The sexual life of woman in its physiological, pathological and hygienic aspects

by E. Heinrich Kisch

A case came under my own observation in which a newly married woman suffered from vaginismus. The husband believed the cause of the trouble was his own partial impotence, consequent upon youthful venereal excesses, and yielded to the desire of his wife and her relatives that a divorce should be obtained. A year later, the woman remarried, when, to her horror, the symptoms returned in full force. Now for the first time she consulted me, and on local examination I could detect no abnormality whatever. The vaginismus was in this instance a pure neurosis, the only possible cause of which was to be found in bygone overstimulation of the vaginal orifice, the wife admitting previous onanistic excesses. In another case known to me, vaginismus in the wife made the husband an involuntary sodomite. The movements of the wife when the spasm came on led to the introduction of the penis per anum, and coitus had repeatedly been effected by this abnormal route, when the fact first became apparent as the result of a local examination.

Le Fort reports the case of a young Russian wedded pair who were spending their honeymoon in Paris. The husband took so much to heart his inability to fulfil his marital obligations in consequence of the vaginismus from which his wife suffered, that he shot himself through the heart. The distressing situation of a husband whose wife suffers from vaginismus, rendering coitus impossible, is depicted in the well-known French romance, “Mademoiselle Giraud, Ma Femme.” From a false shame, women often continue to suffer from vaginismus for months and even years, without a single effective coitus having ever taken place; it is only the consequent sterility which at last leads to medical advice being sought. The physician then usually ascertains that the hymen is still intact, or at least incompletely destroyed, that on this membrane and on various parts of the vulva there are erosions, and that the whole of the external genitals outside the hymen are in a state of inflammation more or less acute. In other cases, however, neither excoriations, erosions, nor inflammation can be detected, and the existence of vaginismus can be proved only by the pain and the muscular spasm set up by contact with the vagina. Often, indeed, the cause of this most distressing affection cannot be discovered.

Introduction of the penis may be rendered impossible by spasm of the constrictor cunni (bulbocavernosus) muscle, but equally so by spasm of the transversus perinei or the levator ani muscle. Sometimes the spasm affects all three muscular groups; in which case the narrowing of the vagina is extreme, and extends for some way up into the canal. When the levator ani alone is affected by the spasm, the penis can, indeed, be introduced into the vagina, to encounter a powerful obstacle in the interior of that canal; and it may happen, when the spasm comes on and affects the levator ani only after complete intromission of the penis, that the glans is retained in the vaginal fornix by the active contraction of the pelvic floor.

More or less credible instances of penis captivus thus brought about are on record. The following history is by Davis: A gentleman entering his stable found therein his coachman and a servant-maid in a most compromising position. All endeavours of the pair thus surprised to separate proved ineffectual, and their attempts to draw apart caused them intense pain. Davis was sent for, and ordered an iced douche, which, however, failed to liberate the imprisoned penis. Release was impossible until the woman had been placed under chloroform. The swollen and livid penis exhibited two strangulation-furrows, a proof that two distinct areas of the levator ani muscle had been spasmodically contracted.

Hildebrand records three cases observed by himself in which there was spasm of the upper part only of the vagina, unaccompanied by vaginismus (i. e., by pain). In two of these cases, the spasm was originated by the contact of the examining finger with very painful ulcers of the portio vaginalis; the third patient had a very sensitive prolapsed ovary. Fritsch reports having had on one occasion to give a woman chloroform for the release of a swollen and imprisoned penis.

Hildebrand suggests that vaginismus may be caused by an abnormal size of the penis, or by a condition occurring in weaklings and alcoholic subjects, in whom the greatest swellings of the glans penis occurs before intromission, whilst this greatest swelling is normally deferred until towards the end of the act, when the glans is in the vaginal fornix.

