What is Vaginismus? A Comprehensive Guide
Authored by the Bodyful Physical Therapy and Wellness Team
Are you looking for vaginismus treatment?
Do you have pain with sex and like you are hitting a wall during sex?
In this blog, you will learn what vaginismus is, the causes of it, and what can be done to support it!
What is vaginismus?
Vaginismus can affect anyone with a vulva, especially during vaginal penetration including pelvic exams and using a menstrual cup or tampon.
Vaginismus can be caused by tight pelvic floor muscles and a fear of pain from any vaginal penetration. Your pelvic floor muscles must stretch for penetration, but if they are “tight,” this can cause penetration to be painful or even feel impossible to achieve.
Vaginismus is important to care for, because you deserve to have pain free intercourse for connection, pleasure, and family planning.
Vaginismus can also affect other areas of health beyond sexual function. This tightening of the pelvic floor muscles may be a barrier to gynecological exams, tampon insertion, and/or menstrual cup insertion.
As with any physical condition, the research is showing it is becoming harder and harder to fully separate the physical from the mental, emotional, and spiritual. So while physical therapists are trained to diagnosis issues with muscles and fascia, your story, medical condition, psychology, and spirituality may also need tending for your muscles and fascia to let go.
For example, when you are anxious, your chest and shoulders will tense and pull your ribs up and forward. Consequently, your respiratory diaphragm cannot flatten fully to sufficiently “massage” your abdominal contents and appropriately “pressurize” your pelvic floor muscles. Over time, even 20 minutes, your pelvic floor muscles can get stiff from the lack of movement from breathing unsustainably.
Vaginismus is researched as a “phobic disorder” from the body. If the components of fear, trauma, and stress are not cared for, then stretching and dilators alone may not feel therapeutic, or even possible, for you.
“Vaginismus,…may be a phobic reflexive response to protect the individual against actual, perceived or anticipated harm from vaginal penetration.”
Felt and perceived safety are the basis for support when treating vaginismus. Pelvic floor physical therapy treatment can support and guide you on how to treat vaginismus at home.
The causes of vaginismus:
Vaginismus is distinct from dyspareunia. Dyspareunia may come from a more acute physiological cause such as a traumatic birthing experience or even a surgery that occurred in the pelvic, hip, back, or abdominal areas. Recurrent infections such as yeast infections, UTIs, or a history of STIs can also create more inflammation, irritation, and therefore holding patterns at the pelvic floor muscles and a sensitive pain experience. Similarly, chronic pelvic pain and inflammatory conditions such as endometriosis and interstitial cystitis can create muscular tension and fascial holding patterns at the pelvic floor due to longstanding pain and inflammation in the pelvic area.
Typically, people with dyspareunia experience pain with sex, but they do not avoid it.
“Excessive dread of pain during penetration is a common symptom reported by people with vaginismus. A phobia is defined as ‘a marked and persistent fear that is excessive or unreasonable that is triggered by the presence or anticipation of a specific object or situation’ thus, vaginismus is considered a phobia.”
Vaginismus treatment responds well to holistic and integrated care for you body, mind, and spirit.
So whether something starts more in the mind and then manifests into physical symptoms, or something starts as physiological and then affects the nervous system, your many systems are always dancing together.
Vaginismus can also be a very real physiological experience that is driven by deeper states of trauma, stress, anxiety, and fear. Especially if there is a history of sexual trauma, abuse, or negative associations with sex, the pelvic floor muscles can have even more reason to want to stay tight and in a protective state. For some people, this can manifest also in relationships with poor communication, lack of safety, or relationships that have a heavy emphasis on strongly religious and/or conservative beliefs about sexuality.
“Women with vaginismus have been found to score higher on tests of anxiety, and anxiety-proneness has been identified as a risk factor for vaginismus” (Watts & Nettle, 2010).
“There may also be a disgust-induced protective response.”
In these cases, somatic pelvic floor physical therapy and somatic psychotherapy can help. Together, the body-mind can be held, supported, and tended, so there is space to reintegrate and create new meanings, experiences, and stories with this powerful part of your body.
Common symptoms of vaginismus:
How might you know if you have vaginismus? One way you might feel symptoms express is through involuntary muscle tightening of your pelvic floor muscles, gluteal muscles, abdomen, and inner thighs, when anticipating vaginal penetration.
Are you experiencing fear? Are you unable to have vaginal penetration no matter what you try?
Have you ever been able to experience vaginal penetration? Do you wish to experience vaginal penetration?
Does it feel like you “hit a wall?”
You may also feel pain with penetration even if you can achieve it, whether that is during intercourse or during a pelvic exam or cervical cancer screening. Oftentimes people with vaginismus who can achieve some penetration experience pain as well as a feeling like a ring of muscles squeezing at the opening, preventing further penetration. These muscles can also continue to feel tight and sore even after the penetration has stopped.
It is possible that alongside symptoms with sexual dysfunction, you may also have a history of constipation and/or straining. You may also have issues with urinary function including urgency, frequency, UTI like symptoms, bladder does not fully empty, or even leaking urine.
These can all result from pelvic floor muscles being too tight, and vaginismus is usually associated with tight and tense pelvic floor muscles.
Types of vaginismus:
Vaginismus can currently be classified into two different categories:
Primary Vaginismus is when the condition is present from the first experience of vaginal penetration. A speculum exam may not be possible. You may have never been able to use tampons.
Secondary Vaginismus is when the condition is acquired, after a period of success with vaginal penetration. It may be acquired from an injury or trauma.
