Obstetric, perineal, and psychosocial outcomes after successful vaginismus treatment: a retrospective cohort study stratified by Lamont grade

Abstract

Background

Whether obstetric, perineal, and psychosocial differences persist after successful vaginismus treatment, particularly by pre-treatment severity, remains unclear.

Methods

In this single-center retrospective cohort study, primigravid women who conceived spontaneously after successful vaginismus treatment and delivered between December 2023 and December 2025 (n = 117) were compared with controls selected at a 1:3 ratio for similar maternal age, body mass index, and gestational age at delivery (n = 351). Pre-treatment severity was graded by Lamont (1–4). Outcomes included cesarean delivery (overall and by Lamont grade), cesarean on maternal request, second-stage cesarean, neonatal outcomes, and Obstetric anal sphincter injuries (OASIS) (grades 3a-4). Prenatal psychosocial adjustment was assessed at 30 weeks (PSEQ total and PSEQ-FHL), and postpartum depressive symptom risk at 6 weeks (EPDS ≥ 13).

Results

Baseline characteristics were similar. Overall cesarean delivery was comparable (43.6% vs. 36.2%; OR 1.36, 95% CI 0.89–2.09), but Lamont grade 4 had a higher cesarean rate than controls (58.1% vs. 36.2%; OR 2.44, 95% CI 1.16–5.15). Cesarean on maternal request (17.9% vs. 5.4%; OR 3.82, 95% CI 1.97–7.40) and second-stage cesarean (5.1% vs. 0.6%; OR 9.43, 95% CI 1.88–47.40) were more frequent in the treated cohort. In vaginal deliveries (treated n = 66; controls n = 224), minor OASIS (3a-3b) was higher after treatment (9.1% vs. 2.2%; OR 4.38, 95% CI 1.29–14.85), and major OASIS (3c-4) occurred only in Lamont grade 4 (15.4% vs. 0.0%; p = 0.003). EPDS ≥ 13 did not differ overall (30.8% vs. 28.5%). PSEQ scores were higher in treated women, mainly in Lamont grades 3–4, indicating poorer late-pregnancy psychosocial adjustment.

Conclusions

After successful vaginismus treatment, most maternal and neonatal outcomes were similar to controls; however, cesarean on maternal request and second-stage cesarean remained more frequent, minor OASIS was increased in vaginal deliveries, and major OASIS was concentrated in Lamont grade 4. Higher Lamont grades were also associated with poorer prenatal psychosocial adjustment.

Trial registration

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-026-09093-2.

Introduction

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), vaginismus is conceptualized as a penetration-related condition in which vaginal penetration, whether with a tampon, finger, dilator, speculum during gynecologic examination, or penile intercourse, is persistently difficult and frequently associated with discomfort [1]. Following successful treatment, many women resume comfortable intercourse and can achieve spontaneous conception without assisted reproduction [2, 3].

Available evidence suggests that vaginismus may be associated with higher rates of obstetric intervention, yet much of the literature concerns women with an active diagnosis rather than those who have completed treatment [4, 5]. In a Swedish population-based register study, women diagnosed with vaginismus were more likely to deliver by cesarean section, particularly on maternal request, and those delivering vaginally experienced higher rates of perineal lacerations [4]. Similarly, a population-based cohort reported vaginismus as an independent risk factor for cesarean delivery [5]. However, because both reports primarily capture outcomes among women with an established diagnosis rather than those assessed after therapy, they provide limited insight into whether these associations continue once vaginismus has been successfully treated and intercourse has been re-established [4, 5].

Obstetric anal sphincter injuries (OASIS) represent the most severe perineal trauma and require standardized classification and reporting; major guidelines recommend structured grading of third- and fourth-degree tears (including 3a-3c subclassification) to ensure comparability across studies [6]. However, in the limited literature evaluating obstetric outcomes specifically after successful vaginismus treatment, OASIS has not been systematically reported using contemporary, guideline-consistent subclassification [2, 3]. The Lamont classification is a commonly used clinical grading system that assesses pre-treatment vaginismus severity; stratifying outcomes by Lamont grade may provide more granular insights within the treated cohort [7].

