Raiyyan Tahsan

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TC(856).(20).Sexology Case No 09. Vaginismus

Vaginismus কাকে বলে?

Vaginismus হলো এমন একটি অবস্থা যেখানে vaginal penetration—যেমন intercourse, tampon, speculum examination—করতে গেলে pelvic floor muscle involuntary tight/spasm হয়ে যায়, ফলে ব্যথা, ভয়, anxiety, penetration difficulty বা সম্পূর্ণ inability হতে পারে। আধুনিক DSM-5 terminology-তে এটি অনেক সময় Genito-Pelvic Pain/Penetration Disorder–এর অংশ হিসেবে ধরা হয়।

Core meaning: ভয়–ব্যথা–muscle spasm cycle তৈরি হয়। রোগী ইচ্ছা করলেও penetration allow করতে পারে না।

Cause of Vaginismus:-

Vaginismus-এর কারণসমূহ (Must Causes)

১. মাসল / ফাংশনাল কারণ

  • পেলভিক ফ্লোর মাসল (pelvic floor muscle) অস্বেচ্ছা সংকোচন বা হাইপারটোনিসিটি
  • লেভেটর এনি (levator ani) বা বুল্বোস্পঙ্গিওসাস (bulbospongiosus) মাসল অতিরিক্ত সক্রিয় হওয়া
  • ব্যথাযুক্ত penetration-এর অভিজ্ঞতা → ভয় → মাসল টাইটনেস → আরও ব্যথা

২. জাইনোকোলজিক্যাল ব্যথা / রোগ

  • ভলভোডাইনিয়া (Vulvodynia) / ভেস্টিবুলার ডাইনিয়া (Vestibulodynia)
  • ভ্যাজিনাল কানডিডিয়াসিস (Candida infection)
  • ব্যাকটেরিয়াল ভ্যাজিনোসিস (Bacterial vaginosis)
  • ট্রাইকোমোনিয়াসিস (Trichomoniasis)
  • জেনিটাল হেরপিস (Genital herpes ulcer)
  • ইউটিআই / ইউরেথ্রাল পেইন সিন্ড্রোম (UTI / urethral pain)
  • এন্ডোমেট্রিওসিস / ক্রনিক পেলভিক পেইন
  • প্রসব পরবর্তী বা এপিসিওটমি স্কার (Perineal scar)

৩. হরমোনাল / শুকনোত্ব সম্পর্কিত

  • মেনোপজ বা জেনিটোরিউরিনারি সিনড্রোম অফ মেনোপজ (GSM)
  • স্তন্যপান / ল্যাকটেশন সংক্রান্ত হাইপোইস্ট্রোজেনিজম
  • কম লুব্রিকেশন (dryness)
  • কিছু ক্ষেত্রে ওরাল কন্ট্রাসেপ্টিভ ব্যবহারে ভেস্টিবুলার ব্যথা

৪. গঠনগত / এনাটমিকাল

  • শক্ত / রিজিড হাইমেন (Rigid hymen) বা মাইক্রোপারফোরেট হাইমেন (Microperforate hymen)
  • ভ্যাজাইনাল সেপটাম (Vaginal septum)
  • জন্মগত ভ্যাজাইনাল অ্যানোমালি
  • পেলভিক মাস বা টিউমার যা ডীপ ডাইস্প্যারুনিয়ার কারণ

৫. মানসিক / সাইকোসোশিয়াল

  • penetration-এ ভয় বা ব্যথার আশঙ্কা
  • প্রথম যৌন সম্পর্কের ব্যথাযুক্ত অভিজ্ঞতা
  • যৌন নির্যাতন / ট্রমা ইতিহাস
  • উদ্বেগ / anxiety disorder
  • সম্পর্কের সমস্যা / conflict
  • অল্প যৌন শিক্ষা বা cultural guilt/shame

       ডিপ্রেশন বা শরীরের ইমেজ সমস্যা

Etiology — কারণগুলো

A. Functional / muscle-related cause

  • Pelvic floor muscle hypertonicity বা involuntary spasm
  • Levator ani / bulbospongiosus muscle overactivity
  • Painful penetration experience → fear → muscle tightening → more pain

