Post Opp Guide

This file contains 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.

The document was set up under WordPerfect Courier 10 cpi with
left justification and then the translation to ASCII made. 

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.

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PATIENT INSTRUCTIONS (after Biber, Hunt, Seghers)
Dilate five times per day, 15 to 20 minutes each time, utilizing
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 utilizing the adjustable dilator and squeezing
it down, ribs are formed on the dilator, so it is very important
to utilize 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
forth week. 
The easiest place to get a firm dilator is to go down to any
adult bookstore and get a plastic dildoe, 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. Utilize 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 gonorrhea, 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....

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Patient Comments:

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

1: 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. 


2: 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.  

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 goes not have unlimited space all to
itself within the pelvis.  It has neighbors 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 MD is worth consulting.

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:

 A: Urethrovaginal-Between the urethra(urinary tract) and vagina. 
 B: Vesicovaginal-Between the bladder and the vagina.
 C: 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, fecal matter from the rectum can 
asily 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.


3: 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 localized infection should
be investigated, or the dilator examined.  The key is to be
observant of pain and have an MD 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.  


4: 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
moisturizing 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 arational
idea.  Emollients are not inherently contaminated, but some
bacteria favor them as a growth media under rare circumstances.

For those women with plans for intercourse, keeping a tube of
vaginal lubricant handy is not a sin.  Many older women 
experience vaginal dryness and the fluid has that as a primary
aid there also.  It is not an auncommon item.  For anyone that is
extra cautious, consult your surgeon or MD about using
contraceptive foam for the special occasion.  For the picky lady,
the foam applicator does make a handy device for inserting some
lubricant into the vagina before dilating. 
 
In one recent visit to my endocrinologist, she discussed the use
of PREMARIN cream for occasional use.  Mead-Johnson Laboratories
also produces an estrogen cream under the trade name ESTRACE
VAGINAL CREAM.  There are estrogen receptors in the "NEW" vaginal
tissue that will respond favorably and specific mucosal cells
will proliferate.  There is no guarantee that extensive natural
lubrication will be achieved.  The cream has been used routinely
by women to improve the vaginal tone and elasticity.  It is also
considered helpful in it's reduction of vaginal atrophy. 
Consultation with the surgeon or MD must be considered since the
cream is available by prescription only.


5: DILATORS: OK, so we all know what they're called.  Like the
text suggests, the local adult bookstore can be a nice place to
shop. For those who feel a little squeamish about the romp,
there's always mail order. Yes, where would we all be without it. 
This is not an endorsement but one company that offers a
selection by mail is:

Lawrence Research Group, Inc.
P.O. Box 319005
San Francisco, CA 94131

I'm sure there are others.  Most surgeons provide a dilator to
start with.  Dr. Seghers was kind enough to do so.  It was a dual
purpose type that had diameters of 21mm (12/16= 3/4 inch) on one
end and 22mm (13/16 inch)  on the other.  It was metal, bright
and silvery like it was plated or stainless steel; I called it
"the silver bullet".  For those who swear "at" metric values
instead of by them, I've included conversions.  That value is
about half the diameter suggested in the text.  However, one
needs only to look at a 4cm dilator (that's 40mm = about 1 1/2
inch) to see that the width might take some getting used to. 
Being a little conservative in choosing a dilator might be worth
it. Going from a 2cm to a 4cm too quickly might do some damage
too.  It seems fairly obvious that the continuity of dilation
will yield the best results and avoidance of a vaginal tear
should be considered.  The key here is to experiment with one or
two different dilators with comfort and safety in mind. Anyone
that has plans to maximize depth and width should include plans
to be diligent and expect to shop for the tools necessary to
produce good results.  Maybe even give them names like I did.
Generally there are nerves around the vaginal entrance and inside
the pelvis that should indicate tissue stress.  Consider making
sure that the dilator is clean before use.  For one that's "old
faithful", clean and ready for use is the best way to keep a
tool.  Sometimes catalog shopping makes for difficulty in choice
of materials.  Since lubricants are to be used and frequent
cleanup is mandated, inspect the dilator for cracks or tears or
any other area that can accumulate water and lubricant residue. 
A hollow dilator might be a little softer, but leaks to the
inside make a nice route for bacteria to grow and eventually
escape.  There are an uncountable number of different bacteria
that could be cultured inside and cause an infection later when
vaginal contact is made.  Using a finger for initial dilation is
mentioned above.  It's not a difficult thing and doesn't produce
much depth, but it helps one understand where the muscles are,
and relative positioning of some parts.  Again, using a latex
glove is optional, but they are inexpensive at 100 count for
about $15 from the right source.  Sometimes a family dentist or
MD will supply them and just add on a fee, also consider asking
your electrologist to buy them for you, then you have a very
convenient source.  Check the drug store also.  Use is an option
and again, chat with a couple of professionals and then make your
decision.  


