Vaginismus

Vaginismus is an involuntary spasm of the muscles surrounding the vagina that closes the vagina. This condition causes penetration to be difficult and painful, or even impossible.

CAUSES, INCIDENCE, AND RISK FACTORS

Vaginismus is considered a sexual dysfunction. It is a complex condition with several possible causes that may result from past sexual trauma or abuse, other psychological factors, or a history of discomfort with sexual intercourse. Sometimes no cause can be determined.

Vaginismus is an uncommon condition, occurring in less than 2% of women in the US.

Women with varying degrees of vaginismus often develop anxiety regarding coitus and penetration, and intercourse is usually painful. However, this does not mean that they cannot achieve or sustain sexual arousal. Many are very sexually responsive and may have orgasms through clitoral stimulation. Women with vaginismus may seek sexual contact and sexual play as long as vaginal penetration is avoided.

SYMPTOMS

Difficulty or inability to allow vaginal penetration for intercourse is the primary symptom. Vaginal pain with attempts at intercourse or during attempted pelvic exam is common.

SIGNS AND TESTS

A gynecological examination can confirm the diagnosis of vaginismus. The health care provider will note whether there is an involuntary muscle contraction when fingers are inserted into the vagina, and this usually reproduces the pain the woman feels with intercourse.

TREATMENT

The treatment of choice with vaginismus is an extensive therapy program that combines education and counseling with behavioral exercises. Exercises include pelvic floor muscle contraction and relaxation (Kegel exercises) to improve voluntary control.

Vaginal dilation exercises are recommended using plastic dilators. This should be done under the direction of a sex therapist or other health care provider and treatment should involve the partner. This treatment should gradually include more intimate contact, ultimately resulting in intercourse.

Educational treatment, including information about sexual anatomy, physiology, the sexual response cycle, and common myths about sex, should be provided as well.

EXPECTATIONS (PROGNOSIS)

When treated by a specialist in sex therapy, success rates are generally very high.

COMPLICATIONS

Vaginismus is one common cause of female sexual dysfunction, which may lead to dissatisfaction and discord in intimate relationships. This problem can lead to erectile dysfunction in the male partner after repeated unsuccessful attempts at intercourse.

PREVENTION

If a woman finds intercourse painful, she should seek medical evaluation right away. When pain continues to be endured as part of sex, it increases the risk of conditioning a vaginismus response.

Prostatitis

Acute prostatitis is an inflammation of the prostate gland that develops suddenly.

CAUSES, INCIDENCE, AND RISK FACTORS

Acute prostatitis is usually caused by a bacterial infection of the prostate gland. Any organism capable of causing an urinary tract infection (UTI) is also capable of causing acute bacterial prostatitis, including enterococci, Escherichia coli, Klebsiella pneumonia, Proteus mirabilis, Pseudomonas aeruginosa, and Staphylococcus aureus.

Some sexually transmitted diseases (STDs) can cause acute prostatitis, typically seen in men younger than 35. These include gonorrhea, chlamydia, urealyticum, and trichomonas. Prostatitis from an STD typically closely follows sexual contact with an infected partner.

In men older than 35, E. coli and other common bacteria are more often the cause of prostatitis. E. coli prostatitis may follow urinary tract infections, urethritis, or epididymitis.

Acute prostatitis may also develop as a result of procedures involving the urethra, such as:

1. Catheterization or cystoscope

2. Trauma

3. Bladder outlet obstruction

4. An infection elsewhere in the body. Prostatitis is rare in young boys.

Prostatitis is diagnosed in approximately 2 of every 10,000 outpatient visits. Men between the ages of 20 and 35 who have multiple sexual partners are at an increased risk. Also at high risk are those who engage in anal intercourse, especially without using condoms.

Men age 50 or older who have an enlarged prostate (benign prostatic hyperplasia), are at increased risk for prostatitis due to their risk of urinary tract infection.

SYMPTOMS

Acute prostatitis often begins with chills and fever, lower abdominal discomfort, perineal pain (pain in the area between the genitals and the anus), and burning with urination. Symptoms of more advanced prostatitis include a diminished urine stream and difficulty urinating.