Schröder writes as follows regarding the etiology of vaginismus: “The affection is dependent upon trauma, sustained in maladroit, frequently repeated attempts at sexual intercourse; for this reason it is met with, in the great majority of cases in young, newly married women. Impotence in the male is by no means necessary for its production, and such impotence is not even a frequent antecedent. Abnormal narrowness of the vagina, or extreme firmness of the hymen, is occasionally found, but neither is in any way necessary; all that can be said in this connection of a small vaginal orifice is, that it predisposes to vaginismus. If the husband is devoid of previous experience in sexual matters, maladroit attempts at intercourse are exceedingly likely to occur. The penis is thrust in the wrong direction, pressing against either the anterior or the posterior commissure of the vulva. Very often, moreover, the position of the vulva, which is subject to very striking individual variations, is concerned in the production of vaginismus. There are many women in whom the vulva lies in part in front of the symphysis pubis, so that the lower border of the symphysis lies below the urethral orifice. In such cases the penis is directed too far backwards, and instead of passing into the vaginal orifice, slips into the fossa navicularis. The frequent repetition of such maladroit attempts at intercourse gives rise to a gradually increasing sensitiveness of the parts concerned, with the formation of excoriations. It now results that, on the one hand, the woman dreads attempts at intercourse on account of the pain to which they give rise; she shrinks away from the man, so that penetration of the vagina by the penis is rendered even more difficult than it was before; and, on the other hand, ungratified sexual desire leads to the frequent repetition of attempts at complete intercourse (from which, moreover, if conception should ensue, a cure of the trouble is expected). In this way, the trauma is rendered more severe, the congestion and excoriation of the fossa navicularis or of the urethral region are aggravated, and the sensitiveness of the parts increases to such a degree that the woman thus affected screams out when the vulva is merely touched. Ultimately reflex cramps set in whenever intercourse is attempted, and we then have the fully developed clinical picture of vaginismus.”

Winckel maintains that in most cases there are two principal elements in the causation of vaginismus. In the first place, in consequence of more or less pronounced anatomical changes, there is undue sensitiveness and tenderness of the vaginal inlet and its neighbourhood, and in exceptional cases also of the upper part of the vagina, the uterus, and the ovaries. In the second place, the patient manifests an increased general sensitiveness and nervous irritability; this is in some cases primary, but in others it is entirely the result of the repeated stimulation; and in either case it is heightened by the effects of ungratified sexual desire.

A. Martin points out that the spasm of the muscles of the pelvic floor, and especially of the levator ani muscle, upon which vaginismus depends, may be due in some cases to the influence of chill, since the same cause will lead to pathological contractions in other muscular areas. But in such cases it is always open to question if masturbation or some other sexual perversion is not the true cause of the disorder. In some instances vaginismus is merely a symptom, in extremely sensitive women, of various diseases of the reproductive organs, and is brought on by the increased pain which in such cases is caused by attempts at intercourse; when produced in this way, vaginismus is usually a transient manifestation.

Veit considers that among the pathological conditions giving rise to vaginismus, we must also enumerate diseases of the internal pelvic organs, such as chronic metritis, displacements of the uterus, oöphoritis, etc.; but he also attaches great importance to nervous predisposition, consequent upon previous sexual stimulation, and upon pre-existing inflammatory changes due to gonorrhœal infection. A peculiar form of vaginismus is, according to Veit, sometimes observed after the birth of the first child; happily the duration of this is usually brief. After parturition the vulval mucous membrane remains for a time very tender, and when cohabitation is resumed, often too soon, and perhaps, after the enforced abstinence, too frequently repeated at brief intervals, fissures are readily produced. Moreover, vaginismus which has existed prior to parturition may, in some cases, recur after that event. An unusual position of the vulva, undue smallness of the vaginal inlet, and relative impotence of the man, may combine to cause such a recurrence. Finally, vaginismus often persists throughout pregnancy, and manifests itself during parturition. The magical effect which chloroform has in some primiparæ, when the head is delayed at the vulva, is explicable only by the supposition of vaginismus.