The diagnosis is made on the basis of the anamnesis. Questioning related to the problem goes through various steps (Table 17.1). The clinical presentation of and the request for help made by women with vaginismus are very diverse: she can be young (around 20 years of age) or somewhat older (around 30 years old); she may be able to function sexually very well without intercourse or on the other hand avoid every sexual situation; she may not be able to insert anything into her vagina, or be able to insert tampons or allow a speculum examination, while insertion of the penis is impossible; and finally she may wish to improve her sexual functioning or she may wish to become pregnant in “a natural way.”

Moreover, it is not always easy through the anamnesis to distinguish between “vaginismus” and “dyspareunia.” In both groups, there can be vulvar pain when the penis is inserted or attempts at insertion of the penis are made. When intercourse has never been successful, the woman is diagnosed with “lifelong vaginismus.” When intercourse has been possible but became painful at the start or over the course of time and eventually is no longer possible, this is acquired “secondary” vaginismus.

An (external) gynecological examination is carried out on women with lifelong vaginismus to assess, on the one hand, any congenital abnormalities of the hymen or vagina and, on the other hand, to inform the woman about her genitals, about the location of the pain that she may be experiencing during an attempt at intercourse, and about what can happen when her pelvic floor muscles tighten voluntarily or involuntarily. The examination thus has an educational purpose. Patient preparation is central to an educational pelvic examination (EPE) to avoid further distress (for details about patient preparation, see also Chap. 30). To facilitate the EPE, the patient is informed of what to expect and reassured that no vaginal insertion (of a finger or speculum) will be attempted. She is invited to be an active participant (e.g., holding a mirror to observe exam, ask questions) and reminded that she can terminate the exam whenever she wishes. Instructions on coping with fear/anxiety can be very helpful (e.g., breathing techniques).

The examination consists of inspection of the external genitals, the vaginal introitus, and the hymeneal ring and palpation of the vaginal vestibule. In a large group of women (40–100 %) with lifelong vaginismus, findings as are described in the diagnosis “provoked vestibulodynia” (PVD) (see Chap. 18) can be found. In that case, the woman indicates having pain when the vaginal vestibulum is touched with a moistened cotton wool swab, the so-called “touch test” or “Q-tip test,” in which sometimes vestibular erythema is also visible. The pain is regularly recognized by the woman as the pain that she feels during (attempted) intercourse.

After the physical examination, it is logical to discuss the findings and to explain the complaint in a way that is comprehensible for the woman and her partner. It can help to make a schematic drawing of the vulva on which the urethra, vaginal introitus, the pain spots, and location of the pelvic floor muscles can be drawn while talking. It is not possible to say what a possible cause might be, but one can explain how physical and psychological factors could influence sexual functioning and the inability to have intercourse. The FAM-V model can be useful in this context (Fig. 17.1). The FAM-V model can give the woman pointers to understand her own physical and emotional response(s) to (attempts at) penetration. She often recognizes various elements that are maintaining the vicious circle in which she is caught up.

On the basis of the information obtained from the anamnesis and the physical examination, a purely medical approach is not appropriate. In the further course of the consultation, the different components of treatment can be discussed. When the wish for a child is prominent, an explanation can be given about self-insemination do-it-yourself (DIY insemination with own sperm). For women with vaginismus who wish to have intercourse, a sexological coaching session is appropriate. Clinical psychologists/sexologists, who are trained in the basic principles of exposure, are best equipped to accompany the couple during exposure treatment. There is, above all, a role for the pelvic floor physiotherapist in addition to medical and psychological expertise specifically when a woman prefers this approach.

Different forms of treatment have been used to address the somatic correlates of vaginismus, for example, surgical removal of the hymen or widening of the introitus [29], injections of botulinum toxin in the pelvic musculature [30], or application of topical anesthetic creams [31]. No evidence of the effectiveness of one of these treatments is available from controlled studies [21, 32].

Although physical therapy is often used in clinical practice, evidences from prospective and controlled studies is lacking [32].

The widespread application of the anxiety-reduction approach of gradual exposure reflects the consensus among theoreticians and clinicians about the important role of anxiety in vaginismus [32]. Since Masters and Johnson (1970) [33], most therapies for vaginismus have used vaginal “dilatation” in which initially the woman becomes accustomed to self-touch to the vaginal introitus and insertion of her own finger or dilators through the introitus and pass way into her vagina, and then places the first of a series of inserts of gradually increasing diameter into her vagina. In reality, of course, there is no actual dilation but rather a gradual reduction of fear. According to the FAM-V model, the penetration-related fears are maintained in women with vaginismus because avoidance prevents disconfirmation of the catastrophic beliefs. By directly reducing avoidance and increasing successful penetration behaviors, fears are disconfirmed; catastrophization is reduced and eventually eliminated.