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Botox Injections for Sexual Pain, Vaginismus and Vulvodynia.

Botox has been proven to be a safe and effective treatment for sexual pain, vaginismus and more recently also for vulvodynia.   Depending on the diagnosis and cause of the pain, it is used in conjunction with various other medical treatments, physiotherapy, counselling, hypnotherapy and sex therapy.  We do not recommend it as first line therapy for any form of sexual pain, but we have helped many patients by adding Botox to their treatment plan.  I (Dr Elna Rudolph) have presented the results of those patients who needed Botox for the treatment of their sexual pain at the International Conference of Sexual Medicine in Portugal.  My research from our clinic shows that our patients perceive Botox to be a safe and effective treatment for sexual pain, vaginismus and vulvodynia.  I have also found that it works exceptionally well for couples in unconsummated relationships and for people who cannot use tampons.


A few facts about Vaginal Botox:

  • Botox does not take away the sensation around your vagina.
  • Botox does not change the appearance of your vagina or vulva.
  • The procedure we use only relaxes the small muscles around the vaginal opening that makes penetration difficult or irritates the nerves and cause burning and stinging. We only use Botox in the external pelvic floor muscles.  It therefore does not help for deep pelvic pain, only pain on insertion. 
  • In eight years of using Botox as treatment, we have never had a patient or partner who complained that the vagina was too big or too relaxed after the procedure, or that it influenced their ability to experience pleasure during foreplay or intercourse. It just makes it less sensitive to pain and to being stretched.
  • Complications such as a leaking bladder or leaking stools have never happened in our clinic and it is extremely unlikely to happen due to the technique we use. We also use real Botox that does not have a tendency to spread to other areas. These are however two of the listed possible complications of Botox.  If either of these complications do occur, it is reversible after three to four months when the Botox begins to work out of your system.
  • The procedure is performed under conscious sedation in our procedure room at the practice.


The Botox will only begin to take effect after ten to fourteen days.  It will then work for three to four months.  If you have established regular intercourse during this time, it is highly unlikely that you will need to repeat the Botox procedure.  Less than 10% of our patients have had to repeat the procedure.


I cannot guarantee that Botox will make your sex completely pain-free or take away your vulvodynia, but if I recommended it to a patient it is because I believe there to be a very good chance that it will make a significant difference.  If I could offer it for free, I would recommend it to 90% of my pain patients.


If you have never been able to insert the number 5 dilator, please talk to me about signing consent for a partial hymenectomy to be performed during the Botox procedure.  In some cases, the hymen may be too tight, and the number 5 dilator cannot be inserted, despite relaxing the muscles completely.  In these cases, it is advisable to make a few small incisions in the hymen.  We do not use any stitches and there is usually minimal bleeding (bleeding as much as during a normal menstrual cycle is nothing to worry about).  The bleeding usually stops within a day or two, but some spotting might occur when the dilator is inserted.  This usually also stops within a week after the procedure.  If you aren’t able to dilate after a partial hymenectomy, the slits may heal with scar tissue formation and the procedure will have to be repeated. 


You can also have a Mirena inserted or have a pap smear done during the procedure.  Please discuss this with me before the procedure and remind me about it on the day of your procedure.


What to expect from the procedure:


On arrival, you will be given a local anaesthetic cream to be applied around your vaginal opening.  You should arrive at least 15 minutes prior to your scheduled appointment to allow enough time for the anaesthetic cream to take effect.  


If you are having your Botox procedure done by me in Bryanston, you will first meet with Dr Jeanne Aspeling, who will be performing your conscious sedation.  This is a very light form of anaesthesia where you will be partially awake and aware, but you will not have any memory of the event.  It helps you to relax enough to allow me to perform the procedure.


I will then clean the area and inject 10 ml of a long-acting local anaesthetic into your external pelvic floor (around the outside of your vaginal opening).  These injections are somewhat painful.  I will then inject 50 units of Botox, mixed with saline, into the affected muscles. You will receive between 20 and 30 injections in total, so you can expect some bleeding and bruising.  The sensation will come back later during the course of the day when the local anaesthetic wears off, and the Botox will take up to fourteen days to start working.


There will be no pain initially, but as soon as the anaesthetic starts to work out of your system, you may experience pain.  Many patients contact me after the procedure, worried because it feels like the pain is worse than before the procedure.  This is just the body’s reaction to the minor trauma caused by the injections.  The Botox will start working in ten to fourteen days.  Just use the biggest dilator you can insert and take a break for a day if you have to. 


