Injection of Botox in the Perineal Muscles in Resistant Cases of Vaginal Spasm
Injection of Botox in the Perineal Muscles in Resistant Cases of Vaginal Spasm
During the first visit, the couple will be acquainted with their condition. This will include
 the epidemiology of their condition, some sex education tips, as well as the therapeutic
 modalities available. This is followed by short description of the protocol. In the procedure
 room, each patient will be examined to determine the degree of vaginismus and classify her
 condition according to Lemont's classification as modified by Pacik, from 1 to 5. In the same
 or subsequent sessions, surface anesthesia of the area of injection followed by ice packs is
 used before the BOTOX is injected into the muscle.
In the first session, proper history taking includes the difficulties they are facing, and
 the measures taken to solve it whether medical or folk treatment. Proper counseling of the
 couple to describe the new modality including the BOTOX injection and subsequent dilatation
 sessions. Proper informed consent forms will be signed. Therapy sessions will starts with the
 gentle informed approach to the genital area to gain trust of the patient. This is followed
 by the digital vaginal examination of the patient to determine the degree of spasm and the
 muscle(s) involved.

 The patient will be asked to lie down comfortably on the examination table in the lithotomy
 position. Her husband is allowed to stand on her left shoulder side and may be allowed to
 hold her hand. We started by sterilizing the perineal area and injection site in the vaginal
 introitus using povidone iodine solution. The patient is warned effectively before each step
 of the procedure and what to expect as regards pain. We used surface (Xylocaine gel)
 anesthesia half an hour before the injection.We did not use local anesthetic infiltration
 injections at the site of BOTOX injection. In addition we used ice packs, pre-prepared in a
 surgical latex glove finger, on the perineum and introitus before the injection of BOTOX to
 act as a counter irritant. However in advanced cases of Vaginismus (V4-5), we used general
 intravenous anesthesia

 We made sure to check that the tip of the needle is not in a vessel by aspirating before
 proceeding with the injection of each bolus of BOTOX. We only did one skin puncture, and used
 that to radially injecting the intended area by changing the direction of the tip of the
 needle. We found this much less painful to the patient. The injection site will be monitored
 by the other free hand index and thumb. Following the withdrawal of the needle from the
 muscle, we distributed the bolus of BOTOX uniformly within the muscle digitally using an arc
 fashion massage of the introitus. We applied pressure, whenever needed to stop the bleeding
 from the injection site.

 Following the procedure, we instruct the patient to do Kegel exercises as much as 100
 contractions or more over 48 hours. This will help in distributing the BOTOX within the
 muscles as well as recognition of the patient of the whereabouts of the muscles involved in
 vaginismus. We followed up on our patients daily by phone calls for 4 days following the
 procedure for possible adverse effects.

 Thereafter, the patient will be instructed to attend dilatation sessions twice weekly in the
 clinic, in the presence of the husband, for 3-4 weeks. We use silicone dilators covered by
 lubricated condoms. We prepared the vaginal introitus by the use K-Y jelly for lubrication of
 the dilators. The patient is introduced to the dilator and allowed to hold it in her hand,
 for size and feel, prior to its introduction into her vagina. During each session the patient
 will be asked to lie down on the examination table in the lithotomy position, relax and feel
 comfortable. The husband may stand beside her and may hold her hand. In the initial phase of
 the dilatation procedure we start with the appropriate size of the dilator according to the
 capacity of the introitus and the degree of vaginismus, in each session, and increase the
 size gradually. We always start by the smaller size and move up size wise. At later sessions
 we allow the patient herself with its introduction into the vagina using only her tactile
 sense, with no visual aid or doctor instructions, covering her thighs with sheets to feel
 more private. She is asked to report the termination of the introduction or difficulties she
 is facing. Verbal support is always and repeatedly used. In case of difficulty, the doctor
 does not offer to help and ask the patient to try on her own once more. This helps her to be
 proactive and gain control of the procedure. They usually succeed to carry on the procedure
 on their own. The couple will be instructed not to have trials of intercourse before the
 patient uses dilator number 4 comfortably.
Inclusion Criteria:

 -  cases with resistant vaginismus

 Exclusion Criteria:

 -  cases with congenital anomalies in the lower female genital tract