Using Vaginal Dilators After Pelvic Radiation

A dilator is a smooth plastic or silicone tube, shaped a bit like a tampon, that you insert into the vagina to keep it 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," meaning narrowing, along with "vaginal atrophy," where the muscles weaken and the walls become thin, and "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," and "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. If you have had radiation or surgery to your pelvis, your doctor or cancer care team may encourage you to use dilators to prevent problems."

There is a second reason, and 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 examinations become painful or impossible, and those examinations are part of watching for the cancer coming back.

Be aware that the specifics vary. Written guidance from cancer organisations 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," and that "you will also be taught when to start using it, and how and when to use it." Individual cancer centres publish more detailed schedules, and those schedules differ from each other. The evidence base for any one protocol is limited, so follow the instructions your own team gives you rather than 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," with each session taking "about 10 to 15 minutes." That gives you the scale: short, regular, ongoing.

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" and 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 and oil-based or silicone-based products. Vaginal lubricants or moisturisers are also recommended for dryness after treatment generally: a lubricant is for the moment, a moisturiser is used regularly.

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 healthcare provider if bleeding "soaks a sanitary napkin (pad), or if the bleeding continues for longer than 1 day."

If insertion hurts every time, if you cannot get the dilator in at all, or if you have quietly stopped using it, that is a clinical problem with clinical answers.

Ask your oncology team or nurse, and ask specifically about a pelvic floor therapist: "first, ask your doctor for a referral to a pelvic floor therapist. Cancer treatment centers often have pelvic floor therapists who specialize in helping patients." Their toolkit includes stretching tight pelvic floor muscles, biofeedback, and "vaginal dilators, which stretch the vaginal tissue to help relieve pain." Dilators also work better alongside learning 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

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