Botox injections and physical therapy for Vaginismus: A Comprehensive Guide

March 16th, 2024
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Vaginismus is a condition that affects many women, causing involuntary tightening of the vaginal muscles. This can make penetration difficult, leading to pain and discomfort during sexual activity. While vaginismus can be challenging, there are effective treatment options available, including the use of Botulinum toxin (Botox) injections. In this blog, we’ll explore how Botox can help treat vaginismus, what the procedure involves, and what to expect during recovery.

Understanding Vaginismus

Vaginismus is more than just physical muscle tightness; it’s a mind-body response triggered by fear and anxiety related to vaginal penetration. Women with vaginismus often experience pain and discomfort during attempts at intercourse, which can significantly impact their quality of life. The condition can be classified as primary (present from the beginning) or secondary (developing after a period of normal sexual function).

How Botox Injections Can Help

Botox has shown some promise in treating chronic pain conditions. When injected into the pelvic floor muscles, Botox can effectively relax the vaginal muscles, allowing for a less painful or a pain-free penetration.

Here’s How the Procedure Works:

  • Patient Evaluation: Before treatment, a thorough evaluation is essential. Your healthcare provider will assess your symptoms, medical history, and overall health.
  • Botox Injections: The procedure involves injecting Botox into multiple areas of the pelvic floor muscles. The injections are performed under local anaesthetic, as appropriate.
  • Relaxation and Recovery: After the procedure, you’ll need to follow post-treatment instructions carefully. Relaxation of the pelvic floor takes time, so patience is crucial. Some women experience mild temporary side effects like stress incontinence or vaginal dryness, but these usually resolve within a few weeks.

Targeting the Levator Ani Muscles with Botox for Vaginismus:

The levator ani muscles are a group of muscles that form the bulk of the pelvic floor. They play a vital role in maintaining pelvic organ support, controlling continence, and facilitating sexual function. When these muscles become overly tense or spasm, they contribute to the symptoms of vaginismus.

Levator Ani Complex:

The levator ani complex consists of several individual muscles, including the puborectalis, pubococcygeus, and iliococcygeus muscles. These muscles wrap around the pelvic organs, forming a supportive hammock-like structure. Tension or hypertonicity in the levator ani complex can lead to pain, discomfort, and involuntary contractions during attempted vaginal penetration.

Botox Injection Technique:

During Botox treatment for vaginismus, healthcare providers carefully inject Botox into specific points within the levator ani muscles. The goal is to induce muscle relaxation by blocking the release of acetylcholine, a neurotransmitter responsible for muscle contraction. By targeting the levator ani muscles, Botox helps reduce muscle spasms and allows for easier penetration.

Precise Placement:

The injection sites within the levator ani muscles are determined based on individual anatomy and symptoms. Providers use palpation to ensure accurate placement. They may also use ultrasound guidance depending on the muscles that are being injected.

Botox is typically injected bilaterally (on both sides) to achieve balanced muscle relaxation. However, in some patients, only one side may be injected, depending on the individual symptoms.

Obturator Internus and Piriformis Muscles in Pelvic Floor Hypertonicity and Vaginismus

Beyond the levator ani muscles, other pelvic floor muscles can also play a significant role in contributing to pelvic floor hypertonicity and vaginismus. Two such muscles are the obturator internus and the piriformis:

Obturator Internus Muscle:

The obturator internus muscle is located deep within the pelvis, near the obturator foramen. When this muscle becomes tight or spasms, it can lead to increased pelvic floor tension. Hypertonicity of the obturator internus may contribute to pain, discomfort, and difficulty with vaginal penetration. Botox injections into the obturator internus can help relax the muscle, alleviating symptoms associated with vaginismus.

Piriformis Muscle:

The piriformis muscle is primarily known for its role in hip rotation and stability. However, its proximity to the pelvic floor means that tension in the piriformis can indirectly affect pelvic floor function. Chronic tightness or spasms in the piriformis may exacerbate vaginismus symptoms. Botox injections into the piriformis muscle can promote overall pelvic floor relaxation and improve sexual comfort.

