Got Vaginismus? Here’s Your Ultimate Guide to Using Vaginal Dilators

Disclaimer: This post contains affiliate links, meaning I may receive a small commission from any purchases made on my blog. This does not affect the price you pay for products or services. Thank you for supporting Heal with Haley!

If you have pain with penetration, you know that simply looking at a set of vaginal dilators can be overwhelming. For many people with chronic pelvic pain (CPP), even the smallest dilator in the set feels daunting — nevermind the largest one! But as someone who struggles with vaginismus and vestibulodynia, I believe that it is possible to overcome pain and fear surrounding penetration… and research shows that dilators can play an important role in the healing process for people like me.

Nearly 3 out of 4 vaginismus patients are able to have pain-free intercourse after completing a full vaginal dilator protocol — which takes, on average, about five weeks. Still, the experience of healing from vaginismus is often physically and emotionally challenging for us. While research shows that dilator therapy is an effective treatment for vaginismus, it also shows that womxn healing from vaginismus often lack access to the emotional support they need throughout the process.

I may not be able to give each and every one of you a hug in person, but I’d like to think that my blog can support you through your journey in some small way. Whether you’re starting dilator therapy on your own or with the guidance of a physical therapist, this post is designed as a jumping off point to get you through the early days of treatment — with all the patient-only insight that a doctor or PT won’t be able to give you.

How Do I Know If I Have Vaginismus?

You might be here because you think you have vaginismus, but you aren’t quite sure. Unfortunately, I’m not a doctor or physical therapist — and only a medical professional can let you know for certain if you’re struggling with vaginismus. Still, there are some telltale signs and symptoms that often go along with vaginismus.

Pain during sex, or dyspareunia, is the most characteristic sign of vaginismus. But dyspareunia alone doesn’t say much, since so many conditions can cause it. People who have vaginismus often describe their particular sexual pain as burning, stabbing, or like something is “blocking” penetration.

The pain is usually felt at the vaginal opening upon penetration. Sometimes, it is so bad that it prevents sex from happening at all, whether because the person with vaginismus avoids sex due to the pain or because their muscles clench so hard that not even a Q-tip could penetrate them comfortably.

Another important characteristic of vaginismus, which makes it different from other CPP conditions, is that it causes anxiety or fear surrounding penetration. That penetration doesn’t always have to be sexual: it could also mean fear of inserting a tampon or having a gynecologic exam due to painful penetration.

Vaginismus can be primary, meaning that it occurs without a trigger, often from a person’s first sexual experience, or secondary, meaning that it occurs later in life and is often triggered by another event. This event could be emotional, such as sexual trauma, or physical, such as childbirth or another CPP condition. For example, many people with vulvodynia go on to develop vaginismus.

Other signs and symptoms of vaginismus that aren’t related to pain or anxiety surrounding sex include:

  • Constipation. People who have tight pelvic floor muscles often can’t relax them in order to have a proper bowel movement, leading to constipation and painful poops.
  • Urinary problems. If your pelvic floor muscles are tight, you may experience incomplete emptying, leading to urinary frequency (a.k.a. needing to pee more often than usual). If you have muscle spasms, you might also experience a sudden urge to use the restroom.
  • Anxiety disorders. Vaginismus itself does not cause an anxiety disorder, but people with anxiety disorders appear to be more prone to developing the condition.
  • Low sexual desire. When sex is painful, we naturally want to avoid the source of the pain. This can lead to a low sex drive and sexual dysfunction (such as inability to orgasm or to become aroused during sex).

How Dilators Work

Dilators are phallic-shaped medical devices (not sex toys) that are used to progressively stretch and relax the pelvic floor. They are used for many CPP conditions, but were originally developed by infamous sex researchers Masters & Johnson as a treatment for vaginismus.

For vaginismus, most dilators are sold as a set ranging from small to large. The smallest dilator may be no larger than the width of your pinky finger, while the largest may be somewhat wider than the average penis. You should start with the smallest dilator and work your way up.

There are two main types of vaginal dilators: silicone and plastic.

