Episode 06: Pelvic Floor Dilator Therapy – A Beginner’s Guide

Did she REALLY just call a pelvic floor dilator a “nervous system re-education tool”? In today’s episode, Dr. Alexis Anderson discusses the use of pelvic floor dilators: their purpose, selection, care, and its potential impact on conditions like vaginismus and rectal pain. The episode emphasizes slow, mindful practice, the role of mental and physical readiness, and the importance of personalized pacing. 

Welcome to The Alexis Anderson Podcast. 

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RESOURCES AND REFERENCES 

• Good Vibrations: sexual education and inclusive pleausre products 
• Episode 02: Belly Breathing and Total Body Relaxation 
• Episode 01: Pelvic Floor 101 
• Article on the 2 Scale System 

SHOW NOTES  

0:57 – A welcome and introduction to what we are talking about today! 

1:08 – Alexis explains what a dilator is, and shares some examples of how its used 

4:08 – Things to consider when choosing a dilator 

8:10 – Care instructions for your dilator 

8:44 – Addressing skin and tissue issues PRIOR to dilator use 

10:44 – Let's talk about how to use dilators 

14:25 – Prerequisites before starting dilator therapy 

22:34 – It's time to introduce the use of the dilator (make sure to take care of ALL prerequisites, first!) 

30:13 – Alexis shares some important notes about dilator therapy 

33:47 – Alexis brings the episode to a close with a review of what we talked about 

