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Vaginismus: 3 ways to dilate without dilators

Here we are: the next stop on your search engine tour in the hope of finding out why you or someone you know is having pain when intimate. Likely, somewhere along your journey the words vaginismus and dilation therapy popped up before you stumbled upon my blog. Let’s look further into what vaginismus and dilation therapy are.

The accepted classifications and definitions of vaginismus change from time to time as research and trials generate new findings. But generally, vaginismus is known as a penetration disorder in which any form of vaginal penetration is often painful, difficult, or impossible despite the desire to do so.[1] As the definition of vaginismus is ever-evolving, so is the accepted treatment. This is where dilation therapy comes in … figuratively speaking of course.

Dilation therapy is a treatment typically used for penetrative pain disorders such as vaginismus. Much of what is described to me when I speak with practitioners and recipients of dilation therapy is something that resembles gauging an infected ear piercing (ouch). Rest assured, dilation therapy is not intended to be painful and should not cause a great deal of discomfort when conducted by an experienced healthcare professional.

Let’s take a look at how the experienced pelvic health practitioner deals with vaginismus pragmatically when increased pelvic floor muscle tension and sympathetic (“fight or flight”) nervous system activity are present upon examination.

A dilator (similar in composition and structure to the sex toy commonly referred to as a “dildo”) is inserted vaginally while the patient is lying on her back, and remains in position for between five and fifteen minutes. At the beginning of therapy, patients can typically expect to use something smaller in diameter than a pinky finger, increasing in diameter every week or two. As one becomes more comfortable with dilation therapy in the initial position, new positions may be introduced (for example, standing).

Like some of the dilation-less dilation techniques we will discuss, dilation therapy is intended to promote pelvic floor muscle relaxation in order to decrease pain during intercourse. Despite its good intentions, some patients are still reluctant to attempt dilation therapy, however, there are less invasive alternatives that can help in some cases. Here are three ways to dilate without dilators.

Everyday life is full of stress. The constant stressors may inadvertently increase use of the sympathetic nervous system, which often will manifest physically as tension in pelvic musculature.[2] Short-term meditation (approximately twenty minutes) has been shown to increase utilization of the parasympathetic (“stay and play”) nervous system.[3] Increased activation of the parasympathetic nervous system permits the release of tension in muscles connected to vaginal penetrative pain.[4]

The studies suggesting meditation as a way to regulate nervous system activity do not specify what parameters were used. However, I found anecdotally that guided meditative recordings online, which encourage users to focus on breathing and staying alert, as opposed to falling asleep, evoked favorable outcomes. But why would breathing be important to nervous system control?

While the reason is not clear, there is no shortage of studies linking respiration to parasympathetic nervous system response. [5] To decrease sympathetic nervous system activation in daily life, control studies almost literally propose taking a minute, or thirty, to stop and smell the roses. Slow prānāyāma breathing —a practice focusing on the inhalation, retention, and exhalation of a breath—has been shown to increase parasympathetic nervous system activation and decrease sympathetic nervous system activation when used in increments of eight to ten minutes for thirty minutes a day.[6] As discussed earlier, decreased sympathetic nervous system activation is a key factor in successfully decreasing tension in the pelvic floor musculature and further reducing vaginal penetrative pain.[7]

Along with slow prānāyāma breathing, there is evidence emerging that the respiratory diaphragm (breathing muscle) has ties to regulating nervous system activation. The picture being painted by emerging evidence regarding the role of breathing and muscles involved is great and all, but they may have another responsibility paramount to the battle against vaginismus and dilation therapy.

Shallow, chest-dominant breathing may deny our pelvic floor muscles the rest and stretch they deserve; deep, belly-dominant breathing may provide that rest and stretch. Pistoning is a term coined by Julie Wiebe to describe the dynamic interaction between the pelvic floor musculature and respiratory diaphragm. When the respiratory diaphragm is used for breathing, the pelvic floor muscles lengthen to accommodate the change in position of the abdominal and organs; larger respiratory diaphragm contraction (deeper breaths) should equate to larger pelvic floor muscle lengthening. There are studies showing a link between activity in the respiratory diaphragm and pelvic floor musculature, which lends some validity to the notion of “pistoning.”[8]

You are not a car, so why should you care about this whole piston thing? The vaginal canal passes through an opening in the pelvic floor musculature called the levator hiatus. As the pelvic floor muscles lengthen, the width of the levator hiatus increases, permitting less restricted passage of anatomical structures out of it and, for intimate purposes, into it.[9]

The pistoning effect can be demonstrated with a simple exercise for those who desire a healthier pelvic floor. Try lying on your back with hips and knees resting at approximately 90 degrees and knees separated slightly further than feet; this puts the muscles of the pelvic floor in a relaxed position. From here, place your dominant hand just below the rib cage and non-dominant hand on your chest. During inhalation, allow your stomach to push the dominant hand outward with as little chest movement as possible. As you exhale, let your belly fall to the floor; remain in this position and repeat.

