Image by Joanna Nix-Walkup

Vaginismus treatment

The Botulinum Toxin Cure For Vaginismus - when sex is painful

“Part of the problem for women with vaginismus is they frequently feel that the condition is

somehow their fault, which is obviously not true at all."

Dr Sonya Jessup


It’s the most natural thing in the world and yet for women with vaginismus, sex is so painful

it becomes impossible. To make matters worse, many women who have this condition

don’t have a name for it. It’s just an unbearable pain and a feeling of dread that increases

with every attempt to overcome it.

Women with vaginismus may have no history of trauma to explain it. We frequently hear

women say: ‘No one knew what to do about it. I was told it was all in the mind.’

What is Vaginismus?

Vaginismus causes pain with sex and affects up to 7% of women.

It is the involuntary spasm or contraction of the muscles surrounding the lower third of the

vagina with attempts at any form of vaginal penetration. It involves the muscles just below

the skin called the perineal muscles and the deeper pelvic floor muscles.

Primary vaginismus is where no vaginal penetration has ever been successful, this

includes tampons, intercourse and ultrasound etc. Secondary vaginismus is where vaginal

penetration was possible in the past but is now no longer possible due to a variety of

reasons which may lead to fear of pain with attempts at penetration.

Women who have had vaginal pain in the past, may, very reasonably, fear pain with

penetration. This can lead to involuntary contraction of their pelvic floor and vaginal

muscles as a protective mechanism. Often this can then lead to the contraction of other

surrounding muscles such as the legs, buttocks and hips, often squeezing their legs

closed. Many women perceive that the pain they experience is very harmful but this is not

always the case. The anxiety they may feel however may be very real with

hyperventilation, sweating and crying being common symptoms.

Once you have experienced pain with attempts at penetration, it makes the next time even

more difficult.These involuntary reactions perpetuate the cycle of fear of pain leading to

muscle contraction which leads to increased pain and increased muscle contraction and

so on.Vaginismus is a paradox, it is involuntary contraction of voluntary muscles, and often

occurs before the genital area is even touched.

There are many physical conditions that may contribute to painful intercourse. A

congenitally tight hymen, tight perineal skin bands, vaginal and vulval dermatological

issues such as “ thrush” , “ lichen sclerosis” , “psoriasis” or pelvic infections can all cause

pain on penetration. Endometriosis can cause deep pain with intercourse, and the poor

healing of post vaginal delivery tears or scars can all contribute to a woman’s discomfort.

Vaginismus after menopause may be due to the genitourinary syndrome of menopause

where, due to decreased levels of oestrogen, the vaginal walls become thin, red and dry

often leading to splitting of the perineal skin with intercourse, and ongoing discomfort,

which can lead to anticipatory vaginismus.

The treatment of these conditions with medication or surgery is obviously the first step to

treating painful sex.

The first step is often to see a pelvic floor physiotherapist who is specialised at identifying

the contracted vaginal muscles and who can coach women though how to start relaxing

these muscles with or without the use of vaginal dilators. Sex therapists can assist with

any psychological issues that contribute.

If vaginismus persists however, the Botulinum Toxin may be an integral step that allows

treatment to move forward quickly and effectively.

How does treatment with Botulinum Toxin help?

Vaginal botox involves the injection of Botulinum Toxin ( a purified toxin from

bacteria) into the tight, spasmed lower vaginal muscles. This is generally performed under

general anaesthetic or in the rooms under a light sedation.

The botox toxin acts as a selective muscle weakening and/or paralysing agent, and helps

reduce nerve pain.

The effect is reversible but provides a temporary window of opportunity to rehabilitate and

stretch the over contracted spastic vaginal muscles that are obstructing penetration.

Very small needles are used to inject 100 units of Botulinum Toxin into the three key vagina muscles

that can obstruct penetration. Only the areas in the vaginal side walls that are palpably

spasmed and sore are injected. Once these muscles can no longer tighten, it is usually

possible to have comfortable intercourse. Once a woman experiences sex without pain,

she can relax and begins to enjoy it. The vaginal muscles can then stretch and start to

relax of their own accord.

The treatment takes approximately 10 days to begin to work. By week 3-4 post injection it will be

starting to have its effect on the muscle which will then reach a plateau at around 4-5

months post injection.

Usually, once the muscles have been relaxed, no further treatments are required, although

some women benefit from a second or third treatment to fully and permanently relax their

pelvic floor and vaginal muscles.

The treatment has been shown to be effective in around 90% of women

What are the side effects of using Botulinum Toxin?

For the vast majority of women, there are no noticeable side effects of vaginal botox. The

potential for a small muscle haematoma or infection exists, as with all procedures where a

needle is used.

There are case reports in the literature of bladder or bowel urgency or difficulty with controlling wind or incontinence. No botox injected near the rectum or urethra so the risk of these side effects is minimal.

One article reported a case of vaginal dryness due to a parasympathetic partial nerve block.


As the effects of botox only last 12 weeks, these rare side effects are completely reversible