Transcript

SPEAKER_00 0:01

Hello, and welcome to the Alexis Anderson Podcast. I'm your host, Alexis Anderson, pelvic health physiotherapist and guide for anyone navigating the messy, confusing, and often isolating world of pelvic and sexual health. This season, we're breaking down the myths, sharing real stories, and giving you evidence-informed tools to understand your body. Whether you're a patient, a clinician, or someone quietly struggling, you're in the right place. Let's take the shame out of the conversation, bring clarity where there's confusion, and make pelvic health feel human, hopeful, and actually talked about. Before we get into it, let's talk the legal stuff. While I am a physical therapist, I am not your personal physical therapist. So please remember, this content is for educational purposes only and not a substitute for personalized medical advice, diagnosis, or treatment. Now let's get started. Hello, and welcome to the Alexis Anderson Podcast. I am your host, Dr. Alexis Anderson, Doctor of Physical Therapy. Today I will be talking about dilators. Dilators are a tool that pelvic floor physical therapists often use with clients for a variety of reasons. But the term dilate, right, refers to something getting larger. Like you can imagine someone's dilating your pupils, right? They put eye drops in them and then it makes your pupil larger. Basically, dilators start in a smaller size and then they graduate slowly to larger sizes, like a Russian doll set. We use them vaginally and we use them rectally. However, word of caution, if you're using a dilator rectally, make sure it has a stopper on the end. I repeat, you never want to insert anything rectally that doesn't have a stopper on the end. If you insert something rectally that does not have a stopper, it can get stuck and go all the way into the rectum, and you may have to go to the emergency department to have it removed. So let's avoid that. If you're using rectal dilators, they need to have a stopper at the end. Like I said, we use dilators for a variety of reasons. I'm not going to go into all of the reasons why we might use a dilator. That's another podcast episode. But just to give you a brief overview, one of the main reasons we use dilators is so that people can tolerate pain-free penetration. We use dilators, like I said, vaginally and rectally. Basically, when we're using a dilator, we are retraining someone's nervous system. We are retraining the patient to relax, to not contract, to not react when something is in the vagina andor when something is in the rectum. For example, we use dilators a lot to treat vaginismus. Vaginismus is a condition that upon penetration and or potential penetration into the vagina, the pelvic flow muscles contract, they spasm, oftentimes causing the patient pain and or making it very difficult for penetration to occur. This can also happen rectally. So just like in the case of vaginismus, when trying to tolerate penetration rectally, the pelvic flow muscles will contract and/or spasm and make rectal penetration difficult. This can happen for a variety of reasons. Maybe you have a new partner who has a larger size penis that is trying to penetrate a patient vaginally and erectile. Maybe someone is postpartum and they're trying to return to penetrative sex for the first time after having their baby. Maybe somebody had an issue like hemorrhoids or an anal fissure and they're trying to get back into their rectal sexual practice. I've had some patients use rectal dilators when trying to get back to having pain-free bowel movements. So we do use them for a variety of reasons in pelvic floor physical therapy. But I just wanted to give you some examples so you can think about the application of its use. Before I talk about how to use a dilator, let's talk about choosing a dilator. There are different factors to consider when choosing a dilator. They come in different sizes, they have different textures, some have handles, some don't. So let's talk about some of those things to consider. First is size. Think about your goals. What are your goals for penetration either vaginally or rectally? When choosing the dilator size, it depends on where you're starting and what your end goal is. So, for example, if you're using a dilator to accept your partner's erect penis, you'll need to measure your partner's erect penis, measure the length and measure the girth so that you know which dilator size that you'll need to get to. Some patients like to get the same size of their partner's penis and or maybe a size larger. Some people decide to do this because they want to make sure that they can really tolerate their partner's penis size. So it makes them feel a little bit better if they can tolerate a size that's just a little larger, just puts them at ease. If you're not able to tolerate penetration of a dilator that is the size of two fingers, then you need to start with a dilator size that's smaller than that. So when considering dilator size, think about where you're starting from and think about what your end goal is. Every person's gonna have a different goal, and they're all good. So make sure that you're starting with a size that you can tolerate, make sure that you're getting the size that you'd like to end up with, and make sure that you have sizes in between so that you can progress with. I have had patients who say that they can't find a dilator size that is as big as their partner. They're having a difficult time finding that size. I hear you. There is a company that makes a create a mate and they have molds. So you can actually make a mold of your partner's penis. I had a patient who struggled with this as her husband's penis size was very large. So she found a company that is called Create a Mate. This is not sponsored by them. Believe me, I don't even know if they still exist. This is not an episode that is sponsored by them, but they have these molds. And so she was able to mold her partner's penis and make a dilator that was exactly the size of her partner. It was the same shape. It had all of her partner's characteristics. She inserted a vibrator inside because she wanted a dilator that was not only the same size as her husband's penis, but also vibrated, and it worked wonders for her. The kit came with a couple of molds in case you messed up. So what she did was she