B. Pain-related gynecological cause

  • Vulvodynia / vestibulodynia
  • Vaginal candidiasis
  • Bacterial vaginosis
  • Trichomoniasis
  • Genital herpes ulcer
  • UTI / urethral pain syndrome
  • Endometriosis / chronic pelvic pain
  • PID
  • Postpartum perineal scar pain
  • Episiotomy scar tenderness

C. Hormonal / dryness-related cause

  • Menopause-related vaginal atrophy / GSM
  • Lactation-related hypoestrogenism
  • Low lubrication
  • Oral contraceptive–associated vestibular pain in some patients

NICE recommends adequate treatment of menopausal genitourinary symptoms, including vaginal oestrogen, to avoid dyspareunia.

D. Structural / anatomical cause

  • Rigid hymen / microperforate hymen
  • Vaginal septum
  • Congenital vaginal anomaly
  • Pelvic mass causing deep dyspareunia

E. Psychological / psychosocial cause

  • Fear of pain or bleeding
  • Previous painful first intercourse
  • Sexual trauma / abuse history
  • Anxiety disorder
  • Relationship conflict
  • Poor sex education
  • Cultural guilt or shame regarding sex
  • Depression or body image issues

Symptopms:-

  Penetration করতে গেলে vaginal opening tight হয়ে যাওয়া

  Intercourse করতে না পারা বা খুব painful হওয়া

  Speculum examination tolerate করতে না পারা

  Tampon / menstrual cup insert করতে সমস্যা

  “ভেতরে ঢুকছে না” বা “wall-এর মতো বাধা” অনুভব

  Burning, stinging, tearing pain at introitus

  Penetration attempt-এর আগে ভয়, panic, crying, avoidance

  Pelvic floor muscle contraction

  Partner approach করলেই anxiety বা body tightening

  Recurrent failed intercourse despite desire

  Libido normal থাকতে পারে, কিন্তু penetration-fear থাকে

Vaginismus-এর লক্ষণসমূহ :-

  • ভ্যাজাইনাল penetration (যেমন intercourse, tampon, speculum) করতে গেলে ভেতরের মাসল স্বেচ্ছার বাইরে সংকুচিত হয়ে যাওয়া
  • Intercourse করতে পারা না বা খুব ব্যথা হওয়া
  • Speculum বা ডাক্তারের পরীক্ষা সহ্য করতে না পারা
  • Tampon বা menstrual cup insert করতে সমস্যা
  • “ভেতরে ঢুকছে না” বা “দেয়ালের মতো বাধা” অনুভব করা
  • দাহ, ঝাঁঝালো বা ছিঁড়ে যাওয়ার মতো ব্যথা ইন্ট্রোটাসে
  • Penetration-এ চেষ্টা করার আগে ভয়, panic, কাঁদা বা এড়ানোর চেষ্টা
  • Pelvic floor মাসল অস্বেচ্ছা সংকোচন
  • Partner-কে কাছে পেলে anxiety বা শরীর টাইট হওয়া
  • বারবার failed intercourse হওয়া, ইচ্ছা থাকলেও না পারা

       Libido স্বাভাবিক থাকতে পারে, কিন্তু penetration fear থাকে

3. Clinical Diagnosis — কীভাবে diagnosis করবেন?

Vaginismus-এর diagnosis মূলত clinical। কোনো single blood test নেই।

A. History taking — specific questions

  • Primary না secondary?
    • Primary: কখনো pain-free penetration হয়নি
    • Secondary: আগে normal ছিল, পরে problem শুরু
  • Pain location: entry pain নাকি deep pelvic pain?
  • Trigger: intercourse, tampon, speculum, finger?
  • Discharge, itching, burning, odor আছে?
  • UTI symptoms আছে?
  • Menopause, postpartum, breastfeeding history?
  • Previous sexual trauma / painful first intercourse?
  • Relationship issue?
  • Previous pelvic surgery, episiotomy, radiation?
  • Current drugs: antidepressant, OCP, isotretinoin, antihistamine etc.

B. Examination — patient-controlled method

  • Consent নিয়ে, slow explanation দিয়ে exam
  • External vulval inspection: redness, fissure, ulcer, discharge, dermatitis
  • Cotton-swab test: vestibulodynia detect করতে
  • Single-digit pelvic floor palpation: levator spasm/tenderness
  • Speculum exam only if tolerated
  • Forced exam করবেন না

ACOG notes that persistent vulvar pain evaluation includes careful history, cotton swab testing, infection exclusion, and pelvic floor assessment when indicated.

