Vaginismus

　　1. Causes of onset

　　Vaginal spasm is divided into four types: primary, secondary, complete, and situational. Primary vaginal spasm accounts for the majority, referring to the onset of vaginal spasm during sexual intercourse from the beginning of sexual activity, and they have never experienced successful sexual intercourse. Secondary vaginal spasm refers to the occurrence of vaginal spasm after a history of normal sexual intercourse. Complete vaginal spasm refers to the inability to insert or complete sexual intercourse under any circumstances. Situational vaginal spasm refers to the ability to insert sometimes and not other times, such as when a gynecological examination can be carried out smoothly by a doctor, but sexual intercourse cannot be inserted.

　　The causes of vaginal spasm include both social psychological factors and organic causes.

　　1. Psychological factors

　　(1) Family education factors: The patient may have been influenced by traditional sexual concepts of feudalism and religion during childhood or adolescence, considering sexual activity as vulgar, evil, and lascivious behavior. They believe that a daughter's most important virtue is chastity, and losing virginity would lead to ruin. If a woman shows an interest in sexual activity, she is regarded as improper. Therefore, sexual activity is inevitably associated with shame, dishonor, anxiety, fear, and a sense of guilt. An Irish study pointed out that among the 53 cases of vaginal spasm, 18 had been affected by negative sexual education, accounting for 34%; while in the control group of 66 cases, only 29% were affected.

　　(2) Traumatic factors: Suffered from pain during sexual intercourse, leaving an indelible fear memory, forming a negative conditioned reflex. When they anticipate the arrival or the act of sexual intercourse, they will experience vaginal spasm due to fear. Among the 53 cases of vaginal spasm mentioned in the Irish data, 24 had been subjected to sexual violence, accounting for 27%. In the control group of 66 cases, 6 had been subjected to violence, accounting for 9%, showing a significant difference.

　　(3) Disharmony in the marital relationship: The rough sexual behavior of the husband at the time of first marriage can cause severe pain and trauma, causing the woman to have fear of sexual intercourse. On the other hand, disharmony in the marital relationship or incorrect sexual techniques can cause the woman to be irritable, angry, or afraid, leading to vaginismus.

　　2. Organic factors

　　Any gynecological disease that can cause sexual intercourse pain can lead to vaginismus, such as hymen hypertrophy and stiffness, vaginal scar stenosis, vulvitis with vulvar or vaginal vestibule ulceration, endometriosis, and senile atrophic vaginitis, etc.

　　Second, Pathogenesis

　　Vaginismus and female sexual intercourse pain often cause and effect each other, so the estrogen (E2)-NOS-cGMP theory that causes female sexual intercourse pain also causes vaginismus: a decrease in E2 levels leads to a decrease in the expression of nitric oxide synthase (NOS) in the female external genitalia, a decrease in the release of non-adrenergic/non-cholinergic (NANC) neurotransmitter nitric oxide (NO), leading to a decrease in the vasodilation function of the perineal vessels, a decrease in perineal blood flow, insufficient blood filling of the vaginal wall vessels, and a decrease in vaginal secretion; in addition, the decrease in NO leads to an increase in fibrosis of the vaginal wall, damage and apoptosis of the vaginal mucosa, and a decrease in the secretion of the vaginal mucosa and Bartholin's glands; on the one hand, the vagina becomes dry and insufficiently lubricated, causing female sexual intercourse pain, and then reflexively causing vaginismus; on the other hand, the extensibility and compliance of the vagina decrease, making it difficult to insert the penis, leading to vaginismus. Another NANC neurotransmitter, vasoactive intestinal peptide (VIP), can cause vasodilation and relaxation of non-vascular smooth muscle, increase blood flow to the pelvis and vagina, and increase the lubrication and secretion of the vagina, which may also be involved in the pathogenesis of vaginismus, but the specific regulatory mechanism is not yet clear.

　　Vaginismus is essentially a protective muscle spasm caused by pain. Pain is transmitted from local pain receptors or nerve endings to the central nervous system of the brain through the nervous reflex, causing reflexive and forced contraction of the perineal and (or) pelvic muscles, even the gluteal and thigh muscles, leading to the occurrence of vaginismus.

　　Through special molecular probes and RNAase protein analysis, α2 and α2 receptors are found in the smooth muscle cells of the human clitoris and vagina. Exogenous norepinephrine (α1 and α2 agonists) can produce a dose-dependent contraction of the vaginal smooth muscle, while α1 and α2 selective antagonists can inhibit this contraction. It can be seen that adrenergic nerve regulation affects the contraction response of the reproductive organs.

