The Botulinum Cure for Vaginismus:

When Sex Hurts

It’s the most natural thing in the world and yet for women with vaginismus, sex is so painful it becomes impossible. To make matters worse, many women who have this condition don’t have a name for it. It’s just an unbearable pain and a feeling of dread that increases with every attempt to overcome it. “Part of the problem for women with vaginismus is they frequently feel that the condition is somehow their fault, which is obviously not true at all. Women with vaginismus may have no history of trauma to explain it. We frequently hear women say: ‘No one knew what to do about it. I was told it was all in the mind.’

Vaginismus causes pain with sex and affects up to 7% of women. It is the involuntary spasm or contraction of the muscles surrounding the lower third of the vagina with attempts at any form of vaginal penetration. It involves the muscles just below the skin called the perineal muscles and the deeper pelvic floor muscles.

Primary vaginismus is where no vaginal penetration has ever been successful, this includes tampons, intercourse and ultrasound etc. Secondary vaginismus is where vaginal penetration was possible in the past but is now no longer possible due to a variety of reasons which may lead to fear of pain with attempts at penetration.

Women who have had vaginal pain in the past, may, very reasonably, fear pain with  penetration. This can lead to involuntary contraction of their pelvic floor and vaginal muscles as a protective mechanism. Often this can then lead to the contraction of other surrounding muscles such as the legs, buttocks and hips, often squeezing their legs closed. Many women perceive that the pain they experience is very harmful but this is not always the case. The anxiety they may feel however may be very real with hyperventilation,  sweating and crying being common symptoms.

Once you have experienced pain with attempts at penetration, it makes the next time even more difficult. These involuntary reactions perpetuate the cycle of fear of pain leading to muscle contraction which leads to increased pain and increased muscle contraction and so on.  Vaginismus is a paradox, it is an involuntary contraction of voluntary muscles, and often occurs before the genital area is even touched.

There are many physical conditions that may contribute to painful intercourse. A congenitally tight hymen, tight perineal skin bands, vaginal and vulval dermatological issues such as “ thrush” , “ lichen sclerosis” , “psoriasis” or pelvic infections can all cause pain on penetration. Endometriosis can cause deep pain with intercourse, and the poor healing of post vaginal delivery tears or scars can all contribute to a woman’s discomfort. Vaginismus after menopause may be due to the genitourinary syndrome of menopause where, due to decreased levels of oestrogen, the  vaginal walls become thin, red and dry often leading to the splitting of the perineal skin with intercourse, and ongoing discomfort, which can lead to anticipatory vaginismus.

The first step is often to see a pelvic floor physiotherapist who is specialised at identifying the contracted vaginal muscles and who can coach women though how to start relaxing these muscles with or without the use of vaginal dilators. Sex therapists can assist with any psychological issues that contribute. If vaginismus persists however, vaginal Botulinum may be an integral step that allows treatment to move forward quickly and effectively.

Vaginal Botulinum involves the injection of a form of Botulinum Toxin – a purified toxin from bacteria. The toxin (“Botulinum”.,Xeomin” “Dysport”) is injected into multiple specific points in the tight, spasmed lower vaginal muscles. This is generally performed under general anaesthetic or in the rooms under a light sedation. The Botulinum toxin acts as a selective muscle weakening and/or paralysing agent, and helps reduce nerve pain.

The effect is reversible but provides a temporary window of opportunity to rehabilitate and stretch the over contracted spastic vaginal muscles that are obstructing penetration. Very small needles are used to inject 100 units of Botulinum into the three key vagina muscles that can obstruct penetration. Only the areas in the vaginal side walls that are palpably spasmed and sore are injected. Once these muscles can no longer tighten, it is usually possible to have comfortable intercourse. Once a woman experiences sex without pain, she can relax and begins to enjoy it. The vaginal muscles can then stretch and start to relax of their own accord.

 Botulinum takes approximately 10 days to begin to work. By week 1-2 post injection it will be starting to have its effect on the muscle which will then reach a plateau at around a month post injection.

Usually, once the muscles have been relaxed, no further treatments are required, although some women benefit from a second or third treatment to fully and permanently relax their pelvic floor and vaginal muscles. The treatment has been shown to be effective in around 90% of women.

For the vast majority of women, there are no noticeable side effects of vaginal Botulinum. The potential for a small muscle haematoma or infection exists, as with all procedures where a needle is used. There are case reports in the literature of bladder or bowel urgency or difficulty with controlling wind or incontinence. No Botulinum injected near the rectum or urethra so the risk of these side effects is minimal. One article reported a case of vaginal dryness due to a parasympathetic partial nerve block. As the effects of Botulinum only last 12 weeks, these rare side effects are completely reversible

Unlike with using toxins for facial wrinkles, once the spasmed vaginal muscles are released often only one or two treatments are required. The muscles re-learn their previous relaxed state, intercourse is more comfortable and therefore continuing spasm is far less likely.

The cost of the procedure varies depending on whether you have the Botulinum procedure performed in the rooms with local anaesthetic or with “ laughing gas” or whether you go to theatre for the procedure. If you have private hospital cover, then this will decrease the amount of any theatre costs. Some women also have a very tight hymen or vaginal skin band that needs to be divided and this may impact on the length of the procedure and therefore will affect the price. The cost of the Botulinum itself is included in any quote.