The Definition

The assumption that dyspareunia and vaginismus are distinct types of sexual pain disorders has recently been challenged (3-8). Research has demonstrated persistent problems with the sensitivity and specificity of the differential diagnosis of these two phenomena. Both complaints may comprise, to a smaller or larger extent: (1) problems with muscle tension (voluntary, involuntary, limited to vaginal sphincter, or extending to pelvic floor, adductor muscles, back, jaws, or entire body), (2) fear of sexual pain (either specifically associated with genital touching/intercourse or more generalized fear of pain, or fear of sex), and (3) propensity for behavioral approach or avoidance. All these three phenomena are typical of vaginismus, but may also be present in dyspareunia.

Also, differentiation between vaginismus and dyspareunia using clinical tools is difficult, or nearly impossible (3,7,8), and vaginal spasms cannot be diagnosed reliably (3). Only physical therapists can differentiate vaginismic women from matched controls on the basis of muscle tone or strength differences (3,9,10). In addition, for the treatment of vaginismus, despite strong clinical support, vaginal "dilatation" plus psycho-education, desensitization, and so on is not to date supported by scientific study (5,10-13). Finally, there is accumulating basic research to support the idea that the pelvic floor musculature, like other muscle groups, is indirectly innervated by the limbic system and therefore highly reactive to emotional stimuli and states (14-16). On the basis of this emerging knowledge of the underlying pathophysiologic mechanisms, it is obvious that current diagnostic categories of vaginismus and dyspareunia may overlap, and need to be reconceptualized. The same goes for the spasm-based definition of vaginismus despite the absence of research confirming this spasm criterion.

At the 2nd International Consultation on Erectile and Sexual Dysfunctions in July 2003 in Paris, a multidisciplinary group of experts in the field has proposed new definitions of vaginismus and dyspareunia (2,17). Vaginismus is defined as: The persistent or recurrent difficulties of the woman to allow vaginal entry of a penis, a finger, and/or any object, despite the woman's expressed wish to do so. There is often (phobic) avoidance and anticipation/ fear of pain. Structural or physical abnormalities must be ruled out/ addressed. It is emphasized that reflexive involuntary contraction of the pelvic muscles as well as thigh adduction, contraction of the abdominal muscles, muscles in the back and limbs, associated with varying degrees of fear of pain and of the unknown, typically precludes full entry of a penis, tampon, speculum, or finger. However, discomforting or painful vaginal entry may occur.

Dyspareunia is defined as: Persistent or recurrent pain with attempted or complete vaginal entry and/ or penile vaginal intercourse. The authors clarify that the experience of women who cannot tolerate full penile entry and the movements of intercourse because of pain needs to be included in the definition of dyspareunia. Clearly, they state, it depends on the woman's pain tolerance and her partner's hesitance or insistence. A decision to desist the attempt at full entry of the penis or its movement, within the vagina, should not change the diagnosis. Finally, they recommend that the diagnoses be accompanied by descriptors relating to associated contextual factors and to the degree of distress.

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