used one of the molds to make a chocolate cake. So once she and her husband were able to have pleasurable sex, she made a little chocolate cake that was a mold of her husband's penis. So it was really cute. They celebrated with a little chocolate penis cake. There are different types of dilators on the market. Some of them are plastic, some of them are silicone, some of them are bendable. So if your partner tends to bend a little bit to the right or a little bit to the left, you can alter the dilator so that it matches your partner's penis. Some of them have handles. So if reaching that area of your body is challenging, either vaginally or rectally, you might consider using a dilator that has a handle to extend it for better ergonomics. There are dilators that have little markers like the one that I have in my hand. For those of you who are on the podcast who are listening, you're not going to be able to see this. But for those of you on YouTube can see that the dilator that I have here, this is a dilator that's used for our transgender folks, and it has these little dots so that they can keep track of the depth. So think about your goals. Think about the things that you would like to have when choosing your dilator. You can buy dilators online andor in stores. Good Vibrations is one of the stores that you can buy dilators from. This is not an episode that is sponsored by them, but they do have dilators there. So if you have questions, you can ask one of the sales associates to get more information. Care instructions for your dilators. You want to make sure that you wash your dilators with antibacterial soap and warm water before and after each use. Make sure that they completely dry before you use the dilator. If you're using a silicone dilator, make sure that you are using a water-based lubricant because silicone lubricants on silicone products will break each other down. If you have any questions about the cleaning andor care of your dilators, check with the manufacturer or retailer for their specific instructions. One topic that I want to talk about before we get into how to use a dilator is tissue and skin issues. If you have a skin or tissue issue either vaginally or rectally, you have to get that treated before you use a dilator. Very important. Vaginally, people can have tissue issues due to vulfidinia or vulvar vestibulitis. They can have hormonal changes at the opening of the vagina. That's also called the traitis. They may have hormonal changes due to their postpartum status, perimenopause, or menopause. They may have a tissue issue due to a diagnosis of the skin, for example, like lichens. There's different types of lichens out there. You may have a tissue issue rectally due to a hemorrhoid andor a rash. So there are lots of reasons why a person may have a tissue or skin issue vaginally or rectally, but whatever the case may be, you need to get that treated first before using dilators. Also, you never want to use a dilator if you have an open wound, either vaginally or rectally. So if you have a fissure or if you have stitches, any type of wound, vaginally or rectally, you do not use a dilator. So you always, always, always want to have clearance from your medical provider before using a dilator. And you want to get guidance from a professional on how to use the dilator. Often patients will use dilators after they've had Botox injections to their pelvic floor. I've had patients who get their pelvic floor Botox and we use dilators vaginally, and I've had patients who get Botox in their internal analsphincter and use dilators rectally. Again, you want to make sure that you have clearance from your medical team and have guidance from your medical team before, during, and after using dilators. All right, so let's talk about how to use dilators. The key thing is that dilators are a nervous system re-education tool. I will say that again. We use dilators to re-educate the nervous system. A dilator is a repeated and gradual exposure to a non-painful, non-harmful stimulus. I want to repeat that again. We use dilators in a non-painful way. They are not used to insert and stretch the tissue and cause you pain. That is not how I use dilators with my patients. That is not how I recommend people use dilators at all. The goal when using dilators is a repeated exposure to a non-harmful, non-painful stimulus. We are re-educating your nervous system that penetration is okay. So we want to start off with using a size that is small. We want to start off using a size that is non-painful. If you keep inserting a dilator that is too big, or if you're forcefully inserting a dilator, that is reinforcing to your nervous system that it's painful. It's reinforcing to your nervous system that it's not safe. And your nervous system is smart. It's going to protect you by sending out its stress response. So likely you're going to contract, likely your nervous system is going to go into that stress response. And that is not what we're doing with dilators at all. Your nervous system needs to experience over and over and over that this is not painful, that this is safe, and that this is not harmful. It is only through that experience that your nervous system will learn to relax. So it drives me crazy when I hear that there are providers out there that continue to tell patients, oh, just relax, oh, just have a glass of wine. That is not going to change your nervous system at all. And if anything, that is just gaslighting the patient and really downplays their experience. So I'll give you an example. If every time I open the door, somebody hits me in the face with a pillow, I'm going to contract and cover my face every time I walk through the door, right? That is your nervous system's response to a negative penetrative experience. Your nervous system has learned somewhere that penetration is not safe. So your body contracts, it withdraws, it sends out that stress response. Now, if they open the door and I don't get hit in the face with the pillow, I'm still going to contract and cover my face, right? My nervous system has learned that protective response. It is not until I walk out of the door and I experience over and over and over again that I'm not going to get hit in the face with the pillow, that slowly maybe I stop flinching. My hands are probably still going to cover my face. Maybe the next