Evidence specifically addressing pregnancy outcomes after vaginismus treatment remains limited. Zulfikaroglu and Yaman reported obstetric outcomes among 297 women treated for vaginismus but did not include a contemporaneous matched control group, constraining inference about whether risks normalize after treatment [2]. In Turkey, a smaller case-control study by T. Kiremitli and S. Kiremitli compared treated primigravid women with controls; however, perineal morbidity was not evaluated using detailed, guideline-consistent OASIS subclassification [3]. Notably, neither of these studies evaluated maternal psychological status during pregnancy or the postpartum period, and no prenatal or postnatal psychometric assessment was reported [2, 3].

We designed a retrospective cohort study of primigravid women who conceived spontaneously after successful vaginismus treatment and a 1:3 control group selected to achieve comparable distributions of maternal age, BMI, and gestational age at delivery. We compared obstetric and neonatal outcomes and assessed perineal trauma using guideline-consistent OASIS subclassification [6]. We additionally included validated prenatal and postpartum psychometric instruments, an objective dimension not reported in previous treatment-focused cohorts [8–10].

Materials and methods

Study design and reporting standard

This retrospective cohort study was conducted at Ankara Bilkent City Hospital between December 2023 and December 2025 and was prepared in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. A 1:3 control group was selected using a frequency-matching approach to achieve similar overall distributions of maternal age, body mass index (BMI), and gestational age at delivery (Additional file 1).

Participants and case ascertainment

During the study period, 970 patients presented to the Sexual Dysfunction Clinic with vaginismus; treatment was successfully completed in 905, and 654 conceived within the same window. Because our clinic is a tertiary referral center for vaginismus treatment, many women returned to local hospitals or private clinics closer to home for antenatal follow-up and delivery after conception. Therefore, the final cohort included 117 primigravid women who conceived spontaneously after successful treatment and delivered at our institution. Vaginismus was diagnosed according to DSM-5 criteria [1]. The participant selection process is summarized in Fig. 1.

Fig. 1.

Flow diagram of participant selection. Flow diagram showing identification of women treated for vaginismus, subsequent conception during the study window, and final inclusion of primigravid women who delivered at the study institution. Because the clinic functions as a tertiary referral center for vaginismus treatment, many women continued antenatal care and/or delivered at other institutions after conception

Control group and matching

Controls were selected from primigravid women who delivered during the same period, had no history of vaginismus, and conceived spontaneously without ovulation induction or assisted reproductive techniques. A frequency-matching approach was used to obtain a 1:3 control group with similar overall distributions of maternal age, body mass index (BMI), and gestational age at delivery (n = 351). This was a group-level matching strategy rather than individual pair matching.

Severity grading, clinical management, and treatment protocol

Pre-treatment severity was graded by the Lamont classification (1–4) according to pelvic-examination tolerance: grade 1, mild involuntary pelvic floor contraction with examination possible after reassurance; grade 2, persistent contraction with limited relaxation and difficult examination; grade 3, active resistance/withdrawal precluding an adequate examination; and grade 4, complete intolerance with no examination possible [7]. All consultations and therapy were provided by the same experienced gynecologist/sex therapist. Treatment used a structured cognitive-behavioral sex therapy protocol (sexual education, relaxation, pelvic-floor exercises/awareness, and graded vaginal dilator training). Success was defined as patient-reported intercourse; during counselling and 4-month follow-up, all included women reported successful intercourse with no documented relapse. No post-treatment intervention was provided beyond routine obstetric care.

Eligibility criteria

Inclusion required a DSM-5 diagnosis of vaginismus with completed treatment, spontaneous post-treatment conception, primigravidity, and delivery at our institution. We excluded pregnancies conceived with ovulation induction/ART, multiple gestations, intrauterine fetal demise, and pregnancy loss at < 24 weeks’ gestation. Gestational age was based on a reliable last menstrual period and, when needed, confirmed by first-trimester crown-rump length (CRL).

Data sources and outcomes

Data were retrospectively extracted from electronic medical records, delivery/operative notes, and routine follow-up forms. We recorded maternal age, BMI, and obstetric history. Obstetric outcomes included mode of delivery, cesarean rate and indications, labor induction, episiotomy, and cesarean after full dilatation (second-stage cesarean), as well as postpartum length of stay and red blood cell transfusion. Cesarean on maternal request was classified based on review of cesarean indication records together with accompanying clinical documentation, when patient preference appeared to be the main driver of delivery decision in the absence of a clear obstetric or fetal indication. Neonatal outcomes were birth weight, 1- and 5-min Apgar scores, and neonatal intensive care unit (NICU) admission. Change in hemoglobin (ΔHb, g/dL) was calculated as the difference between the hemoglobin level at admission for delivery and the level measured 6 h postpartum.

