Vaginismus:A case presentationby Dr James Walton

A ne busy winter afternoon Mrs B,lvf a new patient aged 21 years,

presented at my surgery with symptomatology typical of foregut patho-logy.

Indigestion and heartburn whichoften awoke her at 3 am had in-creased in intensitY over recentweeks. "My stomach gets into a knotand throbs", she comPlained as sheclutched her fist tightlY at herepigastrium. A friend at work hadrecently had a duodenal ulcerdiagnosed and this had precipitatedher visit to the doctor.

Mrs B went on to describe fre-quent and severe cervico-occipitalheadaches previously diagnosed as"tension" and for wich she had con-sumed regular ly a var iety ofanalgesics and muscle relaxants.Feeling quite bucked with myself fordiscovering the aetiology of herepigastric pain so easily I proceededto order a few routine investigations

Barium Meal, X-Ray cervicalspine and FBC. The Barium Mealand FBC came back negative whilethe cervical X-Rays indicated adisturbance in muscle tone.

Having reassured the patient Iprescribed: Metoclopramide 1 tds,Propraholol 40 mg tds, Rubragel Dprn, and a course of physiotherapy forher neck (not forgetting of course toprohibit the use of those analgesicsirritant to gastric mucosa).

Mrs B went away happy that shedid not have an ulcer, and a follow-up visit a few days later proved thatshe had responded well to medica-tion and her pains had subsided.

The remission was short l ived.Within two weeks Mrs B was back

once more with severe indigestion,headache and her period was veryl a t e . " E v e r y b o d y t h i n k s I ' mneurotic", she exclaimed.

"My husband's mother is in amental institution and I don't want toturn out l ike her. She's such a Dro-b lem to the whole fami ly and myhusband has enough worry with hismother to have me being soneurotic too. Oh I get so depressedabout everything," she sighed.

I could see that Mrs B was deeplydistraught. She was an attractiveyoung woman with a vibrant almostvivacious personality but at thesame time she appeared very im-mature, overtalkative and lacking inself confidence. Her state of anxietywas obvious as she moved restlesslvin her chair, spoke with her handiand looked nervously past me asshe spoke - hardly ever makingeye to eye contact.

Being primarily concerned withher physical symptomsrat this stage Iadvised that a gastroscopy was in-dicated - when I explained the pro-cedure to her she recoiled in horrorand said "nobody is going to stickanything down me" and no amountof persuasion on my part couldchange her attitude.

Groping for ideas I suggested ananti-depressant (having concludedthat her early morning awakeningwas possibly depressive rather thangastric in origin "Oh I've had anti.depressants before" she replied "andthey just make me worse". (l was onlyjust beginning to see why Mrs B waslabelled by her friends and family asneurotic - in fact I felt somewhat ir-ritated by her demanding but unco-operative and negative attitude.)

I suggested that perhaps sheshould see a psychiatrist to whichshe immediately reacted by bursting

"Mg husband's mother is in an institutionand I don't want to turn out like her"

I gently prodded her on in an at.tempt to discuss the cause of heranguish but could pinpoint nothingvery obvious. Mrs B was unhappy inher job, the neighbour's childrenwere always swimming in her poolwithout permission, her mother.in-Iaw was a strain on her husband andthis in turn affected her. There were,however, no financial diff icult ies;she denied marital confl ict anddesc.ribed her husband as quiet,consistent and "not demanding"although of late he had begun toliken her to his mother, a fact whichtroubled her enormously.

into tears and saying that she did notwant to go the same way as hermother-in-law and pleaded with menot to refer her. After a fewmoments she collected herself, saidshe would think about it and comeback to me.

A week or so went by and I heardnothing more except from her phar-macy who asked if they could repeatthe script for Metoclopramide andpropranolol. The physiotherapistreported that Mrs B was receivingregular and apparently successfultreatment for her neck.

26 Family Practice - September 1982

Vaginusmus

One afternoon she came into therooms and asked if I would prescribecimetidine which her friend at workwas finding very effective for herulcer.

Mentally I had already labelledMrs B as being psychosomatic butcouldn't help feeling that she was anunusually young woman and mar-ried for such a short time to be fre-quenting the doctor so regularly withthis type of condition. If thete wasany more to her story of which I wasunaware, she concealed it verydeliberately and effectively.

"She remembered her motheras be@ ouerprotectiue ands o mew hat do mine ering. "

I prescribed the cimetidine as re-quested and was relieved to see hergo. A few days later she phonedfrom work and said she wasdesperate and insisted on seeing methat day. We were heavily bookedbut I sensed an urgency in her voiceand agreed to see her as my last pa-tient that evening. She was unusuallyquiet when she came into my officeand sat down. "There's something Imust tell you about myself. I'vewanted to tellyou before but couldn'tbring myself to do so. I wanted to firstsee if I could talk to you and trust youbut today I feel I can tell.you aboutit." Then the story came out.