C. DSM-5 clinical features

Diagnosis support করে যদি ≥6 months ধরে significant distress সহ:

  • Vaginal penetration difficulty
  • Vulvovaginal / pelvic pain during penetration
  • Fear/anxiety about penetration pain
  • Pelvic floor muscle tensing during attempted penetration

4. Specific Investigations

Investigation cause অনুযায়ী করবেন।

SuspicionInvestigation
CandidaVaginal swab microscopy/KOH, culture if recurrent
BVVaginal pH, whiff test, clue cells, Nugent score if available
TrichomoniasisWet mount / NAAT
Chlamydia/GonorrheaNAAT
Herpes ulcerHSV PCR / swab
UTIUrine R/E, urine culture
Recurrent candidiasisFBS/HbA1c, diabetes screening
Menopause/GSMUsually clinical; vaginal atrophy signs
Deep pelvic painPelvic USG ± laparoscopy if endometriosis suspected
Structural anomalyPelvic exam ± USG/MRI
Trauma/anxietyPsychosexual assessment

CDC recommends syndrome-specific testing and treatment for vulvovaginal discharge causes such as candidiasis, BV, and trichomoniasis.

5. Differential Diagnosis

  • Vulvodynia / provoked vestibulodynia
  • Dyspareunia from vaginal dryness
  • Vaginal candidiasis
  • Bacterial vaginosis
  • Trichomoniasis
  • Genital herpes
  • Lichen sclerosus / lichen planus / eczema
  • Endometriosis
  • PID
  • UTI / interstitial cystitis
  • Hymenal abnormality
  • Vaginal septum
  • Pelvic mass
  • Sexual trauma-related PTSD
  • Anxiety disorder

6. Treatment / Management

First-line treatment: Non-pharmacological

A. Patient education

  • রোগীকে বোঝাতে হবে: “এটা ইচ্ছাকৃত না, muscle reflex.”
  • Forced intercourse বন্ধ রাখতে হবে।
  • Painful attempt বারবার করলে condition worse হয়।

B. Pelvic floor physiotherapy

  • Pelvic floor relaxation
  • Reverse Kegel
  • Diaphragmatic breathing
  • Biofeedback
  • Myofascial release
  • Home relaxation exercise

Pelvic floor physical therapy is considered a first-line minimally invasive treatment for hypertonic pelvic floor disorders including dyspareunia, vaginismus, and vulvodynia.

C. Graded vaginal dilator therapy

  • Smallest dilator দিয়ে শুরু
  • Lubricant ব্যবহার
  • 10–15 মিনিট, সপ্তাহে 3–5 দিন
  • Pain score 0–3/10 এর মধ্যে রাখতে হবে
  • Comfort হলে next size
  • Partner involvement later stage

D. CBT / psychosexual therapy

  • Fear-avoidance cycle ভাঙে
  • Sexual anxiety reduce করে
  • Couple communication improve করে

Cochrane review found that interventions such as sex therapy and desensitisation have been proposed for vaginismus, though high-quality evidence is limited.

7. Pharmacological Treatment — Cause-based

Important: Vaginismus নিজে drug-only disease না। Drug ব্যবহার করবেন only pain, infection, dryness, vulvodynia বা refractory spasm থাকলে।

1. Lidocaine gel — penetration pain / examination support

  1. Generic name: Lidocaine hydrochloride
  2. Therapeutic category: Local analgesic / local anaesthetic
  3. Pharmacological class: Amide local anaesthetic
  4. Bangladesh available brand name: Xylogel 2% gel, Z-Lidocaine 2% gel, Jasocaine 2% gel, GP Caine 2% gel

Dose / use:

  • Thin layer at vestibule/introitus 10–20 minutes before dilator therapy, examination, or intercourse.
  • Wash off before intercourse or use condom to avoid partner penile numbness.
  • Use short term; avoid excessive amount.

