Using Vaginal Dilators After Pelvic Radiation

A dilator is a smooth plastic or silicone tube. It is shaped a bit like a tampon. You put it into the vagina to keep the vagina open and stretchy. Many people are handed one with a leaflet and no conversation. This is the conversation.

Radiation to the pelvis changes vaginal tissue. The National Cancer Institute lists "vaginal stenosis," which means narrowing. It also lists "vaginal atrophy," where the muscles weaken and the walls become thin. And it lists "vaginal itching, burning, and inflammation," which "can also cause pain and discomfort during sex." Radiation "can cause low estrogen levels and, therefore, vaginal dryness." Put another way: "the walls of your vagina may become less soft and flexible." Also, "treatment can also shorten or narrow your vagina."

Dilators are used "to help prevent or reverse scarring, if radiation therapy or graft-versus-host disease has affected your vagina." They "help keep your vagina open and more flexible after cancer treatment." Your team may encourage you to use dilators if you have had radiation or surgery to your pelvis. The goal is to prevent problems.

There is a second reason. It applies whether or not sex is on your mind at all. "Even if you aren't interested in being sexually active, keeping your vagina normal in size allows more comfortable gynecologic exams." If the vagina narrows, follow-up exams become painful or impossible. Those exams are part of watching for the cancer coming back.

The specifics vary. Written guidance from cancer organizations says only that a dilator "can be used several times a week to keep your vagina from getting tight from scar tissue that may develop." It adds that "you will also be taught when to start using it, and how and when to use it." Individual cancer centers publish more detailed schedules. Those schedules differ from each other. The evidence base for any one protocol is limited. So follow the instructions your own team gives you, not a number you found online.

One hospital instruction sheet advises using a dilator "3 to 4 times per week, but don't do it 2 or more days in a row." Each session takes "about 10 to 15 minutes." That gives you the scale: short, regular, ongoing.

Here are the practical steps in that guidance. Lie on your back with your feet flat and your knees slightly bent. "Apply a water-based lubricant (such as Astroglide or K-Y) to the dilator and the opening of your vagina." Insert it "straight toward your spine (backbone) or at a slightly downward angle, like you'd insert a tampon." Afterwards, "wash your dilator with hot, soapy water." Then dry it with a clean towel.

Dilators "come in various widths. You can increase the dilator size as your vagina is able to stretch more." Move up a size only when the current one goes in comfortably.

Use a water-based lubricant on the dilator and at the vaginal opening. Avoid petroleum jelly. Avoid oil-based and silicone-based products too. Vaginal lubricants and moisturizers also help with dryness after treatment in general. A lubricant is for the moment. A moisturizer is used regularly.

Here is the useful benchmark. It "should feel snug but not painful." Insert "slowly until you feel slight discomfort or muscle tension, then stop." Slight discomfort and a feeling of stretch are expected. Pain is the signal to stop, not to push harder: "never use force. Stop if you feel pain."

A small amount of bleeding "while using the dilator or after you're finished using it" is described as normal. Light bleeding after sex can also happen "even if you don't have pain." Rarely, vaginal ulcers or open sores develop.

• Call your care team the same day if bleeding "soaks a sanitary napkin (pad), or if the bleeding continues for longer than 1 day." Light spotting during or just after a session is expected; soaking a pad is not.
• Call your care team within a day or two if you find an open sore or ulcer inside the vagina, if there is new discharge with an odour, or if a session leaves you in pain for hours afterwards rather than easing straight away.
• Call your care team within a day or two if insertion hurts every single time, or you cannot get the smallest dilator in at all. That is the point to ask for a pelvic floor therapist, not to push harder or quietly give up.

Maybe it hurts every time. Maybe you cannot get the dilator in at all. Maybe you have quietly stopped using it. That is a clinical problem with clinical answers.

Ask your oncology team or nurse. Ask in particular about a pelvic floor therapist. The American Cancer Society says to "ask your doctor for a referral to a pelvic floor therapist," and notes that "cancer treatment centers often have pelvic floor therapists who specialize in helping patients." They can stretch tight pelvic floor muscles. They use biofeedback. They also use "vaginal dilators, which stretch the vaginal tissue to help relieve pain." Dilators work better when you learn to relax those muscles with Kegel exercises.

Tell your team about any changes in your sexual life or any new problems that come up. See also sexual health for women with cancer and pelvic floor rehabilitation after cancer treatment.

• National Cancer Institute (NCI): Sexual Health Issues in Women and Cancer Treatment
• American Cancer Society: Managing Sexual Side Effects as a Woman with Cancer
• American Cancer Society: How Radiation Therapy Can Affect Sex for Women
• American Cancer Society: How Pelvic Floor Therapy Can Help During Cancer
• Memorial Sloan Kettering Cancer Center: How To Use a Vaginal Dilator