　　Vaginismus, the patient believes that an erect penis will damage the vulva, vagina, or hymen, causing severe pain. In fact, the vagina is a smooth muscle organ with great expansibility, which can accommodate the delivery of the fetal head, as proven by childbirth. High levels of tension and fear cause local sympathetic nerve excitation of the reproductive organs, and the release of norepinephrine (NA), an adrenergic neurotransmitter, increases, leading to contraction and even spasms of the vaginal wall and even the entire pelvic floor smooth muscle, resulting in a reduction in vaginal volume during sexual intercourse, and fear and tension cannot reach orgasm; the Bartholin's glands do not secrete mucus, and the vaginal blood vessels constrict and do not seep; at the same time, the circular skeletal muscle at the vaginal orifice also undergoes spasmodic contraction under the action of acetylcholine (ACh) released by the pudendal nerve, which hinders the smooth insertion of the penis or causes the penis already inserted to be unable to withdraw, resulting in vaginismus.

　　The typical conditioned reflex formation process of vaginal spasm suggests that they have experienced obvious pain during their first attempt at sexual intercourse, and this pain plays a role of an unconditioned stimulus, causing the natural, self-protective tension of the vaginal muscles (unconditioned response). After a period of time, stimuli associated with vaginal insertion (such as the presence of a naked partner) or even just the thought of sexual intercourse can become conditioned stimuli (conditioned response) that lead to reflexive muscle spasm. The following introduces the typical conditioned reflex formation process of vaginal spasm.

　　Before sexual intercourse has not yet occurred:

　　Conditioned stimulus (idea of sexual intercourse) → No response or irrelevant response

　　Unconditioned stimulus (pain) → Unconditioned response (muscle spasm)

　　After sexual intercourse has already occurred:

　　Conditioned stimulus (idea of sexual intercourse) → Conditioned response (muscle spasm)

　　This typical conditioned reflex formation mechanism is strengthened by operant conditioning, that is, women try to avoid sexual intercourse to prevent the occurrence of vaginal spasm. This avoidance behavior may alleviate their anxiety, but it will play a role in reinforcing their avoidance behavior.

　　In addition, any mechanism that causes increased tension of the perineum or even the pelvic floor muscles may lead to vaginal spasm, and this point needs further study.

　　Although vaginal spasm does not pose a threat to life, it severely affects the quality of marital sexual life, leading to the deterioration of marital and even family interpersonal relationships. Patients are very distressed, often feeling guilty towards their husbands but unable to overcome it. The cause is difficult to explain, causing great mental stress to women, severely affecting their daily life and physical health. If not treated in time, it often lasts for several years, and in severe cases, it may lead to depression and social phobia syndrome, bringing great suffering and disharmony to both partners, and even causing the breakdown of the family.

　　The main symptoms are the inability to insert the penis into the vagina during sexual intercourse or the inability to withdraw the penis that has already been inserted, leading to sexual pain, inability to have sexual intercourse, or sexual emergency due to penile entrapment.

　　Vaginal spasm is often accompanied by different degrees of pain in the vulva, vagina, or lower abdomen, with pain characterized by sharp pain, impact dull pain, stretching pain, or pricking pain, lasting for tens of minutes to 1 day; the pain can be superficial or deep, localized or diffuse, with patients often experiencing clonic contraction of muscles in the perineum or the inner side of the thigh, high muscle tension, fear, or even refusal of gynecological examination.

　　If vaginal spasm is caused by organic lesions, it is accompanied by clinical manifestations of associated organic diseases, such as urinary and reproductive system infectious diseases, congenital maldevelopment of external genitalia, endometriosis, and so on.

　　Due to the varying degrees of vaginal spasm, the symptoms may not be the same for everyone. Those with mild symptoms can still have sexual intercourse, but both partners feel discomfort, with the female partner showing symptoms of severe pain, and some even experience lower back pain or a sensation of lower abdominal坠胀 when the penis is inserted into the vagina; severe spasm not only causes the female partner to feel extremely uncomfortable or painful locally, but also makes it impossible for the male's penis to be inserted into the vagina. This severe pain can affect normal marital sexual life.

　　Upon inquiry, it may be found that the patient has certain mental and emotional abnormalities, such as severe pain, guilt, inferiority complex, depression, or neuroticism, depending on the doctor's conversational skills and keen insight, which can induce and discover the potential factors causing vaginismus.