five times I walk outside the door and I don't get hit with the pillow, then maybe I'll put my hands down, right? Maybe my eyes are still closed. Maybe after 10 more times of walking outside that door without getting hit in the face with the pillow, then my body will start to relax. So I just want to give you an example that your nervous system really has to experience non-harm over and over and over again for it to learn this relaxed response. So to review, using dilators is a re-education tool for your nervous system. Not something we force, not something that is painful, that is quite the opposite of how we use it. Prerequisites before starting dilator therapy. You want to make sure that you have your dilators with you and you want to make sure that you have the appropriate lubricant. Also, you want to get into a position that is comfortable for you. That could be sitting on your bed with your back supported and pillows underneath your knees to support your body. Or you could be lying on your side and have pillows in between your knees to keep the knees open. Whichever position you choose, you want to make sure that your body is fully relaxed and supported, and you can reach whichever orifice that you are treating. For example, you want to make sure that you can reach to insert something into the vagina andor that you can reach and insert something into the rectum comfortably. You also want to make sure that you are in an environment that endorses relaxation. And that may look different for everyone. You may be in a room that's dark, you may be in a room that has candlelight, you might choose to put on some relaxing music, you might choose to have a heated blanket, you may choose to have some scents in the room that make you feel relaxed. For example, using aromatherapy, turning your phone on silent, having a quiet space, whatever makes you feel comfortable and enables you to relax. Before you use your dilators, I usually recommend that patients participate in total body relaxation and belly breathing. This primes the nervous system to be in that parasympathetic nervous system, that rest, that digest system. If you're unsure how to do this, check out my episode two of the podcast where I talk about and lead you through a guided total body relaxation with belly breathing. I typically have patients do this for about 10 minutes before they start their dilation practice. Also, you want to make sure that you have control over your pelvic floor muscles. This means that you have the ability to contract, to relax, and to open and elongate your pelvic floor muscles. If you're not sure about this or haven't had any practice, please refer to episode one of my podcast where I review how to contract, relax, and open and elongate your pelvic floor muscles. This is really important because oftentimes when I'm with patients and we're using dilators, a few things happen. One, either the patient can't tell that they're contracting when trying to insert the dilator, or two, they can feel themselves contract, but they have a very difficult time relaxing andor elongating their pelvic floor. Having voluntary control of your pelvic floor makes using a dilator much, much easier. Having control of your pelvic floor allows you to contract your muscles when you want to contract, relax your muscles when you want, and open and elongate them when you want, which is critical for dilation therapy. Okay, so you've got your dilators, you've got your lubricant, you're in your relaxed position, and you've done 10 minutes of belly breathing and total body relaxation, and now you're ready to start using your dilators. Prerequisites before starting dilators that we've already discussed include total body relaxation with belly breathing, pelvic floromuscular control so that you have the ability to contract, relax, and elongate, and positioning. The last topic I want to cover is the two-scale system. This comes from Tolly Rosenbaum. She is a therapist and pelvic floral therapy who came up with the scale and protocol when using dilators. She has an article online, and I will attach the resource of her original article in the show notes. I use the two-scale system with my clients when using dilators. The two scales are an emotional scale and a physical scale. Your emotional scale goes from zero to 10. Zero is you emotionally feel absolutely fine. You don't have any anxiety, no feelings of fear or frustration. You are cool as a cucumber. A 10 out of 10, for example, would be that you are having an anxiety attack. We're rushing you to the ED, right? You cannot breathe, you cannot move, you are a full-blown anxiety attack. When you're using dilators, I have patients stay under a four emotionally. When using your emotional scale, it can include any negative emotion that you have. All emotions are okay. All emotions are welcome into your dilation practice. And oftentimes we worked with those emotions together during dilation practice when I'm with my patients. And I also have patients write down their emotions so they can bring that information back to their mental health care provider so that they can discuss it together. Now let's talk about the physical scale. Your physical scale goes from zero to 10. Your physical scale includes pain, but it can also include things like your heart rate, your respiratory rate. Are you sweating? Is your body clenching? Is your body tightening? Is your body freezing? What facial expressions you have? So this is your physical scale. It is all of the physical things that are happening to your body during your dilation practice. Again, that scale goes from zero to 10. Zero, you're totally relaxed, you're not having any pain, your heart rate is normal, your respiratory rate is normal, you're not sweating, your body feels absolutely fine. 10 out of 10, for example, would be the most extreme pain you can imagine. You're going to the emergency department. A four in my book is that you are contracting, right? So you've contracted at a four. A four in my book is that you're clenching, you're squeezing your body, right? So again, on the physical scale, I have my patients stay below a four. When you're using your dilators, it is important to stay in the safe zone. The safe zone is staying below a four on your physical and emotional scale. Like I said, if you're contracting, that's a four. If