Dilation Dilators in Genital Reassignment Surgery
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Why do post-op transsexuals have to dilate?
How important is dilating? Here’s a quote from Dr Eugene Schrang, MD, SRS surgeon:
“As healing progresses, contractures of the neo-vagina can occur and are usually due to lack of diligent neo-vaginal dilation [on] the part of the patient. It is difficult to understand why anyone would neglect to dilate on a regular basis when it is so vital to the outcome of their surgery, especially after they have come so far, but it does happen.”
Why do you have to dilate? Several things are happening. The surrounding tissues, including the PC muscle, are trying to move back to their original positions, forcing the neovagina closed. The scar tissue that is forming is contracting, again closing the neovagina. As if this wasn’t enough, when the neovagina relaxes and contracts between dilations, it develops wrinkles. These wrinkles will actually start healing together, narrowing the diameter of the neovagina. This will continue until the tissue has enough time to heal, so adequate dilation must be maintained during the healing process.
Obviously, you have to dilate frequently, for at least 30 to 45 minutes at least six times per day at first. You also have to pay attention to the quality of your dilations. Your dilators need to have several features to make absolutely certain that you are getting the best possible dilation for your time and effort:
- A smooth finish. You are going to be inserting the dilator over sensitive new tissue. Would you rather use something that was polished and smooth, or something literally as rough as sandpaper?
- Proper nose shape is important for three key reasons:
During initial penetration, the nose should gradually expand the vaginal canal and the PC muscle, making insertion more comfortable.
The nose must be blunt enough to minimize the danger of penetrating the vaginal wall. While a dilator that is very pointed or tapered may seem easier to insert, it is also capable of causing severe damage.
When fully inserted, the nose shape must help increase vaginal depth by creating enough stress to encourage the formation of new tissue without causing outright tearing. - Another problem with a dilator that is too tapered or made of a soft material is that the neovagina will be stretched less and less as you move inward, resulting in an tapered neovagina.
- Your stents should be designed for maximum therapeutic results rather than temporary, anatomical ‘fit’, like recreational devices.
- There should be multiple diameters to allow you to gradually stretch the neovagina. One size does not fit all.
Stents are designed to meet all of the above requirements.
Each Standard Set has five diameters
#16 1 inch (25mm)
#18 1 1/8 inch (28mm)
#20 1 1/4 inch (32mm)
#22 1 3/8 inch (35mm)
#24 1 1/2 inch (38mm)
Average cost per set is around £150 pounds.
That stretch the tissues in small, incremental steps, thus providing greater comfort. While five sizes may seem excessive, no one can ever know their surgical result in advance. And these are most commonly supplied by SRS Surgeons.
Dilation is, by its very nature, not a comfortable process. It is the part of the process for which you have total control and responsibility. Dilating infrequently or with poorly designed products can have devastaing long-term effects. Ensure you surgeon supplies a quality set of stents!
Every standard set should include two pieces with shallow, easy-to-clean grooves to help measure your progress in half inch increments. The eight inch length provides a comfortable grip even during maximum penetration. All stents should be hand polished and made of Delrin®, a smooth, non-porous plastic used in the medical field. Delrin® does not chip or crack, cannot absorb bacteria, and does not support the growth of bacteria or fungus. This makes it easy to keep the stents clean and sterile when following a conventional hygienic routine.
Dilators should not be made out of silicone or some other soft material. The reasons are quite simple. First, the vast majority of surgeons we are aware of require their patients to use rigid, hard dilators, and second, soft dilators are not going to provide the rigidity necessary to stretch forming scar tissue. If people want a softer dilator, there are plenty of companies that sell silicone toys, but they are never as effective as a stent because they are not designed for dilating.
Stent and Dilator use
The neovagina is an artificially created opening into the body. Because your genetic code has no plan for an opening there, your body will simply heal what it considers to be a gaping wound and close the neovagina completely and permanently. The tissue surrounding the neovagina, including the PC muscle, were pushed aside during the dissection of neovaginal cavity. These tissues will attempt to move back into their original positions. So in order to keep it open, we must insert something into the neovagina on a regular and frequent basis. Such a device is called a stent or dilator.