Silicone Dilators

  • Silicone is body-safe, non-porous material that doesn’t accumulate bacteria
  • These dilators are softer and more flexible than rigid plastic dilators
  • They may be easier to insert and less anxiety-inducing for first-timers
  • The first silicone vaginal dilators were designed by Soul Source

My favorite silicone dilators are made by Soul Source. These are the only silicone dilators made in the USA to date, and they are endorsed by the official Academy of Pelvic Health. You can check out my collaboration with Soul Source for more information on getting started with pelvic floor PT at home. You can also use my code ENDOSTRONG for 15% off your first purchase from Soul Source! Click here to shop.

Plastic Dilators

  • Plastic dilators have been traditionally used to treat vaginismus
  • More rigid dilators are better for trigger-point therapy and for breaking up scar tissue
  • They can be used for other conditions, like recovering from gender-affirming surgery

I love the company VuVa Tech’s Smooth Vaginal Dilator Set for its affordability and the fact that it comes with a full set of progressive sizes. However, Soul Source makes the only dilators specially made for use in transgender patients.

Using Dilators for Vaginismus

No matter whether you choose silicone or plastic dilators, the protocol for treating vaginismus is pretty much the same. (Please note that I can’t offer advice on dilating for gender-affirming surgery or any other medical condition or procedure that I don’t have personal experience with.)

You should always start with the largest size that you can comfortably insert without pain. In my experience, it’s best to try the smallest dilator first, rather than to overshoot and wind up in more pain than you expected. If the first dilator is easy to insert on the first try, feel free to move up until you find one that’s more challenging for you. More than likely, however, you’ll need to start with the first size (I did) and work your way up from there — and that’s okay!

Some people might even find that the largest size is too large at first — and there’s no shame in that. Some dilator kits come with large, fluffy Q-tips for this purpose, so you can start even smaller than the smallest dilator. Other times, you may want to try inserting a finger before working with the dilators. The protocol for practicing is still the same, even if you are using a Q-tip or finger instead of a dilator to start.

Everyone’s PT has a different approach to dilator therapy. Some people will advise you to start with 5-10 minutes of dilator training a day, while others will push you to go for 20-30 minutes. I think 10-15 minutes is a happy medium to start with, if you aren’t dilating under the guidance of a pelvic floor health provider. Most will agree, however, that you’ll need to practice every day, at least for a few minutes, in order to keep up the good habit.

You’ll want to use a lot of lubricant when practicing with your dilators. A water-based lubricant is the best option, especially if you are using silicone dilators (silicone-based lubricant should NEVER be used with silicone dilators). As someone with vulvodynia and vestibulitis, I find that good old-fashioned Astroglide is the best option. However, I also have had a good experience with Sliquid H2O.

You should also clean your vaginal dilators before and after use, just to be safe. I use #ToyLife foaming cleanser, which is meant for sex toys but works great on vaginal dilators, too. It is safe for use on both silicone and plastic products, is hypoallergenic, and contains no harsh ingredients like alcohol that may dry out your sensitive skin down there.

To practice dilator therapy, choose the dilator you’re going to start with (if it’s your first time, choose the smallest in the set). Cleanse and dry it thoroughly, then apply plenty of water-based lubricant and find a comfortable position to insert the dilator in.

If you have ever been successful in using a tampon, I say try whatever position you’ve been able to insert a tampon in before. Squatting slightly with your knees apart, or laying down with your knees spread (as if you’re at the gynecologist’s office), are both good positions if you aren’t sure where to start. Remember that you’ll need to stay in that position for at least 10 minutes, so make sure you’re good and comfortable — get pillows and blankets if you need them!

Before inserting the dilator, I like to close my eyes and take a few deep breaths from my belly. This relaxes the pelvic floor muscles and alleviates some of the anxiety. As you get ready to insert the dilator, you might find it useful to start by resting the tip against the vaginal opening before pushing the dilator inside. This helps you get used to the feeling of having something near the vaginal opening, especially if you have been avoiding it or never done it before.

Your first time using a dilator, that might be as far as you go. You might find that your muscles contract as soon as they feel the dilator at the opening — and that’s okay. Stay in that position and breathe through it for the full 10-15 minutes. If you’re comfortable, however, try pushing the dilator inside, a little bit at a time, as far as it will comfortably go.