Perineal trauma classification

Perineal trauma was recorded using the Sultan classification. OASIS were defined as third- and fourth-degree perineal tears (grades 3a-4) and were analyzed as minor (grades 3a-3b) versus major (grades 3c-4) [6].

Psychometric assessments

All participants completed the Lederman Prenatal Self-Evaluation Questionnaire (PSEQ; 79 items; 4-point Likert) at 30 weeks’ gestation [8]. We analyzed the total score and the “fear of pain, helplessness, and loss of control in labor” subscale (PSEQ-FHL); lower scores indicated better prenatal adaptation. The Edinburgh Postnatal Depression Scale (EPDS; 10 items; score range 0–30) was administered at 6 weeks postpartum; EPDS is a screening instrument rather than a diagnostic tool, and an EPDS score ≥ 13 was used to indicate increased risk for postpartum depression [9, 10]. Validated Turkish versions were used for both instruments [8, 10].

Statistical analysis

Statistical analyses were performed using IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, NY, USA). Because this was a retrospective cohort study, no formal a priori sample size calculation was used to determine enrollment. The study sample comprised all eligible primigravid women who conceived spontaneously after successful vaginismus treatment and delivered at our institution during the study period (n = 117). Controls were selected at a 1:3 ratio from the same delivery period using a frequency-matching approach to achieve similar overall distributions of maternal age, body mass index, and gestational age at delivery (n = 351). Normality was assessed with the Shapiro-Wilk test. Continuous variables were compared using independent-samples t tests, and categorical variables using Pearson’s chi-square test. Continuous variables are summarized using appropriate measures of central tendency and dispersion, and categorical variables are presented as n(%). Effect sizes are reported as odds ratios and risk ratios with 95% confidence intervals (controls as reference). Because matching was performed at the group level rather than as individually linked pairs or sets, comparisons were conducted using independent-samples tests. Analyses were conducted on available data; no imputation was performed.

Primary outcomes were overall cesarean delivery (and by Lamont grade within the treated cohort), cesarean on maternal request (overall and among cesarean deliveries), second-stage cesarean (after complete cervical dilatation), red blood cell transfusion, and NICU admission. In the vaginal-delivery subgroup, episiotomy, labor induction, and obstetric anal sphincter injury (OASIS) were evaluated. Postpartum depressive symptom risk was assessed at 6 weeks postpartum and dichotomized as EPDS ≥ 13 versus < 13.

Prenatal psychosocial outcomes included PSEQ Total and the PSEQ-FHL subscale at 30 weeks’ gestation. Because PSEQ scores were non-normally distributed in controls, comparisons versus controls were performed using two-sided Mann-Whitney U tests (overall treated cohort [Lamont 1–4] and each Lamont grade separately), and differences across Lamont grades (1–4) were assessed with Kruskal-Wallis tests. A Cochran-Armitage trend test evaluated trends in cesarean delivery across Lamont grades 1–4. Two-sided p values < 0.05 were considered statistically significant. Because the study included multiple subgroup and secondary outcome comparisons, these analyses should be interpreted as exploratory.

During manuscript preparation, the authors used ChatGPT (OpenAI) for language editing and clarity. All authors reviewed and edited the manuscript and take full responsibility for the content.

Results

Baseline maternal and neonatal characteristics were similar between groups, including age, BMI, gestational age at delivery, birth weight, ΔHb, Apgar scores, and length of stay (p > 0.05; Table 1). Overall cesarean delivery rates were comparable (43.6% vs. 36.2%, p > 0.05), but Lamont grade 4 showed a higher cesarean rate than controls (58.1% vs. 36.2%, p < 0.05; Table 2). Cesarean delivery on maternal request was more common in the treated cohort (17.9% vs. 5.4%, p < 0.001), as was second-stage cesarean delivery (5.1% vs. 0.6%, p < 0.01). Red blood cell transfusion and NICU admission did not differ between groups (p > 0.05). EPDS ≥ 13 at 6 weeks postpartum was similar overall between groups (30.8% vs. 28.5%, p = 0.640). , pIn Lamont-stratified analyses, EPDS ≥13 did not differ significantly from controls in any Lamont subgroup.

Table 1.