Why used:

  • Entry pain কমাতে
  • Dilator therapy tolerate করতে
  • Speculum exam easier করতে

Side effects:

  • Local burning
  • Numbness
  • Irritation
  • Allergy
  • Excessive use করলে dizziness, arrhythmia, seizure rare

Drug interaction:

  • Class I antiarrhythmic drugs
  • Amiodarone
  • Beta-blocker/cimetidine may increase lidocaine level if large systemic absorption occurs

Patient.info notes topical lidocaine may help intercourse-related vulvar pain but should be used cautiously due to contact irritation and partner numbness.

2. Clotrimazole vaginal tablet — Candida suspected/confirmed হলে

  1. Generic name: Clotrimazole vaginal tablet
  2. Therapeutic category: Antifungal
  3. Pharmacological class: Imidazole antifungal
  4. Bangladesh available brand name: Afun VT 200 mg, Dermasim VT 200 mg / 500 mg

Dose / duration:

  • 500 mg vaginal tablet single dose at bedtime
    or
  • 200 mg vaginal tablet at bedtime for 3 days

Why used:

  • Candida vaginitis থাকলে itching, burning, discharge ও entry pain কমে

Side effects:

  • Vaginal burning
  • Irritation
  • Lower abdominal discomfort
  • Rare allergy

Drug interaction:

  • Vaginal latex condom/diaphragm effectiveness reduce হতে পারে during treatment
  • Warfarin interaction rare but reported with azoles

CDC lists clotrimazole intravaginal regimens as recommended options for vulvovaginal candidiasis.

3. Fluconazole — Candida vaginitis, oral option

  1. Generic name: Fluconazole
  2. Therapeutic category: Antifungal
  3. Pharmacological class: Triazole antifungal
  4. Bangladesh available brand name: Fluco-S 150 mg, Flucoder 150 mg, Fluconal 150 mg, Omastin 150 mg, Nispore 150 mg, Lucan-R 150 mg

Dose / duration:

  • Uncomplicated VVC: 150 mg orally single dose
  • Severe VVC: 150 mg orally, repeat after 72 hours
  • Recurrent VVC: specialist plan; often induction then weekly maintenance

Why used:

  • Candida-related itching, discharge, burning, dyspareunia reduce করতে

Side effects:

  • Nausea
  • Abdominal pain
  • Headache
  • Rash
  • Raised liver enzyme
  • QT prolongation rare

Drug interaction:

  • Warfarin → bleeding risk
  • Sulfonylurea → hypoglycemia
  • Phenytoin/carbamazepine level increase
  • Statin → myopathy risk
  • QT-prolonging drugs
  • Pregnancy: avoid routine oral fluconazole; topical azole preferred

CDC recommends fluconazole 150 mg oral single dose as an option for uncomplicated vulvovaginal candidiasis.

4. Metronidazole — BV / Trichomoniasis থাকলে

  1. Generic name: Metronidazole
  2. Therapeutic category: Antibacterial / antiprotozoal
  3. Pharmacological class: Nitroimidazole
  4. Bangladesh available brand name: Flagyl 400 mg, Amodis 400 mg, Metryl 500 mg, Flamyd V 1.3% vaginal gel

Dose / duration:

  • BV: Metronidazole 500 mg orally twice daily for 7 days
  • Trichomoniasis in women: Metronidazole 500 mg orally twice daily for 7 days
  • Partner treatment required for trichomoniasis

Why used:

  • BV/trichomoniasis-related discharge, odor, irritation, burning, dyspareunia কমাতে

Side effects:

  • Nausea
  • Metallic taste
  • Abdominal pain
  • Headache
  • Dark urine
  • Peripheral neuropathy with prolonged/high dose

Drug interaction:

  • Alcohol: avoid during and 24–72 hours after course
  • Warfarin: INR increase
  • Lithium toxicity risk
  • Disulfiram: psychotic reaction risk

CDC recommends metronidazole 500 mg twice daily for 7 days for bacterial vaginosis and for trichomoniasis in women.

