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[Heather34]

Hi Rachel. I found an excellent resource article written by Dr. Pacik – http://www.plasticsurgerypa.com/organization-lectures-ssss/

I had the honor of being invited to teach a continuing education course on vaginismus at their Eastern Regional Meeting, June 5-7, 2009. The 1-1/2 hour course was an excellent blend of therapists interested in learning about the cure of vaginismus using Botox and dilators. Two hour continuing education courses were presented at the 2010 annual Las Vegas meeting and the 2011 annual Houston meetings titled “An Overview of Vaginismus: Etiology, Diagnosis, and Treatment with Botox and Dilators under Anesthesia: Physicians and Sexological Clinicians Working Together for Healing” I was impressed by the large turnout for these educational sessions, and pleased that more and more heath care professionals want to learn about vaginismus. The audiance was very engaged, and each of the two-hour sessions went by very quickly.

The abstract that the attendees recieved was as follows:

“Vaginismus is an involuntary, uncontrollable contraction of the pelvic floor muscles surrounding the vagina occurring when any penetration is attempted, even a finger or tampon, causing severe pain, burning, and fear. Vaginismus, the main cause of unconsummated relationships, impairs or prevents gynecological examination and has serious personal and social implications for the sufferer. This condition is under-reported; its extent is unknown, but it is far more common than previously believed, now thought to afflict one to six percent of women worldwide. These women, often maintaining a wall of silence and isolation, are in desperate need of treatment. Because many physicians and clinicians are misinformed or unfamiliar with the symptoms, causes, and scope of sexual pain, sufferers of vaginismus who do seek help are often misdiagnosed and inappropriately treated.

The syllabus included:
1. Clarification of painful intercourse from dyspareunia to vaginismus, and the effects of these on the lives of individuals and couples, will be presented.
2. Lamont’s classification of vaginismus, a system identifying severity levels of the condition and impacting determination of treatment, will be reviewed.
3. Issues discussed will include medical conditions: possible causes that may need ruling out; updating terminology: clarifying a plethora of misconceptions, terms used, and differences among similar conditions, including vulvodynia and vaginismus; reasons for failure, despite often prolonged use, of conservative treatments; description of minimal penetration intercourse, a strategy which allows some patients to transition from dilators to intercourse without fear; and pelvic floor anatomy with illustrations, terminology, and conceptual understanding of the underlying anatomical problems.
4. Treatments to be discussed include emerging researched approaches using Botox and vaginal dilation under anesthesia, combined with post-procedure care and counseling. A review of case histories with audience participation will elucidate types of counseling needed for this population both before and after treatment. Over 90% of women treated with Botox and dilation were able to achieve pain-free intercourse within two weeks to three months and required no further treatment. Prior conservative treatment received, some for as long twenty years, had failed. In addition to medical treatment, most patients benefit from clinical sex counseling for quality of life, mental health, relationship issues, and to support a comfortable transition from dilators to intercourse. Among the 10% of women who do not transition to intercourse easily, most are successful with dilators, but concomitant relationship and sexuality issues require additional sex therapy.”