Basic characteristics of mothers and newborns in women who became pregnant after vaginismus treatment and in a control group

Variable	Vaginismus (n = 117)	Control (n = 351)	p
Age	24.90 ± 4.86	25.38 ± 5.32	0.390
BMI (kg/m²)	25.92 ± 4.69	25.89 ± 4.41	0.943
Gestational age at delivery (weeks)	38.82 ± 1.43	38.72 ± 1.49	0.505
Birth weight (g)	3396.90 ± 379.87	3406.66 ± 375.91	0.808
ΔHb, g/dL	1.82 ± 0.92	1.68 ± 0.84	0.140
Apgar score at 1 min	8.40 ± 1.01	8.39 ± 1.04	0.918
Apgar score at 5 min	9.17 ± 0.72	9.16 ± 0.76	0.859
Length of hospital stay (days)	1.16 ± 0.45	1.10 ± 0.30	0.165

Values are presented as mean ± standard deviation unless otherwise stated

Table 2.

Comparison of obstetric, neonatal, and psychometric outcomes in women who became pregnant after vaginismus treatment and in a control group

Outcome / subgroup	Events/N (%)	Control events/N (%)	OR (95% CI)	RR (95% CI)	p
Cesarean delivery - Treated vaginismus (overall)	51/117 (43.6%)	127/351 (36.2%)	1.36 (0.89–2.09)	1.20 (0.94–1.54)	0.155
Cesarean delivery - Lamont 1	3/14 (21.4%)	127/351 (36.2%)	0.48 (0.13–1.76)	0.59 (0.22–1.63)	0.394
Cesarean delivery - Lamont 2	9/25 (36.0%)	127/351 (36.2%)	0.99 (0.43–2.31)	0.99 (0.58–1.71)	1.000
Cesarean delivery - Lamont 3	21/47 (44.7%)	127/351 (36.2%)	1.42 (0.77–2.63)	1.23 (0.87–1.75)	0.265
Cesarean delivery - Lamont 4	18/31 (58.1%)	127/351 (36.2%)	2.44 (1.16–5.15)	1.60 (1.15–2.23)	0.020
Cesarean on maternal request (all deliveries)	21/117 (17.9%)	19/351 (5.4%)	3.82 (1.97–7.40)	3.32 (1.85–5.95)	< 0.001
Maternal request among cesarean deliveries	21/51 (41.2%)	19/127 (15.0%)	3.98 (1.90–8.35)	2.75 (1.62–4.67)	< 0.001
Second-stage cesarean (after full dilatation)*	6/117 (5.1%)	2/351 (0.6%)	9.43 (1.88–47.40)	9.00 (1.84–43.98)	0.004
Red blood cell transfusion	7/117 (6.0%)	21/351 (6.0%)	1.00 (0.41–2.42)	1.00 (0.44–2.29)	1.000
NICU admission	4/117 (3.4%)	15/351 (4.3%)	0.79 (0.26–2.44)	0.80 (0.27–2.36)	0.793
EPDS ≥ 13 (6 weeks postpartum) - Treated vaginismus (overall)	36/117 (30.8%)	100/351 (28.5%)	1.12 (0.71–1.76)	1.08 (0.79–1.48)	0.640
EPDS ≥ 13 - Lamont 1	4/14 (28.6%)	100/351 (28.5%)	1.00 (0.31–3.28)	1.00 (0.43–2.33)	1.000
EPDS ≥ 13 - Lamont 2	7/25 (28.0%)	100/351 (28.5%)	0.98 (0.40–2.41)	0.98 (0.51–1.88)	1.000
EPDS ≥ 13 - Lamont 3	12/47 (25.5%)	100/351 (28.5%)	0.86 (0.43–1.73)	0.90 (0.54–1.50)	0.733
EPDS ≥ 13 - Lamont 4	13/31 (41.9%)	100/351 (28.5%)	1.81 (0.86–3.84)	1.47 (0.94–2.30)	0.149

CI Confidence interval, EPDS Edinburgh Postnatal Depression Scale, NICU Neonatal intensive care unit, OR Odds ratio, RR Risk ratio

*Second-stage cesarean was defined as cesarean delivery performed after full cervical dilatation

In the vaginal-delivery subgroup (treated n = 66; controls n = 224), episiotomy and labor induction rates were comparable (p > 0.05; Table 3). Minor OASIS (3a-3b) occurred more frequently in treated women than in controls (9.1% vs. 2.2%, p = 0.020). Major OASIS (3c-4) was uncommon overall and did not reach conventional statistical significance in the overall subgroup comparison (3.0% vs. 0.0%, p = 0.051). Notably, all major OASIS cases occurred in Lamont grade 4, in which the rate was significantly higher than in controls (15.4% vs. 0.0%, p = 0.003). Minor OASIS in Lamont grade 4 was also higher than in controls (23.1% vs 2.2%, p=0.006), although this subgroup finding should still be interpreted cautiously given the small subgroup size.