The more complex issue concerns the vaginal lining. In the penile inversion procedure, the surgeon takes the penile skin and stretches it down and into the neovaginal cavity that he created. During this process he/she has to cut and form the skin to the proper shape using sutures. If a graft is being used, the donor tissue is sutured to the end of the penile skin. Scar tissue will form at any place that two pieces of tissue are joined together in this manner. Scar tissue has very different properties than the rest of the skin. The two most important differences are that a) as it heals it becomes much less elastic and b) it contracts as it heals.
Another factor we must consider is that during the early weeks after surgery when the vagina relaxes between dilations, the folds of the lining will actually start healing together.
We can counter the contraction by regular insertion of a dilator to stretch the forming scar tissue to a size determined by the needs of the patient. The loss of elasticity can be countered by keeping the scar tissue stretched to its maximum size during the later stages of healing. Further stretching of the scar tissue after it has completely healed is possible by using progressively larger dilators, but it is a slow and difficult process. Therefore it is necessary to encourage proper dilation techniques with the proper tools during the early stages of healing.
The dilator must perform several functions. The first is penetration. The nose of thedilator must gently spread the vaginal opening, the PC muscle, and the scar tissue in the vaginal barrel as comfortably as possible. As the dilator is inserted, in this case moving from left to right, each point on the nose pushes against the tissue, either moving it sideways or pushing it forward. This diagram shows that the ratio of the forward movement to the sideways movement changes along the entire length of the nose
The second function is to hold the tissue at its maximum stretch over as much of the length of the vagina as possible. The third function is to aid in creating new tissue.
What is the best shape for the stent so that it performs all these necessary functions while minimizing the risk of injury? It turns out that no single shape is ideal, but by an analysis of the requirements, an optimum shape can be determined. Let’s define our goals in choosing a shape for our dilator.
- It must be safe. The shape must minimize the danger of puncturing the neovaginal wall.
- Insertion should be as comfortable as possible. Abrupt changes in diameter can be very uncomfortable and should be avoided.
- Stretching must be uniform over as much of the length of the neovagina as possible. Remember that there can be scar tissue for the entire length.
- The shape must be capable of helping to create new tissue through the formation of microtears.
Microtears
A microtear is just what the name says; a microscopic tear in tissue.
A microtear forms when there is sufficient stress
placed on the tissue that some of the cells rupture,
releasing their contents. Among the many chemicals that are released are those messengers that inform the body and the surrounding cells that damage is occurring, and somebody better do something quick. The cells surrounding the microtear shift into reproductive high gear,
creating new cells to fill the gap.
While a one cell width microtear does relatively little, a sufficient number of repeated microtears actually results in the formation of new tissue. This is the goal we are after.
Let’s start with a cylinder that has a hemispherical end
This shape will almost certainly be safe, as the force is spread over a very wide area. It will also provide a very uniform stretch over almost 92% of the length of the dilator. This shape fails, however, because 56% of the nose (indicated in red) pushes the tissue forward more than it spreads it apart. For the same reason it will not create microtears.
Let’s look at the other extreme.
This shape would provide very easy penetration because only 6% (indicated in red) of the nose pushes the tissue forward more than it pushes it apart. This is also the reason that it fails in every other respect. 32% of the length of the dilator will be tapered. Some dilators on the market are tapered over 50% of their length. This will not provide a uniform stretch, in fact you would end up with a very tapered vagina. While it would be very good at creating microtears, it would also be very good at penetrating the vaginal wall. We could modify the nose by blunting the tip, but we would lose the ability to create controlled microtears.
Somewhere between these two extremes we should be able to reach a compromise.
This shape maintains ease of insertion with only 18% of the nose (indicated in red) pushing forward. The nose is only 16% of the length, and it has a very low risk of penetrating the vaginal wall while still promoting microtear formation.
Dilating after Sex reassignment surgery
Dilating is the most important thing you can do to ensure the success of your surgery.
If you gain the excellent depth after the SRS, but you ignore on your part to diligently dilate your new vagina, this will result in shortening the depth and width of the newly made vagina because of the scar contracture.
Failure to dilate properly can result in serious injury. You will be instructed to gently dilate into the right direction after the vaginal packing is removed.
Dilating technique
- Before dilating, you should wash the surgical site with antibacterial soap and then clean it with baby wipes or your personal towels. Also cleaning your stents and douche kit with antibacterial soap such as Hibiscrub.
- You must always apply an adequate amount of lubricant jelly at the vaginal opening and also on the stent prior to dilating. Also, lubricate into your vagina using some lubricant with your longest finger or a vaginal applicator.
