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About the new MSH Silicone Dilators

This product is our pride and joy because it has helped so many couples to have pain-free intercourse. They have been custom made here in South Africa, according to the needs of the thousands of individuals and couples that the My Sexual Health (MSH) doctors have treated for vaginismus and other forms of painful intercourse.

Two major advantages are that the silicone dilators have a soft tip and they do not cause infections. We have many patients who have tried plastic or glass dilators in the past, as well as other household items, but they all prefer our silicone dilators now, because of their softness and suppleness. You can also place the silicone dilator in hot water before you use it to retain heat – so much more comfortable than plastic or glass objects that can cause reflex muscle spasm due to being cold.

The highest quality material for its specific purpose has been used in the manufacturing process, and each product is individually casted and sterilised – our products are not mass produced.

We also make a size six (6) and a size seven (7) dilators for women who have a partner with a penis larger than the size five (5). However, the penis of a typical man is between a size four (4) and five (5) dilator. The silicone dilators can be purchased individually should you not need the whole set. We also make “stub dilators” with the same girth as the standard sizes, but they are much shorter and therefore easier to sleep with or keep inside you during the day.

The silicone dilators can be cleaned either with normal fragrance-free soap, or the soap from the FEMAGENE range, and warm water – rinsed and dried thoroughly before storing it in a cool and dry place.

What is the Success Rate of the MSH Dilators?

According to statistics from our MSH doctors, patients progress on average to the number four (4) and five (5) dilator within three (3) to four (4) weeks if they take their medication and see the physiotherapist. Those who do not progress as well, often need Botox or further intensive psychological treatments.

Our dilators have shown work particularly well not only for treating vaginismus but for a host of other conditions too! Pelvic surgery, radiation for genital and rectal cancers, transgender patients with neo-vaginas or any other intersex condition where a vagina had to be constructed or stretched, women who cannot use tampons, women who find intercourse difficult due to a long period of abstinence, menopause setting in or due to skin conditions like lichen sclerosis and lichen planus, after childbirth, and for painful anal intercourse.

How the MSH Treatment Process works

After you have been evaluated by one of our MSH doctors, you will likely get a prescription for a special medicinal cream to address the hormonal and nerve problems you may have, as well as treatment for infections or treatment to prevent infections, muscle relaxants and further medication to help you cope with anxiety when you are dilating or visiting the physiotherapist.

MSH patients see a specialist pelvic function physiotherapist to teach them breathing and positioning techniques, evaluate their pelvic floor muscles, show them how to actively relax their pelvic floor muscles, demonstrate to them how to use the dilators and progress from the different sizes, and help them with trouble shooting when they get stuck. Specialist pelvic function physiotherapists also attempt to find and treat the cause for tight pelvic floor muscles, rather than just addressing the symptoms.

We also recommend that you use the medication for about ten (10) days before visiting the physiotherapist and preferably first see the physiotherapist before you attempt to use the dilators.

Some patients experience painful intercourse due solely to medical reasons. If, however, you expect that there may also be a psychological component (especially if you were victim to childhood sexual abuse or traumatic sexual experiences), we strongly recommend that you also see one of the specialist psychologists or trained hypnotherapists on our team.

If you have not seen one of the MSH doctors and you are struggling with your dilators, please visit one of them as soon as possible. There is usually an untreated medical condition preventing you from progressing, or psychological issues which have not been attended to. Thousands of women around the world have cured their vaginismus and other sexual pain conditions by only using dilators. If you feel comfortable to first try it on your own – go for it! (But please do see a doctor who specialises in pelvic pain if you have any concerns).

How to use your MSH Silicone Dilators step-by-step

  • Select an appropriate time and a warm comfortable place – allow for relaxation and no interruption.
  • Position your body lying down with your legs bent – place pillows or cushions under your turned-out thighs to allow your leg muscles to completely relax.
  • You can warm the dilator before using it – put it in hot water for 5-10 minutes to slightly warm it (avoid it getting too hot).
  • Apply your prescribed cream if you are a MSH patient. Make sure you rub it in around the opening and into the opening, using the tip of your finger, for at least two (2) minutes.
  • Very important: if you are not using these dilators for vaginismus, but for another reason relating to being transgender, intersex or a male, please ask your MSH doctor or physiotherapist if you have any uncertainties.

Step One: Lubrication

You can use any kind of lubrication, however, we recommend that you use Pjur Body Glide Lube or Pjur Med Premium Glide if you struggle with recurrent infections, or if you are very sensitive. If you are being treated by one of the MSH doctors, you can also use the cream they have prescribed as a lubricant. These lubricants can be ordered online from www.MySexualHealthShop.co.za.

Avoid lubricants containing petrochemicals as these can cause pelvic floor tissue irritation and exacerbate pain. Even natural oils can disturb the natural balance of your vagina and contribute to painful intercourse.

Place a small amount of lubricant on the tip of the dilator and around the opening of the vagina.

Step Two: Breathe

Focus on your breathing by using a series of slow, deep breaths. Try to breathe with relaxed, deep breaths so that your belly rises when breathing in and falls when breathing out. This is called diaphragmatic breathing and its purpose is to switch on your parasympathetic nervous system, which makes you feel safe and relaxed, and switch off your fight and flight reaction, which is often over-active in people with vaginismus or painful intercourse.

Count while you are breathing. If you take four (4) counts to inhale, try to take eight (8) counts to exhale. Continue diaphragmatic deep breathing for up to five (5) minutes at the outset of the session.

Step Three – Scanning

Scan your body for any area of muscle tension from head to toes. Notice any muscular tension around your eyes, jaw, throat, shoulders, buttocks and legs. Mentally encourage each area to relax and loosen with each exhalation. As you exhale, let the pelvic area soften with each breath. Visualise or imagine this area in a state of softness, relaxing further with every exhalation.

Step Four: Insert the Dilator

  • Start with the smallest size dilator and gradually progress to a larger size as comfort permits.
  • Rest the narrow end of the dilator against the opening whilst continuing relaxed diaphragmatic breathing.
  • Gently insert the end of the dilator into the entrance when you feel ready to do so.
  • Gradually insert the dilator to a tolerable depth. Keep the level of discomfort minimal – if you feel any discomfort, pause for up to a minute at a time, continuing to breathe and relax your pelvic floor.
  • When discomfort has eased, progress further while stopping at regular intervals to get your body accustomed to the sensation and lengthening of the tissue.
  • Try to keep the dilator in for 30 minutes at a time.
  • If you find that the dilator goes in easily, it is time to progress to the next size. Some people will start the session with a smaller dilator, leave it in for five (5) minutes and then feel ready to progress to a larger dilator.
  • Never force the dilator beyond a level of personal comfort.

Step Five: Dilator Withdrawal

  • After your session, gently withdraw the dilator and allow yourself to rest and recover before getting up.
  • Make sure you are completely relaxed before withdrawing the dilator. The pelvic floor will often contract as a reflex reaction when you start to withdraw. Just give your body time to relax.
  • It is normal to feel a burning sensation after dilating. This is due to the stretched muscles that irritated the nerves. If you are an MSH patient, you can use the cream your doctor prescribed after dilating again. You can also use the FEMAGENE Soothing Gel after dilating.
  • Wash the dilator with warm soapy water thoroughly, dry and store. No need to wash or wipe the cream or lubricant from your genital area – it will only irritate the area more.

Frequency and Timing of Dilator Therapy

  • Aim to use your dilator for 30 minutes during each session. However, when starting out, this time frame may be well reduced.
  • We recommend that you dilate every day for 30 minutes. Many of our patients get comfortable enough to sleep with their dilators a few hours every night (wear leggings to keep it in) or buy the stub dilators and walk around with them during the day.
  • Once you have established pain-free intercourse, we recommend that you maintain the relaxation of the pelvic floor muscles by either dilating, having sex or having physiotherapy three (3) times a week (i.e. if you are having pain-free sex three (3) times a week, there is probably no need to keep on dilating, but if you are getting to sex only once per week, you will need some regular dilating to maintain the relaxation of the pelvic floor.

Additional Dilator Therapy Techniques

These are some of the typical dilator therapy techniques that may be discussed during your visit to the therapist or doctor regarding their suitability for use:

  • Gradually increasing the depth of dilator penetration.
  • Massaging in a circular motion.
  • Moving the dilator diagonally i.e. forwards and backwards, and left to right.
  • Moving the dilator in and out of the vagina while maintaining gentle pressure against the vaginal wall.
  • Maintaining gentle pressure against an area of discomfort for up to 60 seconds.
  • Involving your partner in dilator therapy.

Important Precautions to take while using Dilators

  • Keep discomfort to a minimum – you should not feel physical or psychological discomfort when you are dilating. Of course, you will need to push yourself a little to progress to the next size, but if you feel overly anxious or uncomfortable, first speak to your doctor, your physiotherapist or psychologist about it.
  • Avoid using a dilator with active pelvic infection and see your doctor if you think that you might have an infection.
  • Avoid using a dilator immediately following pelvic surgery – be guided by your specialists’ recommendations regarding all forms of post-operative penetration and dilator use. You also do not want to wait too long either – as soon the sutures have dissolved, you should be able to begin with dilator therapy.
  • Dilating should never lead to bleeding – if you are bleeding, you MUST see a doctor. It may be due to infection or extreme thinning of the outer layer of your vagina.
  • Never use someone else’s dilator.
  • Clean and dry your dilator thoroughly after each use.

