Vaginismus: Spastic Muscles

Patients often don’t understand the concept of vaginal spastic muscles and are also confused why the spasm does not return after the Botox wears off.

“Hitting a brick wall”

In filling out their questionnaires, a surprisingly large number of patients use the terminology that attempting intercourse is like “hitting a brick wall’! This “brick wall” represents spasm of the entry muscle of the bulbocavernosum. It is much like making a tightly closed fist and attempting to push the opposite index finger into this tightly constricted muscle mass. Not possible. Neither is penile penetration. For severe cases of vaginismus, NO PENETRATION IS POSSIBLE!

The reflex of vaginismus

It is likely that the spasm of the vaginal muscles, especially the entry muscle, the bulbocavernosum, represents a reflex. The brain appears to perceive that penetration will be painful, and the vagina responds (protective reflex) with spasm which is equivalent to the body protecting itself by saying “no entry”.

Phobic avoidance

The reaction to penetration in vaginismus patients is much like any phobia. For the person afraid of heights, you have to practically drag them to high points, there is so much fear and anxiety. The heart races, they break into a sweat, they begin shaking uncontrollably and are sure they will faint. These same responses take place in vaginismus patients faced with penile penetration. This is the bodies way of avoiding a perceived threat.

Botox injections for vaginismus

When I examine patients in the operating room there is often intense anxiety that requires sedation before an examination can be done. In the very severe cases of vaginismus (Lamont grade 4 and Pacik grade 5 vaginismus) I can actually see the constricted mass of muscle at the entrance to the vagina, making it impossible to introduce my finger until they are asleep with an anesthetic. The spastic muscle is targeted with Botox injections. Any other tight or spastic vaginal muscles are also injected with Botox.

Progressive dilation for vaginismus under anesthesia

Following the Botox injections, which are done under anesthesia, the vagina is then progressively dilated using a series of larger dilators to stretch the vagina. This is left in place and the patient wakes up with usually the largest dilator. As the Botox becomes effective during the next 2-7 days, the stretching becomes easier because of the dilators.

Stretching of the tight vaginal muscles

As patients begin stretching these tight muscles they begin to understand that dilation is not the end of the world and in fact becomes easier with time. Sooner or later they make the next leap of faith having intercourse and even GYN exams.

The home stretch

Now the brain realizes it has nothing to be afraid of and this protective reflex begins to disappear. Long after the Botox has worn off, the body appears to understand it no longer needs to protect itself against the perceived pain of penetration and the protective reflex appears to disappear. I feel I can say this because as of March 2012, having treated over 160 patients during the past six years mostly with severe vaginismus, there has been no need to re-inject any patient with Botox. When patients send me their daily logs, and follow the dilation schedule, the spasm of the vaginal muscles does not appear to return in primary vaginismus patients.

Secondary vaginismus

In patients with secondary vaginismus which seems to have different causes, two patients in this time frame were noted to have three recurrences. Both patients were treated with resuming their dilation schedule and neither required additional Botox treatments.


The use of Botox and progressive dilation under anesthesia for vaginismus appears to set the stage that allows patients to continue their dilation programs and in this way overcome the spasm of the vaginal muscles which are the hallmark of severe vaginismus.

If you have any questions about our Botox treatment for vaginismus and progressive dilation under anesthesia, please contact us via our contact us form.

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About Dr. Pacik

Peter Pacik, MD, FACS is a recognized pioneer in treating patients with Botox for vaginismus and the author of When Sex Seems Impossible: Stories of Vaginismus and How You Can Achieve Intimacy. He has been in practice for over thirty years and belongs to a small group of prestigious surgeons who are double board certified by both the American Board of Surgery and the American Board of Plastic Surgery. In 2010, Dr. Pacik received FDA approval to continue his study to treat vaginismus using intravaginal injections of Botox together with progressive dilation under anesthesia.
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