you're disassociating emotionally, if you're clenching, if you're sweating, that's a four, and you need to stop. I love working with these two scales because oftentimes patients have a very difficult time learning where they are on these two scales. So it's really helpful to go through this with a pelvic floor physical therapist first so that you can learn where you are on these two scales. So I love going through this process with patients because oftentimes I'll check in with them and say, okay, where are you on your physical scale? Where are you on your emotional scale? And they're like, I'm a two, I'm a two. And I said, oh, I think you're a little higher than that because I can see their carotid artery pulsing through their neck, right? Their heart rate has increased, their heart rate's, you know, they just have this racing heart rate. And I'm like, I'm pretty sure you're above a four. And we need to stop, right? We need to calm the nervous system down. So it's really great so that they start to learn the subtle signs in their body that's happening during their dilation process. Also, I love using the two scale system because it allows the patient to identify the moment when things change. So we go through this process really slow together. I think oftentimes patients are shocked by. How slow that I actually go when working with them. But in the end, they really appreciate it because then they can start to identify the subtle signs in their body as well. Using the two-scale system also allows you to experience what's happening in real time so that you can stop, you can take a few steps back, you can take one step forward, you're really adjusting your practice to whatever your needs are based on your body's response emotionally and physically. Okay, so let's begin using your dilator. First, you want to get into the position that makes you feel comfortable and relaxed and supported. You want to have your dilator set and your lubricant and remove all distractions. Now, after you've done your 10 minutes of belly breathing and total body relaxation, check in with yourself. Where are you on your physical scale? Where are you on your emotional scale? If you're below a four, green light go, move to the next phase. I typically want my patients to be in that zero to two range before they move to the next phase. But after practicing with my patients, I let them be the best judge of what works for them. So phase one, after you've done your relaxation and belly breathing, you're ready to move into phase two, where you introduce the dilator. This will look different for everyone. Some folks may start off with a pillow over their body and have their underwear on. Some folks may feel comfortable removing their underwear and just having a blanket over their body to begin. However, you want to start, it's really up to you. Just make sure that your two scales are in the zero and one range before moving to the next step. Now you're going to take out your dilator, you're going to hold it in your hand, then check in with yourself. Where are you on your two scales? Did they change? Did you shoot up to a five because you're holding the dilator in your hand and now you know that penetration's going to come? Or are you totally relaxed? Not bothered at all, right? If you're in that zero to one phase holding the dilator in your hand, move to the next step. Go ahead and take your underwear off. Check in with yourself. Where are you on your emotional scale? Where are you on your physical scale? If taking your underwear off really shot you up to a five, stop. Make the decision. Do you need to pause for a moment and practice your belly breathing? Practice letting your body go, doing your guided body relaxation, or do you need to take a step back? Do you maybe need to put the blanket back on you or put your underwear back on? And then wait for your nervous system and your physical system to go back down to that zero to one phase. This is how slow I typically take my patients through this process. For some folks, they may keep the blanket on them, remove the underwear, have the dilator in their hand, put lubricant on the dilator, put lubricant on their orifice, whether that be vaginally or rectally, and they are in that zero to one state on their emotional and physical scale. Great. If that's you, then you're ready to progress to the next phase. You're gonna place the dilator at the opening, either vaginally or rectally, and see what happens. Does your body contract? Do you start to sweat? Do you withdraw? What happens? Then make the decision if you want to stay with the dilator at the opening and see if you can down-regulate yourself, or maybe you take a step back and you remove the dilator from your body and wait for your systems to regulate. Once you're back in the safe zone, then take a step forward and place the dilator at the opening again. If this is a difficult phase for you, you may stay in this phase for a while. This may be your practice. You might practice placing the dilator at the opening and waiting for your nervous system to regulate and wait for your physical system to regulate until you're in that zero to one phase. If you place the dilator at the opening and your physical or emotional scale jump up to a five and you can't get it back down, then take a few steps back, right? Remove the dilator. Put the blanket over the top of your body. If after a few minutes you still can't regulate your nervous system, then that's where your practice stops. And that is okay. That is where you need to be. And that may be where you practice for a while. And again, that's okay. We cannot force this. Remember, your nervous system has to experience non-harm over and over and over again until it feels safe enough to progress to the next phase. Now, once you're to the phase to where you can leave the dilator at the vaginal and or rectal opening, then you're gonna practice here. You're gonna practice your contraction, you're gonna practice your relaxation, you're gonna practice your opening and your elongation. This is great because the dilator gives you feedback as to where you are in space. It's gonna give you feedback so you can feel your contraction, you can feel your relaxation, you can feel opening and elongation. And when you're ready, then you're gonna time it. Can you do your big belly