How to Progress to Intercourse:

Once you can insert the number five (5) dilator without physical or emotional discomfort, we recommend that you involve your partner in the process. Only when your partner can insert the number five (5) dilator without causing discomfort for you, you can progress to attempt penetration as if your partner is the next size dilator (rather than through a passionate love-making session). We find that it is better if you take the first few attempts at penetration very slowly and then progress to normal intercourse when you are comfortable with penetration.

If you or your partner suffer from painful intercourse, please make an appointment to see one of our specialist health care providers.

To purchase any of our MSH Silicone Dilators, visit the My Sexual Health Shop.
For more information on MSH Silicone Dilators, contact us on 086 7272 950

LOCALISED PROVOKED VULVAR PAIN (Vestibulodynia)

Localised provoked vulvar pain (vestibulodynia) is a term used to describe pain upon penetration of the vagina. There is also tenderness to touch around the vaginal opening (vestibule) during physical examination. It occurs in women of all ages. It is estimated that approximately 15% of women will experience this type of vulvar pain sometime in their lifetime. Other names used in the past to describe this pain included vulvar vestibulitis syndrome, superficial dyspareunia and vulvodynia.

What causes it?

Researchers are studying vestibulodynia to learn more about the cause of the pain. In the last two decades they have shown that the painful tissue of the vestibule has increased nerve endings and inflammation. Although the cause is unknown at this time, there are theories that chronic inflammation from frequent yeast infections, hormonal changes, poor sexual arousal or chronic skin conditions may trigger the pain. It is likely that there is a combination of factors involved in the cause of vestibulodynia.

What are the symptoms?

Pain with vaginal penetration during sexual activity is the most common symptom experienced by most women with vestibulodynia. The pain can be described many different ways including burning, stinging, tearing, throbbing, searing and occasionally itchy. Some women may experience pain for several hours or days after intercourse. Some women may also have pain with tampon insertion or speculum exam during a routine gynaecologic exam. Most women have pain only with touch to the vestibule and are otherwise not bothered by pain.

What do I see?

The appearance of the vulva can vary with each woman. Some women will have redness at the vaginal opening but some will not. For many, the vulva and vestibule look entirely normal.

How is it diagnosed?

Vestibulodynia is a clinical condition which means that there are no laboratory tests or X—ray imaging that are done to secure the diagnosis. However, it is important that you see a practitioner who is experienced in the management of vulvar conditions. By listening to your history and performing a physical examination, your practitioner can be sure there is no other reason for your pain. Your physical examination may include a “Q—tip test” which is when your doctor or practitioner touches the vestibule gently with a Q—tip to determine if you have pain or not. Your health care provider may feel that other tests are necessary and these could include swabs to rule out infections or a biopsy to exclude skin conditions.

How can I help myself?

It is important to minimize irritation to the vulva and vagina. Avoiding soaps, detergents and scented products is ideal. Bland lubricants that are unscented are best for sexual activity. Ask your health care provider for suggestions. White cotton underwear is best and thongs, G strings, synthetic fabrics and tight clothing against the vulva should be avoided. Lidocaine in the form of a liquid, gel or ointment can provide relief when it is applied directly to the vestibule. This can be used for sexual activity as a way to reduce the pain. If you experience such sexual difficulties it may be helpful to see a sexual therapist and it may be best to avoid penetrative intercourse until your symptoms improve.

What do I see?

Many different treatment options have been tried for vestibulodynia. Some women experience a great sense of relief just knowing that the pain they are experiencing is real and has a name. With a supportive team that may include a spouse or partner, gynecologist, physical therapist (physiotherapist), sexologist, pain specialist, and psychologist most women will have improvement of their pain. Often, different treatment options are combined to maximize therapy.

Since research supports that there may be changes in the nerve endings in this condition, some of the treatment options target the nervous system of the vulva. These are sometimes called “neuromodulators” or “chronic pain medicines”. Examples of these medicines include the oral tricyclic medications like amitriptyline, notriptyline, imipramine and desipramine. These medications are used in high doses as an anti—depressant but they do not work in this way when they are used in smaller doses to treat pain problems. In these situations, they are used to try and reduce the hypersensitivity of the nerve endings. Other medicines used for this pain condition include gabapentin, pregabalin, and duloxetine. Recent research has also looked at these same medicines made up as a cream that are then applied directly to the vestibule where the pain is occurring. These medicines include 2—6% gabapentin cream and 2% baclofen—amitriptyline cream.

Other therapies that have been studied for the treatment of vestibulodynia are physical therapy (physiotherapy), sexual therapy, psychological therapy and surgery. Physical therapy means working directly with a therapist that specializes in rehabilitation of the muscles of the pelvis. Many women with vestibulodynia also experience sore, tight muscles of the pelvis which contribute to their distress. Learning how to relax and soften these muscles can often reduce pain but usually requires learning how to work with these muscles. Tools that the physical therapist may use include vaginal massage, heat therapy, biofeedback and dilator work. Each of these will be tailored to the special need of the patient.

There is also good evidence that women who have vestibulodynia often suffer from sexual problems. This can include low desire (poor libido), difficult arousal (poor natural lubrication or wetness) and lack of orgasm. Many couples feel troubled by their sexual problems. Engaging in sexual counselling has been shown not only to help couples with intimacy, but often reduces pain. Finding ways to have sexual activity in a non—painful way is very important towards healing.

Finally, surgery is another option that has been studied for the treatment of vestibulodynia. This outpatient surgery is performed by gynaecologists who specialize in vulvar conditions. The surgery called a vestibulectomy literally involves removing the superficial skin of the vestibule (painful skin) and advancing a piece of non—painful skin over the excised area. Surgical outcomes are best when it is coupled with both physical therapy and sexual therapy.

Vestibulodynia is a challenging and difficult disorder for women and couples to manage. Many vulvar experts believe that there is no single treatment that will cure this disorder. Using a combined approach of treatments is often the most successful in reducing pain. This means that a treatment plan incorporating physical therapy, sexual therapy and direct treatment for the vestibule skin may be suggested. Usually, with this combined therapy plan, most women will have improvement of their pain.

VAGINISMUS

What is Vaginismus?

Vaginismus is vaginal tightness causing discomfort, burning, pain, penetration problems, or complete inability to have intercourse.

Depending on the intensity, Vaginismus symptoms range from minor burning sensations with tightness to total closure of the vaginal opening with impossible penetration.

The vaginal tightness results from the involuntary tightening of the pelvic floor, especially the pubococcygeus (PC) muscle group, although the woman may not be aware that this is the cause of her penetration or pain difficulties.

Vaginismus is a common cause of ongoing sexual pain and is also the primary female cause of sexless (unconsummated) marriages. Sexual pain can affect women in all stages of life; even women who have had years of comfortable sex. While temporarily experiencing discomfort during sexual intercourse is not unusual, ongoing problems should be diagnosed and treated.

Common Symptoms of Vaginismus

  • Burning or stinging with tightness during sex
  • Difficult or impossible penetration, entry pain, uncomfortable insertion of penis
  • Unconsummated marriage
  • Ongoing sexual discomfort or pain following childbirth, yeast/urinary infections, STDs, IC, hysterectomy, cancer and surgeries, rape, menopause, or other issues
  • Ongoing sexual pain of unknown origin, with no apparent cause
  • Difficulty inserting tampons or undergoing a pelvic/gynaecological exam
  • Spasms in other body muscle groups (legs, lower back, etc.) and/or halted breathing during attempts at intercourse
  • Avoidance of sex due to pain and/or failure

Examples of the effects of Vaginismus

Left diagram – As the man approaches the woman to attempt intercourse, her PC muscle group (darkly shaded) involuntarily tightens the vaginal entrance making intercourse painfully impossible ‘like bumping into a wall’. This type of Vaginismus makes penetration impossible.

Right diagram – In other cases of Vaginismus, penetration may be possible, but the woman experiences periods of involuntary tightness causing burning, discomfort, or pain.

Vaginismus can be triggered in both younger and older women, in those with no sexual experience and those with years of experience. Not all women experience Vaginismus the same way, and the extensiveness of Vaginismus varies:

  • Some women are unable to insert anything at all.
  • Some women are able to insert a tampon and complete a gynaecological exam, yet are unable to insert a penis.
  • Others are able to partially insert a penis, although the process is very painful.
  • Some are able to fully insert a penis, but tightness and discomfort interrupt the normal progression from arousal through to orgasm and bring pain instead.
  • Some women are able to tolerate years of uncomfortable intercourse with gradually increasing pain and discomfort that eventually interrupts the sexual experience.

Women may also experience years of intermittent difficulty with entry or movement and have to constantly be on their guard to control and relax their pelvic area when it suddenly ‘acts up’.

