Whether intercourse is painful or impossible, proper use of dilators is essential for a successful outcome. There are a number of stages a patient needs to pass through, and these are much easier than imagined.
For women who have a mild condition of vaginismus where some penetration is possible, but intercourse is painful, progressive dilation from smaller to larger dilators is recommended.
For the more severe vaginismus patients (Lamont/Pacik level 3-5) dilation often begins in the operating room under anesthesia at the time Botox is injected. The Botox helps relax the spastic muscles which are commonly present in these more severe cases.
Though patients routinely wake up with the largest dilator, and are able to dilate back up to the largest dilator during the first and second days, commonly patients will regress somewhat to smaller dilators when returning home. This is not a problem. By progressively dilating to the next larger size that is comfortable, the vaginal muscles will be sufficiently stretched over a period of time that intercourse becomes possible.
Dilation schedule
Sleep
Patients are asked to sleep with the medium sized dilator (#4 Purple in the Pure Romance line of dilators) every second night. The larger dilators are not needed during sleep.
AM Dilation
Upon awakening, remove this dilator and immediately advance to the pink #5 for one hour. (For those who do not have the time in the morning, even 5 minutes is of value, or simply add the missed hour to the evening schedule.)
PM Dilation
One hour. Start with the medium #4 of 6 dilator and advance to the next sizes. Early on the medium dilator is used for a longer period of time and the larger dilators are tolerated for a shorter period of time. As the vaginal muscles get stretched, patients become more comfortable so that often the medium #4 dilator is used for the first 10 minutes, then the pink #5 of 6 for 20-30 minutes and the large blue #6 of 6 for the remainder of time. One hour is usually sufficient.
Aids to Dilation
- Kegel exercises. Squeeze down as though you are holding back the need to urinate. Squeeze hard for 5-10 seconds and completely release. Repeat 5 times. On the last squeeze, release completely and push the dilator in. If it does not go in all the way, even a short distance is helpful. Once past the spastic entry muscle, the dilator tends to slide in easily the rest of the way.
- Use a vibrator to help relax.
- Enjoy a warm bath and dilate in the bathtub or shower.
- Find a position of comfort. It can be standing, lying down or sitting in a recliner.
Transition to Intercourse
Use the pink #5 or large blue #6 for about 30-60 minutes prior to intercourse. Remove the dilator and quickly insert the erect penis as though it were a dilator. For the first few times I recommend tip only minimal penetration, no thrusting, until the patient becomes comfortable with this. Later full penetration is possible. The patient has to communicate when light thrusting can begin.
Aids to Achieving Intercourse
- Set the stage. Music, wine, candles . . . Start with love, explore sensate focus exercises (www.sexsmartfilms.com). Early on, intercourse tends to be more mechanical and most patients do not orgasm. With time intercourse becomes more enjoyable for both partners.
- Use the dilators as toys for erotic stimulation
- Use a vibrator to help relax
- Take a warm bath or begin the loving in a warm shower or hot tub
- Find a comfortable position
- Missionary position used by most.
- Woman on top to maintain control over the amount of penetration. This position may result in penetration that is too deep but is under the control of the woman.
- Woman bent over two pillows, entry from behind. This gives maximum relaxation to the pelvic muscles.
- Side by side “spooning” also a position of relaxation.
- “Doggie” style, another position of relaxation.
- Sometimes men experience erectile dysfunction during these early stages often due to residual fear of inflicting pain. Cialis or Viagra may be needed.
Intercourse is Not a Substitute for Dilation
It doesn’t last long enough. Continue your dilation program.
Risks and Complications
Dilating is very safe. Toxic shock syndrome (bacterial infection from a saturated tampon in place for a long period of time) is not a problem because the dilators are made of silicone and do not absorb fluids. Simple hygiene with soap and water is sufficient to keep the dilators clean.
Try to avoid hitting a tender spot repeatedly. This can be done by being careful with the insertion of the dilator and using lots of lube. If an area becomes sore, discontinue the dilators for a day or two and use ibuprofen or Tylenol as needed.
Menses
Even 5-10 minutes of dilation during the menstrual cycle is valuable. If the flow is too heavy women do just fine eliminating dilation for the necessary time and then starting with the smaller dilators and working back up to the larger ones.
Dilate for a Year
The two hour a day schedule is usually only necessary for the first month or two. After this the amount of dilation time can be reduced to as little as 30-60 minutes a day. I do recommend that patients sleep with the medium purple #4 dilator every second night for the first year. Some of my patients sleep with the dilator nightly. If discomfort from intercourse resumes, it is simply an indication to increase the amount of time dilating.
Pregnancy
A number of my patients have gotten pregnant during the first year after treatment. It is advised to continue with the dilation program until the later months of pregnancy and then resume dilation after the baby is born. Vaginal delivery is achievable in most. Please check with your doctor for his/her recommendations.
Summary
Dilation is an integral part of the Botox program to treat vaginismus and to achieve intercourse. Though most patients are scared of this, when combined with Botox injections, it is actually fairly easy to accomplish.