When did the confusion between vulvodynia and vaginismus start?

To the Editor,

Vulvodynia, defined as vulvar pain persisting for at least three months without an identifiable cause, potentially accompanied by associated factors, is common yet remains enigmatic (1). “Vulvodynia” and “vaginismus” are frequently confused by both laypeople and healthcare professionals. Vaginismus is characterized by involuntary spasms of the pelvic floor muscles, which can be primary or secondary; secondary vaginismus may result from vulvodynia.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders included dyspareunia and vaginismus into the newly created category of “genito-pelvic pain/penetration disorder”, which remains a theoretical concept, lacking scientific validation (2). This change may have increased confusion, potentially denying women the appropriate diagnosis and, consequently, the correct management.

It appears that vulvodynia was addressed as early as 1825 BC in ancient Egyptian papyri. Some authors arguably sustain that “satyriasis” (excessive or abnormal sexual desire), described by Soranos (1^st century AD) may correspond to vulvodynia. Possible descriptions of vulvodynia can be found in books from Thomas (3), Kellogg (4), and Skene (5), in 1868, 1891, and 1898, respectively. The latter proposed surgical removal of the area of “excessive sensitivity” (5).

The term “vaginismus” was coined by Sims (6), a controversial yet pivotal figure in medical history, in 1862. In his seminal work, he described five cases of women who were either unable to engage in intercourse (four cases) or had only experienced it a few times, incompletely, due to severe pain (Table 1). One woman had an “irritable bowel,” which may have corresponded to irritable bowel syndrome. Each woman reported intense pain upon light touching of the vulvar vestibule and hymen. He stated, “the gentlest touch with the finger, a probe, or even a feather, produces the most excruciating agony.” Given this description, we believe that these cases represent vulvodynia, rather than vaginismus. Although many women with vulvar pain may develop some degree of secondary vaginismus, introital pain alone does not define vaginismus.

Table 1. Clinical histories and treatment approaches for five women reported by Sims (6).

Year	Age	Clinical history	Gynecological exam	Treatment and outcome
1857	45	Woman of high social position unable to ever have intercourse. Married at age 20. “Painful menstruation” “Irritable bowel” “Sensation of bearing down” “Nervous system in a deplorable condition” Consulted several specialists in the US, Paris, London and other centers without success. Previous treatments included:  Surgical removal of a “sanguineous tubercle at the meatus urinarius” 2-3 years after marriage (no benefit) Dilation with “graduated bougies” (“intolerable suffering”)	“The slightest touch at the mouth of the vagina produced the most intense agony, throwing her nervous system into great agitation, with general muscular spasm and shivering of the whole frame, as if with the rigors of an intermittent, while she shrieked aloud, her eyes glaring wildly, and tears rolled down her cheeks, all rendering her a pitiable object of terror and suffering.” “I succeeded in introducing the index finger into the vagina, up to the second joint, but no further. The resistance to the passage was so great, and the vaginal contraction so firm, as to deaden the sensation of the finger” The exam under anesthesia (“etherization”) revealed a normal vagina.	No treatment proposed. Sims believed that surgical division of the muscles and nerves of the vulva could help, but refused to perform the surgery as it would be experimental and the lady was of a high social position.
1858 (?)	Not specified	Woman married two years before, with the “same dread instinct of being touched”	“Utterly impossible to pass a finger into the vagina”	Since the husband threatened to divorce, surgical treatment was proposed. Division only of the edges of the hymeneal membrane on each side of the fourchette - no improvement Division at the same points, but deeper “through the mucous membrane, and through some of the fibres of the sphincter muscle” - tolerated the introduction of 2 fingers, but with significant pain Proposed excision of the hymen, deeper incisions, followed by use of dilators - not allowed by the mother
1859	Not specified	Wife of a clergyman, married for 6 years and unable to have intercourse. Already consulted several surgeons.	“The slightest touch at the reduplication of the hymeneal membrane with a feather or a camel’s hair pencil, produced as severe suffering as if she were cut with a knife.”	Complete excision of the hymen V-shaped incision starting above the hymen and finishing in the raphe Use of dilators
1859	Not specified	Woman married for 3 years during which “sexual intercourse had been imperfectly accomplished a few times during the first few weeks after marriage”. Stopped attempting intercourse (“lived and loved as innocently as two little children”) Concerned about having child (family pressure)	Similar to the previous cases
1859	Not specified	Married for 2.5 years, with a “truly unhappy” husband due to “persistent virginity”	Similar to the previous cases

The solution proposed for the problem was surgical: complete excision of the hymen and a V-shaped incision extending from above the hymen to the perineal raphe, followed by the use of dilators. He advised starting using glass or metal dilators within 24 hours after the surgery. While they experienced some soreness, it was not comparable to their previous pain levels. This outcome is unexpected for vaginismus but aligns with what might be anticipated for localized provoked vulvodynia (vestibulodynia).

He concluded that this condition was not uncommon as he and a colleague observed 17 cases over a 24-month period. He reported a surprisingly high success rate (88%), with some women even achieving pregnancy a few months post-procedure. This success rate aligns closely with current outcomes reported for the surgical treatment of localized provoked vulvodynia, despite the differences between his technique and the current ones (7, 8).

To our knowledge, the most accurate detailed description of vulvodynia, which included a highly successful treatment approach, was provided by Sims (6). Juliet famously questioned, “What’s in a name?”. In this instance, an inaccurate term has led to a common condition remaining largely unknown and understudied for over one and a half centuries since its first description.