This file is a transcription of a patient instruction sheet that was distributed by Dr. Michel Seghers of Belgium. It would be typically given out to SRS patients as guidance for follow-up care. It contains specific information about dilation and appears to be of a generic nature based on the inclusion of other surgeon's names. It is reproduced here to be of an informative nature to pre-operative patients to indicate one aspect of personal care that will have to be incorporated into a daily routine for an indefinite period of time. It is not meant to override the instructions of a specific surgeon that may have different guidelines. The text was distributed in 1992.

After that are some comments that elaborate on items in the text. These are meant to be general in nature and hopefully will be found helpful in learning about one aspect of personal care. They can also provide topics for discussion with professionals when there are any doubts about proper health maintenance.

PATIENT INSTRUCTIONS (after Biber, Hunt, Seghers)

Dilate five times per day, 15 to 20 minutes each time, utilising your middle finger at the beginning and later using a vibrator or the adjustable dilator. Space the dilations over the 24-hour period as much as can possibly be done. It is very important to keep the depth in the vagina especially the first days after discharge. When utilising the adjustable dilator and squeezing it down, ribs are formed on the dilator, so it is very important to utilise plenty of jelly and place the dilator in such a fashion down toward the rectum primarily for a small distance then directly inside into the vagina, without using a screwing motion, because when you use a screwing motion, the ribs on the dilator might harm the new baby skin that is healing in the vaginal cavity. Graduate to a firm dilator between the third and fourth week.

The easiest place to get a firm dilator is to go down to any adult bookstore and get a plastic dildo, get it the same diameter as the adjustable dilator when full: approximately 4 cm in diameter and get it two inches longer which will make it about 7(seven) inches in length. Utilise this in a similar fashion as the adjustable dilator, and continue the dilation for a period of at least six months.

You may begin intercourse about the sixth week period. It is important in the pre-sex period to insert K-Y jelly and be prepared for penetration. If you do not use the K-Y jelly, you are going to tear yourself up. When beginning intercourse for the first time, take it slow and easy to avoid any damage that difficult and forceful penetration may cause. You are again on female hormones as before surgery; after two or three months, you should consult your endocrinologist to check the dosage and eventually reduce it.

Sometimes antibiotics are to be taken after discharge, but even more important than the antibiotics is to drink copious amounts of fluids- 10 to 12 glasses a day. You may also drink a couple of glasses of cranberry juice a day, which will acidify the urine and take away some of the smell. You may also douche, even once or twice a day because the vagina will present some obnoxious material while healing. You may douche twice a day if you wish with a tablespoon of white vinegar to a quart of warm water, not dark vinegar but white vinegar. Do not do any heavy lifting for a period of six weeks. If you have any specific problems, call my office or write to me. If you have seen a doctor at home and that for any reason he does not understand what is going on, please have him call me. Also remember that you are specifically female now. You are subject to all female diseases: you can get triconomas infections, you can get yeast infections and these have to be treated just like any natural female. It is probably wise to get yourself a pap smear once every year. Remember, you are subject to other diseases as well. Be very careful with your exposures, you can still pick up gonorrhoea, you can pick up syphilis and all other exotic diseases that females are subject to.

Keep in touch with me!! Any time you feel like writing, let me know about your general status i.e. financially, socially, what you think about body image, and what adaptation you are making to your new role. I'd be more than happy to hear from you.

In other words, keep in touch….

Comments by Patients

These comments are general in nature and printed for purposes of addressing queries to one's professionals.

General

There should be no excuse for "NOT" dilating other than specific instances of guidance by the surgeon or physician. The concept is very important and can enhance the results of SRS by conditioning the pelvic cavity and muscles around the vaginal orifice. The broadening and deepening of the vagina itself is generally of concern to most patients, and the vaginal tissue will respond with time.

Depth

The matter of depth is quite rare to find in on-line literature. Discussion with one's therapist can be enlightening and yield expectations, but seeking out the counsel of someone who has been through the process and been diligent will also help. It takes time to achieve results. My first follow-up visit to the therapist yielded a value of "about 1/16 inch per week" as being a good result. In some cases there can be a noticeable gain up to an inch within the first few weeks of surgery. This can be attributed to reductions in swelling in the pelvis and expansion of tissue that was contracted by pressure. If the patient has some of the vaginal stitches removed, this can also show up with a quick gain. The general assumption is that within a month after surgery, the most immediate gains will be noticed. Any resulting depth can generally be attributed to the tissue available for construction of the vagina. Additional depth is factored by the routine, time and body cavity considerations like size and vaginal angles.

Pain

Almost any dilatory procedure has some pain associated with it. Beginning a dilation routine shortly after surgery is bound to be accompanied by pain. Pain tolerance will vary by individual, but a more important item is to understand the source. The common sources to consider would be muscle tension close to the vaginal entrance, skin tension near stitches, vaginal fistulas, pressure on an internal organ or simple irritation. An observant person can usually ascertain the cause. Effecting the cure might take some work. Irritation has causes that are described further on. Muscle tension is encountered shortly after surgery and can be alleviated with "over the counter" medications of choice. For muscle tension that's tougher to deal with, some discussion with the surgeon or MD is a necessity. Once a major portion of the pain is gone, easier dilating can make for necessary progress. In some cases, complete blockage of the muscular pain is not necessary. A simple reduction can actually be a help in understanding where things are and proper body positioning to use for dilation. The medication used should not be expected to work instantly. Some knowledge of it's functional effects might mean that planning dilation an hour after ingestion would be best. Medications that have rapid clearance from the body should be considered. Any pain that lingers for more than 10 days or increases as days go by would indicate a more serious problem and a call to the MD. A more complex item is pressure on an internal organ. Here one must understand that the vagina does not have unlimited space all to itself within the pelvis. It has neighbours and they can be but not too far at one time. Dilation will produce some natural position for the vagina, but if it was poorly positioned, dilation can be painful. A sudden stop in all progress over a several week period coupled with reproducible pain can be an indicator of pressure. The some variance of the dilation angle may be worth trying as long as it is done gently. Don't expect miracles. If there are any doubts or questions, it becomes the surgeon's job to answer questions and an Doctor is worth consulting.