It’s helpful to know that most women’s vagina slopes upwards a tad, so you may want to insert the dilator at a slight angle. You may also want to time your breathing with the insertion of the dilator. Inhale as you push the dilator in and exhale as you pause. Stop any time your pain level exceeds a 3 or 4 on a scale of 1 to 10. You should never get past that point when practicing using dilators, as severe pain conditions your body to fear penetration even more.

After you locate your stopping point, hold the dilator in place, actively breathing and relaxing the pelvic floor muscles, for at least 5-10 minutes. Once you can comfortably insert the entire length of the dilator without any pain, you should try pushing the dilator in and out, as you would during penetrative sex. Go slowly and, as always, stop anytime your pain level exceeds a 3 or 4. And, when you can finally do that without any pain, you’re ready to move on to the next largest size dilator!

Continue this process as long as it takes to comfortably insert the largest dilator without any pain, and to move it in and out. After that, you might move onto sex toys or penetration with a partner. If you’re going to work with a partner, start by having them insert the dilator for you a few times until attempting penetrative sex. The process of trusting someone else not to hurt you is very different from trusting yourself, so don’t feel bad if you find this step difficult, even if the dilator is smaller than the largest one.

Remember that completing the entire course of dilator therapy, from the smallest dilator to penetrative intercourse, takes time. On average, an entire course of treatment takes most vaginismus patients about five weeks. You might find that it takes more or less time for you. No matter the case, that’s okay. What’s important is that you don’t rush yourself or force yourself to “push through” the pain before you’re ready, as pain conditions your body to fear sex even more than you already might with vaginismus.

In a healthy relationship, your partner should not pressure you to move faster, either. They should be willing to wait until you are fully better before attempting penetrative intercourse. Many doctors recommend taking a mini break from P-in-V sex (if you’re able to have it) until you complete your dilator therapy and/or course of PT.

In the meantime, know that avoiding penetration does not mean that intimacy is off the table. Other activities, like mutual masturbation, external sex toys, oral sex, or manual stimulation, can help you feel physically close to your partner without worsening your pain. If even the thought of intimacy is scary to you (which is not uncommon with vaginismus), you can also try a sex therapy exercise called sensate focus, which works gradually toward penetration in the same way that dilators do. Get the directions for it here.

Dealing with Vaginismus Emotionally

If you have vaginismus, you know that dilator therapy is only half the battle of getting better. The other half is working on the psychological origins of the disease.

Whether it’s related to trauma, anxiety, or fear of pain, know that vaginismus is a totally normal response to what you have experienced emotionally. Even so, it might not feel that way when you are in the throngs of struggling with sexual pain. In order to understand how vaginismus can impact you emotionally, it helps to understand how the cycle of pain works in our brains.

Source: Vagi Wave

First, I think it’s important to acknowledge that sexual pain can occur for a lot of reasons besides vaginismus. The most common cause is a lack of lubrication due to inadequate foreplay or simply not using lube. For most womxn, one experience of sexual pain won’t rewire your brain to expect pain every time. It’s only when pain reoccurs two, three, or more times that we begin to anticipate pain.

Our body has a natural physical response to anticipating pain: we tense our muscles to “brace” ourselves for pain. This can lead to pelvic floor dysfunction in women with chronic sexual pain. As we tense our vaginal muscles to protect ourselves from pain, they can become too tight by default, leading to CPP. In vaginismus, those vaginal muscles become so tight that penetration is painful or even impossible. Some womxn with vaginismus can’t even insert a Q-tip comfortably without excruciating spasms of pain.

As a result of ongoing pain, we begin to associate sex with pain. This leads many of us to avoid sex, since it’s something we associate with pain — and, obviously, we would rather avoid pain whenever possible. When this cycle goes on for a long time, the avoidance can gradually extend to any kind of intimacy. My pelvic pain doctor has told me that many of the womxn she sees in her clinic will avoid any kind of touching, hugging, or kissing with their partner, for fear it will lead to sex.