Vaginismus Symptom Severity Range

  1. Minor discomfort or burning with tightness is experienced with vaginal entry or thrusting but may diminish.
  2. More significant burning and tightness is experienced with vaginal entry or thrusting and tends to persist.
  3. Involuntary tightness of the vaginal muscles makes entry and movement difficult and painful.
  4. Partner is unable to penetrate due to tightly closed vaginal opening. If entry is forced significant pain results.

How does Vaginismus cause problems?

With Vaginismus, the mind and body have developed a conditioned response against penetration. The body has learned to expect or anticipate pain upon penetration, so that the powerful PC muscle ‘flinches’ or contracts to protect against the potential of intercourse pain. This can be equated to automatically blinking one’s eyes and wincing when an object is hurled toward us. It is not something a woman thinks about doing – it just happens (see Causes).

The tightened PC muscles may cause burning or pain with sex or may completely block entry. Instead of preventing pain, the tightening of the PC muscle group ultimately causes pain; although acting as a defence mechanism against pain, the opposite effect results.

Vaginismus has a wide range of manifestations, from impossible penetration, to intercourse with discomfort, pain or burning, all resulting from involuntary pelvic tightness. When a woman has never been able to have pain-free sexual intercourse due to penetration difficulties, it is generally classified as primary Vaginismus. When a woman develops the Vaginismus condition after having previously enjoyed problem-free sex, it is generally classified as secondary Vaginismus. Depending upon the classification, there may be some minor differences in the way in which Vaginismus is treated.

Primary Vaginismus

When a woman has never at any time been able to have pain-free intercourse due to Vaginismus tightness, her condition is known as primary Vaginismus.

Primary Vaginismus refers to the experience of Vaginismus with ‘first-time’ intercourse attempts. Typically, primary Vaginismus will be discovered when a woman attempts to have sex for the very first time. The spouse/partner is unable to achieve penetration and it is like he just bumps into a ‘wall’ where there should be the opening to the vagina. Entry is impossible or extremely difficult. Primary Vaginismus is the common cause of sexless, unconsummated marriages. Some women with primary Vaginismus will also experience problems with tampon insertion or gynaecological exams. The PC muscles constrict and tighten the vaginal opening making it uncomfortable or in many cases virtually impossible to have entry. When tightened, attempts to insert anything into the vagina produce pain or discomfort.

Some women also experience related spasms in other body muscle groups or even halted breathing. Generally, when the attempt to put something in the vagina has ended, the muscles relax and return to normal. For this reason, medical examinations often fail to reveal any apparent problems unless the tightness occurs and is noted during the pelvic exam.

Vaginismus Risk Factors

Vaginismus can strike any woman at any time at any age. Contributing factors could include:

  • Pelvic pain due to a medical condition, infection, physical trauma or assault, age-related changes, or painful physical events such as childbirth.
  • Emotional distress, anxiety, fear, relational difficulties, or other similar emotions that relate to sex, intimacy, past trauma, or relationships.
  • The anticipation pelvic pain due to some past or present condition or situation.
  • Other causes.

Secondary Vaginismus sexual pain can affect women in all stages of life, even women who have had many years of pain-free intercourse.

Secondary Vaginismus refers to the experience of tightness pain or penetration difficulties later in life, after previously being able to have normal, pain-free intercourse. It typically follows or is triggered by temporary pelvic pain or other related problems. It can be triggered by medical conditions, traumatic events, relationship issues, surgery, life-changes (e.g. menopause), or for no apparent reason. Secondary Vaginismus is the common culprit where there is continued, ongoing sexual pain or penetration tightness where there had been no problem before.

Most commonly, secondary Vaginismus strikes women experiencing temporary pelvic pain problems such as urinary or yeast infections, pain from delivering babies, menopause, or surgery. The initial pain problems are addressed medically, healed, and/or managed, yet women continue to experience ongoing sexual pain or penetration difficulties due to Vaginismus. While the initial temporary pain was experienced, their bodies developed a conditioned response resulting in ongoing, involuntary vaginal tightness with attempts at intercourse.

Left untreated, Vaginismus often worsens, because the experience of ongoing sexual pain further increases the duration and intensity of the involuntary PC muscle contraction. The severity of secondary Vaginismus may escalate so that sex or even penetration is no longer possible without great difficulty. Some women will also experience difficulty with gynaecological exams or tampon insertion. Vaginismus can also impede a woman’s ability to experience orgasm during intercourse, as any sudden pangs of pain will abruptly terminate the arousal build-up toward orgasm.

Vaginismus is involuntary – not intentional

It is important to note that Vaginismus is not triggered deliberately or intentionally by women. It happens involuntarily without their intentional control and often without any awareness on their part. Vaginismus has a variety of causes, often in response to a combination of physical or emotional factors. The mystery of the problem can be very frustrating and distressing for both women and their partners. Despite the fact that Vaginismus is involuntary and can strike any woman, many women feel intense shame from being unable to have intercourse and keep their pain private, feeling uncomfortable sharing their secret with anyone.

“It always felt tight and uncomfortable. I never realized it was Vaginismus.”
“I’m still a virgin even though we’ve tried many times – it’s like he hits a wall.”
“Sex was fine until after the baby – now it always hurts.”
“The doctor says there’s nothing wrong with me. So why does it still hurt?”
“Ever since the operation I feel burning pain when I try to get him in.”
“I don’t wear tampons because it is too hard to get them in.”
“There’s no way I’m doing a pelvic exam again – it’s unbearable.”
“I experience burning pain upon penetration attempts.”
“Sex used to be great, but now I close up – it burns and stings.”
“We can’t consummate our marriage – it’s impossible.”
“When he starts to move, it feels uncomfortable and we have to stop.”
“After menopause I began to feel soreness and now I tighten up.”
“I seem to ‘tighten’ up down there even when I really want to have sex.”
“Sex has never been comfortable for me.”

Unconsummated Marriages & Impossible Penetration

With severe cases of Vaginismus where there has never been penetration, is it really possible to overcome? Is there hope for unconsummated couples?

Yes. Fortunately Vaginismus is highly treatable with full restoration of sexual intercourse. Couples completing treatment fully consummate and enjoy normal penetrative sex.

Vaginismus is by far the most common cause of unconsummated marriages (where the problem is due to female issues). Couples often describe their attempts at intercourse as there being a “wall” where the vaginal opening should be. It is baffling to some women as to how this condition originated in them if they had no prior sexual contact or pelvic problems. Intercourse is impossible and painful insertion attempts reinforce the Vaginismus response. The conditioned reflex continues to happen every time there is potential for vaginal penetration. The muscles act rebelliously, refusing to allow entry even though the woman may truly want to consummate and receive her spouse vaginally. This is extremely frustrating. For the aroused man, it is like running into a brick wall. For the woman, it is like her body is no longer under her control.

Sex is an activity involving many complex conditioned responses. Bodies do not start out as skilled reactors to sexual stimulus. Successful intercourse is learned through experience and interaction. The nervous system and musculature discover and remember what feels good, works, and what isn’t comfortable. Normally, the transition to intercourse becomes more pleasurable after the first few experiences. The mind and body allow entry and learn to anticipate intercourse positively. Healthy messages result and they generate arousal in anticipation of intercourse. In a woman with primary Vaginismus, the mind and body never get the chance to be trained through positive intercourse experiences. The process of learning how to have successful intercourse is cut short when the vaginal muscles spasm as a protective device against pain. With the absence of any direct conscious control on the woman’s part, nerves controlling the vaginal muscles react to the anticipation of intercourse as a call to tightly constrict, brace, protect, and guard against the onset of potential penetration pain.

What Causes Vaginismus?

Vaginismus is a unique condition in that it may result from a combination of either physical or non-physical causes or it may seem to have no cause at all.

For many women, Vaginismus comes as a surprise; unexplained tightness, discomfort, pain, and entry problems are unexpectedly experienced during intercourse attempts. The pain results from the tightening of the muscles around the vagina (PC muscles). Since this occurs without the conscious intent or control of the woman, it can be very perplexing.

Usually at the root of Vaginismus is a combination of physical or non-physical triggers that cause the body to anticipate pain. Reacting to the anticipation of pain, the body automatically tightens the vaginal muscles, bracing to protect itself from harm. Sex becomes uncomfortable or painful, and entry may be more difficult or impossible depending upon the severity of this tightened state. With attempts at sex, any resulting discomfort further reinforces the reflex response so that it intensifies more. The body experiences increased pain and reacts by bracing more on an ongoing basis, further entrenching this response and creating a Vaginismus ‘cycle of pain’.

Examples of Non-physical Causes:

Fears: Fear or anticipation of intercourse pain, fear of not being completely physically healed following pelvic trauma, fear of tissue damage (ie. “being torn”), fear of getting pregnant, concern that a pelvic medical problem may reoccur, etc.
Anxiety or stress: General anxiety, performance pressures, previous unpleasant sexual experiences, negativity toward sex, guilt, emotional traumas, or other unhealthy sexual emotions.
Partner issues: Abuse, emotional detachment, fear of commitment, distrust, anxiety about being vulnerable, losing control, etc.
Traumatic events: Past emotional/sexual abuse, witness of violence or abuse, repressed memories.
Childhood experiences: Overly rigid parenting, unbalanced religious teaching (ie.”Sex is BAD”), exposure to shocking sexual imagery, inadequate sex education.
No cause: Sometimes there is no identifiable cause (physical or non-physical).

