Dilators are the mainstay of most vaginismus treatment programs yet little is available for women to understand the effective use of dilators.
Dilators have been used for the treatment of vaginismus dating back to at least 1861 when Dr. Sims used glass dilators [Ref 1]. He is credited with first using the term vaginismus. In 2010 Dr. Pacik received FDA approval for continued research using a multimodal program for the treatment of vaginismus which included the use of Botox, bupivacaine (a long acting local anesthetic), dilators, post procedure counseling, support and follow up.
New to dilation
Perhaps the biggest stumbling block to using dilators is the fear and anxiety related to their use. Vaginismus is more than having severe pain with attempted intercourse. Women struggling with vaginismus have pain with most aspects of penetration including tampons, cotton tipped applicators, fingers, GYN exams, dilators and intercourse despite a desire to do so. As a result of severe pain with attempted penetration it is normal to have considerable fear and anxiety related to penetration. More severe vaginismus patients order the dilators but are unable to open the package. Male partners have little patience for this and typically accuse these women of not trying hard enough, yet for these women it would be similar to ask them to jump off a high bridge. It is simply impossible.
Getting started, overcoming fear and anxiety
It is important to assess the severity of vaginismus which can be done by viewing a one hour film created by Dr. Pacik. In this film, one is given the tools to self-assess the severity of their vaginismus and how to incorporate dilation as therapy to overcome vaginismus.
Styles and materials of vaginal dilators
Dilators are made of plastic, silicone or borosilicate glass and come in a variety of sizes. Pacik borosilicate dilators are available in sizes 3-8. In contrast to other dilators (which are too long in the larger sizes) the Pacik vaginal dilators are all 3 ½ inches long and were designed to help women dilate for longer periods of time during which time they can be mobile. Dilators longer than 3.5 inches interfere with mobility. Candles are not recommended.
Less severe vaginismus patients are often able to progress on their own by following the recommended dilation schedule noted in the one hour film and the Table below. More severe vaginismus patients progress more slowly or not at all without some outside help such as physical therapy by a pelvic floor specialist, psychotherapy and sex counseling. Severe vaginismus may need to be treated using the Pacik Botox multimodal program. Centers using this technique can be found by linking to resources.
For those who wish to dilate on their own, patience is key. As with physical therapy (PT) for tight muscles it takes time to stretch muscles that are either tight or in spasm. A minimum of 6-8 weeks will be needed and for some at least 2-3 months. This is no different than the length of time needed for PT for other musculo-skeletal conditions.
Start by using your own finger or your partner’s finger. Start with the smallest dilator in the set to determine if this can be introduced without pain. The size that is not painful is your starting point. In the beginning use this dilator for at least thirty minutes before advancing to the next size. Sometimes the next size can be tolerated for only 5-10 minutes. If this is so, remove the larger dilator and finish the amount of time with a comfortable dilator for a total of about two hours: one hour in the morning and one hour in the evening or two hours during the day. On the next day always start with a small dilator before advancing. It is a mistake to try to insert a large dilator before using a small one. Then every few days see if you can advance to the next larger dilator for a longer period of time, understanding that this process may take several months. Dilation for two hours a day and sleeping with a comfortable sized dilator every second night seems to be of great benefit for women struggling with vaginismus. Keeping a daily log of your dilation allows you to see the progress you are making and holds you accountable to yourself. The log is of value when there is a regression. An example of this is the woman who does not dilate during menses and then further misses another few days. In this situation, it is important to return to the smaller dilators and dilate back up as possible. Never force a larger dilator, it does not work, causes pain and results in a setback. Always use plenty of lube.
It is expected that women will struggle with fear and anxiety as well as performance pressure to please a loved one. There are a number of tricks that women have used including soft music, lighting candles, having unrushed time, dilating in a warm bathtub, drinking a glass of wine, turning off the cell phone and the use of vibrators to help relax the pelvic floor. Any device or thought that is joyful or relaxing is of help while dilating. Mindfulness and yoga can be helpful. One woman thought of the smell of freshly baked chocolate chip cookies as part of her dilation process. Any form of relaxation is of great value while dilating.
Fingers and a mirror as a start
The normal vagina dilates in response to finger penetration. This is part of the natural process of the vagina preparing for intercourse. Use the different sized fingers using lots of lube to progressively dilate to a larger size finger. For those who are able, use two fingers for penetration. As you progress consider inserting a finger from each hand stretching the vaginal opening apart. Patients often do not understand their own anatomy making the use of a mirror worthwhile. Having your partner assist you allows the woman to give up control and begin the process of trust.
Mixing it up: Different positions
Try a number of different positions for dilating. This can include the "missionary" position, placing a foot on a chair and dilating while standing and using a squat position. As you become more comfortable having your partner assist, you can try "doggy style" or the "spooning" position which can be an excellent segway to intercourse. Gentle thrusting can be done with the dilators as comfort with dilation increases.