I give you my full permission to use my story as one of your case studies. I suffered with primary vaginismus for as long as I can remember. I was never able to insert a tampon and tried numerous times while in high school. I then went off to college and began my first committed and long-term relationship. We tried several times to have intercourse and it was absolutely impossible. It even hurt terribly bad when he tried to insert a finger and was impossible. We were both in our early 20s and he broke up with me because of our inability to have sex. Thereafter, I met my husband when I was 24 years old. I fell so in love with him and thought that sex would now somehow magically work because of my intense feelings. It didn’t. We tried and tried and every time, he said it felt like he was hitting a wall and I felt this terrible pain, burning, resistance feeling. Also, my body would physically withdraw from any touch at all in the area because I learned to associate it with terrible pain. I tried many times to sabotage the relationship and to push my husband away, but he didn’t move even an inch and was truly my one and only support and my rock while enduring this time. I reiterate that he was my one and only support during this because I lied to all of my close friends and family or simply did not tell them what we were going through. I wanted to be similar to all of my friends who spoke of their great sexual relationships with their boyfriends/husbands while the whole time suffering in silence with this huge problem. We were intimate in other ways (i.e. kissing, touch, oral sex, etc.) but I often felt like a failure because I wanted so badly to be able to have actual intercourse. For many years, I ignored and put off this problem. To this day, I don’t know why I put it off for so long, but at the time, I truly believed that it would somehow just go away on it’s own and the next time would be different. The next time was never different despite my preparation (i.e. booking a romantic getaway, wearing a sexy costume, etc.). It always caused excruciating pain with any touch and sex was simply impossible. I finally took the step to visit a gynecologist at the age of 29. While my husband wanted to support me and go with me, I didn’t want him to and wanted to simply visit the doctor and fix “my” problem and then everything would be fine. I went to the appointment alone, telling absolutely nobody about it, and it was one of the worst experiences I’ve ever had. I researched the symptoms I had on-line, including excruciating and burning pain with ANY attempt at penetration (i.e. tampons, fingers, penis) as well as the feeling like every time I tried to insert anything (even a q-tip), I couldn’t get past the wall of resistance and nothing would go in. I had no pain whatsoever with touch on the outside area of my vagina and also while wearing tight clothing. After researching the symptoms that I both did and did not have, I determined that I had vaginismus. I printed out my symptoms described and an abbreviated handout about vaginismus. When I got to the gynecologist’s office, I was incredibly nervous (i.e. sweating, feeling like I was going to pass out, rapid heartbeat, etc.) just while sitting in the waiting room. This was the first time that I had ever experienced anxiety/panic simply from visiting a doctor and it felt horrible and frightening. I then went into the exam room and undressed, while still feeling all of the physical anxiety symptoms described but now intensified to the highest degree. When the doctor came in and we met for the first time, she asked me what I had been experiencing. It was incredibly difficult for me to explain to her my symptoms of vaginismus while being so nervous, so this is why I had written them out in advance. I gave her a copy of my symptoms and how they correspond to a diagnosis of vaginismus and also provided her with the abbreviated handout on vaginismus. She didn’t read any of what I had written nor the information about vaginismus and just placed the papers to the side. She then asked me to try to relax and she would do the exam. I could not relax at all and when she got even close to touching the outside area (skin), I almost jumped off of the table and felt a sharp, stinging, burning, excruciating pain. She was very frustrated and said, “I’m not even near your vagina and you can’t even relax.” She tried the exam again and I had the same reaction, except I was crying at this point. She told me to get dressed and we would speak in her office. I was so embarrased and just felt so humiliated at that moment. I got dressed and went into her office, trying very, very hard to not cry. There, she told me that I had vulvodynia and she would not see me again nor ever try to perform an examination until I visited a sex therapist that she recommended. She said she believed that I had some serious issues that needed to be sorted out there and, only after receiving this treatment, would she be able to examine me. I left this appointment feeling so ashamed, embarrased, and humiliated. I never returned to see her again nor did I visit her recommended sex therapist. I continued on-line research about vaginismus and ordered dilators and a workbook. I completed every step of this workbook and tried every single night to insert the q-tip, the smallest type of tampon, and the smallest dilator and nothing would go in without the same burning/stinging pain and the feeling like I was hitting a wall. I then tried pelvic floor physical therapy but I could not make any progress with stretch and dilation because I couldn’t insert anything. This was an epic fail and I gave up hope that I would ever find a cure. I felt several emotions during this time as did my husband. He was constantly supportive and my rock but I felt like the condition was really hard on our entire relationship/marriage. The years passed and I became concerned with age as we both wanted to start a family together. This prompted me to continue researching vaginismus on-line and through yahoo forums. In May of 2011, I was fortunate enough to see a new post from one of these Forum members about Dr. Pacik and his comprehensive treatment program, which included Botox injections which progressive dilation as well as counseling. Finding this treatment provided both my husband and I with a hope that we hadn’t had in so long that we could finally put this behind us and this would work. I underwent the procedure in June 2011 at the age of 34 with my husband right by my side. Concerning the emotional aspects of this treatment program and vaginismus as a whole, Dr. Pacik and his staff treated us like no clinician ever had and we could feel in our heart and know that they cared so much. I experienced a tremendous amount of anxiety pre-procedure and this was addressed in consultation as well as office communication. I even remember bringing my handouts about vaginismus to our consult and Dr. Pacik taking the time to read what I had written and to also listen to my story and then thoroughly explain vaginismus and the procedure. I asked so many questions and they had so much patience and, again, really cared. My anxiety was further addressed on the day of the procedure as I was able to receive a tremendous amount of support from Dr. Pacik and the staff prior to the procedure. I was also given IV Verced prior to going into the procedure room and this worked magnificantly to relax me. All of my physical symptoms of anxiety that I had experienced during my first terrible visit to a gynecologist weren’t there and I felt relaxed, supported, and ready to face vaginismus head on. I had the procedure and remember waking up with the largest dilator inside of me. This was the first time in my life that something was inside of me. My husband and I were both in absolute shock but so happy. I felt like I wasn’t broken and it really felt surreal that a large sized dilator was inside of me when I wasn’t able to insert a q-tip for so many years. I then relaxed in the recovery room with heated blankets and my husband sitting right by my side and holding my hand. I then practiced removing this dilator and re-inserting it. It was liberally coated with lidocaine/surgilube and the resistance feeling that I had always had (i.e. the brick wall) wasn’t there. I could now insert, remove, and reinsert these dilators. I then slept with the medium sized dilator in the evening of day 1. This did not cause physical pain but I simply felt strange at times because something was inside of me and a little uncomfortable/sore at times. I found that taking a Tylenol PM helped me a lot this night. On day 2, I returned to the office and practiced, again, inserting, removing, and reinserting the 3 medium to largest sized dilators. Also, on day 2, Dr. Pacik and Ellen provided us with comprehensive counseling regarding tips for transitioning to intercourse and building our intimacy within our marriage post-vaginismus. I recall returning home and practicing very hard with the dilators. I dilated for 2 hours per day and every other night and sent Dr. Pacik and his staff daily dilation logs which also addressed any issues that I had post-procedure with discomfort as well as anxiety. Thereafter, on July 4, 2011, seven days post-procedure, I dilated for 2 hours with the largest blue dilator and my husband and I decided to try intercourse. We both decided that there was no pressure if it didn’t work. We were intimate with the dilators and he removed the largest blue dilator and gently inserted himself in. It went right in with NO resistance and we even tried thrusting. WE DID IT AND FINALLY ACHIEVED INTERCOURSE!!!!!! Thereafter, it took us 3-6 months until we got into a rhythym and discovered how to turn robotic and just-happy-to-be-working intercourse into pleasurable love-making. This step also required post-procedure follow-up and communication with the office which helped greatly. Today, I am 100% cured from my struggles with vaginismus and believe in my heart that this never would’ve been possible without a physician and staff who truly cared and all of the important elements of the treatment program.

