Doctor with patient

Diagnosis

Vaginismus Diagnosis

How do I know if I have vaginismus?

Women often realize they have vaginismus simply from their symptoms. In nearly all cases where penetration is either impossible or difficult, vaginismus is present. Similarly, ongoing sexual pain or tightness after resolving or managing a pelvic problem, medical issue, surgery or childbirth (still painful or tight after everything has healed) typically indicates vaginismus.

Optimally, a woman could confirm a medical diagnosis of vaginismus with her doctor. A doctor can evaluate the possibility of other factors or conditions present. This is especially important among late-onset sufferers. If other underlying conditions are present, they should be identified and addressed.

Medical diagnosis is typically determined through patient history and description of the problem/pain, gynecological examination and the process of ruling out other conditions. Unfortunately, no direct and definitive test for vaginismus exists, and physicians are sometimes under-informed about the condition.

As with many health issues, you may need to strongly advocate for yourself to ensure that your concerns are fully heard and acknowledged. Educating yourself about the condition and advocating for proper diagnosis and treatment is key. If unsatisfied with a physician’s interaction and findings, seek a second opinion.

How to make the most of your doctor visit

Review the following suggestions prior to your medical visit for tips on how to communicate with your health care professional when seeking a diagnosis for sexual pain:

Before Your Appointment - In advance of the appointment, document the history of your problem. It is normal to feel anxious and rushed once the physician enters the room. Doctors have a limited amount of time, so having a list of symptoms and questions already prepared benefits both you and the physician.

Introduce the Problem - Immediately and directly state your problem to the doctor: “I have been having problems with intercourse and hope you will be able to help me.”

Describe the Pain - Provide a description of the pain or problems as specifically as possible, considering the following sample script to help you clearly outline your symptoms:

It happens when ... “my husband attempts penetration.”

The pain is located ... “at the entrance to my vagina. My vagina is like a wall; he just cannot get it in/all the way.” or "It's always tight and painful."

The pain lasts ... “as long as he keeps trying, especially if we try forcing it in. Once he stops there is no pain.”

This has been happening since ... “our honeymoon two years ago and has continued to happen every time we try to have sex.” (primary vaginismus); ...“my hysterectomy five months ago.” (secondary vaginismus)

It feels like ... “burning, stinging, hitting a wall.”

I have tried to reduce or eliminate the pain by ... “using lubricant, changing sexual positions, relaxing more.“

I am able / unable to ... “complete an internal gynecological exam.”

Inform your doctor if you have been able to previously have sexual intercourse without pain.

Mention any Past Problems - Have you had any sexually transmitted diseases, yeast infections, bladder problems, or any pelvic pain outside of penetration? Mention any past sexual abuse.

State What You Think is the Cause - “I think it may be vaginismus. My symptoms sound similar to those outlined in an article I read. However, I have also read there are other things that can cause pain during sex and would like to have them ruled out.”

Questions for the Doctor - “Are you familiar with vaginismus? How many patients have you had with vaginismus? What do you propose as the next step or possible plan of action?”

Doctors have a limited amount of time, so having a list of symptoms and questions already prepared benefits both you and the physician. Consider reading our book and searching information on the internet to both educate yourself about vaginismus and to try to narrow the possibilities. 

What takes place during a typical pelvic exam?

A typical pelvic exam involves two parts: an external review of your genital area, and an internal examination using a speculum and/or finger. The exam takes place while you are lying on your back on an exam table with your knees spread apart. Your abdomen and thighs are covered with a paper sheet or blanket. 

External Exam - The doctor will visually inspect the outer genitalia, which includes the clitoris, vaginal opening, urinary outlet, and the labia. Any signs of unusual redness, discharge, irritations, or growths are recorded. She may then take a cotton swab and touch it to several spots around the vaginal area to check for any spots sensitive to pain.

Internal Exam - When vaginismus is suspected, doctors will often begin the internal exam by inserting one or two lubricated fingers into the vaginal opening to see if there is any resistance and to check for any tenderness or abnormalities along the vaginal walls. Depending on how the finger insertion goes, she may then move on to inserting a speculum.

The speculum is a tool that separates the walls of the vagina so that the vagina and cervix can be clearly visualized for examination. To increase comfort, most doctors lubricate and warm the speculum to body temperature before inserting it. You may feel a slight pressure as the speculum is opened to widen the vagina.

