Clinical Psychiatry

Sexual pain-penetration disorder (vaginismus)

ICD-10F52.5Nonorganic vaginismus
DSM-5-TRF52.6Genito-Pelvic Pain/Penetration Disorder

1. Definition and nosology

Sexual pain-penetration disorder (vaginismus; ICD-11: HA20; DSM-5-TR: Genito-Pelvic Pain/Penetration Disorder F52.6) — during penetration attempts: (a) difficulty, (b) genital or pelvic pain, (c) fear of pain, (d) tension of pelvic floor muscles. Classic vaginismus and dyspareunia are combined in this entity.

Duration ≥ 6 months; lifelong or acquired.

2. History

  1. Sims J.M. (1861) — description of vaginismus.
  2. Masters & Johnson (1970) — pelvic floor tension.
  3. DSM-5 (2013) — vaginismus and dyspareunia combined into GPPPD.
  4. ISSWSH and ACOG guidelines.

3. Epidemiology

  • Prevalence in women is 5–17% (in clinical and non-clinical samples).
  • Lifelong vaginismus — in young women, at first penetration attempt.
  • Acquired — trauma, infection, atrophic vaginitis, post-surgery.

4. Etiology and pathogenesis

  • Biological — atrophic vaginitis (postmenopausal), vulvodynia, endometriosis, infection, surgical wound.
  • Psychological — sexual trauma, anxiety, abstinence education, fear of pain.
  • Relationship and partner factors.

5. Clinical features

  • Reflexive tension of pelvic floor muscles during penetration.
  • Pain (burning, stabbing).
  • Penetration avoidance.
  • Gynecological examination also difficult or impossible.

6. Diagnosis

6.1 Unified diagnostic criteria (DSM-5-TR)

A. At least one of the following:

  • Difficulty in penetration;
  • Pain in vulvovaginal or pelvic region during penetration attempts.
  • Fear of pain associated with anticipation of penetration.
  • In attempted penetration, tension of the pelvic floor muscles.

B. Duration ≥ 6 months.

C. Distress.

6.2 Differences between sources

  • ISSWSH and ACOG.

6.3 Diagnostic algorithm

  • Clinical interview (sexual history, pain characteristics, trauma).
  • Careful gynecological examination — with caution, with patient consent.
  • Vulvodynia screening (Q-tip test).
  • Infection, atrophic vaginitis, exclusion of endometriosis.
  • Pelvic floor assessment.

6.4 Differential diagnosis

Condition Distinguishing feature
Vulvodynia Localized vulvar pain, Q-tip positive.
Atrophic vaginitis Postmenopausal, estrogen deficiency.
Endometriosis Deep dyspareunia, dysmenorrhea.
Infection (candida, vaginosis) Exudation, microbiological.

7. Examination and assessment

  1. Gynecological examination.
  2. Pelvic floor assessment.
  3. FSFI; pain scales.

8. Treatment

  • Multidisciplinary approach — pelvic floor physiotherapy + CBT + education.
  • Pelvic Floor Physiotherapy — biofeedback, manual therapy, dilator therapy (gradual size increase).
  • CBT and exposure therapy — fear of pain and avoidance; ter Kuile M.M. RCT.
  • Sensate focus and couple therapy.
  • Topical anesthetic (lidocaine) — in provoked vulvodynia (Goldstein A.T.).
  • Local estrogen for atrophic vaginitis.
  • Botulinum toxin A — in refractory vaginismus; evidence base is growing.
  • Antidepressant/anticonvulsant (amitriptyline, gabapentin) — for neuropathic component.

8.1 Treatment methods

  1. Dilator Therapy — Gradual increase in size; combined with relaxation.
  2. Pelvic Floor Physiotherapy — Biofeedback, manual therapy.
  3. CBT/Exposure — Fear of pain and avoidance.
  4. Topical Estrogen — Atrophic vaginitis.
  5. Botox (off-label) — For refractory vaginismus; selective.

8.2 Differences between sources

  1. ter Kuile M.M. et al. CBT vaginismus.
  2. Goldstein A.T. et al. ISSWSH vulvodynia consensus.

9. Prognosis

With a multidisciplinary approach, prognosis is good (70–90%); in refractory cases, botox or intensive psychological intervention.

10. Myths and misconceptions

Myth 1: “Vaginismus is an emotional rejection of the partner”

Evidence: Reflex muscle tension — outside conscious control; accusing the patient is harmful.

Myth 2: “Vaginismus cannot be treated”

Evidence: CBT + dilator + physiotherapy combination 70–90% efficacy; ter Kuile RCTs.

Myth 3: “Treatment should be done to increase penetration frequency”

Evidence: target is reducing patient distress, restoring sense of control and choice; not a performance indicator.

Myth 4: “Local anesthetic is effective for all sexual pain”

Evidence: Effective in provoked vulvodynia; use limited in generalized vaginismus — main problem is muscle tension.

Myth 5: “Forcing ‘compulsory exercise’ helps with penetration attempts”

Evidence: urgent, painful repetition increases avoidance and fear; gradual, controlled exposure effective.

11. Sources

  • WHO. ICD-11. HA20 Sexual pain-penetration disorder. 2024.
  • APA. DSM-5-TR. 2022.
  • Ter Kuile M.M. et al. Therapist-aided exposure for women with lifelong vaginismus: a RCT. J Consult Clin Psychol 2013;81(6):1127–1136.
  • Goldstein A.T. et al. Vulvodynia: Assessment and Treatment. J Sex Med 2016;13(4):572–590.
  • Bergeron S. et al. Genital pain in women and men: It can hurt more than your sex life. Sex Med Rev 2020.