ICD-11HA20	SEXUAL PAIN-PENETRATION DISORDER (VAGINISMUS) Sexual pain-penetration disorder
ICD-10F52.5	Nonorganic vaginismus
DSM-5-TRF52.6	Genito-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

• Sims J.M. (1861) — description of vaginismus.
• Masters & Johnson (1970) — pelvic floor tension.
• DSM-5 (2013) — vaginismus and dyspareunia combined into GPPPD.
• 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. Aetiology 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 or attempted penetration.
• 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

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

6.4 Differential diagnosis

7. Examination and assessment

• Gynecological examination.
• Pelvic floor assessment.
• FSFI; pain scales.

8. Treatment

1. Multidisciplinary approach — pelvic floor physiotherapy + CBT + education.
2. Pelvic Floor Physiotherapy — biofeedback, manual therapy, dilator therapy (gradual size increase).
3. CBT and exposure therapy — fear of pain and avoidance; ter Kuile M.M. RCT.
4. Sensate focus and couple therapy.
5. Topical anesthetic (lidocaine) — in provoked vulvodynia (Goldstein A.T.).
6. Local estrogen for atrophic vaginitis.
7. Botulinum toxin A — in refractory vaginismus; evidence base is growing.
8. 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

• ter Kuile M.M. et al. CBT vaginismus.
• 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 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

1. WHO. ICD-11. HA20 Genito-pelvic pain/penetration disorder. 2024.
2. APA. DSM-5-TR. 2022.
3. 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.
4. Goldstein A.T. et al. Vulvodynia: Assessment and Treatment. J Sex Med 2016;13(4):572–590.
5. Bergeron S. et al. Genital pain in women and men: It can hurt more than your sex life. Sex Med Rev 2020.