Vaginismus Treatment: The 1,2,3 Punch

Vaginismus treatment using the Pacik Botox program

With now more than 170 patients treated using the Botox program, vaginismus treatment continues to become easier. The program consists of Botox injections, injections of a long acting local anesthetic, and progressive dilation under anesthesia. The treatment of vaginismus has continued to undergo refinements making treatment more reliable, more effective, long lasting and quick.

Vaginismus Symptoms

The symptoms of severe Pacik grade 5 vaginismus (Ref.1) and Lamont grades 3 and 4 (Ref. 2) vaginismus have been identified and include the complete inability to have almost any type of vaginal penetration, and the total inability to tolerate intercourse. The history that intercourse is “like hitting a wall” is perhaps the most important symptom that patients record in their detailed questionnaire.

Vaginismus Findings: “The Great Wall” and spasm of the vaginal entry muscle

Vaginismus TreatmentThe symptom of “hitting a wall” with attempted penetration is due to the entry muscle of the vagina looking like a tightly closed fist. This is apparent during examination under sedation. It can be seen and felt. It is nearly impossible to introduce my index finger into this tightly constricted spastic mass of muscle present at the entry of the vagina, the bulbocavernosum. This finding during examination is the most important verification of vaginismus. The husband of one of my patients, not knowing any of these details, named his wife “The Great Wall”.

Diagnosis of Vaginismus

The diagnosis of vaginismus, especially severe vaginismus, is made more by a good history rather than by examination. This is because severe vaginismus patients are unable to relax for a GYN exam and for the most part are often unable to complete the exam. Uncontrollable shaking, palpitations, hyperventilation, crying, thinking they are going to die, are all symptoms of the most severe form of vaginismus now known as Pacik grade 5 vaginismus (Ref. 1) and make examination all but impossible.

Vaginismus Treatment

Botox is well known to prevent the contraction of muscles by chemically interfering with the nerves going to the targeted muscles. The injected muscle is simply unable to contract. Spasm is eliminated.

The 1,2,3 punch of vaginismus treatment

The first punch is the injection of Botox under anesthesia. This is the knockout punch for the spastic muscle at the entry of the vagina (the “closed fist”). It will be unable to recover for about four months.

The second punch is the progressive dilation under anesthesia, stretching the tight muscle(s). Once these muscles are weakened and stretched under anesthesia, the continued post treatment dilation keeps these muscles stretched.

The third punch is reduction of anxiety. It is well known that fear and anxiety play an important role in continued spasm of the entry muscle. The brain says “PAIN“, the vagina responds with a protective reflex “NO ENTRY“. Once fear and anxiety lessen and women are able to tolerate penetration as well as having comfortable pain free intercourse, this protective reflex appears to diminish, and the reflexive spasm of the vaginal muscles appears to disappear.

Vaginismus cure

The entire Botox program is what is so effective in curing vaginismus in more than 90% patients who are treated with the full Botox program.

The three punches described must be combined with careful post-procedure monitoring, which includes:

  • The review of daily logs to help patients with their post procedure dilation program
  • The counseling done after treatment is of utmost importance to help women understand what needs to be done when they return home and the steps needed to succeed in having pain free intercourse.

Botox alone, without the full program including post-procedure counseling and follow-up is a setup for failure as has been seen in several of my patients. Some of these patients even had two courses of Botox and failed each time. In our practice we continue to follow our patients for a number of years at no charge to ensure their success.


The combination of Botox injections, dilation and reduction of fear and anxiety are responsible for the high rate of success when treating vaginismus.


  1. Pacik, PT. Vaginismus: Review of Current Concepts and Treatment Using Botox Injections, Bupivacaine Injections, and Progressive Dilation with the Patient Under Anesthesia (2011) Aesth Plast Surg. DOI 10.1007/s00266-011-9737-5
  2. Lamont JA. Vaginismus. Am J Obstet Gynecol 1978;131:633–6.

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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