Vaginismus

Definition

Sexual dysfunction is broadly defined as the inability to fully enjoy sexual intercourse. Specifically, sexual dysfunctions are disorders that interfere with a full sexual response cycle. These disorders make it difficult for a person to enjoy or to have sexual intercourse. While sexual dysfunction rarely threatens physical health, it can take a heavy psychological toll, bringing on depression, anxiety, and debilitating feelings of inadequacy.

Description

Sexual dysfunction takes different forms in men and women. A dysfunction can be life-long and always present, acquired, situational, or generalized, occurring despite the situation. A man may have a sexual problem if he:

• Ejaculates before he or his partner desires
• Does not ejaculate, or experiences delayed ejaculation
• Is unable to have an erection sufficient for pleasurable intercourse
• Feels pain during intercourse
• Lacks or loses sexual desire.

A woman may have a sexual problem if she:

• Lacks or loses sexual desire
• Has difficulty achieving orgasm
• Feels anxiety during intercourse
• Feels pain during intercourse
• Feels vaginal or other muscles contract involuntarily before or during sex
• Has inadequate lubrication.

The most common sexual dysfunctions in men include:

• Erectile dysfunction: an impairment of the erectile reflex. The man is unable to have or maintain an erection that is firm enough for coitus or intercourse.
• Premature ejaculation, or rapid ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it.
• Ejaculatory incompetence: the inability to ejaculate within the vagina despite a firm erection and relatively high levels of sexual arousal.
• Retarded ejaculation: a condition in which the bladder neck does not close off properly during orgasm so that the semen spurts backward into the bladder.

Until recently, it was presumed that women were less sexual than men. In the past two decades, traditional views of female sexuality were all but demolished, and women's sexual needs became accepted as legitimate in their own right.

Female sexual dysfunctions include:

• Sexual arousal disorder: the inhibition of the general arousal aspect of sexual response. A woman with this disorder does not lubricate, her vagina does not swell, and the muscle that surrounds the outer third of the vagina does not tighten-a series of changes that normally prepare the body for orgasm ("the orgasmic platform"). Also, in this disorder, the woman typically does not feel erotic sensations.
• Orgasmic disorder: the impairment of the orgasmic component of the female sexual response. The woman may be sexually aroused but never reach orgasm. Orgasmic capacity is less than would be reasonable for her age, sexual experience, and the adequacy of sexual stimulation she receives.
• Vaginismus: a condition in which the muscles around the outer third of the vagina have involuntary spasms in response to attempts at vaginal penetration.
• Painful intercourse: a condition that can occur at any age. Pain can appear at the start of intercourse, midway through coital activities, at the time of orgasm, or after intercourse is completed. The pain can be felt as burning, sharp searing, or cramping; it can be external, within the vagina, or deep in the pelvic region or abdomen.

Causes & symptoms

Many factors, of both physical and psychological natures, can affect sexual response and performance. Injuries, ailments, and drugs are among the physical influences; in addition, there is increasing evidence that chemicals and other environmental pollutants depress sexual function. As for psychological factors, sexual dysfunction may have roots in traumatic events such as rape or incest, guilt feelings, a poor self-image, depression, chronic fatigue, certain religious beliefs, or marital problems. Dysfunction is often associated with anxiety. If a man operates under the misconception that all sexual activity must lead to intercourse and to orgasm by his partner, and if the expectation is not met, he may consider the act a failure.

Men

With premature ejaculation, physical causes are rare, although the problem is sometimes linked to a neurological disorder, prostate infection, or urethritis. Possible psychological causes include anxiety (mainly performance anxiety), guilt feelings about sex, and ambivalence toward women. However, research has failed to show a direct link between premature ejaculation and anxiety. Rather, premature ejaculation seems more related to sexual inexperience in learning to modulate arousal.

When men experience painful intercourse, the cause is usually physical; an infection of the prostate, urethra, or testes, or an allergic reaction to spermicide or condoms. Painful erections may be caused by Peyronie's disease, fibrous plaques on the upper side of the penis that often produce a bend during erection. Cancer of the penis or testis and arthritis of the lower back can also cause pain.

Retrograde ejaculation occurs in men who have had prostate or urethral surgery, take medication that keeps the bladder open, or suffer from diabetes, a disease that can injure the nerves that normally close the bladder during ejaculation.

Erectile dysfunction is more likely than other dysfunctions to have a physical cause. Drugs, diabetes (the most common physical cause), Parkinson's disease, multiple sclerosis, and spinal cord lesions can all be causes of erectile dysfunction. When physical causes are ruled out, anxiety is the most likely psychological cause of erectile dysfunction.

Dysfunctions of arousal and orgasm in women also may be physical or psychological in origin. Among the most common causes are day-to-day discord with one's partner and inadequate stimulation by the partner. Finally, sexual desire can wane as one ages, although this varies greatly from person to person.

Pain during intercourse can occur for any number of reasons, and location is sometimes a clue to the cause. Pain in the vaginal area may be due to infection, such as urethritis; also, vaginal tissues may become thinner and more sensitive during breast-feeding and after menopause. Deeper pain may have a pelvic source, such as endometriosis, pelvic adhesions, or uterine abnormalities. Pain can also have a psychological cause, such as fear of injury, guilt feelings about sex, fear of pregnancy or injury to the fetus during pregnancy, or recollection of a previous painful experience.

Vaginismus may be provoked by these psychological causes as well, or it may begin as a response to pain, and continue after the pain is gone. Both partners should understand that the vaginal contraction is an involuntary response, outside the woman's control.

