1. Prof. Aboubakr Elnashar ًًWhen woman's body says no to sex: Vaginismus Benha University Hospital, EGYPT E-mail: elnashar53@hotmail.com

4. In general population: The exact prevalence rate is not known. Rare(1%) In family planning clinic in Iran: 12% In sexual dysfunction clinics: 5-40% Prevalence

5. 1. Primary (never able to have intercourse) or secondary (past history of vaginal penetration without problems). Secondary vaginismus is often associated with dysparunia Types

6. 2.Global (unable to place any thing in the vagina) or situational (able to use a tampon & can tolerate a pelvic examination but cannot have intercourse)

8. I. Psychological 1. An unpleasant experience: Past sexual abuse, painful first attempt of coitus or vaginal examination 2. Extreme fear of penetration because of wrong belief that her vagina is too small to accommodate an erect penis, fear of pregnancy or intimacy 3. Unexpressed negative feelings towards her husband 4. Religious orthodoxy 5. Pain-tension-pain cycle Causes

9. II. Physical: Rare. PID endometriosis tender scar partially imperforate hymen vaginal stenosis

11. Lines of treatment: 1.Exploration of phobia 2.Sex education 3.Guided tour 4.Control of muscles: Adductor muscles & P coccygeus

12. 5. Systematic vaginal desensitization: Step 1:Insertion of a trainers under controlled relaxation Step 2: Sharing of control with husband Step 3: Insertion of penis with the woman in control Step 4: Transfer control of insertion of penis to husband 6. Drugs 7. Surgical treatment

13. 1. Exploration of phobia. It is the most difficult part of the treatment. Psychological causes should be addressed. If there is a history of childhood traumatic experience, this has to be recalled & the emotions which accompanied it relived in order to help the woman to come to terms with them

15. 3. Self exploration of sexual anatomy (guided tour) Patient in semi-sitting position & legs apart & mirror placed in front of her vulva, she explores her genitalia with the doctor explaining the anatomy & physiology.

17. b. Contraction /relaxation exercise (Kegel ‘s exercise) to gain control over the muscles surrounding her introits . The patient must learn first how to identify the muscle for herself. She is advised to sit on the toilet with her legs spread as far apart as possible. If she then starts & stops the flow of urine, she becomes aware of the pubococcygeus action.

18. Once the muscle is identified, the woman can practice contracting it repeatedly whenever she has time. She simply flexes this muscle 20 times in a row 3 to 5 times every day till it is firm .

20. Approaches 1. Gradual using vaginal self-dilatation or Rapid using vaginal mould insertion. Duration: 2-6 weeks Rapid desensitization is preferred (Biswas & Ratnam,1995) 2. In-vitro: The dilator is introduced by the doctor or In-vivo: the dilator is introduced by the patient According to Cochrane library, 2002 , No discernable differences between the 2 forms of systematic desensitization Success rate: 90%

22. Step 2: Sharing of control with husband. When she is comfortable inserting the larger dilators, she can instruct her husband how to place the dilator in her vagina while she maintains control how quickly the dilator are placed. The husband becomes active in the vaginal dilatation exercises only when the patient is emotionally & physically ready & after anxiety of being touched is extinguished.

23. Step 3: Insertion of penis with the woman in control . Sitting or kneeling over her husband, female superior position & inserting his penis herself.

24. Step 4: Transfer control of insertion of penis to husband During sex therapy the patient are advised to refrain from coitus. The patient is told to perform the exercise for 10 to 15 minutes, 5 times per week. Therapy sessions are conducted every 2 weeks to follow & support the progress made in the treatment, to reduce resistance & to provide large dilator according to progress made.

25. 6. Drugs Anxiolytics & antispasmodics have nothing to offer (Guirguis,1984). The only indication for drugs when vaginismus is a part of a more generalized syndrome of sexual phobia. A trial of imipramine 30-75 mg daily Benzodiazepines to aid both relaxation & interviews (Mikhail, 1976)

26. 7. Surgical treatment Almost never required & may be detrimental to achieving success. The resulting scar may aggravate the condition. Indications to remove an organic cause: septum, stricture, partially imperforate hymen .

28. . Lines of treatment of vaginismus are: Exploration of phobia, sex education, guided tour, control of the adductors & P coccygeus muscles, systematic vaginal desensitization & drugs . Surgical treatment is almost never required & may be detrimental to achieving success

29. Thank you Prof. Aboubakr Elnashar Benha University Hospital, EGYPT E-mail: elnashar53@hotmail.com