Continue to use your Fluconazole weekly to prevent candida infection and contact the practice immediately if you think you have developed an infection or any other complication.




You have to spend as much time as possible with the largest dilator inside you.  Start as soon as you get home and stay in bed for the rest of the day and night.  Over the weekend you will be able to resume normal activities, but it is still advisable to keep the dilator in for as many hours as possible.  Put a heavy book or other object between your legs to keep it in place if it keeps slipping out.  We suggest that you sleep with the dilators during this two-week period, if you are able to.  If it becomes uncomfortable during the night, you can remove it.  If it becomes too painful to use your dilators, especially if you have pain for an extended period after removing it, take a break for a day before trying again.


You may want to get a stub dilator to make it easier to sleep with your dilator or to walk around with it inside your vagina.  They are the same girth as the normal dilator, but they are shorter, and the outside is oval shaped to make it more comfortable between your legs.  They are available in sizes 3 to 6 and can be purchased at the practice or from www.mysexualhealthSHOP.co.za.


If we have been treated with Botox for vulvodynia, you may be too tender and irritated to keep the dilators in for such long periods.  Just do as much as your body allows you to do.


Please bring your dilators with you on the day of the procedure as I may need to use them during your procedure.


The Botox will take at least ten to fourteen days to start working.  Please do not attempt intercourse before then and also not before you are able to insert the number 5 dilator.  If you feel ready, please do attempt intercourse before you see me for your two-week follow-up. Please follow the steps in the “Penetration Programme” initially – you can request the programme to be emailed to you by our staff. 


I would like to see you again two weeks after your procedure.  Please arrange the follow-up appointment with my staff when you book your Botox appointment to avoid disappointment. The follow-up appointment is included in the cost of the Botox and can be claimed from your medical aid (the amount that your medical aid pays out for a normal GP consultation).

I recommend that you see your physiotherapist shortly before you see me for your follow-up.  It helps to get rid of the tightness around the muscles that may still be pinching the nerves.  Since Botox only helps for superficial pain, you may need to continue seeing the physiotherapist for deeper pain or other problems.

After your two-week follow-up, if you are having pain-free intercourse, I would like to see you again between six weeks and six months, depending on your situation and condition.  I will then evaluate the need to repeat the procedure and confirm that all your sexual problems have been resolved.  Although most of our patients go on to have pain-free or much more comfortable sex after the procedure, up to half of our patients still experience some form of sexual dysfunction a few months or years after the procedure.  Please be aware of this.  You may still need to get additional help for your libido, for instance, or any difficulties with orgasm, any fears around sex or any relationship issues.  Remember that we have a comprehensive team of experts who will be very happy to assist you.  You are welcome to arrange a follow-up appointment with me at any time.


The best time for performing the Botox procedure is on a Friday, or any other day which would allow you to keep activity to a minimum for at least two days following the procedure, mostly because we would like you to have as much possible time to dilate.  I will give you a certificate for sick leave if you need it.


Some medical aids pay a portion of the procedure.  You are welcome to contact the practice for a quotation to send to your medical aid.


To make a booking:


  1. Booking your Botox procedure is a sensitive matter, so please call my office on 011 568 4844 to book your appointment. I am usually fully booked a few weeks ahead so book as early as you can.
  2. If you would like to have a Mirena® fitted at the same time, please inform my staff. We do keep the Mirena in stock, and you don’t need a prescription for it.  If you have the Mirena fitted during your Botox procedure, you will only pay extra for the Mirena device – the procedure will be included in the Botox price, making it possible for you to claim more money back from your medical aid.
  3. You will be asked to pay the full amount at least four days prior to your procedure (we do not keep Botox in stock – we order it as soon as your appointment has been confirmed and paid).

Please be sure to arrange for someone to collect you from the procedure room. Under no circumstances will you be allowed to drive during the first 8 hours after receiving the conscious sedation, and you should also not be left unaccompanied for the rest of the day.

If you experience any complications due to the procedure, please email me immediately (elna.rudolph@mysexualhealth.co.za).  Pain, bleeding and bruising are normal for the first few days.  Infection and problems with your bladder or bowel are unexpected problems, so I would definitely want to know about them.


Written by Dr Elna Rudolph