The key to interrupting the pain cycle is rewiring our brains to no longer anticipate pain with penetration. This takes a lot of time and practice. Vaginal dilation therapy is one way to train your body to comfortably tolerate penetration, little by little. As we mentioned previously, it’s critical that you don’t exceed a 3 or 4 on a pain scale of 1 to 10 when dilating to ensure your brain doesn’t continue to associate penetration with pain. You can also incorporate pleasure into dilation to create a positive association, by masturbating while you use your dilators or even using sex toys instead of traditional dilators.

Many pelvic pain doctors will recommend you temporarily avoid partnered penetrative sex while training with vaginal dilators. The goal is to achieve pain-free penetration with the largest size dilator before moving on to partnered penetration. In the meantime, however, that does not mean you cannot enjoy other non-penetrative activities to stay close to your partner(s), physically and emotionally.

If you are someone who avoids any kind of intimacy, you may want to try a sex therapy exercise called sensate focus with your long-term partner. Like dilator therapy, it focuses on gradually working your way up to partnered sex, starting with completely non-sexual touching for 10-15 minutes at a time. This works as a type of exposure hierarchy, to condition your brain to no longer fear intimate touch — and to rediscover the pleasure of being with your partner.

What Else Can I Try for Vaginismus Pain?

For years, vaginal dilators have been the gold standard treatment for vaginismus. Still, not every womxn gets relief from vaginal dilators — or feels comfortable using them. At best, they are unfamiliar and uncomfortable for all of us. But some womxn find them overly-clinical, meaning that using them zaps their already low sex drive.

Nowadays, some physical therapists and other sex experts are advising that womxn use different sized vibrators or dildos instead of dilators. For some people, sex toys feel more human and less medical. For others, it helps ease the pain to incorporate self-pleasure into their dilation routine. (By the way, you can still try this when using dilators — clitoral stimulation might make insertion more pleasurable and less painful!)

In addition to dilator training, you might get relief from adding stretches, yoga, and/or foam rolling into your routine. These types of exercise can be customized to specifically target the pelvic floor muscles. Rather than contracting or strengthening, they ask that you relax and release your pelvic floor muscles, which can help with the pain of hypertonic pelvic floor (a.k.a. vaginismus). The resources section below offers links to some stretching and foam rolling videos I’ve found helpful — so keep reading!

For severe pain, your doctor can prescribe certain medications, such as antidepressants, muscle relaxants, or numbing agents, to help you relax your pelvic floor muscles. Some of these medications are taken orally, while others are applied directly to the affected areas. You might also consider trigger point injections, in which Botox or another muscle relaxant is injected directly into tight points along the pelvic floor.

It also helps to practice good vaginal hygiene. Practicing good hygiene ensures that irritation from soaps, fabrics, detergents, or other contaminants isn’t contributing to your vulvovaginal pain. This list of tips comes from the National Vulvodynia Association, but is also helpful for vaginismus:

  • Wear all-white, 100% cotton underwear (or underwear with a white cotton swatch inside the crotch).
  • Use dermatologist-approved laundry products, such as All Free & Clear and wool dryer balls.
  • Do not use fabric softener or scented laundry products on your underwear!
  • Gently wash the vulva with unscented soap and cool to lukewarm water only.
  • If you menstruate, use 100% cotton, unbleached, unchlorinated pads. Avoid tampons if you’re prone to irritation or vaginal infections, such as yeast or BV.
  • Use a gentle water-based lubricant, like Astroglide or Sliquid H2O.
  • After sexual intercourse, wrap an ice pack in a soft washcloth and gently ice the vulva for 15 minutes to relieve burning pain.
  • Urinate after sex to prevent urinary tract infections, which can worsen pain.
  • Consider taking a fiber supplement and/or probiotic supplement to keep your bowel movements soft and regular. (Constipation is a common side effect of a tight pelvic floor.)
  • Don’t swim in chlorinated pools or soak in hot tubs.
  • If you must sit for long periods of time, consider using a foam donut.

More Resources for Your Vaginismus Journey

Blog Posts

Vagi-WHAT?! What Is Vaginismus? The Cycle of Pain

This blog post is a great introduction to vaginismus for the newly diagnosed or explaining the condition to loved ones.

Vaginal Dilator Therapy

An introduction to dilator therapy with one of Soul Source’s doctor partners.

How Can I Relax My Pelvic Muscles?

The VuvaTech dilator company has many helpful posts on their blog, including this one on how to relax your pelvic floor.