[Heather34]

Hi ladies. One of my greatest fears pre-procedure was dilating (see my above post). How would I ever be able to dilate when I hadn’t been able to even insert a q-tip in the past without the feeling like I was hitting a wall and pain/burning. I was simply terrified of everything about the dilators. Dr. Pacik has addressed this fear and writes the following:

Q. I am terrified of even the thought of dilators. How is it possible for me not to have pain with dilators? “Most women with severe vaginismus and severe painful sex are unable to use dilators on their own. During the treatment with Botox under anesthesia, a long acting anesthetic is injected so that the entire vagina is numbed for about eight to twelve hours. By the time the patient returns the next morning, having maintained a dilator for 24 hours, the vaginal muscles are sufficiently stretched that dilation to the larger dilators is easy and not painful. During this time a topical anesthetic is used to coat the dilator and this adds to the comfort of post procedure dilation. Later, patients are able to continue their dilation program easily without the need for topical anesthesia.”

To the veterans reading this, what was your greatest surprise with dilation post-procedure? For those patients who were successful using dilator kits on your own pre-procedure, what was the difference you noticed in using the pure romance and/or glass dilators post-procedure???

[Heather34]

Hi ladies. Dr. Pacik was recently asked to participate as a “Guest Author” on Jane Murphy’s vaginismus blog:

http://www.myvaginismusstory.com/blog/2013/07/29/insurance-coverage-for-treating-vaginismus-with-botox/

In his posting, the issue of insurance coverage for vaginismus treatment was re-visited and is so very important:

“A frequently asked question concerns insurance coverage for vaginismus using the Botox treatment program. Since there is much more to treatment of vaginismus than injecting the spastic muscle(s) with Botox it follows that a delineation of treatment plans will be helpful in getting coverage. Many of my patients have failed to make progress using dilators. For severe vaginismus, dilation can be a form of torture! Little to no progress is made despite the support of physical therapy and counseling. Nevertheless this is covered by most insurance companies. It is for this reason that progressive dilation under anesthesia, as a part of the Botox treatment program for vaginismus, is carefully documented in the operative summary. In addition counseling is frequently covered, and the counseling we do as part of the program is also delineated as part of the medical record. The counseling includes instruction in using the dilators effectively to help stretch the vaginal muscles and transition to intercourse. This is made easier because of the Botox injections. Most of my patients are able to achieve pain free intercourse within weeks of the treatment. Though the Botox injections may not be covered, enough information is provided regarding other forms of therapy during the treatment program that often patients receive about 1/2 to 2/3 insurance coverage. We work with Diane, an experienced third party insurance biller, who has been very effective in helping women with vaginismus get reimbursement. She can be reached through my office in Manchester, NH at 603 669 0290.”

There are several additional posts concerning insurance coverage for vaginismus treatment. One of my favorites is a post from the husband of one of Dr. Pacik’s previously treated patients:

“We were fortunate that our insurance covered Dr. Pacik and his office. His practice was in our insurance network! When we had our procedure done, a wonderful lady named Diane Tremblay filled the insurance for Dr. Pacik’s office. She was awesome! She made sure that we would get as much of a refund as possible. We had to pay up front for the procedure, but in about a month, we got our insurance reimbursement. After going to Manchester, and meeting the wonderful staff, I would have paid for the procedure regardless if the insurance covered or not. The work that they’re doing is remarkable in my opinion.”

In a prior post, we discussed how insurance may be now more likely than not to cover the procedure based on the new DSMV name for vaginismus – genito-pelvic pain/penetration disorder. What other questions do you have regarding insurance coverage? To the veterans, what has been your experience receiving insurance coverage? Has anyone taken out a private loan (i.e. through CareCredit, etc.) and then paid this back with your insurance reimbursement check? I would love to receive your comments and feedback here regarding insurance coverage for this treatment.

[Heather34]

Hi ladies. I read an interesting article concerning the differing views of vaginismus from surgeons, gynecologists, and psychiatrists.

http://www.thedailybeast.com/articles/2010/03/27/the-female-sex-pain-mystery.html

Excerpts from the article include:

