Post-vaginoplasty dilation

OK, here's a run-down of dilation tips from me and several correspondents. This is not to be construed as medical advice, check with your surgeon, blah-dee blah, blah.

If you are experiencing post-operative problems that cause excessive pain or difficulty when dilating, it is imperative you discuss the problem with your surgeon to avoid loss of depth, vaginal constriction (stenosis), or partial to total collapse. Whatever you do, don't just skip it because it hurts. You could be throwing away all the money you just spent.

There are some good general comments about dilating on Zen and the Art of Post-Operative Maintenance, notably a good diagram on insertion technique.

Preparation

Follow your surgeon's instructions as closely as possible. Each has different stents and different instructions, so one person's advice may not apply to you.

Urinating or having a bowel movement prior to dilation can sometimes make dilation more comfortable. Take extra care with hygiene!

Wash your hands with antibacterial soap before starting.

Lie on a towel, and have a couple of paper towels between you and the towel. Most of the mess is disposable that way.

Lubrication

Lubricate thoroughly. You should use the lubricant recommended by your surgeon, especially in the first three months. Some find it useful to use a vaginal applicator like the one that comes with Monistat or the Premarin cream Dr. Meltzer gives out to insert lube prior to starting.

In 1999, a correspondent wrote: "I noticed that you recommend the use of Astroglide as a dilation lubrication as an alternative to KY. You should know that Dr. Meltzer has reported that the use of liquid lubes has caused granulation of the vaginal lining. He recommends that such lubes not be used until at least three months post-op."

Paula writes: A couple of weeks into dilation I was going up to the next stent. I got it in all the way. I did the constant pressure thing and left it in for 15 minutes. Then I tried to take it out. It wouldn't budge. After several anxious minutes and a bit of twisting I was able to unglue it. I suspect that the constant pressure squeezed all the lube out and the resulting suction made it very difficult to remove. I suggest moving the stint in and out from 1/4 inch to 1 inch. This seems to move lubrication back into areas that have been squeezed. It also gives you a better feel of what is going on inside.

As far as the sticky dilator, I believe the problem is not suction, but lubrication drying/getting absorbed. This causes it to be like glue. The place where mine often sticks is near the opening, where the lube is exposed to air. The slight movement is one way to solve it, as you mentioned. I recommend keeping a small cup of water nearby for re-moistening as you dilate.

If your surgeon says it's OK, many find switching from jelly-type lube of the K-Y variety to liquids like Astroglide causes less sticking. I sometimes get a little sticking from this, but nothing like I used to get! As far as lubricant, I found that K-Y stuck to the dilator better, but Astroglide, while messier, makes things easier.

Insertion

Before starting, move the muscles you want to relax. Flex them-- they're the same muscles that let you cut off a urine stream. Feel what you're trying to relax?

Start small. Fingers can be good. The other good thing about fingers is that you can really feel the muscles you need to relax. I know some trans women are squeamish about sticking their fingers in their vaginas. Don't be. Stick a finger in, then try to squeeze your finger with the vaginal muscles. That's what you want to relax.

Start with the smallest dilator and move up if starting with a large one hurts. I found the first two inches painful, and the pressure of it all the way in hurt in the back.

You may want to supplement your surgeon's stents with a set of progressive diameter stents. Cathy writes, "My surgeon did NOT provide me with adequate stents after vaginoplasty, and this nearly caused a catastrophe. I've heard the same from some former Biber patients. Getting ahold of these dilators probably saved my sexual function as well as prevented a total crisis for the men of America. I suspect the same may be true with others."

Your healthcare provider may be able to direct you to options if you need narrower stents.

Tips and tricks

Immediately post-surgery

There seem to be several things that are potentially painful: the collection of dissolvable sutures near the perineum, which can often pull loose (one of mine did-- no biggie). Some people have inadvertently crushed their urethra against their pubic bone during insertion. Be careful of this, since it can cause nasty urethral clots. I also found some discomfort initially as the stent passed the prostate. Some have also mentioned pain where the drains emerged from the labia.

Be careful if you're dilating while on pain meds. It increases the likelihood you'll hurt yourself without knowing, since you won't respond to signals you're hurting yourself.

Julia writes: I've had a lot of irritation and pain inserting the stent, caused by my pubic hair getting caught between the stent and vaginal opening and pulling. So.... last night after I applied lube to the stent (I use Astroglide or ID -- i'd recommend a glop on the palm of your hand and stroke the stent to distribute it evenly), then I used the leftover lube to lube the opening, and then spread the labia apart moving the hair out of the way. Guess what? No pain.

From a reader flying back after surgery: "I was able to dilate briefly while on a layover at Chicago's O'Hare (ORD) airport. While transferring from one gate tree to another, I noticed signs for 'medical station'. In Terminal One, UIC Medical School runs a small walk-in clinic for travelers. They had three exam rooms, and all were empty. I asked for one (politely, of course) and got the old in-out done in time. This was especially important since our whole flight scheme was confounded by a snowstorm in Montreal. We left there two hours early and the next transfer was almost three hours after we'd arrived in O'Hare. I wouldn't try this if you have less than 90 minutes layover time. Remember, it will take a few minutes to change gates, and normally, you board 15 - 40 minutes before departure time."

Someone wrote me a note with the observation that there seems to be a volume limitation-- in other words, it's harder to get larger stents in as far. I think there's something to this.

The good suggestion of a pillow under the back can allow lower back and butt muscles to relax. These are often the culprit.

A common mistake is to plant the heels up near the butt and spread your knees apart. This only makes everything tighter. At the very least, keep your knees together with your feet about the width of your hips apart. A better suggestion it to have one knee up, with the other leg out straight and relaxed (don't lock your knee). Turn your foot so the pinkie toe is closer to the bed. This helps relax the thigh even more. It takes a little more doing, but if you can lie at a slight angle on the bed and dangle the relaxed leg from the bed, you might be able to relax even more.

If you can swing it, put both legs out with the knees slightly bent and toes facing out. The tricky thing with having both legs out straight is that there's a temptation to tighten the abdomen when using your arms to position the stent. One way to alleviate this problem is to have a couple of pillows behind the shoulderblades and neck to allow for easier reaching.

Another way that works for me is to put a couple of pillows under my calves. This allows complete relaxation of the thighs. Again, take care not to tighten your abdomen when reaching down to position the dilator.

My favorite way is to lie on the sofa with my legs over the arm. I lie there and watch TV and read magazines.

I find I can push the dilator deeper with my knees pulled up and together. This is not possible with the knees pulled up and spread.

I have not experimented with it, but I suppose you could try on your side with a pillow between your knees if the above methods weren't working.

Squeezing the muscles around the stent once it's in can help relax muscles for larger sizes.While it's important to maintain pressure on the stent, I found I could hold it in place with my thighs for short periods of time, like when I was turning newspaper pages.

If you feel a sneeze coming on, you should quickly but carefully remove the stent, as sneezing with it in can be painful.

If dilation is painful, don't just skip it. I know someone who did this, and she had partial collapse.

Dilation is a chore at first and requires discipline. Discipline is simply facing something you don't like to do and doing it anyway.

Rinsing out the lubricant after is not always necessary, but I found it made less of a mess later. After douching, bear down like you're having a bowel movement to expel any water. It'll save you a potential problem later.

Supplemental or replacement stents

The companies below offer a range of sizes and types if you need larger or smaller stents than the ones provided by your surgeon, or if you need new or better ones.

Femistent

Vaginismus.com

http://www.vaginismus.com/products/dilator_set

Amielle Care

Soul Source GRS dilators

http://www.soulsourceenterprises.com/html/products_grs.html