How to Overcome Fear of Physical Intimacy

Fear is one of the driving factors behind vaginismus. Here’s another gem from VuvaTech on how to cope with anxiety surrounding sexual activity.

PDFs

Woke is the New Sexy Workbook

A free PDF to help you explore the underlying beliefs you hold about sex, which are a contributing factor in vaginismus for many womxn.

Come as You Are Worksheets

Free worksheets from Emily Nagoski’s book, Come as You Are, which explores what you need to feel sexually comfortable and aroused.

What I Want to Do Worksheet

A great questionnaire to fill out with a partner so you can set sexual boundaries while healing from vaginismus.

Vaginal Dilator Basic Instructions

Printable directions to help you get started with vaginal dilator therapy. Keep it in your PT kit!

Erotica Menu: Ideas for Alternatives to Traditional Sex

Exactly what it sounds like — a list of alternatives for intimacy and physical touching that don’t involve penetration.

A New Way to Look at Sex

This one is all about changing your perspective so you don’t feel “broken” by missing out on penetrative sex and can instead focus on the healing process in its entirety.

Books

Heal Pelvic Pain by Amy Stein

If you’re tired of me talking about this book, GO OUT AND BUY IT ALREADY! This is the first book I ever read on pelvic pain and it’s considered a classic when it comes to PT exercises for CPP.

Sex Without Pain by Heather Jeffcoat, DPT

This book by Heather Jeffcoat, DPT provides a home treatment plan for pelvic pain conditions like vaginismus, vestibulodynia, and more. Use my code ENDOSTRONG at Soul Source for 15% off your purchase!

Videos

From Ouch to Oh Yeah

This digital course from the sexual wellness app Rosy comes with 55 minutes of video content around reducing sexual pain with dilators, lubricants, and other products and techniques. Check out my review of Rosy on the blog!

How to Use Vaginal Dilators

There are so many excellent videos from the PTs at Intimate Rose. This one is a basic introduction to using vaginal dilators for vaginismus — you may find it helpful to visualize the dilator by watching a video, versus reading PDF instructions, the first time you try dilation.

Vaginal Dilators: How Deep and How Long Do I Put It In?

This one from Intimate Rose is all about how deep and how often to insert your dilators when practicing dilator therapy. It’s a common question that many of us are afraid to ask!

Pelvic Floor Release

The last one from Intimate Rose on this list is all about releasing your tight pelvic floor muscles. I find it especially helpful that she uses a model of the pelvis to really visualize what she means.

45-Minute Sequence to Release Pelvic Floor Tension

The Flower Empowered is a great YouTube channel if you’re looking for 30-45 minute stretching routines you can do to relax your pelvic floor at home alongside your dilator therapy.

Foam Rolling Exercises to Relieve Pelvic Pain

Pelvic Health and Rehabilitation Center is another must-follow YouTube channel for pelvic floor PT exercises. This routine uses a foam roller for myofascial release of the muscles surrounding the pelvic floor.

Hypertonic vs. Hypotonic Pelvic Floor Dysfunction: Vaginismus, Pelvic Organ Prolapse, & More

Disclaimer: This blog post contains affiliate links, meaning I may receive a portion of proceeds from any purchases made through my blog. Please note that this does not affect product prices. Thank you for supporting Heal with Haley!

Pelvic floor dysfunction (PFD) isn’t a single diagnosis: it’s a spectrum. PFD ranges from hypertonic (pelvic floor muscles that are too tight) to hypotonic (pelvic floor muscles that are too weak). And within those categories lie subcategories — diagnoses like vaginismus, pelvic organ prolapse, and urinary incontinence — each with their own point along the spectrum.

Unfortunately, many doctors still view PFD as one diagnosis. They prescribe Kegel exercises for incontinence, or “more lube” for sexual pain, then send you on your merry way… only you don’t feel very merry, do you? You feel confused and disappointed, wondering if you will ever find a cure for your pain.

The problem with treating PFD as a single diagnosis is that it overlooks the spectrum of dysfunction that exists within our pelvic floor muscles. Without pinpointing the exact problem, your pelvic floor PT (or whatever provider is treating you) won’t know the right exercises to help you overcome your specific complaints.