At the age of 16 years she hadbeen raped on the way home fromschool. She had fallen pregnant as aresult and was whisked off to the U Kby her parents where at two monthsthe pregnancy was terminated. "Andnow every year towards September Istart working myself up into a realstate as I am reminded of the ordeal.You see l'll never get over it?" shewhimpered.

Having a special interest in bothpsycho, as well as sex therapy I wasable to extract from her that hermarriage had in fact never been con-sumated as any attempt at Penetra-tion had not only been impossiblephysically but extremely traumaticemotionally. Although she had en-joyed clitoral and other foreplay ear-ly on in the marriage relationshipand in fact had been orgasmic onclitoral stimulation there was now far

less physical affection and loveplaybetween her husband and herselfand she feared that her husband waslosing his pat ience and couldpossibly stray.

Hav ing made a prov is iona ldiagnosis of vaginismus - whichwas confirmed during a subsequentconsultation when a vaginal ex-amination was attempted and failedas the patient kept snapping herknees back together and squirming.The introitus was impassable due tothe tight contraction of the surroun-ding vaginal musculature.

I explained to Mrs B that I believedshe could b'e helped but I wouldneed to see her for a series of con.sultations to work through her fearsand the pattern of avoidance sheh a d d e v e l o p e d . S o m e w h a thope less ly she consented toundergo therapy but was completelyresistant to involving Mr B in anyway.

Initially I agreed to go along withthis as I anticipated that a lot ofheadway could be made by workingthrough her own intrapsychic fearsand conflicts on an individualtherapy basis. At a later stage Ihoped Mr B could be included inorder to resolve the marital dysfunc-tion.

Mrs B's reluctance to involve herhusband was seen as part of theavoidance pattern pursued by a pa-tient suffering from Vaginismus asany attempt at penetration which isfeared and thus avoided. I was confi-dent enough that Mrs B could bebrought to a place where she wouldbe agreeable to involving her hus-band.

The relevant points to be workedon were:o Her sense of general failure and

worthlessness.

o Her anger towards her Parents aswell as fear of her mother.

a Her guilt regarding the abortionand falling pregnant in the firstplace.

o Her sense of failure as a wife.Mrs B herself was an only child,

the result of an unplanned pregnan-cy. Her parents were both veryyoung when she was born. The factthat her parents had never con.t e m p l a t e d f u r t h e r c h i l d r e npresented many possibilities withregard to her parent's attitude to heras a child. She remembered her

mother as always being overprotec-tive and somewhat domineering. ltwas postulated that her mother hadprobably been resentful at beingthrust into parenthood so unex-pectedly and that initially this hadbeen reflected in her attitude to herchild. This resentment had subse-quently given rise to feelings of guiltand remorse which culminated in areversal of feelings with overprotec.tion and "smother" love being theconsequence.

Mrs B's abortion at the age of 16years could be seen as her mother'sfinal attempt to protect her daughterfrom men and the ills of this world.

Mrs B had subconsciously receiv-ed certain inconsistent and im-mature injunctions or messagesfrom her mother during childhoodand adolescence.

For example:

o DON'T EXIST - | never plann.ed you or wanted you when youwere born - you messed up mylife so just remain quiet and in-significant so I can get along withmy own life.

o DON'T GROW UP - Remainyoung and immature and Mom-my will look after you to makeup for all her guilty feelingsabout rejecting you!

o I'M THE BOSS - You're notallowed to do what you want orhave your own feelings - I'myour mother after all and I knowwhat is best for you!

o DON'T ENJOY SEX - I twi l lon.ly get you into trouble like it gotme!

. DON'T HAVE CHILDREN - Orthey'll mess up your life like youmessed up mine!

She was allowing these messagesto perpetuate through into her adultlife giving her a poor self image withfeelings of worthlessness, negativityand resultant emotional immaturity.Guilt regarding her very existance letalone enjoyment of sex and havingbabies, dominated her psyche.

During therapy it was pointed outto her that as an adult she was nolonger bound to parental overtonesbut was free to make her own deci-sions and to "feel" the wav shechose to.

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Famify Practice - September 1982 27

She had never expressed heranger to her mother over her upbr-inging and the forced abortion andthis she was encouraged to do dur-ing therapy sessions. She wasshown how to express her own feel-ing to her mother . . . . . "Now lookmom - you may have decided howI should feel, think and be - but I 'man adult now and I don't have tostick with your opinions. I 'm going togive myself permission to do what Ichoose to do and not feel guiltyabout i t . "

I explained that Vaginismus is aconditioned reflex under voluntarycontrol and that by clamming upvaginally she was in fact acting in ac-cordance with those negative paren-tal injunctions.