　　First, precautions

　　1. "The heart needs the medicine of the heart to heal," as vaginismus is generally caused by the female partner's psychology, the first step is to eliminate the bride's mental tension and fear.

　　2. Newlyweds can learn some knowledge about sex before marriage. The bride should fully understand that "marital sex is not a disgraceful thing." The groom should be gentle and tender, giving the bride multiple caresses to make her feel comfortable and accelerate sexual desire.

　　Second, prognosis

　　There is no significant adverse prognosis. After patient and comprehensive psychological treatment, vaginismus can be relieved or cured.

　　Diagnostic pelvic examination, palpation of the vulva, deep palpation, speculum examination, Papanicolaou smear examination, vaginal secretion culture, etc.

　　1. The doctor first performs an external examination of the patient's vulva, which often reveals vaginismus, stiffness, or twitching of the muscles on the inner side of the thighs or perineum. At this time, it is necessary to determine whether the muscle contraction is a voluntary contraction, as there may be involuntary spasms when there is voluntary contraction. The method is to allow the patient to fully relax, take deep breaths, and talk to them to shift their focus from the tension caused by their intense concentration. After the patient is fully relaxed, the muscle tension caused by voluntary contraction will disappear. The reasons for the patient's voluntary contractions include tension, bringing the legs together, or trying to leave the examination table.

　　2. Subsequently, a palpation examination of the vulva should be conducted. First, show the patient the finger wearing gloves, and inform them that during the examination, the doctor will separate their labia, examine the external structures such as the vestibule and urethral opening. Then, slowly separate the labia, reminding the patient at all times not to be tense or fearful, and pay attention to the examination of the labia, clitoris, urethral opening, and vaginal opening, and note any occurrence of spasms.

　　3. The next step is to examine the superficial part of the vagina, that is, the outer third of the vaginal canal. First, show the patient the finger coated with lubricant, then gently place the finger at the vaginal opening, apply slight pressure, and ask the patient if they feel any discomfort or if they can tolerate it. Talking while examining helps the patient relax and feel at ease. Once the patient is no longer tense and has no obvious discomfort, insert the finger slowly into the vagina by 2-5 centimeters. When inserting the finger, apply slight pressure backward rather than directly forward. If there is an involuntary spastic contraction or a narrowing ring around the vaginal opening, a diagnosis can be made. This discovery will surprise the patient, as she may not have been aware of this issue before or may have mistakenly attributed it to an overly thick hymen. Such an examination confirms to both partners in a visible and dynamic form what the essence of vaginal closure is. For example, the young woman mentioned earlier felt guilty after learning she had vaginismus during the physical examination, feeling that she had misunderstood the male partner's 'impotence' as being too naive. The male partner's doubts were dispelled, and he no longer felt anxious.

　　Ganmai Dazao Decoction:9 grams of Glycyrrhiza uralensis, 18 grams of Triticum aestivum, and 5 dates, placed in a pot, decocted with an appropriate amount of water for 20 minutes, taken all at once, twice a day: The main ingredient, Triticum aestivum, is sweet and slightly cold, nourishing the heart yin to calm the mind and spirit, which is the meaning of 'The Internal Classic': 'For those with heart disease, it is advisable to eat wheat', with the sweet and mild nature of wheat, nourishing the heart and alleviating urgency; assisted by Glycyrrhiza uralensis, which harmonizes and alleviates urgency; and supported by dates, which are sweet and moist, and moisten the internal organs. The combination of these three herbs has the effect of nourishing and moistening, nourishing the heart and calming the mind, harmonizing and alleviating urgency; women with vaginal spasm may try this formula.

　　First, the traditional Chinese medicine treatment for vaginal spasm

　　1. Liver Qi Stagnation

　　Depressed mood, fullness in the chest and hypochondrium, irritability, insomnia with frequent dreams, tendency to sigh, feeling relief upon sighing. Vaginal spasm during coitus, resulting in unsuccessful coitus, exacerbating during emotional fluctuations, with a white tongue coating and wiry pulse. Treatment should focus on soothing the liver and resolving depression, regulating qi and alleviating urgency, with the formula of Xiaoyao Powder modified. The ingredients include: 6 grams of Bupleurum chinense, 10 grams of Angelica sinensis, 12 grams of white peony, 8 grams of Citrus aurantium, 10 grams of prepared Atractylodes macrocephala, 6 grams of Chuanxiong, 10 grams of Curcuma wenyujin, 10 grams of Strychnos nux-vomica, 5 grams of Bombyx batryticatus, and 30 grams of Oyster shell (decocted first). Decocted for oral administration, one dose per day.

