Vaginismus

VAGINISMUS, vaginismus, tetanic contraction of all the muscles of the pelvic floor during attempts at sexual intercourse or gynecological examination. Until recently, V. was viewed exclusively as a reflex phenomenon arising from mechanically perceived painful irritations of the sensory nerves of the external genital organs, especially when there were any abrasions, cracks, ulcers, tears, or scars on the hymen (due to the narrowness of its opening or the density of its tissue). A significant pelvic tilt may also play a role here, as due to the displacement of the entire vulva backward, sexual intercourse becomes painful for the woman, because the penis presses against the area of the clitoris or urethra. The existence of these so-called neurogenic forms of V. is beyond doubt—this will be the so-called pseudovaginismus, false, organic, local, secondary V. Naturally, in these cases, treatment, corresponding to the etiology, should, as much as possible, be directed at eliminating purely local phenomena. - The true typical V., in the proper sense of this word (the credit for developing its pathogenesis and therapy belongs to Walthard), manifests, however, completely independently of the greater or lesser sensitivity of the external genitals and, what is very characteristic of it, in the complete absence of any changes in them (often with an intact hymen). These cases are undoubtedly of purely psychogenic origin. The following facts speak for this: spasmodic contractions of the pelvic floor muscles can be observed not only during attempts at sexual intercourse or gynecological examination, but also without any contact with the genitals, connected only with certain visual or auditory perceptions or even with mere ideas and emotions: the patient sometimes only needs to think about a possible touch to her sexual organs for the associated feeling of fear of pain to cause the corresponding symptom-complex. Such a sharp increase in psychological excitability is often only a partial manifestation of a constitutional psychoneurosis with a tendency to obsessive phobias (see). - If such a defect in the psyche, which always intensifies under the influence of various harmful factors from the surrounding conditions (but at the same time yields to preventively beneficial measures), is sharply expressed, then sexual intercourse immediately becomes impossible: the woman relates to it with prejudice and already purely psychologically resists it; because of this, there is no sexual readiness, which is a necessary psycho-physiological prerequisite for a normal sexual act, and therefore there is no material substrate of this readiness, i.e., the moistening of the external genital parts with mucus, which is necessary for the unimpeded and painless completion of coitus. Constitutional psychopathic tendencies can intensify and develop depending on the entire environment in which the sexual life develops. The attitude of the man (at the moment of sexual rapprochement) plays a very large role here. A cautious and careful approach, when the man consciously takes into account the female psyche, easily overcomes some, partly naturally occurring, psychological resistance and does not give rise to the manifestation of the indicated psychopathic predispositions. On the contrary, a rough first approach by the man under such conditions (especially in a state of intoxication) acts on the woman as a strong psycho-sexual trauma, as a sharp dissonant standing in complete contradiction to all her previously formed ideas and illusions. Sexual life, beginning with such psychological violence and disappointment, is subsequently established with difficulty. The woman awaits each new attempt to perform the sexual act with fear, as this not only cannot give her any satisfaction or cause any pleasant emotions, but on the contrary is associated with a new experience of purely psychological pain. Naturally, under such conditions, a constant oppressive fear quickly develops, and, in connection with it, at each new attempt at sexual rapprochement, that psychoreflex which constitutes the primum movens and essence of the entire symptom-complex of V. Very often, the slightest hint of the possibility of coitus causes contraction of all the striated muscles of the pelvic floor (sometimes with simultaneous tetanic contraction of the smooth muscles of the vagina, giving as it were a functional temporary stenosis of it). In far-advanced, long untreated cases, as a result of V., a purely psychological impotence can gradually develop in the man as a secondary phenomenon. Since a clearly expressed state of V. excludes the possibility of introducing even the thinnest instrument into the sexual cleft, of course the man, even with maximum sexual potency, cannot forcibly overcome this resistance, which is complex in its origin and contains both purely psychological and somatic elements; it is not surprising that, with insufficient potency, attempts to perform the sexual act, remaining unsuccessful each time, lead to the man, prone to obsessive states and not confident in his abilities, with each new failure losing more and more confidence in himself; it is precisely in this way that a rather persistent psychological impotence sometimes gradually develops in him. When things reach this point, a 'vicious circle' is created. The indicated pathological conditions in the man and woman mutually reinforce and support each other to such an extent that a complete disruption of sexual life occurs with all its often very serious socio-domestic consequences. In addition to this, in the origin of V., of course, organic impotence of the man, various manifestations of his sexual perversity, and some repulsive physical and psychological features of his can indirectly play a role; further, certain obsessive thoughts that play the