Table 3.

Comparison of vaginal delivery outcomes in a subgroup of women who became pregnant after vaginismus treatment with a control group

Outcome / subgroup	Events/N (%)	Control events/N (%)	OR (95% CI)	RR  (95% CI)	p
Episiotomy	15/66 (22.7%)	49/224 (21.9%)	1.05 (0.54–2.03)	1.04 (0.62–1.73)	0.867
Labor induction	19/66 (28.8%)	60/224 (26.8%)	1.10 (0.60–2.03)	1.07 (0.69–1.66)	0.755
OASIS minor (3a-3b) - overall treated vaginismus	6/66 (9.1%)	5/224 (2.2%)	4.38 (1.29–14.85)	4.07 (1.28–12.92)	0.020
OASIS minor (3a-3b) - Lamont 1	0/11 (0.0%)	5/224 (2.2%)	NE	NE	1.000
OASIS minor (3a-3b) - Lamont 2	1/16 (6.2%)	5/224 (2.2%)	2.92 (0.32–26.61)	2.80 (0.35–22.55)	0.342
OASIS minor (3a-3b) - Lamont 3	2/26 (7.7%)	5/224 (2.2%)	3.65 (0.67–19.84)	3.45 (0.70-16.88)	0.158
OASIS minor (3a-3b) - Lamont 4	3/13 (23.1%)	5/224 (2.2%)	13.14 (2.75–62.87)	10.34 (2.77–38.61)	0.006
OASIS major (3c-4) - overall treated vaginismus	2/66 (3.0%)	0/224 (0.0%)	NE	NE	0.051
OASIS major (3c-4) - Lamont 1	0/11 (0.0%)	0/224 (0.0%)	NE	NE	1.000
OASIS major (3c-4) - Lamont 2	0/16 (0.0%)	0/224 (0.0%)	NE	NE	1.000
OASIS major (3c-4) - Lamont 3	0/26 (0.0%)	0/224 (0.0%)	NE	NE	1.000
OASIS major (3c-4) - Lamont 4	2/13 (15.4%)	0/224 (0.0%)	NE	NE	0.003

CI Confidence interval, OASIS Obstetric anal sphincter injury, OR Odds ratio, RR Risk ratio

Denominators in this table include vaginal deliveries only (treated vaginismus: n = 66; controls: n = 224). Effect sizes are reported as ORs and RRs with 95% CIs, using the control group as the reference category. For Lamont subgroup rows, comparisons were performed against the control vaginal-delivery group. NE indicates that an effect size could not be reliably estimated because at least one comparison cell contained zero events

At 30 weeks’ gestation, PSEQ total and PSEQ-FHL scores were higher in the treated cohort overall than in controls (both p < 0.001; Table 4). Lamont grades 1–2 did not differ from controls for either PSEQ measure (p > 0.05), whereas Lamont grades 3 and 4 demonstrated higher scores for both outcomes (p < 0.001; Table 4).

Table 4.

PSEQ total and PSEQ-FHL subscale scores by Lamont grade

Group	n	PSEQ Total	P vs. control	PSEQ-FHL	P vs. control
Control	351	145.04 ± 10.57	−	21.83 ± 2.59	−
Lamont 1–4 (Treated vaginismus, overall)	117	159.25 ± 25.43	< 0.001	23.93 ± 3.72	< 0.001
Lamont 1	14	144.93 ± 10.00	0.942	21.57 ± 2.47	0.698
Lamont 2	25	144.92 ± 10.41	0.964	21.88 ± 2.39	0.849
Lamont 3	47	153.53 ± 14.02	< 0.001	23.85 ± 3.14	< 0.001
Lamont 4	31	185.94 ± 31.85	< 0.001	26.77 ± 4.09	< 0.001