Addressing Vaginismus Causes

Vaginismus does not always have an obvious cause. Sometimes women with near perfect childhoods, great relationships, strong education, and few anxieties, have trouble finding any plausible explanation for what caused their Vaginismus. Understanding why they had Vaginismus may remain a mystery even after it is fully resolved. Fortunately, though it is helpful to know the causes, full knowledge is not necessary to complete successful treatment.

Examples of Physical Causes:

Medical conditions: Urinary tract infections or urination problems, yeast infections, sexually transmitted disease, endometriosis, genital or pelvic tumors, cysts, cancer, vulvodynia / vestibulodynia, pelvic inflammatory disease, lichen planus, lichen sclerosus, eczema, psoriasis, vaginal prolapse, etc.
Childbirth: Pain from normal or difficult vaginal deliveries and complications, c-sections, miscarriages, etc.
Age-related changes: Menopause and hormonal changes, vaginal dryness / inadequate lubrication, vaginal atrophy.
Temporary discomfort: Temporary pain or discomfort resulting from insufficient foreplay, inadequate vaginal lubrication, etc.
Pelvic trauma: Any type of pelvic surgery, difficult pelvic examinations, or other pelvic trauma.
Abuse: Physical attack, rape, sexual/physical abuse or assault.
Medications: Side-effects may cause pelvic pain.

Since Vaginismus can be triggered by physical events as simple as having inadequate foreplay or lubrication, or non-physical emotions as simple as general anxiety, it is important that it be understood that Vaginismus is not the woman’s fault. Once triggered, the involuntary muscle tightness occurs without conscious direction; the woman has not intentionally ’caused’ or directed her body to tighten and cannot simply make it stop. Women with Vaginismus may initially be sexually responsive and deeply desire to make love but over time this desire may diminish due to pain and feelings of failure and discouragement. It is extremely frustrating to be unable to physically engage in pleasurable sexual intercourse.

Why do these causes trigger Vaginismus in some women but not in others?

Life experiences vary dramatically from person to person. Some women’s bodies react with Vaginismus, while others with nearly identical experiences do not.

The anticipation of pain, emotional anxieties, or unhealthy sexual messages can contribute to and reinforce the symptoms of Vaginismus. Frequently, but not always, there are deep-seated underlying negative feelings of anxiety associated with vaginal penetration. Emotional triggers that result in Vaginismus symptoms are not always readily apparent and require some exploration. It is important that effective treatment processes include addressing any emotional triggers so a full pain-free and pleasurable sexual relationship can be enjoyed upon resolution.

Vaginismus is often a complicating factor in the recovery from other pelvic pain conditions. Vaginismus may co-exist with other medical conditions, possibly triggered by temporary pelvic pain resulting from those conditions. Or, it can be the sole cause of sexual pain remaining after the original medical problems are addressed. When the underlying cause has been resolved or managed and ongoing pain, discomfort or penetration difficulties continue to remain, this is typically due to Vaginismus.

In cases where there is clearly both Vaginismus and another pelvic medical problem existing simultaneously, both problems will need to be treated to ensure full resolution. Without addressing the other medical condition, it will be difficult to resolve the Vaginismus as it may continue to be triggered by pain from the other problem.

The Role of the PC muscle group

How it contributes to sexual pain or penetration problems

The pelvic floor muscles predominant in Vaginismus are called the pubococcygeus (PC) muscle group. The PC muscle group plays a key role in the function of a woman’s reproductive system, urinary tract, and bowels. The muscles enable a woman to urinate, have intercourse, orgasm, complete bowel movements, and deliver babies. Hence, they are also referred to as pelvic floor muscles, vaginal muscles, and love muscles.

With Vaginismus, the mind and body have developed a muscle memory or conditioned response against penetration. The body has learned to expect or anticipate pain upon penetration, so that the powerful PC muscle ‘flinches’ or contracts to protect against the potential of intercourse pain. This can be equated to automatically blinking one’s eyes and wincing when an object is hurled toward us. It is not something a woman thinks about doing – it just happens. Unfortunately, instead of preventing pain, the tightening of the PC muscle group ultimately causes pain; although acting as a defence mechanism against pain, the opposite effect results. The spasms cause burning or pain upon penetration or movement and may even completely block entry.

The PC muscle group is large and very powerful. It encircles the urinary opening, vagina, and anus in a figure-eight pattern with one loop of muscles surrounding the vaginal area and the other loop surrounding the anal area. On each end, the muscles are attached to the skeleton and support and hold in place the abdominal and pelvic organs like a net, forming the pelvic floor.

PC Muscles – The anatomy of the female pelvic floor area highlights the internal muscles called the pubococcygeus or PC muscle group. This is the muscle group that tightens involuntarily when Vaginismus is experienced. The powerful muscle group surrounds both the entire vaginal area and the anus area.

Never fully relaxed, but always partially contracted, the PC muscles are ready to spring into action the moment they sense the need, powerfully tightening even without the woman’s awareness. For example, they enable a woman to retain urine or control her bowel movements until a convenient time without her thinking about it. In Vaginismus, during attempted penetration, the PC muscles tighten involuntarily, without conscious intent (thought), and constrict the vaginal opening. This tightening is what makes intercourse uncomfortable, painful, or unachievable. The pain is often experienced without any awareness of the cause. Frustration is often common as a woman knows that there is something wrong, but is unaware her problem is Vaginismus and treatment is available.

Retraining the Body

Retraining the PC muscle group to respond differently to the anticipation of intercourse is key to the successful treatment of Vaginismus. The process of learning to take conscious control of this muscle group changes the conditioned reflex so involuntary tightness no longer occurs (modifying the muscle memories or conditioned responses). Effective program steps will comprehensively address both body and mind components to resolve all triggers so that when intercourse is attempted involuntary spasms no longer occur and pain is eliminated.

Vaginismus Diagnosis & Tests

Women often suspect they have Vaginismus from their symptoms. Medical diagnosis is typically determined by gynaecological exam to rule out the possibility of other conditions and patient history.

Quick diagnosis chart – common manifestations of Vaginismus

Strong indicators of Vaginismus include any of the following:

·       Difficult penetration or impossible intercourse / unconsummated couples

Female penetration problems and unconsummated marriages are typically due to Vaginismus. Entry tightness and pain are common symptoms of Vaginismus.

·       Ongoing sexual pain after a pelvic problem, medical issue, or surgery

The experience of ongoing sexual pain or tightness after resolving or managing a pelvic medical or pain issue is typically due to Vaginismus (see also dyspareunia).

·       Ongoing sexual pain after childbirth

The experience of ongoing sexual pain or tightness following childbirth (after everything has healed) is typically due to secondary Vaginismus.

·       Ongoing sexual pain and tightness with no discernible physical cause

Vaginismus often occurs only during sex attempts. Physicians may initially be unable to find any problem or cause for the sexual difficulties.

·       Avoidance of sex due to pain and/or failure

When a woman states that she avoids being intimate with her husband because sex does not feel good or has become very painful, Vaginismus should be strongly considered.

Is there a simple medical test I can take that would tell me if I have Vaginismus?

There is no medical test that can be taken to confirm the Vaginismus condition. Vaginismus is diagnosed through patient history and description of problem/pain, and gynaecological examination to rule out the possibility of other conditions.

The medical diagnosis of Vaginismus

Women often suspect they have Vaginismus from their symptoms, but getting medical confirmation can be challenging. Confirming a formal diagnosis of Vaginismus may take some planning and perseverance. No definitive medical test exists for the diagnosis of Vaginismus so it may take a number of visits to several physicians or specialists before a medical diagnosis is obtained. When physicians are initially unable to find any specific medical problem (a common experience of Vaginismus sufferers), no diagnosis or misdiagnosis is a common outcome of initial medical exams. Many physicians are unfamiliar with Vaginismus, so part of the process is simply finding a physician that is knowledgeable about the condition. A successful medical diagnosis of Vaginismus is typically determined through patient history and description of the problem, gynaecological examination and the process of ruling out the possibility of other conditions.

Talking to physicians about sexual problems can be difficult. Embarrassment, shame and anxiety are often present, making it hard to communicate and obtain appropriate care. Women may need to strongly advocate for themselves, insisting on a full diagnosis from a knowledgeable professional to rule out any other medical condition and properly confirm the Vaginismus diagnosis. A medical diagnosis is helpful in removing any doubts or anxiety related to identifying the condition and enables women to have more confidence in moving toward treatment solutions.

Sexual pain disorders like Vaginismus are commonly misdiagnosed or left unaddressed. Women may need to be very courageous in persevering until their concerns are given due attention and a reliable medical diagnosis is reached. In some cases and locations, a solid medical diagnosis is not always available or possible. This is especially true in nations with fewer health care options.