Fistula

A fistula is a different ball game entirely. It is defined as an abnormal passage from a hollow organ to the surface or from one organ to another and for the present, some vaginal fistulas will be mentioned. The three types of concern here are:

• Urethrovaginal - Between the urethra (urinary tract) and vagina.
• Vesicovaginal - Between the bladder and the vagina.
• Rectovaginal - Between the rectum and the vagina.

The names are not difficult to learn, and indications are fairly logical to assume. A and B above will sometimes result in urine drainage from the vagina. This is not exactly a pleasant thought or occurrence and not very common if the SRS has been performed properly. B and C have a likelihood to occur if stitches were improperly placed, dilation was improper, or a sharp object should tear tissue. What ever the cause, pain might be present or not depending on the size of the tear and rate of infection For rectovaginal fistulas, faecal matter from the rectum can easily enter the vagina and infections are very likely. It is a serious matter and if there is even a remote possibility of the occurrence, prompt medical help is necessary. The concept are brought up only to impart some awareness to probability, not to foster expectation, fear, or deterrence to dilation.

Routine

There is no doubt that there is time involved in doing an adequate amount of dilation. There is some possibility that the text's suggestion of 5 times per day is a wish, with hopes that the patient approaches 3 or 4. Deviation from the surgeon's guidelines is the patient's choice. Not too many people can locate quiet space for dilation during lunch hour. This means a morning dilation is a must. This can sometimes be the worst one of the day for some patients because the body cavity has been compressed by inactivity and tight sleeping positions. Other patients will find the dilation easier because the muscles are somewhat relaxed. There is only one way to find out and that's to do it. The text recommends spacing out the routine as best as possible. The bottom line is that it just has to be worked out to get some minimum amount of dilating in. It takes effort to add in a few more dilations on a weekend, but that presents opportunity for make-up time. All to often conversation yields the phrase "Well, I should really dilate more often, it would probably be better if I did." I've heard this numerous times from women who are well into their second year beyond surgery. Maybe some creativity can be worked into the routine. I found that the time goes much more quickly when I put on headphones and relax with the music. For a special occasion, try an X-rated movie in the VCR. In the beginning, I found dilation to be just another chore in an already busy schedule. As time went on, and there was less pain, the quiet time alone became special. It gave me a few additional moments to listen to my heart's thoughts about what my new future would be like. As for breaks in the routine, an infection can be one. This will be up to the patient and doctor to work out. Chaffing might be another. Sometimes the construction material of the dilator can chaff skin even if lubricant is used. This can easily occur near the entrance of the vagina where space is at a premium and muscles are tight. There are different guidelines on removal of the vaginal stitches. Occasionally, chaffing will be confused with slight tearing of the tissue around some stitches. What might seem like a little action on a stitch can end up being a spot that heals improperly and ends up becoming more sensitive with dilation. They can be easily removed by any MD using a sterile speculum. A good physician will have the small size on hand for us tiny types. If stitches were the cause of irritation, then the itching usually goes away in about a week. For itching that lasts beyond that, a localised infection should be investigated, or the dilator examined. The key is to be observant of pain and have an Doctor to consult with. At some point in time, the improvements will seem nonexistent. That might be another reason for getting in touch with one's surgeon.

Lubricants

The text suggests the use of "K-Y jelly". Such a name brand is not always available. Even though most grocery stores have sections devoted to "feminine needs", there will be instances where lubricant selections will be limited. A better selection of vaginal lubricants is readily available at a drug store or outlet that handles personal care items. The "ORTHO" line of feminine products has been marketed for years. More recently even "TROJANS" has introduced a vaginal lubricant. The key with the lubricants is experimentation. There are differences in the ingredients. In general they are all water based, but other ingredients such as "glycerine", "propylene glycol" and "copolymers" all change the characteristics of viscosity, comfort and skin reactions. A check for ingredients like "camphor", "PABA", "methyl paraben" and even fragrances should be done. Some individuals react unknowingly to PABA which is a common preservative in cosmetics and skin care formulations. Be observant for skin reactions and be ready to change brands, but don't be paranoid. Vaginal tissue can take some abuse, but when new skin is forming it can be easily damaged. Stretching introduces interstitial cell spacing and is the basis for cell mitosis (reproduction and growth). Macromolecules found in some lubricants can aid in cell growth and produce beneficial results for healing. Only some observation and trial will yield the right lubricant for each individual. For regular dilating though, most of the lubricants are clinically tested and should be fine. Most of the lubricants are basic and provide only general moisturising for the skin. Rarely are emollients included because of problems involving sterility in storage. It might be worth discussing the small addition of hand lotion to one dilating session on a weekly basis. Use of same is not a regular necessity, and douching a few hours later would be a rational idea. Emollients are not inherently contaminated, but some bacteria favour them as a growth media under rare circumstances.