“Pain during sex affects millions of women, and the medical community’s explanations for why it happens seem nearly as numerous. Gynecologists have treated sufferers with everything from vaginal insertions to Botox. Surgeons want to solve the problem with a scalpel. Psychologists prescribe anti-anxiety meds for it. Despite centuries of study, it’s an area that remains in dispute.Stacie, a stay-at-home mom in Nova Scotia, Canada, struggled with sex-related pain for years. She says that she’s seen a shrink who convinced her that her problem was simply a symptom of anxiety. “Doctors automatically think it’s stress,” says Stacie. “They say, ‘You’re too stressed out, just relax.’ I’ve seen a psychiatrist and all he really wanted to do was to prescribe pills.” She’s tried a handful of different antidepressants to no avail and is skeptical of the idea that she has a psychiatric condition. “I have no doubt that there’s something physically wrong with me,” she insists. “I know it’s not in my head.” Binik doesn’t think the idea that pain during sex might have psychological roots should serve as license for providers to write it off. “I don’t have much sympathy for doctors who say, ‘It’s all in your head.’ If it’s used in a dismissive sense, that the pain doesn’t really exist, that’s very unfortunate.” But he still believes that some type of pain/penetration disorder is worthy of inclusion in the DSM, an assessment bolstered by the fact that cognitive-behavioral pain management, a form of psychotherapy that focuses on relaxation and mental control techniques, has been shown to reduce pain during sex significantly. But since talk therapy doesn’t work for every sufferer, a range of other treatments of varying effectiveness have been tried. One of the most controversial is Botox. In a 2004 study by Shirin Ghazizadeh at the University of Tehran, 18 of 24 vaginismus sufferers were able to have relatively pain-free intercourse after a single series of Botox injections to the pelvic region.”

I think this is an interesting article for so many reasons. First, I never knew that vaginismus dates back to 1880 (Sims article). Second, it is interesting how the doctors and clinicians treating this condition have such a different opinion as to what they believe works and what doesn’t work. I have read so many of your stories and testimonials and have experienced myself both a doctor and clinician saying “why don’t you just relax” and “it’s all in your head” when I described my physical symptoms of vaginismus (i.e. every time I went to insert anything, the feeling like I was hitting a wall). I appreciated what Binik wrote “I don’t have much sympathy for doctors who say ‘it’s all in your head if used in a dismissive sense, that the pain doesn’t really exist, that’s very unfortunate.” I believe that vaginismus does have a significant physical component that should be recognized and acknowledged. In the final sentence, the 2010 article discusses Botox as being a controversial treatment yet goes on to note it’s effectiveness.

In a prior post, the husband of one of Dr. Pacik’s treated patients who is a psychiatric nurse, discusses both the psychological and physical aspects of the condition and their post-procedure success:

“A very long story short: we went for treatment, and I saw everything. It is amazing how someone can display muscular spasms and attempt to avoid treatment even under anaesthetic. This underlines the “involuntary” nature of this debilitating condition. Rachel did not feel a thing; she was not aware of anything whatsoever. Yet, she was attempting to resist treatment during the procedure. This is not a problem that is attributable to mere psychological constructs or defense mechanisms. There are psychological components to vaginismus, most definitely. However, this is an essentially physiological condition which is reinforced by the following: lack of education, distorted perceptions and beliefs, rumination, catastrophising. The initial memory and pain of intercourse triggers and maintains these psychological constructs, which simply reinforce the problem. So there is a cognitive element to this condition. However, the root of the problem is not psychological. Rachel had the treatment. She dilated in no time at all. She had inserted the dilators without problem. I had even inserted the dilators without problem – into Rachel that is!!! Where was the impossibility now? Rachel thought that she was too small. Rachel thought that nothing could “get in there”. Now, she had the biggest dilator inside her. The problem is no longer a problem, and Rachel was walking around Portland like a duck with the evidence inside her vagina. So, when the psychological conflicts arose, there was no evidence to substantiate or validate their claims. Rachel and I knew it. We went home, back to Canada. We followed the golden rule of “tip only intercourse”. No problems. Why? The botox has temporarily paralysed Rachel’s vaginal muscles so that she cannot spasm. This has given Rachel time to get over the so-called physical impossibilities and her unsupported psychological constructs. Rachel now knows that she is not too small; she now knows that she does not need a hymenectomy; she now knows that she has a normal vagina; she now knows that she can insert a dilator that is the size of an erect penis. The “arguments” in her head have been levelled to the ground. We have now even had full intercourse.”

In the past, I, too, was told to “just relax” and “it’s all in your head”. Despite hearing this, I persevered and had Dr. Pacik’s Botox treatment program and was able to have pain-free intercourse within 7 days. Has anyone else been told by a doctor or clinician to “just relax” or “it’s all in your head”? What is your advice to other women currently suffering with vaginismus who have also been told this???

[Kesa]

Dear all,

For such a long time now I have read this forum in anticipation of the day that I could join the ranks of you brave ladies, and now sitting here having had the botox I feel quite overwhelmed and out of my depth.

I live in Europe and the option of coming to the states was never feasible given my finances. I’m 30 years old and have primary vaginismus so I could never insert a single thing, no matter how small into my vagina. In an act of kindness I can never repay my husband used all his savings to pay for private botox treatment. Due to my doctors lack of availability the whole thing happened so quickly and 2 weeks ago today I had the botox under general anaesthetic. Unlike Dr Pacik’s program, I did not have dilation and I was told to wait for 10 days before attempting penetration which was somewhat confusing given the way Dr Pacik does it. I followed this advice and for the past four days I’ve been inserting the smallest dilator, although only for 15mins at a time (but i can move it in and out without a problem) The burning sensation and psychological fear is still there, but the muscles give way! It’s a miracle!

I’m starting to panic though. Reading these stories of how other women could have sex within the first two weeks has disturbed me as i’m nowhere near ready to insert something as big as a penis. I also fear that the botox will wear off before I get to the stage where I can accommodate the largest dilator. On the net as well, I read a blog by a women whose doctor told her that most women need 3 injections before they can achieve intercourse. That is not a possible for me.

