Treatment for vaginismus usually begins during a pelvic exam, in which the health-care practitioner demonstrates the vaginal spasm reaction to the woman or couple. Subsequent therapy starts with relaxation and self-awareness exercises, including a

Sexual Difficulties and Solutions

soothing bath, general body exploration, and manual external genital pleasuring. Next the woman learns to insert first a fingertip, then a finger, and eventually three fingers into her vagina without experiencing muscle contractions. At each stage the woman prac­tices relaxing and contracting the vaginal muscles, as with Kegel exercises (see Chapter 3). Dilators, which are cylindrical rods of graduated sizes, are also sometimes used to accustom the vaginal walls to relaxing (Leiblum, 2000). Biofeedback and physical therapy treatments to lessen muscle tension in the pelvic floor can also be helpful for vaginismus and other forms of dyspareunia (Goldfinger et al., 2009; Rosenbaum, 2011).

Once the woman has completed the preceding steps, her partner can begin to partici­pate by following the same steps that she completed by herself. After the man can insert three fingers without inducing a muscle spasm, the woman controls a slow insertion of her partner’s penis, with many motionless pauses that allow the woman to become familiar with vaginal containment of the penis. Pelvic movements and pleasure focusing are added later, only when both partners are comfortable with penetration.