As regards the abortion she cameto see that there was no need for herto feel guilty as she had never beengiven any say in the matter. Similar-ly her being raped and fall ing preg-nant in the first instance had beenbeyond her control and so whyshould she be bearing the conse-quence of the experience?

It was a matter of concern as towhether the Vaginismus was theconsequence of anger at beingraped with the desire to castrate orfrustrate men - the rapist in par-ticular - her husband in effect. Thiswould be in keeping with thepsychoanalytic conceptualisation ofVaginismus as being due to penisenvy. This concern was unwarrantedhowever, as was discovered duringconsequent couple therapy.

During therapy Mrs B proved tobe very co-operative. She obviouslyenjoyed the sessions and her senseof relief at her new found emotionalfreedom was obvious by her spon-taneity and keen participation indiscussion and role play.

After half a dozen sessions or soMrs B had freed herself so muchfrom guilt, resentment and shamethat she asked if she could bring MrB along. She had already told himthat she was undergoing therapyand they were both keen to try andresolve their sexual problem.

My first impression of Mr B was afavourable one. He was quiet yetsolid - concerned and very co-operative. I saw them only as a cou-ple from then on although they wereadvised that should either of themwish to see me alone I would beagreeable. Mr B confirmed the pat-

tern of avoidance - stating that hehad ceased to init iate sexual activityas this invariably led to conflict. Headmitted feeling angry and resentfultowards his wife and shared herconcern over the consequencesshould the problem not be resolved.

Although he never admitted to ex-tramarital affairs his resentmenttowards his wife was beginning tomount up and he felt at t imes thedesire to have an affair to deliberate-ly hurt her.

As a result of our earlier consulta-tions Mrs B had already resolvedmost of her intrapsychic fears, andcommitted herself to doing whateverwas necessary to overcome theVaginismus. After some init ial trepi-dation she was thus able to par-t i c i pa te i n t hese ass ignmen tswithout much diff iculty.

.When she could satisfactori ly re-tain one finger intravaginally shewas encouraged to attempt twofingers. By this time the couple were

"Cuilt regardtng her uerg existence, let alonee4joAment of sex, dominated her psgche."

He commended her for seekinghelp however and had seen such achange in her since she had com-menced therapy that he wasprepared to forgive her and co-operate in therapy.

The objectives at this stage were:to improve the quality of the mar.riage relationship; to teach Mrs B torelax, enjoy her own body anddevelop an awareness of her ownsexuality without feeling guilty; toaccustom her to an intravaginalforeign body.

Init ially the couple were told thatthey were NOT to attempt penetra-tion but were to indulge in non-genital love play for 30 - 45 minuteperiods at least f ive times before thenext session a week later.

After this they progressed intophase two where manual and/or oralgenital caressing was permitted butpenetration, sti l l forbidden. This pro-hibit ion of actual intercourse was in-tended to remove the "threat" toIove play in order that the latter beenjoyed for its own merits.

Running concurrently with theseassignments Mrs B was instructed inthe art of voluntarily contracting andrelaxing her pubococcygeus musclesfor five to ten minutes at a time atleast twice a day. As she became pro-ficient in this she was instructed to in.sert one of her own fingers, welllubricated with K Y Jelly, into hervagina voluntarily contracting andrelaxing the P C muscles around herfinger. This she was instructed to do athome when she could practiceuninterrupted and at her own pace.She was also instructed in variousforms of general body relaxation.

indulging in quite extensive loveplay including genital stimulationand so the transition from insertingher fingers to her husband's fingerswas easily made.

By the middle of the third weekthe couple were permitted to at-tempt penetration in the femalesuperior position where Mrs B couldcontrol the situation. She claimed tobe enraptured with the experience.The first real intercourse took placea couple of days after this and Mrs Bbecame orgasmic during the ex-perience.

During a subsequent interview Ipointed out to Mrs B that during thewhole course of therapy whichlasted some ten weeks - she hadnot once mentioned headaches,epigastric pain or any of her otherpsychosomatic symptoms. She wassomewhat surprised and laughed -agreeing that she had virtuallyforgotten about them!

I did not see Mr or Mrs B for someweeks after we terminated therapy,except to see Mrs B popping into abeauty salon near my surgery oneday. She seemed embarrassed atseeing me and I wondered if theyhad changed doctors as patients sooften do when they realise they haveexposed their thoughts and the in-timacies of their private lives to astranger. Not long after this shecame to see me with a sore throat.

I enquired as to the situation athome and she happily reported thatth ings were st i l l running wel l . Shehad stopped taking her cimetidineand had no recurrence of gastricsymptoms. She had not had aheadache for weeks. O

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