Vulvodynia and vaginismus: how to distinguish them?

There is a form of vulvodinia that can be mistaken for vaginismus, which is the fear of experiencing pain during penetration. This is vulvar vestibulitis or provoked vestibulitis, a specific variant of vulvodinia in which the pain is localized at the level of the vestibule, that is, the tissues located at the entrance to the vagina. Let’s see how to distinguish the two conditions and how to treat them

Vulvodynia and vaginismus: the causes

Can vaginismus and vulvodinia be differentiated based on symptoms? “In both conditions, a hypertonic or difficult-to-explore muscle can be detected, but they are also quite distinct, so for a differential diagnosis, the doctor’s objective examination is essential,” answers Valentina Pecorari, a urologist specializing in pelvic floor health, vulvodinia and incontinence.“The cause, first of all, is very different: one is psychological in origin, the other stems from an alteration of local nerves that cause pain on touch. Although it is easy to find a very contracted pelvic floor muscle in both, it is important to make a differential diagnosis because the treatments are different.”

Vaginismus

The doctor continues, “Vaginismus, which affects 0.51 percent of fertile women, indicates a woman’s persistent difficulty in accepting vaginal penetration, penis, finger or object despite the desire to do so. Avoidance and an anticipatory fear of pain are also often present. Vaginismus is thus a psychogenic cause of intercourse pain, which secondarily results in muscle spasm of the elevator muscle of the anus. It is a phobia of penetration, which can vary depending on situations, levels of anxiety, quality of the relationship with the partner. In the first- and second-degree form, the spasm is moderate and penetration is possible, although painful. In this case, vaginismus is a primary condition that, however, tends to worsen over time due to micro-abrasions that can trigger a chronic inflammatory response, contributing to the onset of vulvar vestibulitis. When third- or fourth-degree is reached, however, the muscle spasm is so tight that penetration is impossible. Penetration phobia triggers true neurovegetative stress, accompanied by symptoms such as vasoconstriction, chills, tachypnea, fear, distress, and air hunger.”

The vulvodinia

The vulvodinia, on the other hand, is a neuropathic pain syndrome, in which the nerves sense a stimulus as painful that should not be (allodynia). “The pain, in vulvar vestibulitis, can be spontaneous, but also just provoked: in this case, the woman feels pain when she tries to insert tampons or have intercourse,” the expert illustrates. “In this case, there is no phobia of penetration: the woman feels pain that may be followed by a defensive spasm, a ‘reflex to pain’ that the woman feels, which is therefore secondary.”

Differential diagnosis

There are no specific tests for vaginismus, while the standard test for vulvodinia is the swab test. “It consists of a normally non-painful stimulus, which the woman feels as more or less painful or simply burning (like a burning sensation),” explains the gynecologist. “For diagnostic purposes, however, it is important to first observe the reaction to the thought of the examination and exploration: a woman with vaginismus often begins to contract even before the examination, even after reassurances from the specialist (who always explains how the first phase of the diagnostic investigation consists of an external examination only). Women with vaginismus begin to have contractions already at the idea or approach of the explorer finger. On the other hand, the woman with vulvodinia may fear the pain, but will contract the muscle instead only after feeling the pain.”

Treatments

The treatment protocol also changes. “Vaginismus treatment must always begin with psychological therapy,” Dr. Pecorari concludes. “Only then will it make use of pelvic floor rehabilitation, to learn about the muscle and avoid reflex contractions. Performing only rehabilitation could have the opposite effect.” One of the most recent analyses confirms that multidisciplinary approaches (combination of physical and psychological therapy) have the highest success rate (about 86 percent). “Instead, the woman with vulvodinia and pelvic floor hypertone will start withantalgic therapy for neuralgic hypersensitivity and pelvic floor rehabilitation. Psychological therapy will serve only in cases where the pain impairs quality of life or romantic and sexual relationships.”