Values are presented as mean ± standard deviation. P values are versus controls

PSEQ Prenatal Self-Evaluation Questionnaire, PSEQ-FHL Fear of pain, helplessness, and loss of control in labor subscale

Discussion

In this retrospective cohort study of women who conceived spontaneously after successful vaginismus treatment and a 1:3 control group selected to achieve comparable distributions of maternal age, BMI, and gestational age at delivery, baseline maternal characteristics and neonatal outcomes were largely similar between groups. While differences did not indicate an overall increase in obstetric risk, they were observed in areas such as decision-making regarding delivery, perineal morbidity, and prenatal psychosocial adaptation in the late stages of pregnancy. This suggests that successful vaginismus treatment can normalize a significant portion of the obstetric course. However, in women with higher pre-treatment Lamont scores, some differences persisted rather than fully reverting to control group patterns.

Evidence on obstetric outcomes after successful vaginismus treatment remains limited, and only two treatment-focused cohort studies have reported cesarean delivery rates in this setting [2, 3]. In the larger series by Zulfikaroglu et al. (n = 297), the post-treatment cesarean rate was 53% versus 43.6% in our cohort; however, interpretation is limited by the lack of a control group and inclusion of pregnancies conceived with assisted reproductive techniques [2]. Given the consistently higher cesarean rates in IVF/ICSI pregnancies, case-mix differences may partly explain their higher proportion [11]. In contrast, the only controlled study (n = 50) concluded that cesarean delivery remained higher after treatment than in controls [3]. Although groups were balanced for BMI and gravidity, treated women were older, and advanced maternal age is a well-established predictor of cesarean delivery [12], which may have contributed to the discrepant findings. Beyond cesarean rates, episiotomy, neonatal Apgar scores, NICU admission, and fetal growth restriction were similar between groups in that study [3], consistent with our results. The same study also suggested that maternal preference and intrapartum examination-related difficulties may be important drivers of cesarean delivery after treatment, paralleling our higher rates of cesarean on maternal request and cesarean after full dilatation. In our Lamont-stratified analyses, Lamont grade 4 was the only subgroup with a significantly higher overall cesarean rate than controls, potentially reflecting this group’s lowest tolerance of intrapartum examinations.

Several large database and registry-based studies have linked vaginismus to higher rates of cesarean delivery and other adverse obstetric outcomes [4, 5, 13]. However, these analyses are based largely on diagnostic codes and generally cannot distinguish treated from untreated disease, active from resolved symptoms, or spontaneous conception from ART-related pregnancies. In contrast, our cohort was restricted to primigravid women who conceived spontaneously after successful treatment and therefore provides more treatment-specific evidence. Within this context, our findings suggest that many obstetric and neonatal outcomes may approximate those of controls after successful treatment, while differences may persist in delivery decision pathways, particularly cesarean on maternal request, and in selected perineal outcomes.

OASIS is a key outcome because it is the most severe perineal trauma and may lead to long-term bowel dysfunction, sexual difficulties, and impaired quality of life [14]. In the Swedish registry study by Möller et al., women diagnosed with vaginismus who delivered vaginally had a higher risk of perineal laceration than those without these diagnoses, although detailed OASIS subclassification was not reported [4]. In the only controlled, treatment-focused cohort, perineal outcomes were described as broadly similar between treated women and controls [3]; however, the small sample size and lack of guideline-consistent OASIS subclassification may have limited the ability to detect differences. Supporting a link between vaginismus and perineal morbidity, a recent large retrospective analysis reported higher rates of perineal lacerations among women with vaginismus and applied the Sultan classification, but did not clarify treatment status [15]. In our cohort, minor OASIS was more frequent in treated vaginal deliveries than in controls (9.1% vs. 2.2%), while major OASIS was concentrated in Lamont grade 4 (15.4% vs. 0.0% in controls); these patterns may have several possible explanations. Persistent pelvic floor hypertonicity may limit perineal relaxation at crowning. Even after successful intercourse, some women may still tolerate intrapartum vaginal examination poorly, which can delay assessment and reduce opportunities for perineal support. In addition, pain-related guarding during the second stage may impair effective pushing and increase the risk of perineal trauma. These mechanisms should be regarded as possible hypotheses rather than direct causal explanations and require prospective evaluation.