All in all, I think I will try to use the dilators for much longer and try to sleep with it in at the weekend before moving up a level. What my husband has given me is the most precious gift of all and i’m so grateful. For years I suffered with depression and abused drugs to block out the impact this condition had on my life. I just pray that this works…

Thanks for reading and any suggestions would be greatly appreciated x

[Heather34]

Hi Chocolate. In a blog in which Dr. Pacik discusses the spastic muscles, it provides an excellent explanation of how this program works to help patients overcome level 5 vaginismus and this is how it worked for me.

He begins by writing:
“In filling out their questionnaires, a surprisingly large number of patients use the terminology that attempting intercourse is like “hitting a brick wall’! This “brick wall” represents spasm of the entry muscle of the bulbocavernosum. It is much like making a tightly closed fist and attempting to push the opposite index finger into this tightly constricted muscle mass. Not possible. Neither is penile penetration. For severe cases of vaginismus, NO PENETRATION IS POSSIBLE!”

This is exactly how it felt every single time I tried to insert anything in the past (i.e. intercourse, speculum for ob/gyn exam, plastic dilators, and even a q-tip).

Next, he writes:
“The reflex of vaginismus: It is likely that the spasm of the vaginal muscles, especially the entry muscle, the bulbocavernosum, represents a reflex. The brain appears to perceive that penetration will be painful, and the vagina responds (protective reflex) with spasm which is equivalent to the body protecting itself by saying “no entry”.
Phobic avoidance: The reaction to penetration in vaginismus patients is much like any phobia. For the person afraid of heights, you have to practically drag them to high points, there is so much fear and anxiety. The heart races, they break into a sweat, they begin shaking uncontrollably and are sure they will faint. These same responses take place in vaginismus patients faced with penile penetration. This is the bodies way of avoiding a perceived threat.”

He goes on to describe progressive dilation under anesthesia:
“Following the Botox injections, which are done under anesthesia, the vagina is then progressively dilated using a series of larger dilators to stretch the vagina. This is left in place and the patient wakes up with usually the largest dilator. As the Botox becomes effective during the next 2-7 days, the stretching becomes easier because of the dilators.”

I know that I’ve written about this extensively but this was seriously the turning point for me in overcoming vaginismus. When I woke up with the largest dilator in place, I knew that something was able to be inside of me pain-free and it worked to change my whole mentality.

He next describes stretching of the tight muscles:
“As patients begin stretching these tight muscles they begin to understand that dilation is not the end of the world and in fact becomes easier with time. Sooner or later they make the next leap of faith having intercourse and even GYN exams.”

This, again, happened for me following the procedure. I was able to practice taking the dilators out and re-inserting them and each time, felt more and more comfortable and confident with this. Again, once I woke up with the dilator in place and knew that it had worked and I was able to re-insert it pain-free, I knew that anything would be possible. We made the transition to intercourse within 1 week. Thereafter, I had my first successful ob/gyn examination.

Dr. Pacik finally describes the home stretch:
“Now the brain realizes it has nothing to be afraid of and this protective reflex begins to disappear. Long after the Botox has worn off, the body appears to understand it no longer needs to protect itself against the perceived pain of penetration and the protective reflex appears to disappear.”

This is exactly what happened for me. Once I woke up with the dilator in place and practiced taking it out and reinserting it, my way of thinking changed from the fear/pain response to “this works and does not cause any pain.” The same thing occurred with both intercourse and ob/gyn exams.

I had very severe Pacik/level 5 vaginismus and could never insert a thing without this fear/excruciating pain response. Today, I am able to have pain-free gynecological exams/tests and my husband and I are enjoying a pain-free and wonderful sex life, all something I never could’ve even dreamed of prior to this procedure.

Please know that I am here for you 100% and always will be. Sending Hugs!!!

[Dr. Pacik]

Hi Chocolate

You raised a number of points in this very valuable exchange of information. You and the others reading this should understand the role of hymenectomy. The main problem with vaginismus is spasm of the vaginal entry muscle. Therefore the treatment needs to address this spasm which is Botox, dilators and post procedure counseling, or dilators alone with counseling in less severe cases. Though the hymen may be a problem, and sometimes I find the need to release the hymen (fairly rare), hymenectomy in of itself will not cure vaginismus. Feeling your muscles going into spasm when kissing confirms your diagnosis of vaginal spasm. This is much like suddenly getting a “Charlie horse” when other muscles in the body go into spasm. “Hitting a wall” is also a very common complaint. All this speaks to muscle spasm and therefore the diagnosis of vaginismus. The inability to have a GYN exam further confirms the diagnosis. A doctor who is able to insert only one finger (or usually no finger when the muscle looks and feels like a tightly closed fist) could be an indication of a tight hymen, but when combined with the proper history, the diagnosis should be muscular spasm rather than the need for a hymenectomy. (A recent patient had both a hymenectomy and an episiotomy (cutting into the vagina) which is sometimes done during childbirth to widen the canal). Of course none of this helps because the diagnosis of spasm was missed. When women are anesthetized to have a GYN exam, the spasm disappears and they are told “everything is normal” which doesn’t help anything other than creating more confusion. I would love to hear from some of the others further discussing these points.