Most pelvic floor PTs can determine whether you have hypertonic or hypotonic PFD upon an initial evaluation. My pelvic floor was so tight at my first PT appointment, there was no way my provider could have missed it! Yet the hard work doesn’t end there: it’s also important to understand the spectrum of pain and where your personal experience lies on that spectrum.

The spectrum of pelvic pain encompasses disorders ranging from vaginismus, the tightest pelvic floor possible, to pelvic organ prolapse, the weakest pelvic floor possible. Treatments for pelvic floor conditions vary widely, making it important to get the right diagnosis.

In this blog post, I’ll share my personal experience with hypertonic pelvic floor dysfunction and vaginismus, as well as explore the different types of PFD that often affect people with vaginas, to help you better understand your pain and what you and your providers can do to treat it.

As always, I’d like to warn that I am not a health expert — just a patient. I cannot diagnose or treat you, so please consult with your doctor before making any important decisions about your health!

Types of Pelvic Floor Dysfunction

The pelvic floor is a bowl-shaped group of muscles that supports your reproductive organs, your bladder, your bowel, and more. Problems can occur with any of these organ systems when the pelvic floor muscles are too tight or too weak.

Exercising your pelvic floor after the birth of your baby

Many people wrongfully assume that pelvic floor dysfunction occurs only in women and only affects reproductive organs like the vagina and uterus. In reality, people of all genders deal with PFD, and PFD can affect any organ supported by the pelvic floor muscles.

You probably remember from high school biology that the prefix “hyper-” means too much and the prefix “hypo-” means too little. From that, we can deduce that hypertonic means too much tone and hypotonic means too little tone — muscle tone, that is.

Rather than separate groups of conditions, I like to think of PFD as a spectrum. If hypertonic PFD and hypotonic PFD are the two extreme points on a line, the ideal pelvic floor is the midpoint of that line. Like Goldilocks, you don’t want a pelvic floor that’s too weak or too tight, but “just right!”

Hypertonic Pelvic Floor Dysfunction

Hypertonic pelvic floor dysfunction occurs when your pelvic floor muscles are too tight…. and yes, there is such a thing as your vagina being too tight. As someone with hypertonic PFD, I find it incredibly ironic that straight men have conditioned us to strive for a “tight vagina.” Thanks, porn!

This problem can develop in a number of ways, but it is often a response to chronic pelvic pain (CPP). When our body is in pain, it learns to clench the muscles surrounding the painful area to protect itself. As a result of this chronic clenching, people with CPP can develop hypertonic PFD.

Signs and symptoms of hypertonic PFD can include:

  • Constipation
  • Dyspareunia (painful sex)
  • Chronic pelvic pain
  • Muscle spasms
  • Urinary frequency
  • Trouble starting the stream of urine
  • Straining to empty the bladder

Unsurprisingly, hypertonic PFD is also linked to chronic pain conditions like endometriosis and irritable bowel syndrome. Having one of these conditions does not guarantee you will develop hypertonic PFD, but it does make it more likely.

Treatment for hypertonic pelvic floor dysfunction involves retraining the pelvic floor musles to relax. This can involve pelvic floor physical therapy and, for people with vaginas, dilator therapy. In severe cases, trigger point injections and even surgery can help alleviate the symptoms of hypertonic PFD.

What is vaginismus?

In people with vaginas, hypertonic pelvic floor dysfunction is often used interchangeably with the term “vaginismus.” Vaginismus involves involuntary contractions of the pelvic floor muscles, paired with intense anxiety and pain surrounding penetration, whether with a partner, a speculum, a tampon, or even a finger.

Like all types of PFD, vaginismus is a spectrum, ranging from “true” vaginismus (where the patient can’t insert so much as a Q-tip comfortably) to milder forms, like the one I suffer from. It frequently develops in conjunction with other pain conditions, like vulvodynia and vestibulitis. Sometimes, vaginismus is linked to sexual trauma and shame, making it especially prevalent in religious communities and among survivors of sexual assault.

Hypotonic Pelvic Floor Dysfunction

Hypotonic pelvic floor dysfunction occurs when, you guessed it, the pelvic floor muscles are too weak. This problem can stem from underuse of the pelvic floor muscles, radiation treatment, pelvic surgery, pregnancy, or delivery.