role of a 'foreign body' in the woman's consciousness (Stoeckel) are important, for example, fear of all possible consequences of the sexual act, which always disrupts its spontaneity and emotional quality. The diagnosis of psychological V. is relatively simple. For it, the attitude of the patient to the gynecologist and to the impending gynecological examination is already typical: the patient becomes very agitated in advance, trembles, squeezes her thighs, tosses about in all directions, and voluntarily or involuntarily performs everything that hinders the examination and even excludes any possibility of touching the genitals. Just as in anticipation of coitus, sometimes only the thought of the impending medical examination or, for example, one glance at the vaginal speculum is enough for the sudden spasmodic contraction not only of the pelvic floor muscles but also of other muscle groups, sometimes of the entire body (opisthotonus) and even the limbs. In such cases, the doctor's approach must be extremely cautious and careful, excluding any violence as much as possible. - In full accordance with the psychogenic origin of the entire symptom-complex of V., its treatment should consist of purely psychological influence on the patient. Any local therapy, previously often practiced in such cases, is here inappropriate and even harmful. In the foreground is the general treatment of the patient, since asthenic phenomena, pure or with admixtures of hysterical complications, arose under the influence of one or another exhausting factors. As for the specific features of V., the doctor needs patience, calmness, endurance, and persistence; he must achieve his goal indirectly, going step by step; first, with a soft but at the same time authoritative approach, the patient must be calmed down and promised that nothing will be done without her consent; when the patient calms down, she herself will first allow a simple examination of the external genitals; at this moment, she can and must be assured that there is apparently nothing abnormal; by talking with her about the groundlessness of her fears of pain and somewhat diverting her attention, it is often possible, almost unnoticed by the patient, to open the sexual cleft and insert a finger into the vagina (of course, withdrawing it at the slightest resistance). One way or another, with persistent but very cautious persistence, often after several unsuccessful attempts, the examination can be completed. It is very advisable to use the method proposed by Walthard in this case: the patient is asked to tense the abdominal muscles strongly, of course, which relaxes all the muscles of the pelvic floor (due to the physiological antagonism between these groups of striated muscles); such a simple procedure, which also diverts the patient's attention, usually makes it possible to insert first one, then two fingers, and finally the vaginal speculum into the vagina, which it is useful to show to the woman and thereby convince her that there is neither narrowness of the vagina (which such patients sometimes think) nor any other mechanical obstacles, that there is no basis for painful sensations in connection with the sexual act, that it is at least mechanically quite possible.

In this way, it is sometimes possible to easily break the chain of incorrect ideas and conclusions that have become entrenched in the patient's consciousness due to self-suggestion or suggestion coming from the husband (it is known that physically or mentally impotent and disabled men, for one reason or another, often seek the cause of unsuccessful attempts at coitus not in themselves but in their wives, suggesting to them that 'something is wrong with their sexual organs'). Of course, simultaneously with the wife, the husband must also become the object of the doctor's psychotherapeutic intervention; in any case, first of all, he needs to be advised to approach his wife as carefully as possible during moments of sexual rapprochement, to explain to him the importance of the gradually developing psychosexual preparedness of her, which should always precede each attempt at the sexual act. It is also important, if the husband shows signs of purely psychological impotence, to explain to him its peculiar pathogenesis, to restore his confidence in his own strength, to instill in him the idea of the transient nature of this purely functional disorder, which is associated with a similar functional disease in his wife; in these cases, as well as during gynecological examination, more or less strong contractions of the abdominal muscles, performed by the woman during coitus, are useful; they not only eliminate the resistance of the pelvic musculature but even lead to a decrease in its tone below normal, causing the vaginal opening to gape and thus mechanically facilitating the sexual act: a few successful attempts are enough for the man to be cured of his psychological impotence. Thus, both sides benefit: V. in the woman and temporary impotence in the man are quickly eliminated. However, it is not always possible to ensure the success of treatment with only these simple measures. In complex (in terms of their psychogenesis) cases, where vaginismus develops under the influence of various inhibitory influences and inhibitory psychological factors, where the aforementioned psychological conflicts are created, where the entire symptom complex of V. is only a partial manifestation of general psycho-neurotic disorders, deeper psychoanalysis and a more subtle, strictly individualized special psychotherapy are required, and above all, general strengthening treatment aimed at the psycho-neurosis as the basic soil. Under conditions of normal physical and mental regime, proper upbringing, and especially physical culture, a disease such as psychological V. should have no place.