Prostatitis may occur in conjunction with epididymitis or orchitis, especially if caused by an STD, in which case symptoms of the accompanying condition may also be present.

Symptoms of acute prostatitis include the following:

1. Fever

2. Chills

3. Low back pain

4. Abdominal pain (above the pubic bone)

5. Perineal pain (pelvic floor)

6. Pain and burning with urination (dysuria)

7. Urinary retention (inability to completely empty bladder)

8. Pain with ejaculation

9. Pain with bowel movement

Additional symptoms that may be associated with this condition:

1. Blood in the urine

2. Increased urinary frequency or urgency

3. Difficulty urinating

4. Decreased force of urinary stream

5. Testicle pain

6. Blood in the semen

7. Foul-smelling urine

SIGNS AND TESTS

Your health care provider may perform a physical examination to assess the prostate (warm, soft, swollen, or tender), the groin lymph nodes (enlarged or tender), the scrotum (swollen or tender), and the urethra (discharge).

Triple-void urine specimens may be collected for urinalysis and urine culture:

#1 initial stream

#2 mid-stream

#3 after prostatic massage by examiner

Note: Your health care provider may choose not to perform prostatic massage if the prostate is obviously swollen and tender, because massage may potentially spread the infection and cause bacteremia or sepsis. These are potentially life-threatening infections in which bacteria are present in the bloodstream, rather than localized to one part of the body.

Urinalysis may reveal increased white blood cells (WBCs) and bacterial growth. Examination of prostatic secretions may also show increased levels of WBCs and concentrated bacterial growth upon culture.

Acute prostatitis may also alter the results of the following tests:

1. CBC

2. Urine analysis

3. PSA

4. Semen analysis

TREATMENT

Most cases of acute prostatitis clear up completely with medication and slight modification of diet and behavior.

Medications:

1. Prostatitis is treated with antibiotics, most often trimethoprim-sulfamethoxazole (Bactrim), fluoroquinolones (Floxin or Cipro), and tetracycline derivatives.

2. For men with prostatitis caused by an STD, a 250 mg shot of ceftriaxone followed by a 10-day course of doxycycline or ofloxacin. For other bacterial causes, a standard course of treatment consists of Bactrim, Cipro, or Floxin for at least 4 weeks.

3. Because recurrence is common, some health care providers recommend even longer therapies -- 6 to 8 weeks - to eliminate the infection. In severe cases, hospitalization and intravenous (IV) antibiotics may be required.

4. Stool softeners may reduce the discomfort associated with bowel movements.

Surgery:

1. Surgery or urethral instrumentation (urinary catheterization or cystoscopy) are not recommended for patients with acute prostatitis.

Other therapy:

1. Frequent and complete urination is recommended to decrease the symptoms of urinary frequency and urgency.

2. If the swollen prostate restricts the urethra, it may be difficult to completely empty the bladder, and insertion of a suprapubic catheter (a drain that empties the bladder through the abdomen) may be necessary.

3. Warm baths may provide some relief of the perineal and lower back pain associated with acute prostatitis.

Diet:

1. Avoid substances that irritate the bladder, such as alcohol, caffeinated food and beverages, and citrus juices, and hot or spicy foods.

2. Increasing the intake of fluids (64 to 128 ounces per day) encourages frequent urination that will help flush the bacteria from the bladder.

Monitoring:

1. Follow-up should include an examination at completion of antibiotic therapy to ensure that infection is no longer present.

EXPECTATIONS (PROGNOSIS)

The majority of men who are accurately diagnosed with acute prostatitis become symptom-free after treatment.

Patients who have had acute prostatitis are prone to recurrence and are likely to develop chronic prostatitis.

COMPLICATIONS

Chronic prostatitis can develop. Urinary retention may occur as a result of the swollen prostate occluding the urethra.

PREVENTION

Not all types of prostatitis are preventable. Thorough hand-washing after a bowel movement and prior to handling the penis may prevent the transfer of bacteria from the rectal area to the genitourinary tract.

Infections that are associated with STDs can be prevented by practicing safer-sex behaviors.