5. Clindamycin vaginal cream — BV alternative

  1. Generic name: Clindamycin vaginal cream
  2. Therapeutic category: Antibacterial
  3. Pharmacological class: Lincosamide antibiotic
  4. Bangladesh available brand name: Cleocin 2%, Clindacin 2%, Clindax 2% vaginal cream

Dose / duration:

  • 2% cream, 5 g intravaginally at bedtime for 7 days

Why used:

  • BV থাকলে alternative regimen

Side effects:

  • Vaginal irritation
  • Candidiasis
  • Diarrhea
  • Rare C. difficile colitis

Drug interaction:

  • Erythromycin antagonism
  • Neuromuscular blocking agents effect increase
  • Latex condom/diaphragm weaken করতে পারে during treatment and short period after

CDC lists clindamycin cream 2% one full applicator intravaginally at bedtime for 7 days as a recommended BV regimen.

6. Vaginal estrogen — menopause/GSM-related dryness pain হলে

Option A

  1. Generic name: Estriol vaginal cream
  2. Therapeutic category: Hormone therapy
  3. Pharmacological class: Estrogen
  4. Bangladesh available brand name: Femastin 0.1%, Gynest 0.1%, Ovestin 0.1%, SRT 0.1%

Option B

  1. Generic name: Estradiol vaginal cream
  2. Therapeutic category: Hormone therapy
  3. Pharmacological class: Estrogen
  4. Bangladesh available brand name: Valena 0.01% vaginal cream

Option C

  1. Generic name: Conjugated estrogen vaginal cream
  2. Therapeutic category: Hormone therapy
  3. Pharmacological class: Estrogen
  4. Bangladesh available brand name: Estracon 0.0625%, Premarin 0.0625%

Typical dose / duration:

  • Daily at bedtime for 2 weeks, then maintenance 2–3 times/week
  • Exact dose depends on preparation and applicator; follow product instruction/specialist prescription.

Why used:

  • Postmenopausal vaginal dryness, atrophy, burning, dyspareunia reduce করতে
  • Tissue elasticity and lubrication improve করতে

Side effects:

  • Vaginal discharge
  • Breast tenderness
  • Spotting
  • Local irritation
  • Rare systemic estrogen effect

Contraindication / caution:

  • Unexplained vaginal bleeding
  • Active estrogen-dependent cancer
  • Active thromboembolic disease
  • Breast cancer patient on aromatase inhibitor: specialist advice required

NICE advises treating menopausal genitourinary symptoms adequately, including use of vaginal oestrogen, to avoid dyspareunia.

7. Amitriptyline — neuropathic vulvodynia component থাকলে

  1. Generic name: Amitriptyline hydrochloride
  2. Therapeutic category: Neuropathic pain modulator / antidepressant
  3. Pharmacological class: Tricyclic antidepressant
  4. Bangladesh available brand name: Amit 10 mg/25 mg, Amitip 10 mg, Amilin 25 mg

Dose / duration:

  • Start 10 mg at night
  • Increase by 10 mg every 1–2 weeks if needed
  • Usual range: 25–75 mg at night
  • Trial: 6–12 weeks; taper gradually when stopping

Why used:

  • Vaginismus itself নয়; unprovoked vulvodynia / neuropathic vulvar pain থাকলে pain sensitization কমাতে

Side effects:

  • Sedation
  • Dry mouth
  • Constipation
  • Weight gain
  • Urinary retention
  • QT prolongation
  • Orthostatic hypotension

Drug interaction:

  • SSRI/SNRI/MAOI → serotonin toxicity risk
  • Alcohol/sedatives → sedation increase
  • Anticholinergics → urinary retention/constipation
  • QT-prolonging drugs

MedEx describes amitriptyline as a tricyclic antidepressant with anticholinergic and sedative properties.

8. Botulinum toxin A — refractory severe vaginismus

  1. Generic name: Botulinum toxin type A
  2. Therapeutic category: Neuromuscular blocker
  3. Pharmacological class: Botulinum neurotoxin
  4. Bangladesh available brand name: Botox 100 unit injection

Dose / use:

  • Specialist-only, off-label
  • Used in refractory high-grade vaginismus after failed pelvic floor therapy/CBT/dilator
  • Injection site and dose vary by protocol; commonly pelvic floor muscles under specialist supervision

Why used:

  • Severe involuntary pelvic floor spasm reduce করতে

Side effects:

  • Injection pain
  • Temporary pelvic floor weakness
  • Urinary incontinence rare
  • Fecal incontinence rare
  • Infection/bleeding rare

Drug interaction:

  • Aminoglycosides
  • Neuromuscular blockers
  • Muscle relaxants
  • Magnesium salts

Systematic review data suggest botulinum toxin may help refractory vaginismus, but conclusions should be interpreted cautiously because randomized trial evidence is limited.