A small spatula or tiny brush is then used to collect cells from the cervix for a Pap test. This test, conducted in a laboratory using the sample, screens for any abnormal cervical cells. You may feel a cramping sensation as the doctor collects the sample. Cultures of cervical discharge may also be taken using a swab. After needed samples are collected, the speculum is removed. 

A pelvic exam also includes assessment of the shape and/or size of the uterus, as well as a check for any fibroid growths, cysts, and/ or signs of infection. For this part of the examination, the doctor may place two fingers into the vagina while pressing down on the uterus.

Easing the examination experience and understanding the unique challenges of vaginismus

For many women who experience vaginal tightness, gynecological exams can be quite frustrating or difficult. The mere approach of the doctor’s hand or speculum can cause the vaginal muscles to tighten. Here are some suggestions:

  • Bring a friend or your partner for support or ask for nurse support.
  • Request the smallest size of speculum.
  • Ask to adjust your body positioning to maximize comfort.
  • As much as possible, relax your stomach, thigh, and buttock muscles. As the exam begins, breathe slowly and deeply. Relaxing helps reduce the level of discomfort.
  • Distract yourself by focusing on a picture on the wall, on your plans for that evening, or by talking to your support person.
  • Ask your doctor to describe what is being done as it is happening.
  • Communicate any discomfort you may feel as the exam is taking place.
  • A physician who is familiar with the vaginismus condition will be better suited to providing a comfortable and sensitive environment.
  • Due to vaginismus tightness, some women find internal exams painful or intolerable. Concerns about this should be communicated to the physician. 
  • Do not allow the exam to become traumatic - agree to pause the exam in response to any overt pain or discomfort, and only continue at your discretion.

A doctor will normally consider this circumstance along with the description of the pain and any difficulties with penetration to help eliminate other conditions and formulate a vaginismus diagnosis. Finding a physician with experience diagnosing and treating vaginismus is helpful. Vaginismus is one of the most overlooked and misdiagnosed of all medical conditions.

A small or tight opening results when the pelvic floor muscles constrict. An uninformed physician encountering a tight opening barring internal examination could easily reach the wrong conclusion that corrective enlargement surgery is needed, instead of recognizing vaginismus. Similarly, a physician might assume incorrectly that the hymen is restricting passage and recommend a hymenectomy when tightness is nearly always due to vaginismus.

Women with vaginismus almost always have completely normal genitalia – though it might not appear that way – so surgery is usually unnecessary and unhelpful. When vaginal tissues are cut surgically, the muscles continue to constrict the opening without improvement. If the muscles are severed, there will be other negative problems. The additional pain and scarring of surgery tends to worsen the situation when vaginismus is present. Surgery can not cure vaginismus – vaginismus is successfully treated through a desensitizing, pelvic control process. 

For some women, symptoms of tightness only occur during intercourse attempts and are not evident at all during the exam. A physician who sees nothing physically wrong, failing to recognize vaginismus, may assume the patient needs emotional or mental health support. For these and other reasons, obtaining an accurate diagnosis can be challenging. So, be bold and advocate for yourself. If unsatisfied with a doctor’s findings, seek a second opinion.

Other causes of painful intercourse

Some additional causes of sexual pain (other than vaginismus) are listed below. It is important to note that secondary vaginismus can coexist with these medical conditions, or continue to be present even after the condition has been resolved. If you suspect that you have one or more of these conditions, make a point of bringing this up when you see your physician: 

Eczema/Dermatitis (Vulvar) – A skin condition that is often characterized by unbearable itchiness. The patches of skin often become thickened, inflamed, and develop thin cracks. There are several different types of eczema, with varying causes and treatments.

Endometriosis – A condition in which tissue from the lining of the uterus (endometrial tissue) grows outside the uterus and attaches to other organs in the abdominal cavity—most often the ovaries and fallopian tubes. Symptoms may include painful menstrual periods, heavy menstrual bleeding, pain during and after sexual intercourse, and infertility. Endometriosis is among the most common causes of pelvic pain.

Interstitial Cystitis – The chronic and often severe inflammation of the bladder wall. The cause is usually unknown. Symptoms include high frequency and urgency of urination, sometimes accompanied by pelvic pain. 