Antenatal and postpartum psychosocial outcomes after successful vaginismus treatment have not previously been studied. Still, vaginismus has been linked to severe fear of childbirth during pregnancy [16]. PSEQ assesses psychosocial adaptation to pregnancy; higher scores generally indicate poorer adjustment and less readiness for childbirth [8]. In our cohort, both PSEQ total and PSEQ-FHL scores were higher at 30 weeks in the treated group, with the difference largely confined to Lamont grades 3–4. This pattern suggests that, despite restored intercourse, some examination-related fear and childbirth anxiety may persist in women with higher pre-treatment severity. This interpretation is also consistent with the broader literature on tokophobia and anxiety-related obstetric decision-making, in which anticipatory fear of labor, pain, and loss of control may influence pregnancy adaptation and delivery preferences [16]. By contrast, postpartum depressive symptom risk (EPDS ≥ 13 at 6 weeks) was not increased overall, and Lamont-stratified analyses did not show a consistent elevation in depressive symptoms [9, 10]. Because vaginismus is often associated with delayed care-seeking and treatment is frequently motivated by the goal of parenthood, similar postpartum scores to controls may reflect the psychological benefit of achieving a long-desired pregnancy [17].

This study has limitations. The retrospective, single-center design limits causal inference and may allow residual confounding despite matching. Because the study was conducted in a tertiary referral center with a specialized vaginismus clinic, the findings may not be directly generalizable to settings with different patient populations, treatment pathways, or labor-management practices. Treatment success was defined as documented intercourse, but durability of remission, tolerance of intrapartum examinations, and key labor-process details (e.g., provider practice patterns, intervention thresholds, and use of perineal protection maneuvers) could not be assessed reliably. Psychometric data were obtained at prespecified time points and were not available longitudinally across pregnancy and the early postpartum period. Future multicenter prospective studies should include standardized confirmation of treatment response, detailed intrapartum process measures, and repeated psychosocial assessments to clarify mechanisms and identify modifiable targets. Overall, restored intercourse after successful treatment appears to normalize much of the obstetric course; however, differences may persist in a subset of women, particularly those with higher pre-treatment severity (Lamont grades 3–4), affecting childbirth-related fears, delivery decision pathways, and perineal morbidity. These findings support closer antenatal attention in more severe cases, with individualized counseling and, when appropriate, integrated psychological support during pregnancy and labor to help approximate outcomes seen in women without a history of vaginismus.

Conclusions

In primigravid women who conceived spontaneously after successful vaginismus treatment, overall obstetric and neonatal outcomes were largely similar to controls. However, cesarean on maternal request and second-stage cesarean remained more frequent, minor OASIS was higher in the vaginal-delivery subgroup, and major OASIS was concentrated in Lamont grade 4. Higher Lamont grades were also associated with higher PSEQ scores at 30 weeks, suggesting persistent childbirth-related fear and reduced psychosocial adjustment. These findings support individualized antenatal counseling and intrapartum strategies focused on examination tolerance, psychological support, and perineal protection, particularly in women with more severe pre-treatment vaginismus.

Abbreviations

ART

Assisted reproductive technology

BMI

Body mass index

CI

Confidence interval

CRL

Crown-rump length

ΔHb

Change in hemoglobin

DSM-5

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

EPDS

Edinburgh Postnatal Depression Scale

NICU

Neonatal intensive care unit

OASIS

Obstetric anal sphincter injury

OR

Odds ratio

PSEQ

Prenatal Self-Evaluation Questionnaire

PSEQ-FHL

PSEQ fear of pain, helplessness, and loss of control in labor subscale

RR

Risk ratio

Authors’ contributions

CU: Conceptualization, Methodology, Investigation, Data curation, Formal analysis, Visualization, Writing-original draft, Project administration, Supervision. GTE: Conceptualization, Methodology, Investigation, Validation, Writing-review & editing. AKA: Conceptualization, Methodology, Investigation, Validation, Writing-review & editing. All authors read and approved the final manuscript and agree to be accountable for all aspects of the work.

Funding

This study received no external funding.

Data availability

The datasets used and/or analyzed during the current study are not publicly available due to privacy and institutional restrictions, but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This retrospective cohort study was approved by the Ethics Committee of Ankara Bilkent City Hospital, Turkey (decision number TABED 2-25-857, dated 22 January 2025). The study was conducted in accordance with the principles of the Declaration of Helsinki. Owing to the retrospective design and the use of de-identified data extracted from existing medical records, the Ethics Committee of Ankara Bilkent City Hospital waived the requirement for written informed consent from individual participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.