Physical Therapy

Physical therapy plays a crucial role in treating vaginismus by addressing the underlying muscle tension and promoting relaxation. Let us delve into how physical therapy can be beneficial:

  1. Pelvic Floor Muscle Education:
    • Understanding the Anatomy: A skilled pelvic floor physical therapist provides education about the pelvic floor muscles, their function, and their role in vaginismus.
    • Breathing Techniques: Learning proper breathing patterns helps relax the pelvic floor. Deep, diaphragmatic breaths can reduce muscle tension.
  2. Stretching and Relaxation Techniques:
    • Manual Techniques: The therapist may use gentle manual techniques to stretch and massage the pelvic floor muscles, especially the trigger points. They work on soft tissue mobilisation and scar tissue release. This helps release tension and improve the flexibility of the pelvic floor muscles.
    • Vaginal Dilators: Gradual use of vaginal dilators (small, smooth devices) helps stretch the vaginal muscles. The therapist guides patients on safe and effective dilator use.
    • Techniques to ensure optimal bowel and bladder habits to reduce possible straining which can contribute to pelvic floor dysfunction
    • Neuromuscular education to correct posture, body mechanics with lifting and working on ergonomics (evaluate low back and hips)
  3. Biofeedback and Mind-Body Connection:
    • Biofeedback: Using specialized equipment, patients receive real-time feedback on muscle activity. This helps them learn to control and relax their pelvic floor muscles.
    • Mindfulness and Relaxation: Techniques such as mindfulness meditation and progressive muscle relaxation enhance mind-body awareness and reduce anxiety.

Vaginal Dilators

Vaginal dilators are tubelike devices made of plastic or medical-grade silicone that you put in your vagina to stretch your vaginal tissue. They’re a treatment option if you have pain during vaginal penetration due to medical conditions such as pelvic floor dysfunction.

Dilators work by gradually improving the flexibility of your vagina and the strength of your pelvic muscles so that penetration becomes more comfortable. They range in size and thickness, and the dilator you choose depends on how tight or narrow your vagina is.

While vaginal dilators are available to purchase without a prescription from most retail pharmacies and online, you should speak with your physical therapist before using one.

How do you choose a vaginal dilator?

Dilators range in length from about 2 inches to 7 inches (in). The circumference, or thickness, also varies from about 0.5 inches to 1.5 inches. The goal is to work your way up to a larger and/or thicker dilator. If treatment is working, you should notice you’re able to more easily insert a larger dilator over time. You must not try to rush through sizes or force yourself to use a larger dilator before you are ready.

Vaginal dilators come in plastic or silicone and resemble the shape of a penis. Both materials have their pros and cons. Plastic tends to be more firm and rigid, which may help stretch your vagina. But some people find it uncomfortable. Silicone is softer, gentler and more flexible. You can also use a silicone dilator chilled or warmed. It is important to find one that feels comfortable to you but also provides enough tension to stretch your vagina.

Your physical therapist may be the best person to recommend which dilator to get. They can perform a pelvic exam or physical exam to see what type and size vaginal dilator will work best for you.

How do you put a vaginal dilator in?

Inserting a dilator can be slightly uncomfortable at first. The process of putting in and using a dilator shouldn’t take more than 20 minutes.

Here are the steps to help you use a vaginal dilator:

  • Apply a water-based lubricant (like KY®) or 5% lidocaine gel (numbing cream) to the dilator. Don’t use oil-based lubricants or products like Vaseline®. Remember, you should use a small dilator to start and work your way up over time.
  • Lay in a comfortable position on your back with your legs bent at the knees. Allow your legs to fall outward if possible, similar to how you would during a pelvic exam.
  • Insert the dilator into your vagina similarly to how you’d insert a tampon (at a downward angle toward your spine). You should feel tension and the dilator should feel snug without causing pain. Once you feel this tension, stop. Don’t force it in further.
  • Often, your provider will recommend doing Kegel exercises with your dilator in to help relax your pelvic floor. Taking long, deep breaths can also help relax your muscles.
  • Spend the next five minutes moving the dilator around while it’s inside your vagina. This part is easier to do if your dilator has a handle or “holder” with it. Rotate the dilator in circles towards the front, rear and sides of your vagina. Then, move it in and out (similar to what occurs during penetration).
  • Gently remove the dilator after 15 minutes.
  • Clean your dilator with gentle soap and warm water. Then, let it air dry or blot it dry with a paper towel.
  • Use dilator therapy as directed by your physical therapist. Some therapists recommend daily use while others recommend every other day.
  • As you go through vaginal dilator therapy, aim for deeper penetration and/or a thicker dilator over time. You should notice the smaller dilator feels too easy and that you’re ready for a larger or thicker dilator.
  • It is important to use the dilator as directed by your physical therapist. Vaginal dilators will come with instructions from the manufacturer on how to use their product. Contact your therapist if you have questions or experience pain while using a dilator.

