Botox for vaginismus

Botox is a popular injectable that contains botulinum toxin type A as its active ingredient. Available in more than 75 countries worldwide, Botox can be used for both cosmetic and medical purposes. These purposes include moderate to severe forehead lines due to frontalis muscle activity, crow's feet (or lateral canthal lines) and glabellar lines caused by procerus/corrugator muscle activity. At the same time, it has also been used for penis and scrotum enhancement. Clinically, Botox has been approved by the FDA for the treatment of overactive bladder; spasticity due to cerebral palsy or spinal injuries; migraines; cervical dystonia; and urinary incontinence due to detrusor overactivity associated with neurologic diseases, such as multiple sclerosis.  Botox has also been used to treat TMJ syndrome, acne, and vaginismus.

What is vaginismus?

Vaginismus (also referred to as vaginism) is a medical condition that affects the ability of a woman to experience vaginal penetration. This includes pap tests (the penetration involved in a gynecological examination), insertion of menstrual cups or tampons, manual penetration, and more commonly, sexual intercourse. Vaginismus is usually caused by involuntary vaginal muscle spasms, which make any forms of vaginal penetration painful (or even impossible). It is believed that the pubococcygeus muscle (also known as the PC muscle) is responsible for the involuntary spasms. It has also been suggested that other muscles, such as the perivaginal, circumvaginal, bulbocavernosus, and levator ani muscles can contribute to vaginismus. It should be emphasized that the spasms cannot be consciously controlled. The reflex in vaginismus is analogous to the corneal reflex when stimulated by a foreign object. The severity of the condition (and the degree of pain during sexual penetration) varies from patient to patient.

How does Botox work?

Botox is a type of neurotoxin that has muscle-relaxant properties. The mechanism of action of Botox is fairly straightforward: it prevents muscle contraction. In more clinical terms: Botox attaches itself to the cholinergic receptors though the H chain. This leads to internalization and endocytosis that, in turn, inhibits the release of presynaptic acetylcholine (ACh). As a result, muscle activities and stiffness are reduced.

Through its muscle-relaxant properties, Botox helps to weaken the spastic vaginal muscles that block penetration. Botox acts on a portion of the vaginal muscles, which encircle the vagina, to inhibit contraction, thereby preventing muscle spasm. As a result, the muscle becomes softer and more pliable. They can now be easily stretched using dilators. Once patients are comfortable with the dilators, transition to sexual intercourse becomes fairly easy, as patients generally find that an erect penis is more comfortable than the dilators.

Botox is not known to cause numbness, as it selectively acts on motor neurons. Botox has no effect on the muscles that controls sensation.

What happens during the procedure? What are the treatment considerations?

Using small needles, Botox is administered superficially into the muscles that interfere with penetration. During the treatment, practitioners should only inject the vaginal side wall and avoid areas around the rectum and urethra. Otherwise, incontinence may occur. It is recommended to use a dose of 100–150 units. The dose of Botox for vaginismus should be determined based on the targeted muscle. As a rule of thumb, a higher dose should be used on larger muscles. As the dose of Botox increases, so does its potency. For example, when treating severe frown lines, small doses of Botox allow some facial animation, while a higher dose will fully eliminate any movement. Similarly, when using Botox for vaginismus, the dose should be determined based on the number of muscles involved in the vaginismus process and the degree of muscle spasms.

The dose should be split among three vaginal muscles, with a higher dose used on the entry muscle, which causes most of the blockage. The entry muscle (clinically known as bulbocavernosus) looks like a tightly-closed fist in more severe cases of vaginismus. Anesthetic can be used to minimize discomfort. Practitioners may choose to inject Botox without anesthesia (Botox is rarely injected with anesthesia when treating facial wrinkles). When treating vaginismus with Botox, there are concerns that any touch in the pelvic region may induce major withdrawal (as occurs during a pelvic examination). Anesthesia may help to prevent this while permitting progressive dilation with larger dilators.

Be aware that Botox alone is not likely to cure vaginismus. For best results, Botox injections should be used in combination with dilators. At the same time, post-procedural supervision is vital to the success of treatment. Patients who struggle with relationships or suffer from a low libido or a fear of penile penetration should seek additional treatments by therapists.

How many treatment sessions are needed to cure vaginismus?

Most patients only require a single treatment session to see results. Extra doses of Botox are seldom needed, as long as dilation is comfortable (and intercourse can be achieved).

What long can Botox for vaginismus last?

Typically, Botox for vaginismus can last for approximately four months, although individual results may vary. Keep in mind that the results of Botox for vaginismus is not permanent.

Is Botox safe?

While Botox is a toxin, it is highly diluted to the point that systemic toxic effects are unlikely to occur. Furthermore, the dose of Botox used in vaginismus treatment is far too low to harm the body systematically. It would take 2500 to 3000 units of Botox to cause any severe systemic adverse effects. At the same time, Botox rarely migrates to another body part from the injection site. Having said that, it may travel up to three centimeters from where it is injected. When injected correctly (by certified medical professionals), Botox can be one of the safest treatments for vaginismus. In fact, many doctors can attest to the safety and effectiveness of Botox for vaginismus.

Although Botox has a good safety profile, it can potentially cause a number of side effects, including the following:

  • Pain and discomfort associated with injection
  • Swelling at the injection site;
  • Painful urination/urinary tract infection.

In order to reduce the risk of side effects, practitioners are advised to avoid injecting near the rectum, bladder or urethra. In a clinical trial in 2011, cases of minor stress incontinence (losing several drops of urine when straining) have been reported. As mentioned earlier, Botox for vaginismus should only be administered into the side walls of the vagina.

Who is the right candidate for Botox for vaginismus?

While well tolerated by most patients, Botox for vaginismus is not suitable for everyone. Botox is contraindicated in patients who are allergic to botulinum toxin or any other inactive components of the formulation. Patients who are allergic to type A botulinum toxin may consider a type B botulinum toxin preparation, such as Myobloc. Botox injections are generally not intended for pediatric patients of less than 18 years of age (except for the treatment of lower limb spasms). It is not recommended to use Botox in patients who are pregnant and breastfeeding. The effects of Botox in pregnancy and lactation are not well understood. As with other interventions, practitioners should carefully evaluate all the potential risks and benefits prior to treatment. The treatment should not be performed if the potential risks outweigh the benefits.