We routinely send brochures to any patient requesting them to give to their doctors and I often speak to other doctors to help them understand. The treatment needs to include the psychologic manifestations in that it is not so easy to overcome the fear and anxiety of penetration in patients with severe vaginismus. This is why Botox alone does not cure the problem because vaginismus women need much more than just injections. I hope this helps. I would be happy to review your questionnaires and discuss my thoughts with you.

[Heather34]

Hi ladies. There is an excellent new blog posted today concerning the importance of distinguishing vestibulodynia from vaginismus.

Excerpts include:

“Women are often told that vestibulodynia is what causes the pain on attempted penetration when the real culprit is vaginismus and associated vaginal spasm.”

One of my patients writes:

“I self-diagnosed that I had vaginismus. I never considered myself to have vulvodynia or vestibulodynia, but I can see how my doctor could misinterpret this pain during a GYN exam because of my high level of anxiety. I mentioned vaginismus to my doctor and she thought I was talking about vulvodynia or vestibulodynia and seemed unaware of vaginismus.”

“Distinguishing vaginismus from vestibulodynia is very important because Botox is effective for both conditions, but one needs to know where it is best to inject this drug. In vaginismus, the entry muscle is usually noted to be in spasm under anesthesia and it is the vaginal muscles that are injected. In vestibulodynia, the vestibule is injected.”

“Dr. Pacik continues to have in excess of 90% cure rate using Botox for vaginismus and has noted that associated vestibulodynia disappears, as the patient is able to achieve intercourse.”

Ladies, I believe this is a very important thread. Were you ever misdiagnosed with vulvodynia or vestibulodynia when you, in fact, had vaginismus?

[Heather34]

JoNel Aleccia, senior writer for NBC News, wrote an excellent article about Dr. Pacik’s Botox Treatment Program for vaginismus.

http://bodyodd.nbcnews.com/_news/2011/02/25/6125525-botox-for-your-bits-shot-may-smooth-over-sex-problems?lite

Excerpts from the article include:

“To treat [vaginismus], Pacik injects the muscles at the entrance of the vagina with Botox, which works as it does in the face, interrupting nerve impulses and allowing the muscles to relax. “When I inject them, I put them asleep,” he said. “You would not be able to approach these people with a needle.” When they wake up, the women find that they are relaxed enough to allow penetration and, soon, to have normal sex with their husbands or partners.”

The article goes on to further reference the successful use of Botox to treat another sexual pain disorder, vulvodynia:

“[Pacik’s] work was echoed this week by a new report in the journal Archives of Dermatologythat said a 26-year-old woman was cured of vulvodynia, an excruciating, persistent burning vaginal pain, with the use of botulinum Toxin A injections.”

This is an excellent article about Dr. Pacik and his Botox treatment for vaginismus that was written by the senior writer for NBC News ladies. Amazing!!! I would welcome your comments and feedback concerning this important article.

[Heather34]

Hi ladies. I was thinking about more helpful tools for those transitioning to intercourse. One thing that may be very helpful to do is to use the regular dilators for a while (an hour or two) and then, after dilating, to also use the Lelo. It’s very comfortable and even smaller than the pink dilator. It also has many different speeds and controls which can serve as a wonderful distraction and also a great source of relaxation for even the most anxious patients.

Concerning the distraction part of using a vibrator, Dr. Pacik writes:
“Clitoral vibration makes both dilation and intercourse easier (and more fun). If the clitoral stimulation is too strong, the vibrator can be placed on the lower abdomen. When I give Botox injections into the facial muscles, I routinely use a dental vibrating toothbrush (without the brush) to help distract my patients during the injections.”

Concerning the relaxation part of using a vibrator, Dr. Pacik writes:
“The Lelo Liv is a very appropriate vibrating dilator for our vaginismus patients. We highly recommend the Lelo Liv because this vibrating dilator allows the vaginal muscles to be stretched while reducing stress and promoting relaxation. To use the Lelo Liv, make sure it is very lubricated, turn the vibrator down to the lowest setting and insert it slowly. Move the vibrator in and out being aware of which sensations you enjoy the most. Many of our vaginismus patients do well combining vibrators with dilation before transitioning to intercourse.”

For the veterans reading this, would you also recommend the Lelo? If so, why and how has it helped you?

[Heather34]

I personally found the blog to be very informative as I previously had Pacik/level 5 vaginismus. This definitely helps to explain the severity level (i.e. a type of phobic reaction with the fear of heights example). I still find the whole thing incredibly fascinating (i.e. how I could go for so many years of my life with such severe vaginismus and no insertion whatsoever to being able to make love to my husband within a week of the procedure). It’s just wonderful that Dr. Pacik can help those women who suffer from this most severe form of vaginismus and really give them their lives back!!!

In a blog in which Dr. Pacik discusses the spastic muscles, it provides an excellent explanation of how this program works to help patients overcome level 5 vaginismus and this is how it worked for me.

He begins by writing:
“In filling out their questionnaires, a surprisingly large number of patients use the terminology that attempting intercourse is like “hitting a brick wall’! This “brick wall” represents spasm of the entry muscle of the bulbocavernosum. It is much like making a tightly closed fist and attempting to push the opposite index finger into this tightly constricted muscle mass. Not possible. Neither is penile penetration. For severe cases of vaginismus, NO PENETRATION IS POSSIBLE!”