What size dilator do I use?

Most people begin with a small vaginal dilator, which can be about 3 in long and as thin as a pencil. These dilators may be labelled as small or size one. As you progress through the sizes, the dilator gets longer and thicker/wider. Not everyone starts as a size one, though. You should start with a dilator that feels snug but isn’t painful to insert. This is where talking to your healthcare provider is helpful because they can recommend what size to start with.

Over time, you should be able to graduate to larger dilators. These may be labelled large, extra-large or size seven, for example. The largest vaginal dilator is meant to replicate an erect penis, so it can be about 7 in long and 1.5 in thick.

Many manufacturers sell vaginal dilators in kits or packs that include several sizes. This can remove the guesswork because you have all the sizes you may need. As always, you should discuss dilator treatment with your physical therapist to make sure you are using it correctly.

How long should you keep a vaginal dilator in?

You should keep a vaginal dilator in for about 10 to 15 minutes each time. How often per week you use a dilator depends on the underlying condition and your therapist’s recommendation. Some people find relief after several weeks, while others continue using a dilator for several months.

Risks / Benefits of Dilator Therapy

What are the benefits of vaginal dilators?

Vaginal dilators are safe and effective. Most people who have pain during sex feel some relief after consistent, regular use of a dilator. Dilators work by gently stretching and expanding your vaginal tissue over time. This improves its elasticity and reduces the pain you may feel with sexual intercourse.

What are the side effects of using a vaginal dilator?

The most common side effect is light bleeding, but the bleeding shouldn’t exceed light pink spotting. See your doctor if you experience heavy bleeding or bleeding for longer than 24 hours after using a vaginal dilator.

Other side effects of vaginal dilator therapy include mild discomfort. You should discuss your pain level with your therapist to make sure you are using the dilator correctly. Don’t continue using a dilator if you are experiencing significant pain.

Recovery and Outlook

How long do dilators take to work?

It depends. How long you need vaginal dilator therapy depends on your symptoms. You should arrange regular follow-ups with your healthcare provider and/or a pelvic floor physical therapist while you are using dilator therapy. Your healthcare provider/ physical therapist will help you determine how long you may need treatment.

You might wonder if this type of therapy is working for you, and you may feel embarrassed or have negative perceptions about using a device inside your vagina. You should discuss these feelings with your provider, as they could impact the success of therapy.

Try to be patient with yourself as you explore different options with your provider. They’ll work with you to find a treatment that allows you to experience comfortable intercourse.

Psychological therapy

Psychological therapy plays a crucial role in managing vaginismus by addressing the emotional and cognitive aspects of this condition. Let’s explore how psychological therapy can be beneficial:

Education and Psychoeducation:

  • Understanding Vaginismus: Psychoeducation helps individuals learn about vaginismus, its causes, and the physical and emotional factors involved.

Cognitive Behavioural Therapy (CBT):

  • CBT aims to identify and modify negative thought patterns related to sexual activity.
  • It helps individuals challenge irrational beliefs, reduce anxiety, and develop healthier coping strategies. By addressing fear, guilt, or shame associated with vaginismus, CBT promotes positive sexual experiences.

Desensitization Techniques:

  • Gradual exposure to sexual stimuli and vaginal penetration is a key component.
  • Therapists guide patients through a step-by-step process, helping them become more comfortable with the idea of penetration.
  • Desensitization reduces fear and anticipatory anxiety.

Relaxation Training:

  • Techniques such as progressive muscle relaxation and deep breathing help manage muscle tension.

Partner’s Counselling:

  • Involving partners in therapy fosters understanding and empathy. Partners learn effective communication, coping strategies, and ways to support each other during treatment.
  • Addressing relationship dynamics enhances treatment outcomes.

Addressing Emotional Barriers:

  • Therapists explore emotional barriers related to sexual intimacy.
  • Fear, past trauma, body image issues, or negative sexual experiences are discussed.
  • Identifying and processing these emotions is essential for progress.

How Dr Krishna Can Help:

As a highly experienced Pain Specialist, Dr Krishna is dedicated to providing compassionate care and effective solutions for patients with pelvic floor hypertonicity, vaginismus, and vestibulodynia. Dr Krishna offers a comprehensive evaluation to assess individual needs and develop personalized treatment plans. With expertise in administering botox injections, Dr Krishna can provide precise injections tailored to target specific muscles and alleviate symptoms, empowering patients on their journey to pain relief and improved quality of life.

Please email us for further details at if you are interested in having a consultation with Dr Krishna.