Sexual Pain Disorders: Vulvodynia and Vaginismus - Case

study

Dr Beata Cybulska - Psychosexual therapist, Sexual and Relationship Problems

Clinic at Guy's Hospital and Genitourinary physician in the Royal London
Hospital in London

Sexual Pain Disorders include vulva] pain syndromes, vaginismus, chronic pelvic pain in women
and prostatodynia in men. Vulvodynia has been defined as chronic discomfort characterised by
burning, stinging, irritation and rawness of the vulva, or exquisite tenderness to touch of the vulval
area on attempted vaginal entry (Bergeron et al., 1997). Vaginismus represents psychologically
induced involuntary spasm of outer one-third of the vagina, making penetration either impossible or
painful. Both conditions can be primary, secondary, situational, mild, moderate or severe.

Sexual dysfunction associated with vulval vestibulitis syndrome is headed by vaginismus (96 %)
followed by poor arousal (57 %), situational anorgasmia (57%), low sexual desire (51 %) and poor
sexual communication (49%) (Schover et al., 1992). The cycle of pain and sexual avoidance
consists of. pain and anticipation of pain during sexual intercourse partial avoidance of sexual
activity seen as protection against pain - sexual arousal disorder - loss of sexual desire - problems
with orgasm - total avoidance of sexual activity - relationship difficulties.

Treatment outcome measures in sexual pain disorders are: alleviation of pain and restoration of
sexual function. Sex therapy has been found to be useful in helping to regain loss of sexual
function. Methods used include an assessment (identification of precipitating, predisposing and
maintaining factors), genorgarn (exploration of relationships in the family for up to three
generations), education about sexual anatomy and physiology of sexual arousal, effective
communication training, self-exploration and vulval massage, sensate focus (Masters and Johnson),
pelvic floor exercises, graded vaginal dilators, stress and anxiety management and relationship
therapy for couples and singles with difficulties maintaining and / or forming relationships.

Case study
30 years old female, a divorced solicitor from middle class English family.

Presenting problem: 6 years history of vulval pain following a 6 months courtship ending in
marriage to a possessive and controlling, Oxford educated barrister from a mixed raceAsian /
English family, which ended in separation and divorce following a honeymoon.

Precipitating factors: request of then future husband for an HIV test following her disclosure of
unremarkable sexual history before the wedding and endless demands for sexual activity during the
honeymoon despite her complaints of vulval pain.

Predisposing factors: being brought up with a handicapped brother, competition with mother's twin
sister for her affection, bullying at school.

Maintaining factors: resentment and anger towards ex-husband who formed a family with a new
partner soon after the divorce, depression, vulval pain reminding of painful events, frustration about
not taking her ex-husband to court for rape.

Methods used during 9 half hourly to one hour sessions: detailed assessment, amitriptiline 100- 150
mg daily for over one year, weekly pain diary, work on insight into her personality traits,
exploration of feelings, genogram, physiology of sexual arousal. Outcome. Ex-husband applied for
annulment of their marriage to a Catholic Church Tribunal. The patient agreed to participate in the
proceedings attending an interview and giving written account of her story. This resulted in
annulment of the marriage by the Catholic Church forbidding ex-husband from remarrying in the
Church. Patient's pain became gradually less over the course of therapy, she joined a dating agency
(not on my advice), started dating again and had pain free with the help of 5 % Lignocaine
ointment. The relationship did not last but helped to restore her confidence in being able to have
pain free sexual activity.