How much, how long?
This depends on whether the vaginismus is primary or secondary (such as menopausal painful sex or menopausal secondary vaginismus) and the severity of vaginismus. This is outlined in the film noted above as well as my book: PT Pacik: When Sex Seems Impossible. Stories of Vaginismus & How You Can Achieve Intimacy available as soft cover or Kindle.
For primary vaginismus, especially the more severe forms, two hours a day is recommended for the first month. As progress becomes more comfortable one can reduce this to about an hour and a half and then one hour. Sleeping with a medium #4 dilator every second or third night allows for passive night time stretch and easier progression to the next size dilator in the morning. Menopausal women struggling with painful sex (dyspareunia) or complete inability to tolerate penetration (secondary vaginismus) do well with about 30-60 minutes of dilation, especially before intercourse. Once a woman starts dilating it becomes obvious how much dilation time is needed. Primary vaginismus women should dilate for about a year because it has been observed that women can still regress after six months. Women with menopause should dilate on a regular basis and before intercourse. Your doctor can recommend creams such as Estrace or capsules such as Vagifem to help with menopausal vulvovaginal atrophy. See Table 1 for summary.
Menses and dilation
You can discontinue dilation during the menstrual cycle. During reduced flow, even five to ten minutes of dilation is of value for those who are able to do this. Start with the smaller dilators when resuming dilation after menses. For those who have advanced to the medium dilators this can be an excellent time to introduce slim tampons.
Advanced dilation techniques
Women have noted that combining vibration with dilation relaxes the pelvic floor and makes dilation easier. One such device is the Lelo Liv which is sized between the #4 and #5 dilator and helps remove the clinical aspects of dilation noted to be especially helpful when transitioning to intercourse.
Pacik borosilicate glass dilators come in larger sizes (#7, 8) to help women achieve the necessary stretch when attempting intercourse with partners who are larger than the #6 dilator.
Transition to tampons, intercourse & GYN exams
The goal of dilation is to be able to progress to comfortable penetration such as being able to use tampons, to be able to progress to intercourse, to undergo a GYN exam and for menopausal women to engage in comfortable sex. It is common for fear and anxiety to once again dominate during this transition. Generally, thirty minutes to one hour of dilation with a large dilator will set the stage for comfortable intercourse. Most women are able to achieve intercourse after dilating to the # 5 or 6 dilators. An erect penis is more comfortable than a large dilator. Dilation with a large dilator is of benefit in making a GYN exam more comfortable. Women can arrive with a large dilator in place which is removed by the doctor prior to insertion of a speculum. For those with discomfort during a GYN exam ask the doctor to use a pediatric speculum.
Reasons for saving your dilators
There are a number of reasons to save your dilators including regression, following childbirth and use during menopause.
Mild soap and water for cleaning the dilators. A towel or wash cloth should be placed in the sink when washing glass dilators to avoid breakage if the dilator slips out of your hand. Pacik borosilicate dilators are dishwasher safe. Clouding from dishwashers does not affect the strength of the dilator.
The correct techniques of using dilators to overcome vaginismus is of considerable benefit to women who struggle with vaginismus. Little is taught by the medical community in this regard. It is hoped that these recommendations will be of value for the woman who is able to do this on her own.
More severe vaginismus women, including severe secondary menopausal vaginismus, benefit from treatment under anesthesia using the Pacik Botox multimodal program allowing them to wake up with a large dilator and shortening the process for achieving comfortable intercourse. Providers for this treatment modality can be found under our Resource Page.
1 Sims, JS. On Vaginismus. Transactions Obstetrical Society of London 1861;3:356-367
Table: Recommendations for effective dilation
- 2 hours a day divided if possible one hour AM, one hour PM.
- Always start with a small dilator or finger and advance as possible.
- Sleep with a small to medium dilator every 2-3 nights.
- Use of lubricants.
- Use of aids such as vibrators and small vibrating dildoes to overcome the clinical aspect of dilating and to help relax the pelvic floor. Orgasm helps relax the pelvic floor.
- Use different positions such as squat, one leg on a chair etc.
- Importance of keeping a dilation diary. This will keep you accountable for dilation as well as keeping the clinician informed.
- No need to dilate during menses. Resume dilation as able.
- Dilate to #5 or #6 if possible for 30 to 60 minutes prior to intercourse. Dilation to #7 and rarely #8 for partners that are large. Use the dilator as a “toy” or a similar size vibrating dildo.
Second month and third months
- Reduce dilation to one hour a day, then 15-30 minutes daily.
- Advance to larger sizes as able.
- Continue some dilation during the day or 2-3 times a week for about one year. Setbacks were noted when dilation was discontinued after six months. Menopausal women do well with periodic dilation.