Table 1 Description of the sexual rehabilitation intervention modules

Module 1: Brief sexual history

This module describes how the nurse can question the patient in-depth about sexual problems on various domains of sexual functioning, including sexual interest/arousal, orgasm, pain and sexual satisfaction. It also covers psycho-education about sexuality and the sexual response curve [33] and provides information about frequently occurring sexual problems and solutions.

Module 2: Pain during intercourse

This module includes practical guidelines that the nurse can provide regarding pain during intercourse after radiotherapy-, with referrals to module 3, 4, 6 and 7, and explains how to provide psycho-education about the circular model of dyspareunia [34], which is based on a cognitive behavioural framework.

Module 3: Vaginal dryness and health

This module provides the nurse with instructions on how to give advice with regard to treatment of vaginal dryness, pain or irritation. It also includes information regarding vaginal health, such as the use of vaginal creams, avoidance of scratching in response to irritated skin or avoidance of washing with soap.

Module 4: Alternatives for intercourse

The exercise in this module helps the woman and her partner (if available) to explore and discuss non-penetrative alternatives for sexual intercourse.

Module 5: The partner and possible sexual problems

This module can be consulted by the nurse when partners experience temporary sexual problems, such as erectile dysfunction during intercourse. The module also includes a reference to module 1.

Module 6: Gradual exposure towards sexual intercourse

The aim of the steps in this module, which are based on a cognitive behavioural gradual exposure therapy for Genito-Pelvic/Penetration Disorder [29], is to learn the woman and her partner how to re-engage in sexual intercourse. The steps include: touching of the vaginal opening with the erect penis without penetration, stepwise vaginal insertion of the erect penis without moving, and vaginal insertion of the erect penis with moving.

Module 7: Pelvic floor exercise

This module includes several pelvic floor relaxation exercises for women who experience tension in the pelvic floor muscles.

Module 8: Difficulties with dilator use at home

This module is suitable for women who experience problems with dilator use and who already practiced under supervision of a nurse (see module 9) or for women who do not want to practice under supervision. This module provides the nurse with instructions on how to give specific advice on how to overcome experienced difficulties, after first exploring the problems during dilator use (e.g. pain/discharge, loss of blood or difficulties with inserting the dilator).

Module 9: Using dilators under supervision at the outpatient clinic

This module focuses on women who experience fear with regard to dilator use or who experience difficulties when using vaginal dilators, due to for example tension of the pelvic floor. The nurse-led session is based on therapist-aided exposure therapy for Genito-Pelvic/Penetration Disorder [29]. The goal is to reduce fear of dilator use by using a stepwise exposure session in which the woman - who performs the vaginal dilation by herself - is facilitated by the nurse. During the session, tips are given with regard to a correct and more comfortable use of the dilators. Furthermore, the nurse helps to evaluate and articulate any unhelpful cognitions about what could (or could not) occur during dilator use. In these instances, the exposure is used as a behavioural experiment, to test the tenability of these cognitions. The module also includes advice on how to handle problems that might occur during practicing at home.

Module 10: Exploring and resolving ambivalence with regard to dilator use

The aim of the exercise in this module is to motivate the woman for dilator use, by acknowledging, exploring and resolving ambivalent feelings towards dilator use by motivational interviewing technique [35]. By exploring pros and cons of both dilator use and no dilator use, the woman can be supported in making an informed choice about dilator use. If she decides to use dilators, problems with dilator use are discussed in more detail and how to overcome them. If a woman decides not to use dilators, tampons covered in petroleum jelly (Vaseline) are recommended and guidelines on how to use these are provided to the woman (see module 11).

Module 11: Petroleum jelly (Vaseline) tampons

This module follows module 10, when a woman decides not to use dilators. The module covers guidelines on how to use tampons covered in petroleum jelly (Vaseline).