6: FEMININE HYGIENE.  This little item probably remains one of
the most personal topics encountered in a female's routine.  My
initial comments are that if you ask 7 different people, you'll
get 7 different answers.  When questioned about the frequency of
douching, my therapist suggested every couple of weeks, my
endocrinologist recommended once per week, a female psychologist
friend suggested twice per week, and the text above considers 
at least once per day acceptable.  This doesn't even include the
question of "what with".  Here again, the drug store usually has
a shelf full of items that safely interact with vaginal tissue.
The text above suggests the use of white vinegar.  This item is
ages old and works very well for some women.  The acidity is
gentle enough to destroy some bacteria and a little warm water
helps with gentle cleansing.  The frequency of douching ends up
being a matter of individual preference and convenience.  Just
some warm shower water every three days worked out well for me. 
I have a known allergy to vinegar and had to avoid it.  There
have been occasions where I was more active over a weekend and a
very faint odor was nature's way of saying, do it now.  In many
parts of the world, the aromatic scent of the human body is
considered acceptable.  In others, it's considered noxious.  I
agree with the latter view.  A good rule of thumb is that where
there's odor, there's bacteria growing in excess.  It is
impossible to remove all bacteria from nooks  in the body, but
simple cleanliness must be considered to keep the body in good
health.  It is a well known fact that different bacteria favor
different  parts of the body. Sometimes a small amount of
bacteria on the hands might proliferate in the warm moist area
common to the vagina.  Some infections can only be destroyed with
antiseptic solutions, and the only means of application is by
douching. The subject ends up with simple wisdom indicating that
some might be better than none.  As a matter of practicality, it
will eventually become necessary, so expect to have to deal with
douching.  The vagina is not a simple biological item.  It has
the characteristic of being considered an internal organ with
secretory function yet must is easily accessed by sources
exterior to the body.  It is technically unique and a marvel like
may organs that compose our bodies.

Another less discussed item is the use of a feminine deodorant.
There are several types available all with different ingredients.
An old favorite of many women is a product know as NORFORMS.  In
addition to a very soft water based wax, it contains lactic acid. 
This ingredient is a very common item found in milk.  It is
beneficial to the skin and keeps bacteria at bay.  Use of this
product might be worth considering one day per week in between
dilations.  I found it very fragrant, non irritating, and works
well after a douche.  It's not a necessity, just an extra which
kept me fresh on some long days.  It's impossible to get into a
vagina even with the tweeze type applicators.  Success came by
scooping up some under a long fingernail and gently making a
finger insertion.  There were some considerations.  Even though
my nails are long, they are not sharp.  I also use a latex exam
glove when I do so.  This would essentially keep any bacteria
that might be found under a nail inside the glove, and the
deodorant can be spread internally with minimal cleanup required
for the hands.  This may sound like overkill, but latex gloves
are easily obtained, and come in handy for keeping my hands free
of bacterial contact when I do general bathroom cleaning.  Even 
moist hair around a tub wall creates a banquet for staphylococcus
bacteria that enjoy the hydrated protein growth media.  In the
case of use on my personal parts, they add a touch of smoothness
to the hand for an occasional vaginal contact.  Some women who do
have sharp nails would best give this matter some thought.  Nail
fungus favors anaerobic conditions and might be easily
transmitted into vaginal tissue if torn unthinkingly.  A little
extra care can save some medical bills from being written.   

7: CLOSING: I hope that you found some of this information
helpful.  It's not a textbook, but it came from asking a few
questions here and there to my female friends, therapists, and
MD's.  Some shopping here and there only took a few extra minutes
to read a label in a store or read the ad in a magazine twice 
instead of passing it by.  The goal was to learn about me and
make me better with a little experience and some help from
professionals.  It might seem like a section on  "actual results"
might be in order, but I haven't accumulated the data for that
yet.  Each person has their own goals in mind and limits to what
results they are satisfied with.  The fact is that dilation is an
important part of the healing process.  It promotes self
awareness and is simply another part of the improvement of self
that was desired from the start.  There is no doubt that it is an
intimate action.  Dilation can get to be a neglected action
because of boredom or its involvement with "less visible parts". 
It need not be.   Think of it as special like polishing our own
unique piece of silverware.  A little reward of tenderness for
what makes us women (at least legally) is worth the time, and so
is a nice warm bath afterwards. 

TJ 6-12-92