|December 2012 · Vol. 24, No. 12
When it’s indicated
and tips on teaching it
Dilator therapy can offer a nonsurgical approach to restoring vaginal capacity and elasticity and alleviating sexual discomfort. Here’s how to instruct your patients on its use.
Dr. Kellogg Spadt is Director of Sexual Medicine.
Ms. Iorio is a Nurse Practitioner, Female Sexual Medicine.
Ms. Fariello is a Nurse Practitioner, Male and Female Sexual Medicine.
Kristene E. Whitmore, MD
Dr. Whitmore is Medical Director and Chief of Surgery.
All are colleagues at the Pelvic & Sexual Health Institute, Philadelphia, Pennsylvania.
The authors report no financial relationships relevant to this article.
Vaginal dilators are used to restore vaginal capacity, to expand the vagina in width and depth, to provide elasticity to the tissues, and to allow for comfortable sexual activity. Vaginal dilators are smooth plastic, rubber, or glass cylinder-shaped objects that come in a variety of graduated sizes and weights.
Several medical conditions may warrant the use of vaginal dilation, including superficial dyspareunia, high-tone pelvic floor dysfunction, vaginismus, provoked vestibulodynia, vaginal atrophy, vulvar dermatoses, vaginal agenesis, and postradiation adhesions. Dilation also can be used as deconditioning therapy for psychogenic dyspareunia.1-4 In addition, Masters and Johnson advocated the use of dilators for patients with female sexual dysfunction in order to interrupt the cycle of pain–fear–muscle spasm–more pain, and to build confidence “in the privacy of the marital bedroom.”5
Vaginal dilators often are sufficient to restore function, with dilator therapy considered successful if a woman is able to resume comfortable sexual intercourse or self-stimulation, as desired.1,6 Vaginal dilation also can be used as an adjunct to pelvic floor muscle physical therapy, psychotherapy, sex therapy, minimally absorbed local vaginal estrogen therapy, intravaginal muscle relaxants, lubricants, moisturizers, and vibrators.
Clinical indications for vaginal dilator use: Cases from practice
Each patient in these case studies achieved success resuming sexual activity after several months of dilator therapy used in combination with other medical interventions.
CASE 1: Chronic vulvovaginal infection and pain
A 26-year-old G0P0 woman presented with a 2-year history of prohibitive penetrative dyspareunia. She had a history of chronic vulvovaginal candidiasis, treated by another clinician with multiple courses of intravaginal antifungal cream.
After extensive evaluation for sexual pain, a diagnosis of pelvic floor muscle spasm, sexual aversion, fear secondary to pain, and contact irritant dermatitis was reached. After vaginal fungal cultures indicated negative results, a size small dilator was introduced in the office using a hypoallergenic intravaginal moisturizer. After daily use of the vaginal dilator for 4 months, with progressed introduction of graduated sizes (small, medium, medium+, large), she was able to accommodate intravaginal intercourse with her partner.
CASE 2: Interstitial cystitis and fear of pain
A 58-year-old G3P3 postmenopausal woman presented with interstitial cystitis (IC), pelvic floor muscle hypertonus, vulvovaginal atrophy, and provoked vestibulodynia. Although her IC symptoms were well-controlled, she was fearful about reestablishing physical intimacy with her partner after 7 years of abstinence.
A program of intravaginal estrogen (Vagifem) 2 to 3 times per week, introital cutaneous lysate (Neogyn) vulvar soothing cream twice per day, and compounded muscle-relaxing intravaginal diazepam suppositories 2 to 3 times per week was initiated. After 2 months of treatment, she was taught in the office to use a size extra small vaginal dilator. She was delighted that use did not result in pain. Two months later, she was able to use a size small dilator, and 4 months later, a size medium dilator. At this point, the patient is confident that she can have sexual intercourse.
CASE 3: Lichen sclerosus
A 50-year-old G0P0 premenopausal woman had a history of IC and biopsy-proven lichen sclerosus. The white plaques surrounding her introitus had become so severe in the past year that she was no longer able to tolerate penile penetration without tearing. Nightly use of topical clobetasol cream and introital estrogen cream (Estrace) was recommended. After 30 days, the patient began twice-a-week maintenance with the creams and also began to use vaginal dilators. After success inserting a size extra large dilator following 5 months of dilator use, she was able to resume intercourse without tearing.
CASE 4: Vestibulodynia and vaginismus
A 25-year-old G0P0 woman underwent vestibulectomy for primary provoked vestibulodynia followed by pelvic floor muscle physical therapy for primary vaginismus. Her marriage of 6 years was unconsummated. Two weeks postoperatively, she began using a size small dilator daily and progressed to a size medium plus dilator after 6 weeks. She managed her chronic constipation and pelvic floor muscle hypertonus with daily fiber supplements, stool softeners, and self-transvaginal massage of the pelvic floor muscles. Seven weeks after surgery, she accomplished intercourse with her husband for the first time.
