Clinical Review

Vaginal dilation: When it’s indicated and tips on teaching it

Author and Disclosure Information

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.


 

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.

Next Article: