Pelvic Physical Therapy and Vaginal Dilators

Most people think of physical therapy in terms of therapeutic treatment for orthopedic or neurological conditions – things such as back pain, knee pain, and strokes. Did you know, though, that there are pelvic health specialty-trained physical therapists who help women and men with very private conditions? The terms often used are: pelvic health physical therapists, women’s health physical therapists, or pelvic PTs.
 
So, how are vaginal dilators utilized for pelvic physical therapy?
 
Vaginal dilators are most effective when used for conditions that prevent the patient from having a desired body part (finger or penis) or object (tampon, speculum for GYN exam, vibrator, etc.) pass the vaginal opening and into the vaginal canal. Some examples of these types of conditions are:

1. Vaginismus
2. Dysparuenia (painful sex)
3. Vulvodynia, Vestibulodynia
4. Dermatological conditions such as: Lichens Sclerosis, Lichens Planus, Dermatitis
5. Hormonal changes at the vulva
6. Vulvar cancer
7. Post Radiation treatments for gynecologic cancers – particularly in the vaginal canal.
8. Vulvar or vaginal traumas/injuries

 
It is important to note that most of the conditions listed need a team approach to treatment, including the medical management component first. For example, if someone has a dermatologic condition, prior to or during the pelvic PT treatment timeframe and use of dilators, they may need a topical ointment applied to the vulvar tissue. Essentially, the use of dilators does not replace optimal medical and physical therapy management. Rather, it is an excellent adjunct to the appropriate treatment plan.
 
As a pelvic PT since 2000, I can attest that many patients over the years arrived for their evaluations with bags of various dilators and frustrated looks. A typical comment is “My doctor told me to get these, but didn’t provide any additional instruction” or “I ordered these online” followed by “but, I have no clue if I am using them the right way and I’m not even sure they are right for me.” Most of the time, the patients have the wrong sizes and/or the wrong product for their condition all-together. I’ve even heard physicians and pelvic PTs say, “I just don’t use them with patients because they aren’t really that effective.” I wholeheartedly disagree and have been on a mission to show the wonders of the dilator! When the appropriate dilators are selected and the patient is instructed properly on how to use them, there’s excellent potential for a successful outcome.  It can make a significant  difference to have a skilled pelvic physical therapy help guide you with dilators! 
 
When selecting dilators:

1. I make sure that the sizes are appropriate for the patient. For a patient who’s never been able to have a GYN exam or use a tampon their starting size may be different than a woman who’s having intercourse regularly and can use tampons, but she has some increased pain initially. Some dilator sets start out at a size that is already too big for the patients to comfortably handle. Soul source has one of the smallest starting sizes.
2. Another consideration is the type of material used. There are numerous sets out there that are made of plastic or other harder synthetic materials. This can be very painful for patients. The silicone material of the Soul Source dilators is softer and has more movement. Hands-down, most patients find this most comfortable.

 
In an ideal world, pelvic PTs should help the patient initially with a demo on how to properly use the dilators. This includes the best way to insert the dilators (many people are unaware of this aspect), lubricants to use, how to properly progress the dilators, and tips on how to facilitate the desired outcome and transition to the ultimate goal.
 
This is where pelvic PT has a large role in a successful outcome for a patient. In most educational manuals I’ve seen, the primary focus of dilators is just to stretch the vaginal canal and muscles enough over time to get a desired outcome. That’s just a part of what is happening and if only that aspect is addressed, it may be why some patients do not progress well.  The way I instruct dilators has to do with 3 primary factors.

1. Desensitization/Neural System Effect: The primary way I believe dilators are helpful is the most neglected part of how they are explained to patients typically. We can use our professional education here in a way that can make a large impact. When someone has pain with attempts at inserting a finger, penis or object into the vagina, there’s more going on than the patient’s end result of the pain experience. Pain is an output of the brain. There can be an increase in someone’s perception of pain when the nervous system is in “alert” mode. So, if someone is already anxious or fearful of using dilators or being touched in this area, their nervous system is essentially “ramped up.” I teach extensively on how to do the exact opposite – how to utilize what we know about the brain/nervous system and anxious responses as a way to set up the potential for a decreased pain experience. Here’s an extensive guide to this approach
2. “Stretch” Effect: This is the usually the most discussed method to use with dilators. We can utilize dilators as a tool to gently and slowly allow the vaginal canal and pelvic floor muscles to stretch or relax. This can be done just via insertion or there are ways to educate patients on how to provide more pressure and a static stretch to the muscles.
3. “Functional” Effect: We often hear patients ask, “how will I know when I’m ready to try intercourse again?” When I explain that dilators are, in essence, a way to gauge that readiness. I explain often that “dilators are the bridge between not tolerating any touch or insertion in that area to tolerating full penetration.” We teach strategies on how to slowly transition from smaller sizes to larger sizes; from no movement to simulating insertion and in/out movements; and from staying in one position to simulating a variety of positions (this can apply to how one puts in a tampon, varying sexual positions, etc).

 
Once the patient feels comfortable with the education and demonstrations, I often recommend dilators as part of a home program. It is a highly effective way for patients to feel proactive in their medical care versus waiting for a medical practitioner to do something to or for them. Moreover, it is a way to facilitate improvements consistently because patients can use them regularly and at times that work for their schedules.
 
* This post was initially  written for  the Soul Source dilator company. 

---

Tracy Sher, MPT, CSCS is a pelvic health and manual orthopedic physical therapist, consultant, international speaker and educator, and founder of the social media brand and blog, Pelvic Guru.  She is the owner and director of small, boutique private practice in Orlando, Sher Pelvic Health and Healing, LLC.  She treats men and women with pelvic health issues, with a focus on persistent pelvic pain, pregnancy/postpartum conditions, pelvic-abdominal conditions, orthopedic hip and pelvis pain, and genital cancers using an integrated care model.  Tracy is co-creator of a Pudendal Neuralgia and Pelvic Pain Differential CEU course (with a focus on the brain and pain) and teaches this internationally.  She developed a new Pelvic PT Boot Camp clinical skills course as well. Previously, she taught pelvic floor CEU courses for Herman and Wallace Pelvic Rehab Institute and assisted for Section on Women's Health courses.

​She is a certified pelvic physical therapist, strength and conditioning specialist and currently completing a sexual counseling certification. Prior to owning her own outpatient practice in 2013, since 2000, Tracy has successfully started or helped expand 3 large hospital-based women's health/pelvic physical therapy programs that are still flourishing today. She is an Emory University graduate and completed her graduate PT studies at Northwestern University

---