How to teach your patient to use vaginal dilation successfully
Before ordering vaginal dilation for your patient, 1) assess the levator ani muscle group for hypertonus or spasm and 2) choose the size dilator to start therapy that does not cause pain with insertion but enters with some resistance.
When beginning to teach your patient to use a vaginal dilator in the office, a mirror demonstration may be helpful. Be sure to instruct your patient regarding the following elements to help her achieve success with dilation therapy.
Relax and allow for privacy. About 10 to 15 minutes of privacy before vaginal dilation can help with the success of each individual therapy session. Relaxation can be facilitated with activities such as deep breathing, soaking in a warm bath, or using prescribed muscle relaxants 30 to 60 minutes prior to dilation.
Use proper positioning. Instruct the patient to lie on the bed with her knees bent and placed apart. Advise her to place the lubricated dilator in the vagina as far as it can go without causing any pain (FIGURE 1). It may be helpful for her to bear down when first inserting the dilator. An in-and-out motion is not necessary.
Be sure to inform her to use a water-based lubricant—not lotion, petroleum jelly, or any non-water-based lubricant.
Dilate daily. The dilator should be used daily and left in place for 5 to 15 minutes. She may experience a small amount of spotting initially, but spotting should abate within 2 weeks of initiating dilator use. Each dilator size should be used for 3 to 4 weeks. When your patient is changing sizes, she should transition to the larger size over several days by dilating for the first few minutes with the smaller dilator, then changing to the larger dilator for the remainder of the time. If she experiences pain or heavy bleeding, she should cease dilation and follow-up with you.
Proper cleaning. Instruct her to wash the dilator with antibacterial soap and water and to dry it thoroughly between uses.
Follow-up. When undergoing vaginal dilation therapy, your patient should be following up with you at regular intervals, usually once a month, to facilitate compliance with the program.
Where to obtain dilators
You can purchase dilators for your medical practice and resell them in your office. Patients also can be directed to purchase dilators directly from a manufacturer (such as Syracuse Medical Devices or AmeriMed Direct) or through a number of Internet sites, including Middlesexmd.com6 or Vaginismus.com.7 Both of these Web sites also offer educational materials, including videos and books and a private support forum or blog.
Most dilators used in the United States are 6 in (15 cm) long and are made from sterilizable, medical-grade, latex-free, rigid plastic with a smooth surface. Some dilators are made of softer material such as silicone, and others have a vibrating inner wand.6 They are available to purchase as single dilators or in sets of 5 to 8 graduated sizes (FIGURE 2). Some sets come with a storage bag and universal handles that lock-on for insertion. Graduated circumference sizes are fairly universal in the United States (TABLE).
Average dilator sizes and circumferences*
||1/2 in; 13 mm
|Extra small plus
||11/16 in; 18 mm
||7/8 in; 22 mm
||1 in; 25 mm
||1 1/8 in; 29 mm
||1 1/4 in; 32 mm
||1 3/8 in; 35 mm
||1 5/8 in; 38 mm
Restoring her sexual health: Our goal
Sexual health is a vitally important quality-of-life issue; restoring that health should be our priority. We need to educate our patients on nonprescription methods to promote their vaginal and sexual health, as vaginal dilation therapy can result in the reduction or elimination of dyspareunia.
We want to hear from you! Tell us what you think.
1. Idama TO, Pring DW. Vaginal dilator therapy—an outpatient gynaecologic option in the management of dyspareunia. J Obstet Gynaecol. 2000;20(3):303–306.
2. Gentilcore-Saulnier E, McLean L, Goldfinger C, Pukall CF, Chamberlain S. Pelvic floor muscle assessment outcomes in women with and without provoked vestibulodynia and the impact of a physical therapy program. J Sex Med. 2010;7(2 Pt 2):1003–1022.
3. Carter J, Goldfrank D, Schover LR. Simple strategies for vaginal health promotion in cancer survivors. J Sex Med. 2011;8(2):549–559.
4. Miles T, Johnson N. Vaginal dilator therapy for women receiving pelvic radiotherapy. Cochrane Database Syst Rev. 2010;(9):CD007291.
5. Masters WH, Johnson VE. Vaginismus. In: Human Sexual Inadequacy. Boston Massachusetts: Little Brown, Co; 1970:250–265.
6. Vaginal dilators. MiddlesexMD: Sexuality for life. http://middlesexmd.com/product-category/vaginal-dilators. Accessed November 13 2012.
7. Vaginal dilator set. Vaginismus Web site. http://www.vaginismus.com/products/dilator_set. Accessed November 13 2012.
OBG Management ©2012 Frontline Medical Communications Inc.