Treatment Protocol

Introduction

Treatment according to protocol comprises an, at the start, unknown number of sessions. The first session takes ^45-60 min. Subsequent sessions take 20 min. Sessions are held once every 2-4 weeks. Major components of the treatment include information about vaginismus, a physical examination, explanation of the treatment, behavioral therapy, sensation focus exercises, pelvic floor muscle exercises, systematic desensitization, and cognitive therapy. These components do not have a fixed order; they are applied electively. During the exercises and during the consultations, underlying factors (causes and/or problems) can become clear.

It is worthwhile to administer a measurement instrument before and after treatment. With the aid of a measurement instrument, possible comorbidity can be detected and the effect of the intervention can be evaluated. Questionnaires in the English language have the advantage that they are well known in the international literature, which facilitates comparisons of international publications, and that they have been used often in research, which facilitates comparisons between results and populations. However, for local use these questionnaires have to be translated and validated again but this is recommended because of cultural differences. A simple but effective instrument to obtain measurement data is the Visual Analogue Scale. From time to time during the treatment, the woman marks a score on a sliding scale to represent the amount of progress that has been made.

Information About Vaginismus

Categorically, information is given about what vaginismus is, the types of vaginismus (complete, situational, primary, secondary), the difference from dyspar-eunia, the vicious circle, how often it occurs, the reaction of the partner, the consequences on sexual satisfaction, the wish to have children, pregnancy, delivery, possible causes (psychological, relational, social, physical), the role of the pelvic floor muscles, the relationship between vaginismus and complaints related to micturition and/or defecation, and treatment methods (education, psychological approach, relational therapy, group therapy, treatment with artificial aids, physical treatment). In addition, the aim of treatment is discussed; this could be the realization of pregnancy without coitus, or making coitus possible.

Explanation of the Treatment

Explain that the treatment protocol depends on the aim of treatment. If the aim solely concerns the wish to have children, then treatment can comprise learning to insert a 1 cc syringe into the vagina, filled with semen obtained by masturbation (artificial insemination). This technique can be applied at home at a time during the menstrual cycle that gives the best chance of conception. For every woman with vaginismus, but particularly for a woman who chooses solely for artificial insemination, it is important to realize that vaginismus does not have any predictive value regarding the course of possible childbirth. They have just as much chance as any other woman of an easy or difficult delivery with or without the aid of technical gadgetry. However, it is of great importance that the person who is supervising the delivery is well informed about the problems and takes them into consideration, that is, as little internal examination as possible and, if necessary, as carefully as possible whereby the patient is given control of the situation.

If the aim is coitus, or to be able to insert a tampon or speculum, then treatment will comprise various elements: information about vaginismus, a physical examination, behavioral therapy, self-exploration, pelvic floor muscle exercises, systematic desensitization, and cognitive therapy. Explain precisely what these elements entail. Make it clear to the patient that she must now do things that she will find very unpleasant and would rather avoid. There is going to be hard work, especially at home with the homework assignments. Explain the importance of the homework assignments. Make it clear to the patient that you are trying to teach her to come to terms with her fear of penetration, but that overcoming the fear will not necessarily mean a more satisfactory sex life. Coitus can be very nice, but it is not of overriding importance for the quality of the sexual interaction. As part of the first consultation, a written report may be very helpful.

Physical Examination

In order to detect or exclude physical causes, the nonphysician and physician will have to work together. Especially in the case of vaginismus, it is not always desirable or practical to perform a medical examination straight away. The patient and care provider must make the decision together and also agree when it will take place and who will be there. The medical examination can best be described as an "educative gynecological sexological examination." In a nutshell, it can be described as an examination with "accessories." Although the doctor is gathering information (where do the patient's boundaries lie), he or she also tells the patient about the anatomy of the external genitals and points out what is normal, or shows the patient possible abnormalities. In this way, the examination can sometimes correct a negative self-image, or the doctor can explain to the patient and ideally also to her partner how physical changes and reactions are correlated with sexual problems.

It is extremely important that the patient knows in advance that she has total control over the situation, knows exactly what is going to happen and that she is the one who decides who is going to be there and who is not, and that she knows that during the examination, her boundaries will be respected and safe-guarded. Through this examination, the foundations are laid for a meaningful discussion afterwards, in which all the findings are repeated and it often happens that sexual complaints come to light that the patient has been concealing.