Signs and symptoms of hypotonic PFD can include:

  • Urinary or anal incontinence (“leaking”)
  • Passing gas when bending or lifting
  • Pain or pressure in the pelvis
  • A feeling of something bulging into or falling out of the vagina
  • Decreased sensation during sex

The most serious consequence of hypotonic PFD is a condition known as pelvic organ prolapse. A prolapse occurs when the muscles surrounding the organs are so weak that they can no longer hold the organs in their proper place.

People with pelvic organ prolapse may experience uterine prolapse, where the uterus inverts or comes out through the vaginal opening; vaginal prolapse, where the top of the vagina drops through the vaginal opening; or rectal prolapse, where the rectum bulges into the vagina.

Treatments for Pelvic Floor Dysfunction

Pelvic floor dysfunction is common, affecting one in five people over the course of their lifetime and about a quarter of women. But just because PFD is common does not mean you have to accept it as normal.

Thankfully, pelvic floor disorders are highly treatable. Many cases resolve with minor treatment, like pelvic floor physical therapy and lifestyle changes, while more severe cases may require medications or surgery.

Treatments for Hypertonic Pelvic Floor Dysfunction

Treating hypertonic PFD involves learning to relax and lengthen the pelvic floor muscles. There are a number of ways to accomplish this, both with medical treatment and self-help strategies at home.

Pelvic Floor Physical Therapy

Pelvic floor physical therapy is the most important thing you can do for hypertonic PFD. As my doctor put it, the first, second, and third recommendations for treating hypertonic PFD are physical therapy! Working with a pelvic floor physical therapist, you can learn to actively relax and lengthen your pelvic floor muscles until it becomes second nature. This process of developing greater control over the pelvic floor is known as biofeedback.

Dilator Therapy

Silicone or plastic dilators can help you stretch and relax the pelvic floor muscles. They are graduated in size and used progressively to rehabilitate your pelvic floor. Traditionally, dilator therapy was developed for the treatment of vaginismus. However, dilators can also be used as tools for the myofascial release of tight pelvic floor muscles.

My favorite dilators are made by Soul Source Therapeutics. All of their products are body safe, latex-free, and soft in texture for gentle dilator therapy. I use the Medium Set of silicone dilators. Best of all, you can use my affiliate code ENDOSTRONG to get 15% off your purchase from Soul Source! Click here to shop.

Soul Source Silicone Vaginal Dilators, Medium Set

Trigger Point Injections

Trigger points are areas where the pelvic floor muscles or fascia are especially tight. Trigger point injections can aid in myofascial release of the pelvic floor by getting medication directly into painful areas. Usually, numbing agents like lidocaine are used. Sometimes, Botox can also be injected to treat pelvic floor muscle spasms. These are not a first-line treatment option but may be used for severe cases.

Estrogen Therapy

Diminished hormone reserves may contribute to pelvic floor pain in some people, especially in people who are taking hormonal birth control or who are menopausal. Topical estrogen cream is an effective solution for some of these patients and may relieve symptoms like dyspareunia. Estrogen therapy starts at very low doses to minimize the associated risks, such as endometrial or ovarian cancers. You may be unable to use topical estrogen if you have had an estrogen-related cancer in the past.

Self-Help

Self-help strategies aren’t a replacement for the medical treatment of hypertonic PFD, but they are effective when used in conjunction with other treatment options, such as pelvic floor physical therapy. Some self-help tips for hypertonic PFD include:

  • Building relaxation into your day with activities like yoga, meditation, or even adult coloring
  • Trying some gentle pelvic floor stretches one to two times per day
  • Modifying your core workouts to avoid sit-ups and crunches
  • Using only 100% cotton, bleach- and chlorine-free menstrual products (or a soft menstrual cup)
  • Cutting out irritants by wearing only 100% cotton underwear and only washing the vulva with fragrance-free soap
  • Avoiding urinary continence, or holding in your pee; instead, try to go before the need to pee becomes urgent
  • Applying an ice pack wrapped in a washcloth or towel to the vulva to relieve pain after sex — or Honey Pot Co.’s cooling Lavender Vulva Cream with mint and coconut oil

Treatments for Hypotonic Pelvic Floor Dysfunction

Treatment for hypotonic PFD involves strengthening the weak pelvic floor muscles through exercise and physical therapy. Occasionally, more invasive treatment — such as surgery — is required.

