| Tara Langdale
Vaginal Dilators are Essential, Doc Says.
Written by Dr. Elizabeth Prusak
Dilators are “Essential”
Vaginal dilators are an essential and beneficial medical treatment for patients who experience pelvic pain and anxiety in response to vaginal penetration. Vaginal dilators, also known as vaginal trainers or spacers are designed to gently and gradually restore and expand the tissue and muscles of the vaginal opening. Combined with the use of pelvic floor physical therapy, behavioral health therapy, correction of underlying medical issues, and some dedication and persistence on the patient’s and provider’s part, this simple tool can increase a patient's quality of life in the area of sexual intercourse and during the routine gynecological office speculum exam. Vaginal dilators are also part of the postoperative care of male to female transgender patients after their surgery to maintain a neovagina.
What is a Dilator?
Vaginal dilators are non sterile cylindrical medical devices that sequentially increase in diameter and/or length. They are placed inside the vagina in a gentle manner by a trained medical professional and then, after some training, by the patient to help expand the vaginal tissues that may be contracted and tight. Dilators are prescribed to patients by a wide array of medical professionals including OB/GYN physicians, physical therapists, counselors, and pain specialists. They have been in use for over 75 years in the medical field and have a long track record of success if used properly. Vaginal dilators are very unique in that they have the ability to treat the patient both psychologically and physically.
How Do They Help?
Dedicated usage reconditions and facilitates an adaptive body/brain connection to stop anticipatory anxiety and pelvic discomfort and pain that is often experienced by patients from a psychological standpoint. Dilator introduction and progression also treats the physical vulvar region and retrains pelvic floor muscles. Over time the muscles are stretched gently by the dilators.
What Conditions Can Dilators Treat?
Patients who suffer from several categories of medical conditions greatly benefit from the use of vaginal dilators. Three categories of patients encompass the clinical scenarios where vaginal dilator usage would be valuable. It is important to address underlying medical issues and be sure they are being treated first before attempting vaginal dilator usage.
1. Change in Pelvic Floor Anatomy
The first category encompasses patients with conditions that have created a change in the normal pelvic anatomy. This includes postoperative patients after a hysterectomy, gender reassignment surgery, or a prolapse repair. Another type would be an alteration due to a cancer therapy, such as radiation. Also included in this group are genetic conditions where either no vagina or a rudimentary vagina is present at birth such as Mullerian agenesis or Mayer Rokitansky Kuster Hauser (MRKH) Syndrome. This group is amongst the more straightforward to treat, because the cause of the vaginal penetration is usually a purely anatomical issue, with less of an emphasis on the psychological area.
2. Problems with Penetration
The second category are patients who have never been able to insert anything into the vagina- a tampon, a speculum, nor any sexual activity with penetration. These patients can have the desire to allow penetration, but even after multiple attempts they cannot. These also can include patients with a strong negative psychological history associated with vaginal penetration, such as those who have been raped or abused in the past. This condition is known as vaginismus and is best treated with vaginal dilators combined with regular behavioral health sessions. This group of patients is very difficult to treat and usually requires a longer time period of dilator usage and training before they achieve success. Frequent behavioral therapy sessions are key to treating these patients.
3. Pelvic Pain Conditions
The third category of patients are ones who have a medical condition that causes painful or restricted vaginal penetration. This encompasses vaginal atrophy during menopause, vulvodynia, vulvar vestibulitis, interstitial cystitis, painful bladder syndrome, endometriosis, pelvic pain after childbirth from episiotomy or perineal tears, lichen sclerosus, chronic vaginal infections, and tumors that create a mass effect such as ovarian cysts, colon tumors and bladder cysts. Ensuring that these patient’s medical conditions are optimized and treated is very beneficial in the success for these patients.
How to Talk About Dilator Use
Approaching the topic of starting to use vaginal dilators with a patient is never easy, but it is usually up to the provider to initiate this discussion, because typically a patient's fear or embarrassment about the subject of unsuccessful vaginal penetration or pain is heightened even more during the office visit.