The pelvic exam as part of Vaginismus diagnosis

One of the most important aspects of Vaginismus diagnosis is simply the thorough elimination of other possible physical or medical conditions that may be causing the symptoms – leaving the near-certain likelihood of Vaginismus. The process of elimination is a critical part of Vaginismus diagnosis.

The diagnostic process will typically entail giving a medical and sexual history and undergoing a pelvic or gynaecological exam. The physician will discuss the location and occurrence of pain to help render an accurate Vaginismus diagnosis or may request some other tests to help rule out any other problems besides Vaginismus.

Note that some women feel more comfortable expressing themselves and being examined by female health care specialists. Where this is an issue, we encourage women to seek a referral with a female specialist. Taking a proactive, systematic approach will help a person get better care and treatment outcomes.

Burning, tightness, and difficult penetration symptoms may not be at all noticeable during the pelvic exam. For some women, these symptoms occur only during intercourse attempts. For this reason, diagnosis must involve serious consideration of the woman’s concerns which might be stated vaguely as “I’m having difficulty with sex.” Sometimes, busy health care professionals will fail to recognize the signs of Vaginismus and give standard (but unhelpful) advice to just “use more lubricant”, “try to relax more”, or “drink some wine”. This may be due to a lack of familiarity with Vaginismus or reliance on outdated literature on the condition.

Due to PC muscle tightness, some women with Vaginismus find gynaecological exams to be extremely painful and are unable to tolerate them. If a woman suspects she may have difficulty completing an exam, she should communicate this to her physician. There are adjustments (e.g. body positioning, size of speculum used, and nurse support) that can be made to contribute to a more positive experience. A physician who is familiar with the Vaginismus condition will be more suited to providing a comfortable and sensitive environment.

When there is constant vaginal tightness for the duration of the pelvic exam, it may appear to the physician as though there is an unusually small vagina or a hymen abnormality problem. Instead of recognizing the Vaginismus condition, a physician may falsely believe a woman’s vagina is too small, when/if she is unable to complete a pelvic exam (see diagram below). This combined with the patient’s urgent complaint that she cannot have penetrative sex with her spouse or that sex really hurts, may further lead to the false assumption that the vagina requires corrective surgery to enlarge the opening and allow entry. Though there may be rare exceptions, women with Vaginismus typically have completely normal genitalia. The constriction of the vagina is due solely to the tight involuntary spasm of the pelvic floor muscles. Unfortunately, some physicians continue to press forward with the pelvic exam causing great discomfort and pain for the woman. This traumatic experience in itself can contribute to the Vaginismus condition.

Figure showing constriction during pelvic exam – With Vaginismus, the simple approach of a physician’s hand may have the effect of tightening the pelvic floor muscles and making the vaginal entrance seem very small and tight. Note that not all women with Vaginismus will experience tightness during a medical exam (tightness may only occur during sex attempts).

There are many dangers in being given an improper diagnosis from an uninformed professional. Unnecessary, invasive and potentially harmful surgeries and medications have been suggested for women with Vaginismus who have not been properly diagnosed.

Misdiagnosis and the promotion of invasive or unhelpful surgeries are sometimes the unfortunate result of all this confusion. There is no surgery to cure Vaginismus. It is very important to seek a second opinion if surgery to ‘widen’ the vaginal opening has been recommended as this does not normally resolve the penetration problem, but instead may further complicate the problem. Unnecessary, invasive, and potentially harmful surgeries and medications have been suggested for women with Vaginismus who have not been properly diagnosed. Vaginismus is a highly treatable condition that does not require any invasive procedures.

Many women seeking diagnosis are often simply left undiagnosed and turned away by physicians who fail to find anything physically wrong and feel there is nothing more they can do. They may not consider a diagnosis of Vaginismus due to simple lack of awareness.

To assist women in obtaining reliable diagnosis for their sexual pain, the following sample script includes helpful tips to prepare for a physician visit. The script provides examples related to the Vaginismus condition, however, it can be easily modified to help communicate the details of any sexual or pelvic pain problem:

Sample Script: Self-Guided History of Sexual Pain

1. Introduce the problem:

“I have been having problems with pain during sex and hope you will be able to help me.”

2. Provide a description of the pain (be specific):

  • It happens when …”my husband tries insert his penis in my vagina” or “once he is inside and starts to move I feel burning and tighten up”, etc.
  • The pain is located …”at the entrance to my vagina. My vagina is like a wall; he just cannot get it in.” or “after he is inside I feel burning around the penis just inside the entrance”, etc.
  • 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) or “my hysterectomy eight months ago”(secondary Vaginismus), etc. [Note: Inform your doctor if you have been able to previously have sexual intercourse without pain.]
  • It feels like …”burning”, “stinging”, “like he’s hitting a wall”, “tightness during/on entry”, etc.
  • I have tried to reduce or eliminate the pain by …”using lubricant, changing sexual positions, relaxing more.”
  • I am able / unable to …”insert a tampon or complete a gynaecological exam.”

3. Mention any past problems:

Have you previously had any sexually transmitted diseases, yeast infections, bladder problems, or any pelvic pain outside of penetration?

4. Mention any past sexual abuse.

5. State what you think the problem is:

“I think it may be Vaginismus. My symptoms are similar to those outlined in an article I read. However, I have read there are other things that can cause pain during sex and would like to have them ruled out.”

Vaginismus Treatment

Vaginismus is considered one of the most successfully treatable female sexual disorders. Many studies have shown treatment success rates approaching nearly 100%. Treatment resolution follows a manageable, step-by-step process.

Successful Vaginismus treatment does not usually require drugs, surgery, hypnosis, nor any other complex invasive technique. Effective treatment approaches combine pelvic floor control exercises, insertion or dilation training, pain elimination techniques, transition steps, and exercises designed to help women identify, express and resolve any contributing emotional components. Treatment steps can often be completed at home, allowing a woman to work at her own pace in privacy, or in cooperation with her health care provider.

  • The sexual pain, tightness and penetration difficulties from Vaginismus are fully treatable and can be completely overcome with no remaining pain or discomfort.
  • Women experiencing sexual tightness/pain, penetration problems, or unconsummated relationships can expect remarkable resolution of their Vaginismus, allowing full, pain-free intercourse.
  • Treatment steps can usually be completed at home using a self-help approach, allowing a woman to work at her own pace in privacy, or in cooperation with her health care provider or specialist.
  • Vaginismus treatment exercises follow a manageable, step-by-step process

The sexual pain, tightness, burning or penetration difficulties caused by Vaginismus are completely treatable, with high success rates for treatment. Couples are often amazed by the sudden life-changing effects of treatment. Those with penetration difficulties, or pain during intercourse, normally transition to pain-free and pleasurable intercourse following a step-by-step approach.

Vaginismus is considered one of the most successfully resolved female sexual disorders. High treatment success rates are typical within reasonable time frames.

Many of the steps to treat Vaginismus are counter-intuitive and not immediately obvious. As failure at any point inhibits recovery (experiencing discomfort tends to intensify Vaginismus) and can cause avoidance or abandonment of progress, it is best to approach Vaginismus with an educated understanding to ensure success in dealing with it.

Sources consulted: www.vaginismus.com

Not tonight Darling… I have a headache (in the pelvis!)

Pelvic pain, like headaches, can have a significant impact on a patient’s sexual functioning, relationship and quality of life.  The common perception is that a headache is the cliché excuse for avoiding intercourse.  But what if the ache is real, only it’s in the pelvis? Is pelvic pain only in the patient’s head?

We look at conditions that cause chronic pelvic pain and other pains that are triggered by sexual intercourse: Chronic pelvic pain conditions are often associated with other pain conditions and are especially common in patients who have had repeated pelvic surgery.  Specific conditions such as Pudendal Neuralgia and Painful Bladder Syndrome are relatively easy to identify and treat, often in the context of a multidisciplinary team. Sexually provoked pain (dyspareunia) can be superficial or deep.  Deep Dyspareunia is often due to an organic cause such as ovarian, uterine or bowel abnormalities.  Superficial Dyspareunia is usually a neuropathic pain associated with induced neuroproliferation and/or a hypertonic pelvic floor.

The aim is to provide practical tools to identify and treat patients with this very frustrating complaint, and hopefully to contribute to increased satisfaction for the doctor, patient and partner.

The Complications of Untreated Chlamydia

By Rebekah Kendal.

We take a closer look at the complications that men and women might experience as a result of untreated chlamydia.

Because at least half of the people with chlamydia don’t experience any symptoms, it is possible to have the infection without realising it.  According to Dr Elna Rudolph, a medical doctor and sexologist from My Sexual Health, it is possible to develop complications over time if the infection goes untreated, particularly if you get infected repeatedly.

Complications in women

  • Pelvic Inflammatory Disease (PID): “The most serious complication is PID,” says Rudolph, “where the infection goes into the fallopian tubes and around the ovaries and other areas in the pelvis.”
  • Infertility: PID can cause scarring and obstruction in the fallopian tubes, which can result in infertility. It can also increase your risk of miscarriage and ectopic pregnancy.
  • Bartholin’s cyst: Untreated chlamydia can cause the glands that produce lubricating mucus during sex, Bartholin’s glands, to become blocked, resulting in a cyst. An abscess may form if the cyst becomes infected.
  • Increased risk of STIs: “If you have untreated chlamydia, you are actually at much higher risk of contracting other infections such as gonorrhoea and HIV,” explains Rudolph.
  • Infection in newborns: Chlamydia can be passed from a mother to her child during delivery. According to Rudolph, this usually results in an eye infection, which can be treated with an antibiotic ointment.