This is exactly how it felt every single time I tried to insert anything in the past (i.e. intercourse, speculum for ob/gyn exam, plastic dilators, and even a q-tip).

Next, he writes:
“The reflex of vaginismus: It is likely that the spasm of the vaginal muscles, especially the entry muscle, the bulbocavernosum, represents a reflex. The brain appears to perceive that penetration will be painful, and the vagina responds (protective reflex) with spasm which is equivalent to the body protecting itself by saying “no entry”.
Phobic avoidance: The reaction to penetration in vaginismus patients is much like any phobia. For the person afraid of heights, you have to practically drag them to high points, there is so much fear and anxiety. The heart races, they break into a sweat, they begin shaking uncontrollably and are sure they will faint. These same responses take place in vaginismus patients faced with penile penetration. This is the bodies way of avoiding a perceived threat.”

He goes on to describe progressive dilation under anesthesia:
“Following the Botox injections, which are done under anesthesia, the vagina is then progressively dilated using a series of larger dilators to stretch the vagina. This is left in place and the patient wakes up with usually the largest dilator. As the Botox becomes effective during the next 2-7 days, the stretching becomes easier because of the dilators.”

I know that I’ve written about this extensively but this was seriously the turning point for me in overcoming vaginismus. When I woke up with the largest dilator in place, I knew that something was able to be inside of me pain-free and it worked to change my whole mentality.

He next describes stretching of the tight muscles:
“As patients begin stretching these tight muscles they begin to understand that dilation is not the end of the world and in fact becomes easier with time. Sooner or later they make the next leap of faith having intercourse and even GYN exams.”

This, again, happened for me following the procedure. I was able to practice taking the dilators out and re-inserting them and each time, felt more and more comfortable and confident with this. Again, once I woke up with the dilator in place and knew that it had worked and I was able to re-insert it pain-free, I knew that anything would be possible. We made the transition to intercourse within 1 week. Thereafter, I had my first successful ob/gyn examination.

Dr. Pacik finally describes the home stretch:
“Now the brain realizes it has nothing to be afraid of and this protective reflex begins to disappear. Long after the Botox has worn off, the body appears to understand it no longer needs to protect itself against the perceived pain of penetration and the protective reflex appears to disappear.”

This is exactly what happened for me. Once I woke up with the dilator in place and practiced taking it out and reinserting it, my way of thinking changed from the fear/pain response to “this works and does not cause any pain.” The same thing occurred with both intercourse and ob/gyn exams.

Ladies, I had very severe Pacik/level 5 vaginismus and could never insert a thing without this fear/excruciating pain response. Today, I am able to have pain-free gynecological exams/tests and my husband and I are enjoying a pain-free and wonderful sex life, all something I never could’ve even dreamed of prior to this procedure.

[Heather34]

Hi K. Howard. I love the title of your post “renewed hope” and thank you so much for sharing your story. I seriously KNOW that you will have tremendous success and you are so strong and courageous for taking this step and the stand to defeat vaginismus once and for all. You wrote “I am nervous yet extremely hopeful.” This is such a common feeling to have pre-procedure and one that I certainly shared with you. I was incredibly nervous but held on to the hope that it would work and I would prevail. In writing this, I keep thinking of Dr. Pacik’s blog: David and Goliath.

http://www.vaginismusmd.com/david-and-goliath/

In it, he writes:
“Speak to the patient. I value each and every conversation I have with my patients before treatment. It helps them understand, helps them overcome some of their anxiety and sets the stage for good communication after treatment. It always gives me some additional insights into what is going on for the patient, and once again I learn something about the struggles of vaginismus or a concept that is re-enforced. Slowly, even at this stage we are beginning to “know the enemy”. Knowledge is power.
The first strike comes in the operating room. Under anesthesia, Goliath has been rendered helpless as the anesthesia takes effect and reduces the muscular spasm to nothing more than an easily stretchable muscle. The power of spasm becomes jelly. The tightly closed fist of the entry muscle disappears. Botox is injected while the enemy is unconscious. Before Goliath regains consciousness, the muscle is dilated to one of the larger dilators and a long acting local anesthetic is injected to keep the powerful enemy weak after he wakes up. This results in a crippling blow . . . BUT
The enemy wakes up, and though weakened, Goliath can still rear its ugly head. The fight is now a balance between the dueling dilators of David and the powerful muscles of Goliath that have been weakened but not yet controlled. David fights on knowing that once the arrows delivering the Botox become effective he will be able to continue to weaken his opponent. The long acting anesthesia allows the patient to continue dilating for several hours after treatment, without fear.
During this time David is further coached on how to overcome the enemy. Hours are spent learning how to prepare daily logs for continued follow up, how to transition from dilators to intercourse, how to become erotic once again, positions of pelvic floor relaxation to make intercourse more comfortable and how to prepare for GYN exams. Much more is taught, but these are the basics leading to victory. More knowledge, more power. Goliath is held at bay, and weakened he begins to fall.
Knowing that Goliath has been weakened gives David the final determination to throw more dilators at the monstrous muscles. Continued daily logs are showing greater comfort using the dilators as anxiety diminishes. The battle at times feels long, but the powerful Goliath is weakening. It is hard to believe, but the end is in sight.
David conquers and the story ends as it should. The underdog wins. Intercourse is suddenly possible without pain. It takes David a little longer to overcome the stress of the battle. “I need to catch up emotionally to where I am physically” simply indicates that any of us need to get beyond stressful times, and this may take awhile.
David believed in God, and God helped him win over the giant.”