1. Creating a comfortable environment
Reassuring the patient that their problem is very common and trying to put them at ease is the first step. Patients will encounter a wide array of emotions during this visit and it might take a few visits before even attempting to use dilators in the office. Showing patients the dilators and how to use them in the office is a key step, followed by co management with a pelvic floor physical therapist, behavioral health therapy, and treatment of any underlying medical conditions.
2. Longer appointment times and frequency
Ensuring that the visit is allotted proper time for this type of patient is very important, so neither the provider nor the patient feels rushed. Many healthcare providers do not address vaginal dilator use at the office visit and barriers such as lack of knowledge, reimbursement issues, physician and patient embarrassment, poor communication, and lack of time are ranked as the top reasons for such problems going unaddressed. Even with a motivated patient and provider, vaginal dilator compliance remains low, so making subsequent visits at close time intervals is helpful and education is key.
3. Seek out a NAMS certified Physical Therapist
Typically providers receive special training and have a special interest in treating patients with vaginal penetration issues and training with vaginal dilators, and these would be the providers most sought out by and recommended to patients with these issues. The North American Menopause Society (NAMS) offers a certification for providers with this special interest, and their website has a list of certified providers. This is a good starting point for patients to look for a provider, although choosing a provider for this type of treatment is a very personal decision, and many patients have to see multiple providers before committing to one for treatment.
How Do Medical Vaginal Dilator Sessions Work?
A first session with vaginal dilators would entail an education session with the patient: explaining the uses of dilators and how they can help with the patient's medical condition and issues of vaginal penetration. Showing them the various sizes of dilators and explaining with simple easily understood words and language that the patient can understand should be done.
Instructing the patient that they will be in a lying down position and using the dilators with lubricant or lidocaine ointment for any pain relief is the first step. Once the patient feels comfortable and wants to start and is properly positioned, the physician first inserts in the smallest dilator into the vaginal opening and allows the patient to relax around the dilator if possible, and leaves the dilator inside the vagina for 15-30 seconds before repeating and moving onto the next dilator size up. This is done in the office until the patient feels even the smallest discomfort with the largest size of dilator. The patient is instructed that different companies sell dilators and the provider recommends a set for him/her to obtain before leaving the office.
For home use, the recommendation is three times a week for fifteen minutes per day being a typical goal for patients to strive to use their dilators. Then moving up from there. Patients should be instructed to write down their progress and which dilator number they are able to achieve on a weekly basis.
Activities such as deep breathing and relaxation techniques can be used during dilator therapy. Scheduling and attending cognitive behavioral therapy along with this is very helpful. A follow up phone call to the patient within a week giving words of encouragement is beneficial to maintaining continuance of usage.
The next follow up appointment should be within a month’s time. A good “bonus plan” for the patient also can be to recommend dilator usage prior to coitus to help relax the patient after he/she becomes more comfortable with the use of dilators. Patients should be reassured that this is a long term solution to their issue of vaginal penetration and that fast results are not going to happen, and that this is normal to achieve success slowly. It is also important to tell patients that use of vaginal dilators will need to be continued even after the patient achieves initial success, although a more infrequent basis is prudent after this.
Final Word on Dilators
Vaginal dilator therapy is an important part of treatment for sexual pain and vaginal penetration issues. Education and reassurance of both physicians and patients is key to a successful journey to treat this issue. Vaginal dilator therapy requires long term patience and goal setting, but it is a safe and effective therapy and is very much underutilized in the medical community. Seeking out providers who have a special interest and education in treating these issues is key for the patient to have a successful treatment.
Dr. Elizabeth Prusak is a board certified OB/Gyn physician and sexual health specialist, ABOG board instructor, and medical writer who has devoted herself to helping and empowering women and transgender patients. She has spoken at several national conferences, educating other physicians on how to better approach patients with the difficult topics of menopause and sexual health.
She takes a holistic approach to gynecology and emphasizes the value of a total mind and body approach to care. She has over 15 years experience with the use of vaginal dilators and pelvic floor physical therapy helping patients.