Lichen Sclerosus – A painful skin disorder that typically affects the vulva and/or anus in women. Symptoms include itching and/or burning, thinning skin, white patches of skin, sores or ulcers from scratching, and pain during sexual intercourse. If not treated, lichen sclerosus can lead to fusing of the skin, atrophy, and narrowing of the vagina. 

Ovarian Cyst – An ovarian cyst is any collection of fluid within the ovary. Any ovarian follicle that is larger than about 3/4" [20 mm] is termed an ovarian cyst. Symptoms may include pain or pressure in the abdomen, problems with urine flow, and pain during intercourse. 

Pelvic Inflammatory Disease (PID) – A general term for infection of the lining of the uterus, the fallopian tubes, or the ovaries. It is a common result of infection with sexually transmitted diseases. 

Post-Surgical Trauma/Scarring – Sometimes following vaginal surgery or pelvic surgery, there can be scarring of tissues that had been torn or cut during the procedure. This can cause pain during intercourse.

Psoriasis – An itchy skin condition characterized by raised, red patches of skin covered with silvery scales. When located in the vulvar area, however, the skin is usually less scaly or raised. 

Sexually Transmitted Disease (STD) – Herpes, human papilloma virus (HPV) and other STD’s can cause discomfort and pain during sexual intercourse.

Trauma of the Vaginal Canal & Vulva During Childbirth – Birth trauma, whether due to difficult labor and/or multiple labors, can result in internal vaginal tears, decreased estrogen levels, less lubrication of the vaginal canal, weakening of the pelvic floor muscles, tearing and scarring of the perineum, and sometimes idiopathic deep pelvic pain. Temporary pain during intercourse can be a consequence of any of these conditions, but if the pain continues to be ongoing it is likely due to secondary vaginismus.

Urinary Tract Infection (UTI) – Infection of the urinary tract (kidneys, bladder, urethra), usually caused by bacteria. 

Vaginal Atrophy (Atrophic Vaginitis) – The inflammation of the vagina due to diminishing estrogen levels, resulting in thinning and shrinking tissues, and reduced lubrication of the vaginal walls. Vaginal atrophy is characterized by vaginal dryness, itching or burning, discomfort, and painful sexual intercourse. It typically occurs following menopause—when estrogen levels are lower—or in younger women, immediately after childbirth or while breastfeeding. However, it can also occur following chemotherapy or radiation, due to the ovaries not functioning properly. See Age Changes for more information.

Vaginal Irritation – Feminine hygiene products, douches, soaps, powders, detergents, and overly tight underwear and pants can all cause irritation of the vaginal area, leading to discomfort and/or pain during sex. 

Vaginal Prolapse – The term “prolapse” generally refers to an organ slipping out of its proper place. Vaginal prolapse can be due to a variety of factors including hysterectomy, menopause, obesity, difficult labor, and/or weak pelvic floor muscles. Symptoms of this condition include urinary incontinence, pain during intercourse, constipation, and/or vaginal heaviness or pain. 

Vulvar Cancer – A rare type of cancer in which cancer cells are found in the vulva. It is often misdiagnosed as a yeast infection. 

Vulvodynia – Chronic vulvar discomfort or pain, characterized by burning, stinging, irritation, or rawness of the female genitalia when there is no infection or skin diseases of the vulva or vagina that could cause these symptoms. Two subtypes of vulvodynia are:

  • Vulvar Vestibulitis (Vestibulodynia, Localized Vulvodynia, Vestibulitis) – This is a type of vulvodynia specifically associated with pain on touch and/or pressure in the vestibule, which is the area within the inner lips surrounding the vaginal opening. There is almost always pain with sexual intercourse.
  • Dysesthetic Vulvodynia (Generalized Vulvodynia) – Pain may be present in the outer lips (labia majora), inner lips (labia minora), and/or the vestibule (area surrounding the vaginal opening). Women have also indicated pain in the clitoris, the mons or pubic mound, the perineum, and/or inner thighs. The pain can exist in one or all of these areas and may be continual or intermittent. Also, pain from this condition may be experienced even when nothing is touching the area.

Note: Definitions for vulvodynia are from The International Society for the Study of Vulvovaginal Disease (www. issvd.org) and the National Vulvodynia Association (www.nva.org). 

Yeast Infection (Vulvovaginal Candidiasis) – Vaginal infection characterized by severe itching, vaginal discharge, soreness or irritation, burning sensation, and pain during sexual intercourse. There also may be burning discomfort during urination.