I’m here for you K. Howard and, again, KNOW that you will have tremendous success and you are so strong and courageous for taking this step and the stand to defeat vaginismus once and for all.

[Heather34]

Hi ladies. There is an excellent new blog posted that thoroughly describes the three components of treatment (i.e. the 1, 2, 3 punch)

http://www.vaginismusmd.com/vaginismus-treatment-the-123-punch/

Excerpts include:
“The first punch is the injection of Botox under anesthesia. This is the knockout punch for the spastic muscle at the entry of the vagina (the “closed fist”). It will be unable to recover for about four months.
The second punch is the progressive dilation under anesthesia, stretching the tight muscle(s). Once these muscles are weakened and stretched under anesthesia, the continued post treatment dilation keeps these muscles stretched.
The third punch is reduction of anxiety. It is well known that fear and anxiety play an important role in continued spasm of the entry muscle. The brain says “PAIN“, the vagina responds with a protective reflex “NO ENTRY“. Once fear and anxiety lessen and women are able to tolerate penetration as well as having comfortable pain free intercourse, this protective reflex appears to diminish, and the reflexive spasm of the vaginal muscles appears to disappear.”

It goes on to describe the importance of post-procedure care:
“The three punches described must be combined with careful post-procedure monitoring, which includes the review of daily logs to help patients with their post-procedure dilation program. The counseling done after treatment is of utmost importance to help women understand what needs to be done when they return home and the steps needed to succeed in having pain free intercourse.”

I entirely agree that all of the combined steps of the treatment program along with the post-procedure care is what makes it work so well and be so effective in curing vaginismus. For me personally, once the first and second punch occurred, the third immediately followed. Specifically, once I woke up from my procedure with the largest dilator in place and knew that I could remove and re-insert it without any pain whatsoever, my anxiety was immediately reduced from around a 10+++ to close to nothing. The more that my husband and I practiced with the dilators this day and the more we saw first-hand that I was experiencing no pain, again, the less anxiety I experienced about future penetration. I knew that if worked this time, it would always work and practicing with the dilators truly does re-train your brain. I no longer experienced this pain/fear with insertion that I had experienced for so many years. I wish I could explain it in better terms but it simply disappeared once I experienced pain-free dilation for the first time.

Ladies, what have been your experiences with the combined 1-2-3 program along with the aftercare component?

[Heather34]

Hi ladies. I have read so many of your stories and have my own story of seeking and receiving several failed treatments for vaginismus. How many of you have heard a doctor or clinician suggest to “just relax”, “don’t think about it”, or “just do it”? The pain associated with vaginismus is not “in the women’s head” and does not readily respond to these suggestions. Vaginismus is a ‘real’ physical pain and the Botox treatment for vaginismus works to address both this physical pain and to also diffuse the fear of penetration. First, the Botox injections work to weaken the tight vaginal muscles that often make penetration impossible. Second, waking up with the dilator already in place works very well to diffuse the fear associated with penetration. For some patients, such as myself, this was the first time that something was inside of me “pain-free” and, in realizing this, it entirely eliminated any anxiety associated with penetration. The uniqueness of this combined approach to vaginismus is what truly makes it work so, so well. I encourage your comments and feedback here ladies and look forward to reading your posts.

[Heather34]

Hi ladies. First, I’d like to sincerely congratulate all of the women who have succeeded with the internet-only counseling program. It is such a tremendous feeling and just one of the best feelings in the world to finally be free from vaginismus.

I had the Botox treatment with Dr. Pacik in June and know that this is the only treatment that would’ve ever worked for me because I was never successful at any form of insertion prior (i.e. tampons, dilators, even a q-tip). I was a Pacik/Lamont level 5+++ and, again, could not experience any insertion without this pain/anxiety response. Following my Botox treatment, I was able to have pain-free intercourse within 1 week.

Dr. P has written extensively on the Pacik/Lamont classification of vaginismus. Specifically, he wrote:

‘Grade 5 patients who have never had any form of penetration carry enormous levels of anxiety and often demonstrate extreme fear at the time of treatment. Treatment of these patients in a setting that incorporates sedation and anesthesia allows them to feel safe knowing they will not have to endure pain. Botox injections reduce the hypertonicity or spasm of the vaginal muscles while bupivacine injections and topical anesthesia allow the patient to wake up in the recovery room with a large dilator in place without discomfort. The combination of Botox and bupivacaine halts the physical pain and allows the patient to develop new emotional and mental responses both to dilation and to intercourse. The difference in behavior between the severe anxiety noted in patients with the higher grades of vaginismus pre-procedure verses their post-procedure demeanor is often profound. Tears, crying, and uncontrolled shaking pre-procedure are replaced by smiles and determination post-procedure.’

I, again, commend and congratulate the patients that are able to do this and succeed with the remote supported dilation therapy. I think it could definitely work and the statistics have proven that it has worked for those women who have been able to have at least some form of insertion prior (i.e. tampons, dilators, etc.).

What are your thoughts here ladies and Dr. P?