breath, open, elongate, and slowly start to insert the dilator? If you find that you contract, that's okay. Can you relax? Can you do your big belly breath, open and elongate? Okay? If you contract again, it's okay. See if you can relax, big belly breath, open and elongate, right? If you insert the dilator and you don't contract, but then maybe you're sweating or you have an emotional response, that's okay too. Just wait, see if your nervous system can down regulate. Do all of your belly breathing, your total body relaxation, relax your pelvic floor, see if you can get down below that four. If you can't, then take a step back. Remove the dilator, wait until that two-scale system goes back down to a zero, one before progressing to the next phase. Okay, now let's say that you're able to insert the dilator and you are staying relaxed. This is wonderful. We have now taught your nervous system non-reactivity to penetration. So now you're able to insert the dilator, you're not contracting, your emotional scale is zero to one, your physical scale is zero to one. That is fabulous. Now you're ready to move the dilator. So once you can insert the dilator to your desired depth and your two scales are zero to one, now you're gonna move the dilator. First, I have patients move it left and right. Left and right. Can you move it left and right and stay in that zero to one phase on both of your scales? Once you can do that, then can you move the dilator in circles? You're gonna move it clockwise, then you're gonna move it counterclockwise. Once you can do that, then you're ready for the final phase, which is often the most difficult phase for people, is to do little ins and outs. You're not gonna take it all the way out and insert it again. We don't want to do that. You just want to insert the dilator, then you wanna do little ins and outs. Again, the goal is to maintain that zero to one on both your physical and your emotional scale. Once you can do that, you're not having any pain, your nervous system feels fine, physically you're not having a stress response, then you're ready to move up to the next size, and then you repeat that process all over again until you're able to insert and use your desired size dilator. Some important notes about dilator therapy. If you have had trauma and this seems to be re-traumatizing you, do not use dilators. Take that information back to your mental health provider and wait until you have clearance from your mental health provider before starting dilators. Dilators should not be painful. Again, I repeat, dilators should not be painful. Are you going to feel a stretch? Yes. Are you going to feel like something is inside your rectum if you're using a rectal dilator? Yes. Are you going to feel like something is inside your vagina if you're using a vaginal dilator? Yes. And this is okay. This is where I use a lot of different techniques with my clients. For example, with patients who have pain or they have fear of pain, I actually have them stop and talk about the other sensations that they're feeling. For example, a stretch. A stretch is okay. It's not pain. They may feel warmth. They may feel silicone on their skin, right? They may feel a vibration. So I really encourage them to increase their sensation vocabulary because oftentimes the only word that they can use is pain, and that may not be what they're feeling, which is good. Your body is learning that there's different sensations besides just pain. But again, dilators should not be painful. That is not what we're doing when we're using the dilator. You want to go slow. I know often patients get super frustrated. They want to be to the next size already. They get frustrated with their nervous system. Why do they contract? Why do they shake? Why do they get nervous? Why do they get anxious, right? They get so frustrated with themselves. I understand that you want to be in a different place than where you are. I totally get it, but you're not going to get there through force. Just be where you are and know that the slower you go, that the more your nervous system experiences non-harm, the faster your progress will be. You never want to jam anything in, you never want to force it. Take your time, be patient, be gentle with yourself. If you're having big thoughts and really big emotions during your dilation practice, take those thoughts and emotions to your mental health provider so that you can work through it in therapy. Bottom line, dilators are a neurological re-education tool. We are slowly exposing your body to a non-harmful, non-painful stimulus over and over and over again so that your nervous system can learn that this is okay. They're a fabulous treatment tool when used correctly. They're not for everybody, and I get that. Everybody is different. And so dilators may not be for you, and that's okay. But they can be effective if used properly. Listen to your body, listen to your emotional self, go slowly, make it enjoyable, make it relaxing, right? I think that oftentimes when patients have to use dilators, they get really discouraged. They're like, I have to use this dilator and it's so medical and it's, you know, frustrating. Get creative. What are some things that you can incorporate that make it more pleasurable, that make it more relaxing, that make it more like a self-care practice versus such a medical one? And as always, get clearance and guidance from your healthcare team before using any dilators. Thank you so much for spending your time with me today. I really appreciate it. If this content helped you, please share, like, and comment. That is how this information can get in front of the people who need it. Thank you so much for being with me today, and I'll see you in the next episode. Thank you so much for joining me in today's episode of the Alexis Anderson Podcast. I hope you learned something that brings you more clarity, validation, and compassion for your body and your journey. If this episode supported you or you think you could help someone else, please share it, leave a review, or send it to someone who might need to hear it. And if you're a clinician or patient looking for more resources, tools, or support, you'll find everything linked in the show notes. Remember, you're not alone, you're not broken, and treatment exists that treats you as a whole person. I'll see you in the next episode.