While exact figures are unknown, a significant portion of gynecological patients present to their doctors with painful spasming of the pubococcygeal and other muscles surrounding the vagina. Vaginismus, which affects women of all ages, presents a complex clinical problem that your patients may not be comfortable discussing. This is especially true if the condition affects a pediatric or adolescent patient.
Vaginismus can be a significant stressor for younger patients, and it can make diagnosing gynecological problems difficult. Fortunately, treating vaginismus is possible, even among this specific patient population. While the condition makes it difficult — if not impossible — to perform a vaginal examination, alternative methods of evaluating your patient can provide valuable diagnostic information while preserving their comfort.
Causes of Vaginismus in Pediatric Patients
Younger patients may first experience vaginismus when trying to use a tampon for the first time. Painful tampon insertion, or the impossibility of insertion, is often the first clue that a problem exists. While the exact cause of vaginismus is unknown, it's thought that psychological factors may contribute to its development. In some cases, physical conditions such as a urinary tract infection may exacerbate symptoms and make vaginal penetration more painful.
According to the Cleveland Clinic, doctors believe vaginismus in adolescent or pediatric patients may result from a variety of factors:
- Anxiety.
- Fear or other negative emotions toward vaginal penetration.
- History of sexual trauma or abuse.
For young LGBTQIA+ identified patients, the Journal of General and Internal Medicine points out that gender dysphoria can be an intense barrier for comfortable pelvic exams. Gender dysphoria is the psychological distress caused by the "mismatch" between a patient's gender identity and assigned sex or outward sex characteristics, according to Scientific American.
Overcoming Pain and Uncertainty
As a physician, you are in a prime position to help your pediatric patient overcome their concerns, about a gynecological examination. Most women already feel anxious about pelvic exams, and young people suffering from vaginismus may be more frightened than adult patients.
To help your young patients overcome their fear before an examination, try to:
- Allow them to view and touch exam equipment prior to use.
- Answer any questions your patient has honestly, using language they can understand.
- Establish a good rapport with your patient and any accompanying family members.
- Explain the purpose of a pelvic examination in plain language.
- Maximize patient comfort and control by allowing them to use blankets or other coverings.
Additionally, you should always ask for the patient's consent before touching them to adjust their position. Talk through the process, explaining what you're doing and when, to keep them at ease.
The process of treating vaginismus itself usually involves familiarizing young patients with their own genitals, along with psychological counseling and, in some cases, pelvic floor physical therapy. It can be helpful to encourage an adolescent to use self-touch to decrease anxiety associated with physical contact. Over time, the adolescent patient may use a finger or vaginal cones to progressively desensitize themselves to vaginal penetration. Eventually, patients may be able to use tampons comfortably.
Alternatives to Transvaginal Ultrasound
Regardless of the reassurance you provide, it may still be impossible to perform a standard pelvic examination on a young patient with vaginismus. You may need to use an alternative method to a pelvic exam or transvaginal ultrasound to diagnose and treat any other gynecological conditions.
Transabdominal ultrasound may sometimes be used to visualize a young patient's uterus and ovaries. Additionally, transperineal or endoanal ultrasound may be used to quickly evaluate the pelvic floor muscles and peritoneal structures. Transperineal and transabdominal ultrasound are noninvasive, which may help reduce an adolescent or pediatric patient's anxiety during the procedure.
Vaginismus may present difficulties for patients in need of pelvic examinations, but it's still possible to obtain necessary diagnostic information using other means. While ultrasound itself does not help diagnose vaginismus, it can be an invaluable tool for completing a thorough gynecological examination on a young patient with the condition.