Complications in men

  • Epididymitis and prostatitis: “Chlamydia can cause infections of the epididymis, the sperm pipe next to the testicles, or an infection in the prostate that can cause pain during intercourse, fever and chills,” says Rudolph.
  • Urethritis: Inflammation of the urethra (urine tube) is most commonly caused by chlamydia. Symptoms of urethritis include a cloudy white discharge from the tip of the penis and pain or burning during urination.
  • Reiter Syndrome: “Occasionally chlamydia is associated with a condition called Reiter Syndrome where there is a reaction to the infection, which affects the whole body,” says Rudolph. “This can cause joint swelling, and can affect the eyes and urethra.”

Shared complications

If chlamydia is contracted during oral or anal sex, it can result in complications that can affect both men and women. “You can get a sore throat, painful swallowing, coughing and fever,” explains Rudolph. “In the anus, it usually causes a discharge and can cause bleeding and painful sex.”

Treatment

“PID and testis infections can be treated with antibiotic treatment and occasionally surgery if abscesses have formed. The infertility can sometimes be reversed, but only with very specialised surgery of the fallopian tubes,” counsels Rudolph. “The Reiter Syndrome is treated with anti-inflammatory drugs and resolves by itself over time.”

For more information and other sex-related queries, visit www.mysexualhealth.co.za.

Seer Seks

Die navorsing wys dat soveel as een uit vyf vroue sukkel met pyn tydens seks.  In my praktyk vind ek dat meer en meer vroue daarvan kla en kom aanklop vir hulp.

Ek werk al ‘n geruime tyd saam met Dr. Elna Rudolph en die res van haar multidissiplinere span by haar kliniek, My Sexual Health, waar ons al honderde vroue gehelp het om pynvrye seks te kan geniet – selfs sommige wat in soveel as dertig jaar van getroude lewe nooit seks kon geniet het nie!

Dr. Elna Rudolph is die kliniese hoof van MySexualHealth.co.za en ‘n mediese dokter wat in seksuele gesondheid spesialiseer.  Sy het in Australia, Engeland en Europa verdere opleiding in seksuele gesondheid opgedoen en het ‘n besonderse belangstelling in die hantering van pynlike seks.  Hier is haar siening oor seks wat seer is:

Glo jy dat pyn tydens seks net in vrou se kop is?

Ek het letterlik nog nooit ‘n pasient gesien wie sy pyn tydens seks net in hulle kop is nie.  Daar is altyd ook ‘n fisiese rede vir die pyn – al is dit net die onwillekeurige sametrekking van die bekkenvloer spiere – daar is altyd ‘n rede vir wanneer seks seer is.  As daar ‘n rede is, is daar ook n oplossing!

Die grootste deel van my werk is om die oorsaak van die pyn op te spoor en dan die beste behandelingsplan voor te stel.  Deel van die behandeling sluit meestal ook sessies met jou of ‘n sielkundige in om die emosionele aspekte van die pyn sowel as die impak van die pyn op die verhouding aan te spreek.  Seer seks sit nie in jou kop nie, maar dit lol tog met jou kop en dikwels ook met jou verhouding.

Wat is die mees algemene oorsake van pyn wat jy in jou praktyk sien?

Ek sien meestal wat ons noem “oppervlakkige dispareunie” dit wil sê pyn wat onstaan naby die opening van die vagina waar dit reeds seer is as die man probeer penetreer, of wanneer selfs die gebruik van ‘n tampon seer (of onmoontlik) is.

Mens kry ook “diep dispareunie” wat soms alleen voorkom en soms saam met oppervlakkige dispareunie.  Dit sien ek nie so dikwels nie, want die pasiënte se ginekoloë sorteer hierdie probleem gewoonlik uit voordat hulle by my uitkom.  Die mees algemene oorsake daarvan is endometriose, siste op die eierstokke, prikkelbare derms en hardlywigheid, en dikwels ook die bindweefsel wat vorm as gevolg van herhaaldelike operasies.  Ek hoor dikwels dat dokters vir pasiënte sê dat die oorsaak van hulle pyn hulle baarmoeder is wat “verkeerde kant toe kyk.”  Dit is ‘n baie onwaarskynlike die rede vir hulle pyn – ek dink dit is die moeite werd om ‘n tweede opinie te kry en die saak verder te ondersoek.

Oppervlakkige pyn word gewoonlik veroorsaak deur ‘n kombinasie van probleem met die vel, senuwees en die spiere rondom die vaginale opening.  Hierdie abnormaliteite word veroorsaak deur hormoonwanbalanse (byvoorbeeld die gebruik van die pil, menopouse of swangerskap en borsvoeding), herhaaldelike infeksies, of dit kan ook ‘n genetiese hipersensitiwitiet van die senuwee wees (in so ‘n geval vind ons dikwels dat die pasiënt se naeltjie ook baie sensitief is).

Daar is amper altyd abnormale werking van die bekkenvloerspiere met spasmas, snellerpunte en soms ook swakheid van sekere spiere.  In sommige vroue word hierdie probleme veroorsaak deur die verkeerde postuur, rugprobleme of selfs net spanning en angstigheid.  Sommige vroue het konstante spasma en by ander gaan die spiere net onwillekeurig in spasma wanneer daar ‘n poging is tot penetrasie, en dan kan die vrou dit nie weer willekeurig ontspan nie.

Wat sluit die behandeling van seer seks gewoonlik in?

Dit hang absoluut af van die diagnose.  Dit is gewoonlik ‘n kombinasie van ‘n salf wat spesiaal gemeng word vir die spesifieke diagnose en rondom die vaginale opening aangewend word, dikwels ook medikasie om die senuwees wat betrokke is te herstel en te help vir angstigheid, die behandeling van kroniese infeksies, die herstel van die hormoonbalans, die gebruik van dilators om stelselmatig die weefsel te rek en die brein te leer dat penetrasie iets is wat nie seer is nie en waaroor die vrou beheer het, fisioterapie deur ‘n handjie vol gespesialiseerde fisioterapeute wat die bekkenvloer spiere kan behandel, seksterapie waar die paartjie gehelp word om stelselmatig weer (of vir die eerste keer!) ‘n sensuele verhouding te ontwikkel waar die fokus aanvanklik glad nie op seks is nie, en dan ook dikwels sessies om die sielkundige aspekte van die pyn en die impak op die verhouding aan te spreek, soos wat ek voorheen genoem het.  In sommige gevalle gebruik ons ook Botox of ander inspuitings as die fisioterapie alleen nie help om die spiere laat ontspan nie.

Eager Beaver

By Nichi Hodgson, Originally published in Women’s Health Magazine, 2015. Edited by Dr. Elna Rudolph.

Things we love about vaginas: they have more names than Snoop Dogg. People have written poems, songs and plays about them, and in our overexposed, overtly sexualized world, vaginas still hold the power to appall, enthrall and excite. Oh, and give birth. But it turns out we still have a few tricks to learn…

Oral sex how-to (for him)

A guide you might want to subtly leave on his bedside table…

  1. “While you’re kissing, press a thigh between her legs,” says sex expert Midori, author of Wild Side Sex (like Madonna, she only needs one name). “Now, grind in, moving up and down. It’s the washing-machine-on-spin-cycle principle – the overall vibration has a greater effect than just using a finger or two.” Noted.
  2. “Next, start to nibble through her skirt as a teasing prelude – she should soon start grinding on your face. But before her panties come off completely, try breathing and licking her through them. It’ll make for a truly explosive touchdown when your tongue finally makes direct contact with her clitoris.”
  3. Now to master your technique. “If you want to practice clitoral stimulation, put a Tic Tac in a sandwich bag. Learn to suck the mint between your lips without using your teeth, then keep it there, while using your tongue to tease it.” Well, that’s something they never mentioned in the advert.

Question Time…

Things you never learnt during high school sex ed…

Q. Can my Rabbit give me an STI?

A. If you’ve had one before, yes, you can get it again from your vibrator, says sex educator Kate McCombs. “Toys made from porous material can harbor infections. Choose silicone, glass or stainless steel and clean them in soap and hot water.” Non-electric silicone ones can even go in the dishwasher. Just watch out who unloads it.

Q. Can his cold sore give me genital herpes?

A. In a nutshell: yes. According to Dr Natalie Hinchcliffe, “The HSV 1 type (usually the oral kind) can be passed to your genitals, even if lesions aren’t present.” Cold sores on your cooch? Not ideal. Dr. Elna Rudolph adds that “the notion that HSV1 is an oral infection and HSV2 is a genital infection is no longer true.  You can get “cold sores” on your genitals and genital herpes in your mouth and on your lips.  If he has ever had a fever blister, he can give you genital herpes! The chance is slim, but not zero.  In SA 80% of people have HSV1 in their mouths – it leaves a very small minority that can safely have oral sex!”

