​Kembara Xtra - Medicine - Vaginismus

​Kembara Xtra - Medicine - Vaginismus 
Formerly known as vaginismus and dyspareunia, these diseases are now classified as genito-pelvic pain/penetration problem.
Involuntary contraction of the vaginal musculature causes vaginismus. Women who have never been able to engage in penetrating sexual activity develop primary vaginismus.
Women with secondary vaginismus used to be able to engage in penetrative sex, but they can no longer.
 persistent or recurring issues with at least one of the following for six months or longer: - Failure to successfully engage in vaginal contact or penetration on at least 50% of tries - Marked genito-pelvic discomfort on at least 50% of efforts at vaginal intercourse or penetration - Marked dread of vaginal intercourse or penetration on at least 50% of attempts at vaginal intercourse or penetration - At least 50% of the time, there is a noticeable tightening or tensing of the pelvic floor muscles upon vaginal contact or penetration. 
● Significant distress or interpersonal problems is brought on by the disruption.
● Dysfunction is not brought on by: a nonsexual mental disorder; a stressful romantic connection; or another major stressor.
- Drug or substance effect
Indicate whether you have any general medical conditions, such as endometriosis or lichen sclerosus.
 pregnant women's issues

first appear during an assessment for infertility
In people with genito-pelvic pain/penetration condition, pregnancy can happen if ejaculation takes place on the perineum.
Vaginismus could be a separate risk factor for cesarean birth.


Prevention Incidence
Vaginismus is estimated to affect 1–17% of people worldwide each year. 12–21% of women in North America experience genito-pelvic pain, which can have a variety of causes.

Prevalence
Due to a lack of statistics and reporting, the true prevalence is unknown.
The prevalence rates in population-based research range from 0.5% to 30%.

 Has an impact on women of all ages.
In North America, 15% of women say they experience pain during sexual activity on a regular basis.

Pathophysiology and Etiology 
In both primary and secondary vaginismus, the most frequent factor is multifactorial.
Primary: Mental health and social problems
 A phobic reaction may result from early exposure to negative messages about sex and sexual relations.
 A negative body image and insufficient knowledge of the genital region
 A history of difficult gynecologic examinations, abnormalities of the hymen, and sexual trauma
Secondary, situational, and frequently linked to dyspareunia as a result of:
Insufficient vaginal lubrication, endometriosis, inflammatory dermatitis, surgical or postpartum scarring, and pelvic radiation
Estrogen deficiency: Conditioned response to pain from the aforementioned medical problems

Risk factors Most frequently idiopathic Many women claim a history of abuse or sexual trauma, though the precise involvement in the disorder is unclear.
Frequently linked to other sexual disorders

Anxiety, family dysfunction, marital stress, vulvodynia, and vestibulodynia are associated conditions.


The diagnosis of genito-pelvic pain/penetration disorder in the DSM-5 combines dyspareunia with vaginismus.

complete medical history, complete psychological history, and complete sexual history, including the following: - The beginning of symptoms, either main or secondary; - If secondary, any events that may have precipitated them;
- Compromised relationships or violence by partners
- Refusal to permit vaginal entrance for various purposes
Penis, digit, item; sexual
Using tampons for hygiene and getting a pelvic exam for health
Traumatic events (exam, sexual, etc.) and infertility
- Beliefs in God
- Sexuality beliefs

clinical assessment 
To rule out structural anomalies or organic pathology, a pelvic exam is required.
Because genital/pelvic examinations can cause patients to experience varied levels of anxiety, it is crucial to inform the patient about the examination and provide her control over how it proceeds.
It may be advisable to refer a patient to a gynecologist, family doctor, or other healthcare specialist who specializes in the treatment of sexual issues.
It's possible to notice the pelvic floor muscles contracting before an inspection.
Lamont's system of classification assists in determining severity: Perineal and levator spasms in the first degree were eased with consolation. Perineal spasm in the second degree, which persisted throughout the pelvic exam. - Elevated buttocks and levator spasm in the third degree
- Elevation with adduction and retreat in the fourth degree, as well as levator and perineal spasm.


Vaginal infection, vulvodynia/vestibulodynia, vulvovaginal atrophy, urogenital structural abnormalities, interstitial cystitis, and endometriosis are among the differential diagnoses.

Laboratory Results 

There is no need for laboratory tests unless an examination reveals symptoms of vaginal infection. There are five things that should be taken into account when this illness has been diagnosed.
Relationship factors and partner factors
Personal vulnerability elements
Cultural/religious considerations

 Medical aspects
Interpretation of Tests
Unavailable; possible requirement to look for secondary causes

Management 
A meta-analysis of RCTs found a trend toward higher efficacy of active treatment compared to controls, while a meta-analysis of observational studies found that nearly 80% of women with vaginismus benefit from a variety of treatments. Genito-pelvic pain/penetration disorder may be successfully treated.

Another meta-analysis of level 1 evidence revealed that placebo accounts for 2/3 of the treatment benefit for female sexual dysfunction (3)[A]. These results suggest that the current treatments for female sexual dysfunction are, generally, only marginally better than placebo, which highlights the ongoing need for more effective treatment for female sexual dysfunction.
Most start with myofascial release and pelvic floor physical therapy.
Some research suggests that cognitive-behavioral treatment, which uses desensitization methods including gradual exposure to lessen avoidance behavior and fear of vaginal penetration, may be useful. A clinically significant impact of systematic desensitization cannot be ruled out, according to a Cochrane review.

There is evidence that sex therapy may be helpful.
- Involves stepwise vaginal desensitization techniques and Kegel movements to improve control over the perineal muscles
With vaginal dilators that the patient inserts and controls, with the woman's own finger(s) to encourage sexual self-awareness, with partner's fingers under patient control, and with coitus after achieving the largest vaginal dilator or three fingers; it's important to start with sensate-focused exercises/sensual caressing without necessarily requiring coitus. Initially passive (nonthrusting), female-directed, and superior in gender Topical anesthetic or anxiolytic with desensitization exercises may be explored. Later, thrusting may be permitted.
Patient education is a crucial part of the healing process.


Medication 
Anticonvulsants and antidepressants have been tried with varying degrees of efficacy. Amitriptyline 10 mg, a low-dose tricyclic antidepressant, may be started and increased as tolerated.
Topical anesthetics or anxiety medications may be combined with the aforementioned cognitive-behavioral therapy or desensitization exercises.

In patients who do not respond to conventional cognitive behavioral and medicinal treatment for vaginismus, injections of botulinum neurotoxin type A may improve vaginismus.
- Dosage: It has been demonstrated that injections of 20, 50, and 100 to 400 U of botulinum toxin type A into the levator ani muscle relieve vaginismus.
While the patient is under anesthesia, an intravaginal injection of botulinum neurotoxin type A (100 to 150 U) followed by a 20 to 30 mL injection of bupivacaine 0.25% with epinephrine 1:400,000 may help with the gradual insertion of dilators and the eventual relief of symptoms.


Referral 

The following sources can be consulted for recommendations on diagnosis and treatment: psychiatry, obstetrics/gynecology, physical therapy for the pelvic floor, hypnotherapy, and sex therapy.


Biofeedback, complementary therapies, and functional electrical stimulation

Gentle, incremental, patient-controlled follow-up desensitization approaches for vaginal dilating patient observation
general health maintenance

Education about the anatomy of the pelvis, the causes of vaginal spasms, and normal adult sexual function. Use of a handheld mirror to learn how to visually tighten and loosen the perineal muscles. Emphasis on teaching the partner that the woman's feelings about her partner are not impacted by the spasms. Instruction in vaginal dilation techniques.