Classification – Severity

How Bad is Bad?
Understanding the Severity of Vaginismus

How bad is bad? This is a common question in an effort in understanding the severity of vaginismus. Though the term “vaginismus” describes painful sex or that intercourse is impossible it is now defined by the DSM 5 as a penetration disorder in that any form of attempted vaginal penetration (tampons, finger, gynecology exams and intercourse) is either very painful or impossible. It needs to be understood that there are many levels of severity of vaginismus. The understanding of this by clinicians and patients alike is important so that the proper treatment can be instituted.

In 1978, Lamont described a classification of vaginismus to describe the severity of the vaginismus. His findings were based both on the history of the patient and observations during an attempted GYN examination. All patients gave a history of painful intercourse and all vaginismus patients were noted to have generalized tightness of the pelvic floor. In 2010, Dr. Pacik expanded the Lamont classification by introducing a Level 5 vaginismus (see references below).

Lamont Classification described the following breakdown:

  • First degree vaginismus as spasm of the pelvic floor that could be relieved with reassurance and the patient could relax for her examination.
  • Second degree vaginismus, generalized spasm of the pelvic floor as a steady state despite reassurance, and the patient was unable to relax for the exam.
  • Third degree vaginismus, the pelvic floor spasm was sufficiently severe that the patient would elevate her buttocks in an attempt to avoid being examined.
  • Fourth degree vaginismus, the most severe form of vaginismus described by Lamont, the patient would totally retreat by elevating the buttocks, moving away from the pelvic exam, and tightly closing the thighs to prevent any examination.
  • Pacik described 5th degree vaginismus as a visceral reaction manifested by increased adrenalin output and resulting in any of the following: Increased heart rate, palpitations, hyperventilation, trembling, shaking, nausea or vomiting, crying uncontrollably, a feeling of light headedness and fainting, a desire to jump off the table, run away or even attack the doctor.

Pacik Classification – 5th Degree

5th degree vaginismus is described in Dr. Pacik’s book “When Sex Seems Impossible”, Chapter 6. A level 5 vaginismus is far more severe than the fourth degree vaginismus originally described by Lamont. Worse, many level 5 vaginismus patients are unable to tolerate any form of penetration.

Patients often give a history of feeling “it’s like hitting a brick wall” when attempting intercourse. This history is consistent with the physical finding of spasm of the entry muscle, the bulbospongiosus. Like any reflex one has no control over it. The spasm of the entry muscle of the vagina is noted to be involuntary in that the patient does not will this to happen. The spasm is often seen even under anesthesia. Vaginismus appears to be both psychologic and physiologic. The mind does play an important role in vaginismus. Telling a patient that “it is all in their head” is a major disservice to these women. Patients who have involuntary and uncontrolled spasm of the pelvic floor do not have the ability to respond to verbal demands.