures, pointing out that none of these conservative measures are evidence based.

Using Botox as a Treatment for Vaginismus:

Botox treatment for vaginismus dates back to at least 1997 (ref 1). Most plastic surgeons, obstetricians, and sex therapists are not familiar with the use of Botox treatment for vaginismus.

A study from Iran using Botox for vaginismus was reported in 2004 (ref 2). In this study, Dysport (a type of Botox used in Europe) 150-400 mIU was used. 23 patients were able to have vaginal examinations one week post procedure showing little or no vaginismus. One patient refused vaginal examination and did not attempt intercourse. Of the 23 patients, 18 (75%) achieved satisfactory intercourse, 4 (17%) had mild pain and one patient was unable to have intercourse because of her husband’s impotence.  A second dose of Dysport was needed on one patient. There were no recurrences during the 2-24 month follow-up period.

Our own experience with Botox as a treatment for vaginismus is equally satisfying.  Our current protocol in 2008-2009 consists of injecting 100 to 150 units of Botox intravaginally into the area of vaginal spasm under anesthesia. Currently, we also leave a dilator in place while the patient is under anesthesia. The dilator is coated with local anesthesia and is not felt by the patient as she is waking up in the recovery room. In addition, a long-acting anesthetic is injected into the vaginal muscles. The combination of Botox and vaginal dilation allows for painless intercourse which can be achieved within 2-6 weeks of Botox injection. Although Botox normally lasts only 2-1/2  to 4 months, once the vagina is dilated, it is rare to require additional injections. The results of our first 20 patients showing a 90 percent plus cure rate were published in the December 2009 issue of Plastic Surgery & Reconstructive Surgery (Ref. 5)

Links:

For more information on the personal experience of two of our patients, please visit the following: Kelsie: You Tube and Rachel: The Blessing of Botox.

References:

Ref. 1: Brin MF, Vapnek JM. Treatment of vaginismus with botulinum toxin injections. Lancet. 1997 Jan 25;349(9047):252-3. No abstract available. Erratum in: Lancet 1997 Mar 1;349(9052):656. PMID: 9014917

Ref 2: Ghazizadeh S, Nikzad M. Botulinum toxin in the treatment of refractory vaginismus. Obstet Gynecol. 2004 Nov;104(5 Pt 1):922-5. PMID: 15516379

Ref 3: Shafik A, El-Sibai O. Vaginismus: Results of treatment with botulin toxin. (2000) Obstet Gynecol. 20:300-2.

Ref 4: Lamont JA. Vaginismus. Am J Obstet Gynecol. 1978 Jul 15; 131(6):633-6. PMID 686049.

Ref 5: Pacik, PT Viewpoint: Botox Treatment for Vaginismus, Dec 2009, Plastic & Reconstructive Surgery, Vol 24, 455e-456e

Contact Us for More Information