Eight years ago we were working with a patient who was hyperventilating from fear during a dilation session. She sat up on the exam table and said “there has to be another way to do this.” And she was right. We set out to find a treatment method for those women who are overwhelmed, fearful and panicked at the idea of inserting something into their vagina; for those women with a significant history of pain or those who have not been successful using traditional dilator therapy. In those cases, we will most often suggest botulinum toxin injections. It takes much of the fear and distress out of the first few steps of treatment. The patient is put under conscious sedation for the procedure which takes approximately 20 minutes. While the woman is “out,” the doctor injects a topical anesthetic in the vaginal walls and massages the introital muscles to break any muscle spasms. This procedure is then followed by an injection of botulinum toxin. The anesthesia and massage allow the muscles to relax so that a large dilator can be inserted. The patient awakens with the dilator in place.
This is the first step to achieving pain and worry free penetration, but it is only a first step. Once the procedure is over, the patient needs to learn to insert the dilators herself, feel comfortable with touching her vulva and vagina and to relax with penile penetration.
Many of us are familiar with the use of botulinum toxin as a treatment for cosmetic reasons; it relaxes the muscles in the face so that smile lines and deep wrinkles do not appear. But it is the very action of releasing muscle tension that has led to its successful use in treating vaginismus. The botulinum toxin injections are administered to the muscles in the vagina, which makes the muscles unable to tighten and as a result, “the wall” that many vaginismus patients experience disappears. The patients who report pain from the tightening of the muscles experience significant relief.
Botulinum toxin is used in cases of vaginismus where the more conservative treatments have not been successful, or, even more frequently, where the first steps are not even attempted because the pain or the fear is so great.
We believe that every woman should be able to choose to put in a tampon, have a complete gynecological exam and experience intercourse if she so chooses and these are our goals with treatment.
Botulinum toxin injections inhibit the muscle spasm that causes the tightening of the vagina. It is these spasms which cause pain during intercourse. In a surgical center a patient is put under conscious sedation for the short procedure. The doctor injects both a topical anesthetic and botulinum toxin into the vaginal canal. The anesthesia and massage allow the muscles to relax so that a large dilator can be inserted. Immediately following the procedure, the patient awakens having achieved the hardest first step, the insertion of the first dilator. The anesthesia that was injected works to ensure that her first experience with the dilator is not painful.
The success rate, in our experience, is almost 100%. What has been observed in research on the use of botulinum toxin for vaginismus is that there is a 75% rate of success (meaning pain-free intercourse) within two-to-six weeks of the treatment. In our experience, the other 25% may take longer but achieve the same end result, complete relief from their symptoms, usually within 8-12 weeks. However, it is important that you understand that there is still work to be done after the procedure with dilators. Although botulinum toxin treatments only last 2 to 3 months, once the vagina is dilated and intercourse is comfortable, additional injections are generally not necessary.
The procedure is done at the Westchester Ambulatory Surgical Center in Purchase, NY, only 10 minutes from our Purchase office.
On procedure day, the patient is prepped for surgery and given an IV and placed in a hospital gown.
Once in the surgical suite, the patient is put under conscious sedation for the procedure which takes approximately 20 minutes. Once the patient is under anesthesia, a full pelvic exam is performed and a pap test is obtained if indicated. Next, dilators are inserted into the vagina; this dilation starts the process of lengthening and relaxing the pelvic floor muscles. After the progressive vaginal dilation, a speculum is inserted and the injections begin. The botulinum toxin is first injected, a total of 100 units, into the tense muscles. The doctor then injects a local anesthetic in the vaginal walls and vaginal entrance. Once the injections are completed, the largest vaginal dilator is inserted. The patient awakens with the dilator in place. There is a recovery and rest period after the procedure. During that time the patient is taught to remove and re-insert the dilators, and she is sent home with the dilators and instructions. It takes 2-5 days for the botulinum toxin to take full effect so the patient is encouraged to continue to use the dilators as much as possible for the first few days. There is a follow-up visit the next day and an individualized follow up treatment plan is developed.
The treatment does not make a woman instantaneously comfortable touching her genitals, or comfortable inserting the dilators. The treatment does not ensure a smooth and easy transition to intercourse with her partner. That is all work that has to be done after the procedure.
But we’re here to help you with all of that.
There is a mandatory follow up visit 24 hours after the procedure. At this visit we will work on continued dilation, discuss progress toward intercourse and help address any unanswered questions you may have. It is at this point that we start to work on having “your head connect with your vagina”. We help you to understand that you are in control of your body, that you can make decisions about what can and cannot go into your vagina and that your genitals are your friend and not your enemy. This procedure is a first step towards getting you there.
Further follow up visits are variable, based on patient’s ability to travel to the office, need for continued counseling, and need for continued guidance with dilation.
We have some local patients who come in for a weekly visit for the next few weeks until we achieve our three markers of vaginal health: ability to insert a tampon, pain-free intercourse and a complete gynecological exam.
For those who come in for the procedure from farther away, we continue the support by phone or refer them to a local treatment option.
In a patient’s own words:
“In the four weeks since then I have, generally, used the dilators every day and it has gotten easier each time. Two and a half weeks after the procedure, I had sex for the first time. It took some patience and preparation, but like using the dilators, it has gotten easier and easier every time after the first. I am currently making the transition from dilating often to having sex often, and I have never felt better or more confident about myself sexually. I have had multiple check-ins by phone and email with the doctors at Maze Women’s Health and they have been so supportive about my progress. The turning point for me after the procedure was learning to change my thinking, not changing my body physically. When I began to believe that I was capable of adapting to this process, it got rid of my fears about being in pain and gave me the ability to relax my body.
“For anyone considering this procedure or some type of vaginismus treatment, my best advice would be to consider what you would do about it if you weren’t afraid of your previous perception of the mental and physical pain associated with your body. My answer to that question was that I had to take the risk, and have faith in my ability to allow something new and good to happen in place of the memories of pain and discomfort. It hasn’t been an easy process in any way, but it’s been a completely rewarding one that I am so proud of overcoming.”
— L, 24 years old
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