You are not alone! These conditions can be cared for and vaginismus treatment is available with somatic pelvic floor therapy.
The impact of vaginismus:
The impact of vaginismus can be huge on person’s life. You may not be able to use menstrual cups or tampons like you would want to. You may be trying to get pregnant. You may desire to have a pleasurable sex experience.
You may experience understandable distress.
Vaginismus can also affect emotional well being. Vaginismus can lead to the avoidance of sexual activities due to fear and may have an unwanted impact on sensual intimacy.
You may experience feelings of shame, frustration, guilt, or isolation when dealing with this. One important aspect to know is that vaginismus is more common than you think, it is just rarely talked about. Shame can be a breeding ground for further pain, and one of the most healing things you can do is communicate what you are going through and what you need with trusted loved ones and expert medical providers such as pelvic floor physical therapists.
Some vaginismus treatment options:
Education about vaginismus, vulvovaginal anatomy and pelvic floor anatomy can help you understand the underlying mechanisms and contributing factors to your experience.
Pelvic floor muscle relaxation is key. Various methods can be used to support this, including verbal instruction, EMG biofeedback for vaginismus, ultrasound biofeedback and the use of trainers (previously known as dilators).
Vaginal trainers (previously known as dilators) are plastic or silicon rods with a round end, used to apply pressure at the vaginal entrance and, if possible, inserted into the vagina. Trainers usually come in sets of increasing size to be progressed through. Some practitioners prefer to teach clients to use their own fingers in place of trainers.
“Systematic desensitisation” is a type of behavioral sex therapy where pelvic floor muscle relaxation and insertion of a dilator or finger into the vagina is used to reduce the anxiety and fear associated with penetration.
“Cognitive behavioral therapy” and gradual, paced exposure exercises can be incorporated with cognitive restructuring to reduce sexual avoidance behaviors.
Pharmacological therapy have limited evidence and are, therefore, not recommended by clinical practice guidelines.
Botulinum toxin A injections to the puborectalis and pubococcygeus are increasingly being used for treating vaginismus but have limited supporting evidence.
How a somatic pelvic floor physical therapist can help:
You deserve pelvic floor physical therapy to care for vaginismus that is appropriately paced, and slow enough for your nervous system to receive, digest, process, and express what you need. You deserve a trauma sensitive therapist who can attune to you and guide your exploration of resources that are tailored to your needs.
A somatic movement therapy approach supports your agency. This means you can explore sensations, emotions, and urges from your body and the therapist may help you to discern what your body’s information is telling you. You may need more time, more space, a different body position, to rest. These are all examples of resourcing and practicing boundaries.
Learn more about our somatic approaches here.
You may also benefit from visceral fascial mobilization to improve your breath support, core stabilization, and pelvic floor muscle integration to improve your embodied experience during penetrative sex.
Consensually, your pelvic floor therapist may begin in areas of your body such as your respiratory diaphragm, abdomen, inner thighs and gluteal muscles to resource you from your more comfortable body parts as you start to receive therapeutic touch and practice your breath work.
Retraining your brain and how your body responds to anticipating vaginal touch can be profoundly therapeutic. Focusing on breath work and grounding practices may open more space for your whole being to practice new ways of responding to perceived threat.
Your pelvic floor therapist can help you to condition your posture and hips to support your pelvic floor muscles to receive the stretch necessary for penetrative sex. Your therapist will also coach you and teach you how to listen to your body so you can start to attempt vaginal penetration gradually and build confidence.
What is a vaginal trainer or dilator practice like for treating vaginismus at home?
Vaginal trainers, dilators, come in various sizes. You may start with smaller sized vaginal trainers, or you may use your finger, to practice embracing vaginal penetration.
Try coordinating the vaginal stretch while breathing fully and slowly. Your breathing should feel relaxing. If it is not, and you feel neck, shoulder, and chest tension, then you must start with relaxation before trying vaginal penetration.
It is encouraged to practice mindful movement during a vaginal trainer, or dilator, practice. You may try slowly gliding the dilator during penetration, vocalizing, and easy hip movements.
You may play with a neurologically rich and sensual practice, helping your brain and body create new experiences of safety with penetration, pressure, and stretching your pelvic floor muscles.
You may also consider inviting your partner to join you at your pelvic floor therapy visit. Your pelvic physical therapist can teach your partner how to best support you. You may also show your partner how you are using your dilators and what works for you.
Sex therapy for you and your partner may also help.
Where to seek help:
Psychotherapy with a therapist who specializes in anxiety and trauma, and who is culturally informed.
Sex therapy for you individually, or with your partner.
Pelvic floor physical therapy
Find a group to move with! Most forms of exercise will improve your pelvic health, your mood, and your confidence.
Vaginismus is an opportunity to learn more about yourself and what your needs are.
References
Chalmers KJ. Clinical assessment and management of vaginismus. Aust J Gen Pract. 2024 Jan-Feb;53(1-2):37-41. doi: 10.31128/AJGP/06-23-6870. PMID: 38316477.
Maria McEvoy, Rosaleen McElvaney & Rita Glover (2024) Understanding vaginismus: a biopsychosocial perspective, Sexual and Relationship Therapy, 39:3, 680-701, DOI: 10.1080/14681994.2021.2007233.
Raveendran AV, Rajini P. Vaginismus: Diagnostic Challenges and Proposed Diagnostic Criteria. Balkan Med J. 2024 Jan 3;41(1):80-82. doi: 10.4274/balkanmedj.galenos.2023.2022-9-62. PMID: 38173226; PMCID: PMC10767778.