8. Prevention — কীভাবে প্রতিরোধ করবেন?

  • Painful penetration জোর করে করবেন না
  • Adequate foreplay and lubrication
  • Water-based lubricant ব্যবহার
  • Vaginal infection হলে early treatment
  • Recurrent itching/discharge হলে self-medication না করে test
  • Menopause/postpartum dryness হলে early vaginal moisturizer/estrogen assessment
  • Douching, scented soap, vaginal spray avoid
  • Cotton underwear, irritant avoidance
  • Pelvic floor relaxation practice
  • Sexual trauma/anxiety থাকলে early counseling
  • Couple communication improve করা
  • First intercourse নিয়ে ভুল ধারণা/ভয় দূর করা
  • Speculum exam বা gynecological procedure gentle, consent-based হওয়া উচিত

Overview / Summary

Vaginismus হলো penetration-related involuntary pelvic floor spasm with fear/pain cycle। Diagnosis clinical; infection, vulvodynia, dryness, structural abnormality, trauma/anxiety বাদ দিতে হবে। Main treatment হলো education + pelvic floor physiotherapy + graded dilator + CBT/psychosexual therapy। Drugs only cause-based: lidocaine for pain support, antifungal for candida, metronidazole/clindamycin for BV/trich, vaginal estrogen for GSM, amitriptyline for neuropathic vulvodynia, Botox only refractory specialist case.

Actionable Plan / Steps

  1. History নিন: primary/secondary, pain site, discharge/itching, trauma, menopause/postpartum.
  2. Gentle vulval exam + cotton-swab test + pelvic floor tone assessment করুন.
  3. Discharge/itching থাকলে pH, wet mount/KOH, swab/NAAT করুন.
  4. Infection/dryness/skin disease থাকলে আগে treat করুন.
  5. Forced penetration stop; lubricant + pelvic relaxation শুরু করুন.
  6. Pelvic floor physiotherapy + graded dilator therapy 6–12 weeks.
  7. CBT/sex therapy add করুন if fear/anxiety/relationship factor prominent.
  8. Refractory severe case হলে vulvar pain specialist/gynecologist referral; Botox only specialist-selected case.

Reference List

Textbook

  1. Harrison’s Principles of Internal Medicine, 21st ed. Sexual dysfunction and chronic pelvic pain sections.
  2. Davidson’s Principles and Practice of Medicine, 24th ed. Psychosexual disorders and women’s health sections.
  3. Berek & Novak’s Gynecology, 16th ed. Female sexual dysfunction, vulvar pain, dyspareunia.
  4. Williams Gynecology, 4th ed. Female sexual pain disorders and vulvovaginal disease.

Guidelines / Clinical Sources

  1. MSD Manual Professional: Genito-Pelvic Pain/Penetration Disorder.
  2. ACOG Committee Opinion: Persistent Vulvar Pain.
  3. CDC STI Treatment Guidelines 2021: Candidiasis, BV, Trichomoniasis.
  4. NICE CKS Menopause: genitourinary symptoms and vaginal oestrogen.
  5. MedEx Bangladesh drug brand database for Bangladesh available brands.

Journal / DOI

  1. Melnik T, Hawton K, McGuire H. Interventions for vaginismus. Cochrane Database Syst Rev. DOI: 10.1002/14651858.CD001760.pub2.
  2. Morin M, et al. Multimodal physical therapy versus topical lidocaine for provoked vestibulodynia. Am J Obstet Gynecol. 2021. DOI: 10.1016/j.ajog.2020.08.038.
  3. Goldfinger C, et al. Effectiveness of CBT and physical therapy for provoked vestibulodynia. J Sex Med. 2016;13:88-94. DOI: 10.1016/j.jsxm.2015.12.003.
  4. Velayati A, et al. Can Botox Offer Help Women With Vaginismus? Int J Sex Health. 2019. DOI: 10.1080/19317611.2019.1616029.

Md.Rafiqul Islam Lipu,Date:-23-05-2026 Saturday, Time:- 07-51-25 Pm

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