A multidisciplinary approach combining cognitive-behavioral therapy (CBT), systemic pharmacotherapy (amitriptyline), and gradual pelvic floor desensitization leads to significant improvement or complete resolution of sexual dysfunction in patients with severe trauma-associated vaginismus, even in cases of long-standing symptoms and prior treatment failures.

A 30-year-old woman presented on August 24, 2024, with a 9-year history of unconsummated marriage due to severe pain (VAS 10/10) and fear upon attempted penetration. Key features:  
- Trauma history: Associated symptoms with childhood sexual assault.  (rape)
- Prior interventions: Multiple consultations with no relief; attempted local anesthetics (unsuccessful due to inability to insert suppositories).  
- Psychosocial impact:Marital strain, despair, and fear of divorce.  
Clinical Findings (Initial Assessment):  
- Examination limitations:Vaginal exam impossible due to extreme pain (VAS 10/10).  
- External palpation: Hypertonic and tender pelvic floor muscles (bulbospongiosus, ischiocavernosus, superficial transverse muscles—right: 10/10, left: 9/10).  
- Exclusion of other pathologies:
  - Negative Carnett test (ruling out abdominal wall pain).  
  - Negative piriformis tenderness, sacrospinous/sacrotuberous ligament tests (no referred musculoskeletal pain).  
  - Negative cotton swab test(no localized vulvodynia).  
Multidisciplinary Treatment Approach: 
1. Pharmacotherapy: 
   - Amitriptyline (2nd-line systemic therapy) for neuropathic pain modulation.  
2. Psychotherapy:  
   - Cognitive Behavioral Therapy (CBT) to address trauma-related fear and anxiety.  
3. Pelvic Floor Rehabilitation: 
   - Breathing techniques + gentle perineal self-massage.  
   - Gradual desensitization using vaginal dilators (after initial improvement).  
Outcome:
- one-week follow-up:Significant improvement—vaginal exam possible (speculum insertion tolerated).  
- Long-term results: Complete resolution of pain (VAS 2/10), successful intercourse after 9 years, and restored marital relationship.

7 days later, the patient noted positive effect, and we had a chance to examine her vaginally, using gynaecological speculums. In order to alleviate the remaining symptoms (muscle tension and soreness) and prevent relapse in the future, she was advised to continue 2nd line therapy for a long time.
1. Pain Reduction:
   - Baseline VAS during attempted penetration: 10/10 → Post-treatment VAS: 2/10 (after one week).  
   - Pelvic floor muscle tenderness (bulbospongiosus/ischiocavernosus): 9–10/10 → 3/10 (palpation).  
2. Functional Improvement: 
   - First successful vaginal speculum exam achieved at one week (previously impossible due to pain/fear).  
   - Pain-free intercourse reported at one-week follow-up (after 9 years of non-consummated marriage).  
3. Psychological & Quality-of-Life Measures:  
   - Patient-reported reduced anxiety (Huds scale 2/2).  
   - Marital reconciliation – divorce avoided per patient statement.  
4. Treatment Adherence & Tolerability:  
   - Amitriptyline: Well-tolerated (no side effects reported at low dose).  
   - CBT Completed 5 sessions; patient engaged actively in exposure exercises.  
   - Dilators: Progressed from smallest to medium size (4/6 sizes) within one weeks.

1. Effectiveness of Multimodal Therapy  
2. Importance of Trauma-Informed Care  
- The patient’s history of sexual assault necessitated a gradual, non-invasive approach (delaying vaginal exams until after initial improvement).  
- CBT likely helped break the fear-avoidance cycle, enabling her to engage in pelvic floor therapy.  
3. Pelvic Floor Muscle Retraining  
4. Rapid Response Despite Chronicity  
5. Implications for Clinical Practice
- Rule out comorbid conditions (e.g., vulvodynia, musculoskeletal dysfunction) before labeling as "pure" vaginismus.  
- Avoid rushed examinations—external assessment first builds trust and guides therapy.  
- Early integration of mental health support may prevent years of distress.

Conclusion: One of the main components in the approach and treatment of patients with vaginismus is a multidisciplinary personalizes approach. Currently, this approach is very broad, including local and systemic therapy, but most importantly, its main focus is on cognitive behavioral therapy combined with pelvic floor rehabilitation. This will reduce the patient's existing pain, improve long-term results and prevent recurrence of previously diagnosed conditions.