Candidates for dilation therapy who are not comfortable with that form of treatment may discuss the alternatives offered by this blog with a healthcare professional. The goal of these three treatment suggestions is to relax the muscles making up the pelvic floor. With vaginismus, be sure to seek professional medical advice. Unlike patients suffering from stress urinary incontinence due to the female athlete triad (discussed in my previous blog), and assuming you are already being seen regularly by a gynecologist, you may want to start by visiting a physical therapist who specializes in pelvic health to avoid any unnecessary pain from a gynecologic exam.[10]

The most difficult portion of getting past vaginismus is staying positive. Try finding one thing you can look forward to every day. It can range from kicking back with a bubble bath to rocking out to your favorite ’90s boy band like I do (NSYNC). A happy, positive state of mind can help you get one step closer to pain-free intercourse and one step further from dilation therapy.


References: [1] Rosemary Basson et al., “Summary of the Recommendations on Sexual Dysfunctions in Women.” The Journal of Sexual Medicine 1, no. 1 (July 2004): 24–34, https://doi.org/10.1111/ j.1743–6109.2004.10105.x; APA (American Psychiatric Association), Diagnostic and Statistical Manual of Mental Disorders: DSM-5, 5th ed. (Washington: American Psychiatric Publishing, 2014); Yitzchak M. Binik, “The DSM Diagnostic Criteria for Vaginismus.” Archives of Sexual Behavior 39 no. 2 (April 2010), 278–291. https://doi.org/10.1007/ s10508-009-9560-0. Retrieved July 31, 2017.

[2] David Wise and Rodney Anderson, A Headache in the Pelvis. (National Center for Pelvic Pain, 2012).

[3] Yi-Yuan Tang et al., “Central and Autonomic Nervous System Interaction Is Altered by Short-Term Meditation,” Proceedings of the National Academy of Sciences 106, no. 22 (June 2, 2009), 8865–8870. https://doi.org/ 10.1073/pnas.0904031106.

[4] Wise, A Headache in the Pelvis; Tang, “Central and Autonomic Nervous System Interaction.”

[5] Ravinder Jerath, “Physiology of Long Pranayamic Breathing: Neural respiratory elements may provide a mechanism that explains how slow deep breathing shifts the autonomic nervous system,” Journal of Yoga & Physical Therapy 6, 252 (July 12, 2016), http://doi.org/ 10.4172/2157-7595.1000252.

[6] Mussadiq Shah et al., “Modulation of Cardiac Vagal Tone During Breathing at 0.1Hz in Fully Conscious Human Volunteers,” Autonomic Neuroscience 192 (November 2015), 76, http://dx.doi.org/10.1016/j.autneu.2015.07.073.

[7] Wise, A Headache in the Pelvis; Tang, “Central and Autonomic Nervous System Interaction.”

[8] Ruth R. Sapsford et al., “The Effect of Abdominal and Pelvic Floor Muscle Activation Patterns on Urethral Pressure,” World Journal of Urology 31, no. 3 (November 2012), 639–644, https://doi.org/10.1007/s00345-012-0995-x; Ruth R. Sapsford and Paul W. Hodges, “Contraction of the Pelvic Floor Muscles during Abdominal Maneuvers,” Archives of Physical Medicine and Rehabilitation 82, no. 8 (August 2001), 1081–1088, https:// doi.org10.1053/apmr.2001.24297; Lia Ferla et al., “Synergism between Abdominal and Pelvic Floor Muscles in Healthy Women: A systematic review of observational studies,” Fisioterapia em Movimento 29, no. 2 (June 2016), 399–410 https://doi.org/ 10.1590/0103-5150.029.002.AO19.

[9] H. P. Dietz et al., “Biometry of the Pubovisceral Muscle and Levator Hiatus by Three-Dimensional Pelvic Floor Ultrasound,” Ultrasound in Obstetrics and Gynecology 25, no. 6 (June 2005), 580–585, https://doi.org/10.1002/uog.1899.

[10] Elke D. Reissing et al., “Vaginal Spasm, Pain, and Behavior: An empirical investigation of the diagnosis of vaginismus,” Archives of Sexual Behavior 33, no. 1 (February 2004), 5–17, https://doi.org/10.1023/ b:aseb.0000007458.32852.c8.

Additional References: Larysa Sydorchuk and M. H. Tryniak, “Effect of Voluntary Regulation of the Respiration on the Functional State of the Autonomic Nervous System,” Likars’ka Sprava, (1–2), 65–68. Retrieved August 1, 2017. (Sydorchuk and Tryniak 2005)

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