- For lubricant, we recommend the medical grade lubricant such as Surgilube or Johnson & Johnson KY Jelly as they are water soluble and non-irritating jelly. The use of liquid sensual lubricant, like Astroglide may interfere with proper healing of the vaginal lining.
- If you have difficulty inserting the stent because of vaginal dryness, withdraw the stent after the first try, you do need to apply some additional lubricant, and insert it again. Dilating should not be painful at all unless your wound does not heal well or you push stent in the wrong direction too hard.
- During the first month after surgery, your dilating must be done regularly four times a day, 15-20 minutes each time. This is the best chance that you can maintain or even increase the width and depth of your vagina.
- After that, two or three times a day for another 2 months, and once a day for another 3 months. After six months, you are not required to dilate everyday.
Lubricant Applicator (left)
Instruction after Sex reassignment surgery
- Douche your vagina once or twice a day with a very mild antiseptic soap or diluted betadine solution (one teaspoon of the solution to 6 ounces of water) because it will clean up the bacteria inside.
- Douching while seated at the toilet bowel. The lubricated douche wand is gently inserted into some depth of the vagina, squeeze and hold tightly the container for a while and then draw it out slowly.
- You can bathe as usual, and wash the wound gently with Hibiscrub or any antibiotic soap solution.
- After douching and washing the wound, please wipe it with your towel and keep it dry in order to avoid infection.
- Drink a lot of water.
- It is usual to have spraying of urine in a variety of directions until the swelling resolves. This is not harmful, but it just messes your wound. All you need to do is to wipe and keep it dry.
- Do not lift any heavy stuff for six weeks.
- You may begin intercourse after the sixth week period. There are some secretions when aroused from the intact prostate and Cowper’s glands. However, it is recommended that you still use the lubricant jelly every time during sexual intercourses.
- You are again on female hormones as before surgery after two months. You should consult your endocrinologist to re-adjust the dosage.
- A sudden change in hormone levels, for some individuals, may result in the fluctuation of emotion.
Care for your new anatomy
1) Dilation. Before you leave hospital, the surgeon will have shown you how to use the dilators. Initially, these should be inserted 3 times a day. Use the small dilator first, leave it in for 5 minutes after pushing it as far as it will go comfortably, then insert the large dilator and leave it in place for a minimum of 10 minutes. The process is often uncomfortable at first, and may be accompanied by a small amount of bleeding. Many patients find it easier to dilate in the bath, and this is quite acceptable. Usually by 2 months it is possible to reduce the frequency to twice daily, and you will know that this is the case if dilation is becoming very easy. Initially drop the lunchtime dilation. If the evening dilation is still relatively easy, you can safely go down to twice a day. Similar reductions in frequency at around 4 and 6 months are usually possible, so that most patients are only dilating 2 or 3 times a week by 9 months. These are general rules only, however, and there is great variation between individual patients, so you should try out each reduction in dilation frequency for yourself, and be prepared to stay on a higher frequency for longer if necessary. Remember that you need to keep dilating for the rest of your life!
2) Hygiene. If possible, you should bathe twice daily for the first month to 6 weeks. There is often a little infected looking matter on the surface, which may easily be removed by gentle washing with water and simple soap. Strong detergents are best avoided, as are strong antiseptics, although there is no harm in very dilute Dettol or similar in the bathwater if you wish. You should aim to douche daily for the first month. In my view the best solution to use is mains tap water (i.e. from the kitchen tap), as this is nearly bug free. You should have been given a suitable syringe before you went home. After the first month douche as often as you feel hygiene requires; many patients find they can stop entirely. In addition, you will have been provided with Betadine pessaries to use weekly for the first 10 weeks. One should be inserted in the evening after the last dilation.
3) Sex. It is unusual for patients to feel up to sexual contact within 2 months of the operation, and, while healing is still in progress, sex should be avoided. If the inclination and opportunity arise after 2 months you should be able to start gently and with care.
4) Hormones. Hormones may safely be restarted on discharge from the hospital. You will typically need only one third to one half of your preoperative dose. You will no longer need to take anti-androgens such as Cyproterone, Casodex and Finasteride, and these can be discontinued. Your final dose of oestrogen may be tailored to your needs by the person who supervised your pre-operative hormone therapy (typically your GP or Psychiatrist).