Q. Could I become vibrator-dependent?

A. Afraid so, says sex therapist Sarah Berry. “Too much vibrator use can desensitise you. If you’re struggling to orgasm with a partner, cut out the toys until you get used to manual stimulation again.” Turn off to get turned on. “If your brain gets used to reaching orgasm in a specific way, without variations, it becomes learned behavior and deviating from that becomes difficult”, says Rudolph.  “Make sure you love yourself in many different ways to keep your clitoris (and brain!) sensitive to all kinds of stimulation.”

Q. Is it possible to grow a vagina?

A. Actually, yes. US scientists have pioneered a way to lab-grow a vagina from a woman’s own cells. It can then be implanted into her body. The process takes just six weeks and the vagina even has full sexual function. But what do they do with the old one?

Three things your vajayjay would veto

Treat your vagina with kindness and it will return the favour.

1. Smoking

The risk of cervical cancer is about double in smokers,” says Hinchcliffe. “Smoking also puts you at greater risk of certain STIs, including trichomonas – you know, the one that gives you a horrible, foul-smelling discharge.” Stub it out for the sake of your vag. Rudolph adds: “It is much more difficult for your body to fight off the damage cause by HPV infection if you smoke.  Women who already have abnormal pap smears have a much higher chance of it getting worse and worse, even up to the point of cervix cancer, if they smoke.  Some infections like the foul-smelling Trichomonas is also more common in smokers.”

2. Douching

“Your vagina actually cleans itself, so there’s no need to douche it with anything,” explains Hinchcliffe. “In fact, bacterial vaginosis is significantly more common among women who douche, as is general irritability in the area. Your vagina is not meant to smell like a rose, so stop trying to make it.” But if you insist, for gynae’s sake put down the lemon verbena soap on a roap and use a specially formulated wash with the right pH balance. FEMAGENE products won’t upset your beaver’s balance, BUT only if you use it externally.  Never ever use any soap inside your vagina and definitely don’t squirt anything into your vagina. It kills all the good stuff and makes your situation worse in the long run. Bacterial Vaginosis, a condition where one or more of the natural bacteria in your vagina overgrows and cause a smelly discharge, is much more common in women who douche or try to wash inside their vaginas.

3. Penetration-only orgasms

Too many of us still prioritise the hole as the goal – to our sexual detriment. A study by neuroendocrinologist Dr Kim Wallen found that seven percent of women can climax from penetrative sex alone. What’s more, he calculated the “C-V ratio” to show it’s the distance between your clitoris and vagina that likely determines your ability to have a hole-in-one orgasm. The perfect pump-to-pleasure measurement was found to be 2.5cm. If yours is longer than that, don’t let him think it’s only his magic wand that counts.

For when your hoo-haa isn’t feeling hunky dory…

Find out when your lady garden needs some love…

> Symptom: Burnt skin thanks to a bad bikini wax

Unless the skin is blistered, this doesn’t require medical attention. Just treat as you would any other burnL run under cold water, apply cream such as E45, avoid intercourse until healed and, most importantly, get yourself a new beautician, pronto!

> Symptom: Discharge after intercourse

As long as there’s no strange colour or sudden change in consistency, it’s normal. Discharge increases with sexual arousal and the amount varies from woman to woman. And if a guy ejaculates inside you, expect to leak.

> Symptom: Soreness or irritation after exercise

A dragging sensation could indicate vaginal prolapse. Cycling is one of the worst culprits for beaver-bruising, as a study in the BMJ found female cyclists were at particular risk of infections and swelling. Saddle and handlebar positions are important – German scientists found sitting with your upper body at a 30-degree angle to the bike frame can reduce blood flow to your vagina by up to 70 percent. Stand up on your pedals every 10 minutes to avoid this.

> Symptom: Pain during and after sex

One in five women experience pain during intercourse.  There can be various reasons for this from serious gynaecological conditions to hormonal imbalances, infections to muscles spasms and nerve abnormalities.  These need to be excluded and then managed by an experienced multi-disciplinary team that can also address the psychological aspects of suffering from painful intercourse.  Treatment might involve using vaginal dilators, physiotherapy and various creams as well as sorting out any infections and gynae problems.

> Symptom: Bleeding between periods

This warrants some form of medical investigation, as it can be caused by infection, cervical cancer or ectropion (also known as cervical erosion). Ectropion is a normal response to hormones and usually occurs in women of reproductive age, especially those using hormonal contraception. It can be scary, but as long as your smear tests are normal, it’s unlikely to be a long-term worry.

> Symptom: Pain at the top of your pubic bone

Generally means pelvic inflammatory disease (PID), an ovarian cyst or endometriosis. PID symptoms include fever, unusual discharge and bleeding between periods. Cysts cause acute pain on one side, but often go away by themselves. Painful sex, severe period pain and pain going for a number two could be endometriosis, which can be eased with oral or hormonal contraceptives.

 

Painful Sex

Many women who complain about low libidos actually experience pain during sex, according to Dr Elna Rudolph, head of the multi-disciplinary team at My Sexual Health in Pretoria.

“When it comes to sex, some medical practitioners feel out of their depth. They know that when sex is painful it can cause a massive divide in a relationship, but they don’t know how to address the issue and they often end up telling the patient there is nothing ‘wrong’ with her, because a clinical examination does not reveal any overt pathology like visible lesions, discharges or anatomical abnormalities.  As a result, patients tend to move from one medical practitioner to the next hoping for a solution. In some instances, it takes years before she is diagnosed and treated.”

Dr Rudolph noted that every time a woman is told that there is nothing wrong with her or that it is ‘all in her head’, she interprets it as meaning there is in fact something seriously wrong with her, because nobody can figure it out.

She appealed to doctors to refrain from using the phrase ‘it is all in your head’ when consulting a patient who complains about painful sex.  Rather say that you cannot find the cause for the pain and refer her to a centre that specialises in the management of painful intercourse.

An Approach to Dyspareunia:

The DSM V now reads Genito-Pelvic Pain/Penetration Disorders and throws all causes for dyspareunia under one psychiatric diagnosis.  The fact that it is in the DSM V acknowledges that dyspareunia has a significant psychological impact on a patient, but it should not be interpreted as “sexual pain is all in the mind.”  This umbrella-term certainly also does not aid in diagnosing and treating the cause of the pain.  The next section aims to provide an approach to dyspareunia: Pain during sex can be either deep or superficial.

Deep Dyspareunia:

Gynaecological Disorders:

Deep pain usually signals a gynaecological problem like ovarian cysts, fibroids, endometriosis, occasionally a retroverted uterus (although this is a relatively common finding, it is seldom the cause of the pain), pelvic inflammatory disease and neoplastic disorders.  If the patient has deep dyspareunia and the cause cannot be diagnosed and or treated by the GP, referral to a gynaecologist is very important.

Bowel Disorders:

Irritable or Inflammatory Bowel Disease as well as simple constipation can cause dyspareunia.  If there is any occult faecal blood, weight loss or any other danger sign, the patient should be referred for colonoscopy.

Bladder Disorders:

A chronic, untreated urinary tract infection and other bladder pathology can cause painful intercourse.  A condition that is often missed is painful bladder syndrome, formerly known as interstitial cystitis.  This is now seen as a pain disorder involving central sensitization rather than being an organic disease.  The patient experiences pain over the bladder and what feels like chronic or recurrent urinary tract infections, but with sterile urine with or without hematuria.  If there is hematuria, urological referral is advised.  If not, it should be treated like a pain disorder in the context if an experienced multi-disciplinary team.  Medications that are used include anti-histamines, gabapentin, pregabalin, amitriptyline, duloxetine, anti-inflammatories, muscle relaxants, etc.

Other Causes:

Repeated abdominal and pelvic surgeries contribute to a large portion of deep dyspareunia.  It also sometimes seen in patients who over-train their core muscles like pilates instructors, triathletes and dancers.  In these cases, referral for myofascial release by a specialist pelvic function physiotherapist can solve the problem.

Superficial Dyspareunia:

Superficial pain is experienced around the vaginal opening and on attempted penetration. Patients usually describes a sharp stinging, burning or tearing sensation and that it feels like her partner is hitting a wall inside her vagina.

It is important to distinguish between localised and generalised pain.

Localised:

Localised pain can be organic and nociceptive in nature with a clear cause like a visible herpes ulcers or fissures.  In the cases where there is a lesion with an unknown cause, especially if it does not respond to empirical therapy in two weeks, a biopsy should be taken to make the correct diagnosis.  Lichen Sclerosis, Erosive Lichen Planus, Spongiotic Dermatitis and undiagnosed Genital Herpes are common causes of localised genital pain.  To take a biopsy of normal looking skin or mucosa is usually of no value – it will just show mild inflammatory changes and make no contribution to the diagnosis or the treatment plan.