Similarly, insufficient lubrication is involuntary, and may be part of a complex cycle. Low sexual response may lead to inadequate lubrication, which may lead to discomfort, and so on.

Diagnosis

In deciding when a sexual dysfunction is present, it is necessary to remember that while some people may be interested in sex at almost any time, others have low or seemingly nonexistent levels of sexual interest. Only when it is a source of personal or relationship distress, instead of voluntary choice, is it classified as a sexual dysfunction.

The first step in diagnosing a sexual dysfunction is usually discussing the problem with a doctor, who will need to ask further questions in an attempt to differentiate among the types of sexual dysfunction. The physician may also perform a physical exam of the genitals, and may order further medical tests, including measurement of hormone levels in the blood. Men may be referred to a specialist in diseases of the urinary and genital organs (urologist), and primary care physicians may refer women to a gynecologist.

Treatment

Treatments break down into two main kinds: behavioral psychotherapy and physical. Sex therapy, which is ideally provided by a member of the American Association of Sexual Educators, Counselors, and Therapists (AASECT), universally emphasizes correcting sexual misinformation, the importance of improved partner communication and honesty, anxiety reduction, sensual experience and pleasure, and interpersonal tolerance and acceptance. Sex therapists believe that many sexual disorders are rooted in learned patterns and values. These are termed psychogenic. An underlying assumption of sex therapy is that relatively short-term outpatient therapy can alleviate learned patterns, restrict symptoms, and allow a greater satisfaction with sexual experiences.

In some cases, a specific technique may be used during intercourse to correct a dysfunction. One of the most common is the "squeeze technique" to prevent premature ejaculation. When a man feels that an orgasm is imminent, he withdraws from his partner. Then, the man or his partner gently squeezes the head of the penis to halt the orgasm. After 20-30 seconds, the couple may resume intercourse. The couple may do this several times before the man proceeds to ejaculation.

In cases where significant sexual dysfunction is linked to a broader emotional problem, such as depression or substance abuse, intensive psychotherapy and/or pharmaceutical intervention may be appropriate.

In many cases, doctors may prescribe medications to treat an underlying physical cause or sexual dysfunction. Possible medical treatments include:

• Clomipramine and fluoxetine for premature ejaculation
• Papaverine and prostaglandin for erectile difficulties
• Hormone replacement therapy for female dysfunctions
• Viagra, a pill approved in 1998 as a treatment for impotence.

Alternative treatment

A variety of alternative therapies can be useful in the treatment of sexual dysfunction. Counseling or psychotherapy is highly recommended to address any emotional or mental components of the disorder. Botanical medicine, either western, Chinese, or ayurvedic, as well as nutritional supplementation, can help resolve biochemical causes of sexual dysfunction. Acupuncture and homeopathic treatment can be helpful by focusing on the energetic aspects of the disorder.

Some problems with sexual function are normal. For example, women starting a new or first relationship may feel sore or bruised after intercourse and find that an over-the-counter lubricant makes sex more pleasurable. Simple techniques, such as soaking in a warm bath, may relax a person before intercourse and improve the experience. Yoga and meditation provide needed mental and physical relaxation for several conditions, such as vaginismus. Relaxation therapy eases and relieves anxiety about dysfunction. Massage is extremely effective at reducing stress, especially if performed by the partner.

Prognosis

There is no single cure for sexual dysfunctions, but almost all can be controlled. Most people who have a sexual dysfunction fare well once they get into a treatment program. For example, a high percentage of men with premature ejaculation can be successfully treated in two to three months. Furthermore, the gains made in sex therapy tend to be long-lasting rather than short-lived.

Key Terms

Erectile dysfunction

Difficulty achieving or maintaining an erect penis.

Ejaculatory incompetence

The inability to ejaculate within the vagina.

Orgasmic disorder

The impairment of the ability to reach sexual climax.

Painful intercourse (dyspareunia)

Generally thought of as a female dysfunction but it also affects males. Pain can occur anywhere.

Premature ejaculation

Rapid ejaculation before the person wishes it, usually in less than one to two minutes after beginning intercourse.

Retrograde ejaculation

A condition in which the semen spurts backward into the bladder.

Sexual arousal disorder

The inhibition of the general arousal aspect of sexual response.

Vaginismus

Muscles around the outer third of the vagina have involuntary spasms in response to attempts at vaginal penetration, not allowing for penetration.

Further Reading

For Your Information

Books

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994.
• Masters, William H., Virginia E. Johnson, and Robert C. Kolodny. Human Sexuality. New York: HarperCollins Publishers, 1992.

  Periodicals

• Cranston-Cuebas, M.A., and D. H. Barlow. "Cognitive and Affective Contributions to Sexual Functioning." Annual Review of Sex Research (1990): 119-162.
• Pollack, M.H., S. Reiter, and P. Hammerness. "Genitourinary and Sexual Adverse Effects of Psychotropic Medication." International Journal of Psychiatry in Medicine 22(1992): 305-327.

  Organizations

• American Academy of Clinical Sexologists. 1929 18th Street NW, Suite 1166, Washington, DC 20009. (202) 462-2122.
• American Association for Marriage and Family Therapy. 1100 17th Street NW, 10th Floor, Washington, DC 20036-4601. (202) 452-0109.
• American Association of Sex Educators, Counselors & Therapists. P.O. Box 238, Mt. Vernon, IA 52314.

Gale Encyclopedia of Medicine. Gale Research, 1999.