(056) Multidisciplinary Treatment of Severe Vaginismus With Pronox: A Case Report

Abstract Introduction Vaginismus is characterized by involuntary pelvic floor muscle contraction causing pain and penetration difficulty. Lamont stage 5 represents the most severe form, where complete contraction prevents penetration and often resists first-line therapies. Multidisciplinary approaches, including botulinum toxin for refractory cases, are increasingly used, but some patients continue to struggle with dilator progression due to persistent pain, anxiety, and guarding. Objective To present a case of Lamont stage 5 vaginismus, highlighting successful progress with dilator therapy only after the addition of Pronox-assisted pelvic floor physical therapy following botulinum toxin injection, and to discuss the impact of anxiety reduction and breathing control on treatment outcomes. Methods A multidisciplinary protocol was implemented for a Muslim woman of Egyptian background with Lamont stage 5 vaginismus and two years of unconsummated marriage. Initial management included transvaginal botulinum toxin injection into pelvic floor muscles, followed by progressive vaginal dilator therapy and pelvic floor physical therapy. Despite these interventions, dilator advancement was unsuccessful until Pronox (50% nitrous oxide/oxygen) was introduced during physical therapy sessions. Pronox was administered via patient-controlled inhalation to enable real-time anxiety reduction, improved breathing control, and muscle relaxation. This approach leveraged the rapid onset and established safety profile of nitrous oxide for procedural pain and anxiety, as supported by studies in gynecologic and urologic settings. Partner involvement and culturally sensitive psychosexual support were integrated throughout to address relational and cultural factors influencing treatment. Results Initial dilator attempts were unsuccessful due to severe pain, anxiety, and pelvic floor hypertonicity, despite botulinum toxin injection and standard pelvic floor therapy. After introduction of Pronox, the patient experienced immediate reduction in procedural anxiety and muscle spasm, allowing tolerance of progressively larger dilators. The anxiolytic and analgesic effects facilitated deep breathing, reduced guarding, and improved relaxation, which were critical for overcoming involuntary pelvic floor contraction. The patient reported increased sense of control during therapy and progressed rapidly to home use of larger dilators, ultimately approaching phallus size. Partner involvement enhanced adherence and emotional support, consistent with evidence that partner participation improves outcomes in vaginismus and unconsummated marriage. Culturally sensitive psychosexual therapy further improved motivation and sexual confidence, though some anticipatory anxiety persisted. No serious adverse events occurred; transient dizziness or discomfort resolved spontaneously, in line with the established safety profile of nitrous oxide. Regular follow-up supported continued progress, with coordinated communication between patient, partner, and care team helping to overcome psychological barriers. Pronox was pivotal in enabling advancement where previous multimodal interventions had failed, supporting its role as an adjunct in refractory cases. Conclusions Pronox (nitrous oxide/oxygen) enabled successful dilator therapy in severe, refractory vaginismus by providing rapid anxiety reduction and muscle relaxation that allowed procedural advancement and improved sexual confidence. Multimodal therapy-including botulinum toxin injection, pelvic floor physical therapy, and psychosexual support-was optimized by Pronox, with no serious adverse events. Partner engagement and culturally tailored care enhanced adherence and psychological outcomes. These findings support the importance of individualized, integrative protocols and further investigation of Pronox for vaginismus and pelvic floor disorders. Disclosure No.