　　2. Kidney Yin Deficiency

　　Vaginal spasm during coitus, often resulting in unsuccessful coitus. Accompanied by dry mouth and throat, decreased vaginal secretion, dry and unlubricated vagina, palpitations, night sweats, hot palms and soles, sore lower back and weak legs, pain in the heel, red tongue with little coating, and thin and rapid pulse. Treatment should focus on nourishing yin and filling essence, calming the liver and benefiting the kidney, with the formula of Liuwei Dihuang Decoction modified. The ingredients include: 15 grams of prepared Rehmannia, 15 grams of Dioscorea opposita, 10 grams of Schisandra chinensis, 10 grams of Polygonum multiflorum, 10 grams of Polygonum apetalum, 6 grams of Moutan bark, 10 grams of Spatholobus suberectus, 10 grams of Semen Ziziphi spinosae, 30 grams of Oyster shell (decocted first), and 10 grams of Radix Paeoniae alba. Decocted for oral administration, one dose per day, for one month consecutively.

　　3. Damp-heat in the Liver Channel

　　The condition is often caused by inflammatory lesions in the perineum or pelvic cavity, leading to sexual pain, leukorrhea, dark yellow urine, red and swollen vulva, or lower abdominal pain, with a yellow greasy tongue coating, red tongue body, and slippery and rapid pulse. Treatment should focus on clearing heat and detoxifying, regulating dampness and draining the liver, with the formula of Longdan Xiegan Decoction modified. The ingredients include: 20 grams of Lonicera japonica, 30 grams of Smilax glabra, 20 grams of Houttuynia cordata, 6 grams of Phellodendron amurense, 6 grams of Bupleurum chinense, 10 grams of Scutellaria baicalensis, 10 grams of Rehmannia glutinosa, 10 grams of Alisma orientale, 6 grams of Coptis chinensis, 15 grams of Plantago asiatica, and 3 grams of Glycyrrhiza uralensis. Decocted for oral administration, one dose per day, for 5-7 days consecutively.

　　4. Other Therapies

　　During coitus, the perineal muscles spasm, causing severe pain, a feeling of坠胀 in the lower abdomen, dry mouth and tongue, short and red urine, chest and胁胀满, tongue red with yellow fur, pulse wiry and rapid. Acupuncture points: Hegu, Zhongji, Shenmen, Guanyuan, Zusanli, Sanyinjiao, Taichong. Acupuncture method: Select 3-5 acupoints each time, perform acupuncture 30 minutes before coitus. The technique uses flat supplementation and drainage, with weak stimulation. After inserting the needle and getting the Qi, leave the needle for 20 minutes, and twirl the needle once every 5 minutes.

　　Second, Western Medical Treatment Methods for Vaginismus

　　Psychological and Spiritual Treatment:

　　The treatment principle of this disease should focus on eliminating psychological barriers, understanding the rhythm of sexual life, encouraging both partners to participate in the treatment together, cooperate with each other, actively care for each other, correct bad sexual habits, and establish a new harmonious sexual behavior through emotional communication and learning. The main method is to use vaginal dilators.

　　1. Psychological Treatment

　　Explain to both the patient and the spouse the medical information related to vaginismus, such as anatomy, possible causes, and discuss the affected areas of vaginismus with them. Emphasize to both the patient and the spouse that the vaginismus reflex is involuntary, eliminate the misconception of the spouse that the patient deliberately hinders sexual intercourse, and make them observe the characteristics of involuntary vaginal narrowing.

　　2. Perform the 'Tighten-Relax' exercises for the pelvic floor muscles

　　Instruct the patient to tighten the pelvic floor muscles with force, maintain for 3-4 seconds, then relax, repeat, and the pelvic floor muscles will become relatively relaxed.

　　3. Vaginal Expansion

　　Based on the 'Tighten-Relax' training, use sequentially (starting from the small size) lubricated vaginal dilators, 4 times a day, each time for 10-15 minutes, continue with the 'Tighten-Relax' exercises after inserting the vaginal dilator, until it can be smoothly inserted with the 4th dilator, and after adapting to the 4th dilator, sexual intercourse can be performed appropriately, usually smoothly.