Pelvic Floor Physical Therapy

Again, pelvic floor physical therapy is the most important step you can take to strengthen your pelvic floor. Many people who suffer from hypotonic pelvic floor dysfunction don’t even know how to locate the pelvic floor muscles. During treatment, a pelvic floor physical therapist will walk you through contracting and relaxing your pelvic floor muscles in an exercise known as Kegels. If you are not sure if you have hypotonic PFD, you should not start doing Kegels without first seeing a physical therapist, as you could have another type of PFD. Kegels can actually make hypertonic PFD worse.

Catheterization

Urinary incontinence — or involuntarily leaking urine when you cough, laugh, sneeze, or exercise — is a common sign of hypotonic PFD. Sometimes, doctors recommend a urinary catheter for the treatment of urinary incontinence, especially in older adults. Catheters are devices that help collect urine without you needing to go to the bathroom to pee. Foley catheters can be used for up to two years and are inserted into the urethra. For long-term treatment longer than two years, doctors use indwelling subrapubic catheters, which are surgically inserted into an incision in the pelvis. Catheters aren’t the first line treatment for hypotonic PFD because they come with a high risk of infection, but they are an option for severe cases of urinary incontinence.

Pessaries

A pessary is a supportive device inserted non-surgically into the vagina to support the pelvic organs. It is used to treat pelvic organ prolapse. Some pessaries can be removed and reinserted at home, while others must be placed by a doctor. If your pessary needs to be inserted and removed by a doctor, you will need to have it replaced at least every three months to prevent infection.

Surgery

Surgery may be necessary if you are experiencing pelvic organ prolapse, especially in the rectum. A specific condition known as a rectocele can form when the rectum bulges into the vagina due to prolapse. Rectoceles often require surgical repair. The two types of surgery for pelvic organ prolapse are obliterative and reconstructive surgery. Obliterative surgery narrows the vagina to provide support for pelvic organs; however, penetrative intercourse is no longer possible after this procedure. Reconstructive surgery is an alternative that aims to restore the organs to their original position. Like endometriosis surgery, it can be done laparoscopically.

Self-Help

You can’t replace medical treatment for hypotonic pelvic floor dysfunction with self-help strategies, but they can improve your quality of life with PFD. Some self-help tips for hypotonic PFD include:

  • Practicing biofeedback using a smart device like the Elvie Trainer
  • Performing Kegels when you sneeze, cough, or laugh to help hold in urine
  • Trying Pilates or yoga to strengthen the pelvic floor
  • Modifying your core workouts to avoid sit-ups and crunches
  • Avoiding dietary triggers like alcohol, artificial sweeteners, caffeine, and carbonated beverages
  • Training yourself to pee on a schedule, gradually increasing the amount of time between urination
  • Wearing pee-proof panties to collect urinary leakage throughout the day

More Resources

Vaginal Dilator Exercises for Psychosexual Therapy

Oxford University Hospitals

Pelvic Floor Exercises with Breathing

Dr. Beth Shelly, PT, DPT

Easy Stretches to Relax the Pelvic Floor

VuVa Tech

Dilating is Doable Series

The Vaginismus Network Blog

Self-Help Tips

National Vulvodynia Association

Effective Kegel Exercises: A Full Workout Plan for Beginners

Ruby Cup

How to Do Pelvic Floor Exercises

Always Discreet

Finding Bladder-Friendly Foods

Interstitial Cystitis Network

Heal Pelvic Pain (Book)

Amy Stein, DPT

Sex Without Pain (Book)

Heather Jeffcoat, DPT

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Ohnut

A set of four protective, stackable rings worn around the base of the penis to limit the depth of penetration for people with vaginas who experience deep dyspareunia.

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Wild Flower Sex Shop

A sexual wellness boutique for people of all genders. I include this link because Wildflower sells flexible dildos that are a great “next step” after completing dilator therapy for vaginismus.