Fissures:

Fissuring or splitting of the posterior fourchette – which can occur at the first attempt at sex or years later –  can cause pain that is described as: ‘like a paper-cut’, ‘knife-like’ or as a tearing sensation.  They have mild to severe pain with penetration and might tear when inserting tampons or during gynaecological examination. They often see bleeding or spotting after sex and will complain of itching, burning or stinging when the area comes into contact with semen, water or urine.  An examination will reveal a tiny split or linear erosion at the midline of the base of the vagina on the perineal skin. In addition, the posterior fourchette may form a tight band or tent (membranous hypertrophy).  Splitting occurs when the posterior fourchette is pulled into the vagina and experiences friction from thrusting, especially if there is not enough lubrication or if the mucosa is atrophic due to hormonal changes.  Correcting the hormonal imbalance, using a non-irritating protective substance like Aquaphor, using a silicone lubricant and making sure the fragile part does not get pushed into the vagina during penetration by manually pulling down on it with a thumb when inserting the penis, works very well.  If this does not help, it is usually due to an undiagnosed chronic infection or other skin condition and a biopsy is warranted.

Genito-Urinary Syndrome of Menopause:

Previously known as atrophic vaginitis, this condition causes significant discomfort and impairment of quality of life for older women.  If peri- or post-menopausal woman experiences pain during sex, it is probably due to a local oestrogen deficiency. They also experience significant urinary symptoms: they feel as though they have recurrent infections, when in fact they don’t and they often have trouble with incontinence as well.  Post- menopausal women who are on topical oestrogen are twice as like as their oestrogen-deficient peers to be sexually active.

Provoked Vestibulodynia:

A common form of localised pain where there is no visible pathology is Provoked Vestibulodynia.  This condition is easily diagnosed by touching the vestibule with a wet ear bud.  If the patient experiences a burning or stinging sensation, it is called allodynia and it is diagnostic.  The patient should be asked to rate the pain out of 10 at the following positions:  above the urethra, under the urethra, as well as at the the 4’O clock 6’O clock and 8’O clock positions.   This condition is due to neuroproliferation and can be genetic, due to recurrent infections or due to hormonal abnormalities caused by hormonal contraception or menopause.  If only the posterior aspect of the vestibule is affected, it is due to a hypertonic pelvic floor with irritation of the pudendal nerve.

Oral contraceptives, especially the low-dose anti-androgenic ones cause a relative oestrogen and testosterone deficiency in the vestibillum, which induces neuroproliferation, in some women.  It is more likely to happen in those who start off with congenital neuroproliferation around the vaginal opening.  You will find that those patients also have a sensitive umbilicus.  Look out for vestibulodynia in the patients with the sensitive umbilicus, those who can’t use tampons and first-time pill users.

Recurrent infections can also cause neuroproliferation, but one of the biggest contributors in those with recurrent infections is the repeated use of topical anti-fungals.  In a sensitive vestibule, it causes a chemical dermatitis that feels like and infection, but is only worsened by continuous use of topical agents.  Do a vaginal swab and ask for sensitivity to be done on the candida if there is any.  We see many cases of candida glabrata and ducreii in clinical practice and it is most likely do to over-use of conventional anti-fungal treatments that selects for the resistant strains.  Only treat what you find on the swab and aim for oral treatment rather than topical treatment in these cases.

In our experience, women with very small labia minora and an exposed introitus are more likely to suffer from provoked vestibulodynia.  It is most likely due to higher exposure of the vestibule with irritation of the nerve-endings.

Provoked Vestibulodynia is treated by taking away the cause of the neuroproliferation, restoring the hormonal balance of the vestibule, treating the associated neuropathic pain and correcting the pelvic floor hypertonicity if it is present.

Hypertonic Pelvic Floor:

Almost all cases of superficial pain will have some degree of pelvic floor hypertonicity.  It is often a chicken-and-egg situation where one is not sure if the muscle spasm caused the nerve irritation or if it was the other way around.  The most important aspect of the treatment of superficial dyspareunia is making sure that the pelvic floor has normal tone.  In the presence of hypertonicitiy, the pain is maintained, and cure is very difficult.

Injury such as traumatic vaginal delivery, pelvic surgery, positional insults such as prolonged driving or occupations that require prolonged sitting, gait disturbances, traumatic injury to the back or pelvis, and sexual abuse can cause the muscles in the pelvic floor to go into spasm.

Vaginismus:

According to the DSM V the more up-to-date term to use would be a “penetration disorder” but with vaginismus there is a distinct phobic reaction and avoidance behaviour associated with attempts at penetration. A hypertonic pelvic floor certainly contributes to vaginismus.  In our clinic, most women with vaginismus also have another superficial pain disorder and the vaginismus is merely a response to repeated attempts at penetration that was extremely painful.  Most of our vaginismus patients have also never been able to use a tampon.  Some do have a history of sexual abuse and dysfunctional families, but that is actually a small percentage.  Almost all patients have a history of a strict religious upbringing, very little sex education as well as negative ideas and messages about sex from early childhood.

The research show that this condition is best managed in the context of a multi-disciplinary team.  These patients need to have the contributing medical conditions like provoked vestibulodynia diagnosed and treated, but they also need sex therapy, relationship therapy, cognitive behavioural therapy (where she learns to take control of her own vagina and what happens in her genital area), dilator therapy and physiotherapy by a women’s health physiotherapist who specialises in the treatment of sexual dysfunction (there is only a handful around!)  During the treatment process sex is forbidden but the couple is given sensate focus exercises to re-establish intimacy if it has dwindled and to rewire the women’s mind – she has to learn that sensual experiences are not always threatening can be pleasurable.  She also needs to get in touch with her sexual self – something that most patients suffering from vaginismus though would never be possible.

The patient will see each of the multi-disciplinary team members alone or with her partner a few times during the treatment period.  When we are satisfied that she is physically and emotionally ready to attempt penetration, it is done in a gradual manner where the partner first helps with dilators and then gently attempts penetration when they are both ready.

The process does consume a lot of resources: time, money, emotional energy, but it is all worth it in the end.  The treatment success of a program like this is very high, all over the world.

Generalised superficial pain:

Generalised superficial pain is often unprovoked and not only associated with intercourse, although an attempt at penetration can worsen the pain.  This is referred to Vulvodynia can be seen as a chronic pain syndrome. The pain usually comes and goes with some patients experiencing long pain-free intervals and some have constant pain that gets better and worse depending on a whole range of factors.

Pudendal Neuralgia:

A specific form of superficial pain is called pudendal neuralgia where patients experience a burning pain in the distribution of the pudendal nerve.  The pain can be in the whole area from the clitoris to the anus or only one specific branch.  It can also be unilateral or bilateral.  This pain usually gets worse when the patient is sitting and better if they are lying on their sides.  The treatment involves physiotherapy, pharmacotherapy with drugs like pregabalin or gabapentin, often pudendal nerve blocks (which is also diagnostic) and only occasionally surgery where a narrowing of Alcock’s canal can be demonstrated.

Chronic Pelvic Pain:

An estimated 40% of diagnostic laparoscopies and 12% of hysterectomies are performed for pelvic pain, according to Weiss et al.  Although diagnositic laparoscopy is necessary to diagnose some important causes of chronic pelvic pain like endometriosis, repeated exploratory laparoscopies and especially laparotomies is not advised.  In fact, it worsens the condition due to scar tissue formation and with worsening of myofascial pain.  This is a complicated condition with often no clear cause or multiple contributing factors.  In many cases, conventional treatment is ineffective and management by a multi-disciplinary team is required.

Other Chronic Pain Disorders:

Patients with disorders like fibromyalgia and rheumatoid arthritis have a higher incidence of dyspareunia – deep or superficial as well as chronic pelvic pain.  In these situations the underlying painful condition should be treated optimally, but it is often necessary to address the painful intercourse separate as well.

Persistent genital arousal disorder:

This condition is marked by constant or intermitted feeling of genital arousal with or without spontaneous orgasms. Its unwanted and not due to sexual stimulation or thoughts and causes significant distress for the patient.  Of late, this condition is seen as a type of genital pain disorder and is treated much like vulvodynia in specialised sexual pain centres.  Referral is advised.

Some useful tips

  • If a women complains about dyspareunia, ask her to tell you about the pain. Let her talk for a minute or two – the diagnosis is usually already clear if you just allow her to describe her symptoms.
  • Then get a good history and ask about her overall physical health and medication use.
  • If a woman is tense or scared, take the time to reassure her by giving her a step-by-step account of what you are going to do next. Start the examination with a general exam and then by touching her thighs – after informing her of your intension – then move to the vulva.
  • In addition, if the patient is scared, do not use a speculum at the first examination – a finger and an ear bud are all you need to diagnose the cause of superficial pain.
  • Always ask a patient to rate her pain on a scale of 1-10 and to describe the sensation. Make a note of this and compare it at the follow-up consultation.  If there is no improvement, refer the patient.

RSG: Pynlike Seks en Lae Libido (Podcast: Painful Sex and Low Libido)

RSG: Seks en Jy, 22 Julie 2016.

Martelize Brink gesels met Dr. Elmari Mulder Craig en Dr. Elna Rudolph oor seksuele disfunksie by vroue, met die fokus op pynlike seks en lae libido.