The Context

In concrete terms: Seat yourself comfortably and have the examination couch adjusted for the woman to be sitting. Give the patient a hand-mirror. Also give her the freedom not to look if she does not want to. Allow her partner to look over your shoulder. Take a moistened cotton bud and tell the patient (and her partner if he is present) what you see, what details you are paying close attention to, what is normal, what is abnormal and whether you consider this is playing a role in the patient's complaints. By conducting the examination in this way, you force yourself to make a thorough inspection. In the case of vaginismus, examining the patient using a speculum or the fingers do not form part of the physical examination. Tell the patient before you start that you are not going to do these things. This will save her from anticipatory anxiety and the examination will go more smoothly, which will promote better results. It is also important to ask the patient about her actual experience of the examination while you are busy and not to just assume that she is picking up your reassuring words and signals. An important aspect of the examination is the nonverbal communication: the patient's behavior and that of her partner during the examination often say much more than words can express. Obviously, the nonverbal communication works in both directions—the doctor also constantly sends out signals.

Adequate Spreading

In order to achieve a good view, you should ask the patient's permission to spread the vulva and then ask her to bear-down. The physician might also ask her to spread her vulva herself with her fingers. Adequate spreading is of great importance, otherwise, for example, you might not be able to see hyperaemic foci at the base of the hymen, which form a symptom of the most common cause of dyspar-eunia in young women, the vulvar vestibulitis syndrome. Adequate spreading also enables the patient to experience the consequences of pelvic floor muscle activity: by bearing-down or coughing, she will be able to see that the entrance to her vagina becomes larger.

Subsequently, you can ask the patient's permission to insert the cotton bud through the hymen while she is bearing-down and assure her that you will stop the procedure immediately if she wishes. If the cotton bud can be inserted easily without any problem (which is very often an eye-opener!), the procedure can be repeated with a finger or with a smooth metal rod that is the slightly thicker than the cotton bud. Hegar rods are extremely useful for this purpose because they are available in many small diameters. If it is possible to proceed to larger diameters during the procedure, you can switch over to vaginal rods. These are plastic rods with different diameters to match the natural situation, that is, the size of the partner's penis.

Measuring of Pain

To measure vulvar pain, the cotton-swab test is widely used (57,58). Pain is diagnosed by palpating different sites around the vulvar vestibule in a clockwise fashion and noting the patient's verbal and physical reactions. However, the cotton-swab test is prone to measurement error when used for experimental purposes or to measure treatment outcome (59). Ideally, the degree of pain should be documented with a diagnostic tool, for example, the vulvalgesiometer (60). It can be used as a diagnostic tool capable of differentiating among women with different types of genital pain, and because of its large range of exertable pressures, it may aid in quantifying the severity of pain (mild, moderate, and severe) experienced by these women. This device also has applications in quantifying changes in vestibular sensitivity as a result of treatment.

The Pelvic Floor

The sheet of pelvic floor muscles can be easily translated for the patient by describing it as a sort of trampoline: an elastic sheet that closes off the lower pelvis and has two openings, the anus and the vagina. The pelvic floor muscles contain both these openings in loops and they determine the discharge diameter of the anus and access diameter of the vagina. Women with dyspareunia or vaginismus contract these muscles in order to voluntarily or involuntarily control the accessibility of the vagina. This results in an inability to relax at times when this would be desirable, for example, during love-making or when being examined on the gynecology couch. Involuntary contraction on the gynecology couch does not infer that this also happens at home.

Inversely, some women can undergo a gynecological examination without any problem, but have vaginistic reactions in other circumstances, depending on what they find threatening. In many cases, the pelvic floor muscles are chronically contracted and feel like "steel cables." Muscles that are constantly contracted will start to cause pain, especially if pressure is also exerted from the other side, such as during an attempt at coitus.

In order to find out pelvic floor muscle problems, the physician places his or her finger between the woman's labia just in front of the vaginal opening and see how that feels. At the same time, she can be advised to reduce the tension in her pelvic floor muscles by repeatedly contracting or relaxing them and giving reversed pressure. This reversed pressure creates room to continue pushing or contracting the muscles, which is followed by relaxation. At the moment of relaxation, the physician moves the finger slowly inside. As the finger moves, keep it dorsally curved to feel the pelvic floor muscle without touching any painful areas at the vestibulum. In the end of the examination, the finger is slowly withdrawn. The use of a lubricant will facilitate the examination and also prevent tissue damage (Sensilube, Sonogel).

If physical abnormalities are found that can cause pain, for example, a stiff hymen or epithelial defects, then the patient may have dyspareunia with secondary pelvic floor muscle hypertonia that contributes to maintaining the complaints. All forms of physical illness or abnormality that cause vaginismus or pain during coitus require medical treatment by a doctor. If the patient has general pelvic floor muscle problems with impaired micturition or defecation, then attention must also be paid to these aspects by means of learning to adopt a correct toilet position and micturition frequency, and breaking the habit of bearing-down during micturition. In the case of the irritable bowel syndrome, dietary measures can be discussed.

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