Vaginal stenosis is an abnormal condition in which the

vagina In mammals, the vagina is the elastic, muscular part of the female genital tract. In humans, it extends from the vestibule to the cervix. The outer vaginal opening is normally partly covered by a thin layer of mucosal tissue called the hymen ...

becomes narrower and shorter due to the formation of fibrous tissue. Vaginal stenosis can contribute to

sexual dysfunction Sexual dysfunction is difficulty experienced by an individual or partners during any stage of normal sexual activity, including physical pleasure, desire, preference, arousal, or orgasm. The World Health Organization defines sexual dysfunction as ...

dyspareunia Dyspareunia ( ) is painful sexual intercourse due to medical or psychological causes. The term ''dyspareunia'' covers both female dyspareunia and male dyspareunia, but many discussions that use the term without further specification concern the f ...

and make pelvic exams difficult and painful. The lining of the vagina may also be thinner and drier and contain scar tissue. This condition can result in pain during

sexual intercourse Sexual intercourse (or coitus or copulation) is a sexual activity typically involving the insertion and thrusting of the penis into the vagina for sexual pleasure or reproduction.Sexual intercourse most commonly means penile–vaginal penetrat ...

or a

pelvic exam A pelvic examination is the physical examination of the external and internal female pelvic organs. It is frequently used in gynecology for the evaluation of symptoms affecting the female reproductive and urinary tract, such as pain, bleeding, dis ...

. Vaginal stenosis is often caused by

radiation therapy Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is a therapy using ionizing radiation, generally provided as part of cancer treatment to control or kill malignant cells and normally delivered by a linear accelerator. Radia ...

to the

pelvis The pelvis (plural pelves or pelvises) is the lower part of the trunk, between the abdomen and the thighs (sometimes also called pelvic region), together with its embedded skeleton (sometimes also called bony pelvis, or pelvic skeleton). The ...

, an

episiotomy Episiotomy, also known as perineotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or obstetrician. Episiotomy is usually performed during second stage of labor to quickly enlarge the opening ...

, or other forms of surgical procedures.

Chemotherapy Chemotherapy (often abbreviated to chemo and sometimes CTX or CTx) is a type of cancer treatment that uses one or more anti-cancer drugs (chemotherapeutic agents or alkylating agents) as part of a standardized chemotherapy regimen. Chemotherap ...

can also increase the likelihood of developing vaginal stenosis. Vaginal stenosis can also result from genital reconstructive surgery in people with

congenital adrenal hyperplasia Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders characterized by impaired cortisol synthesis. It results from the deficiency of one of the five enzymes required for the synthesis of cortisol in the adrenal cortex. ...

Signs and symptoms

Common indicators of vaginal stenosis include pain and bleeding during sexual intercourse along with other types of

. This can lead to challenges such as difficulty engaging in intercourse and decreased sex drive. Severe forms of vaginal stenosis can be associated with a complete inability to participate in sexual intercourse.

Atrophy Atrophy is the partial or complete wasting away of a part of the body. Causes of atrophy include mutations (which can destroy the gene to build up the organ), poor nourishment, poor circulation, loss of hormonal support, loss of nerve supply t ...

, scarring, and damage to the vaginal tissue due to vaginal stenosis can lead to dryness, inflammation, and decreased elasticity of the tissue. Lasting effects of vaginal stenosis could include impacts on psychological well-being in addition to physical limitations. Symptoms can worsen from post treatment ovarian failure or menopausal status, leading to reduced lubrication and increased thinning of the vaginal tissue.

Causes

Radiation-induced

Uterine The uterus (from Latin ''uterus'', plural ''uteri'') or womb () is the hollow organ, organ in the female reproductive system, reproductive system of most female mammals, including humans that accommodates the embryonic development, embryonic an ...

vaginal In mammals, the vagina is the elastic, muscular part of the female genital tract. In humans, it extends from the vestibule to the cervix. The outer vaginal opening is normally partly covered by a thin layer of mucosal tissue called the hyme ...

anal Anal may refer to: Related to the anus *Related to the anus of animals: ** Anal fin, in fish anatomy ** Anal vein, in insect anatomy ** Anal scale, in reptile anatomy *Related to the human anus: ** Anal sex, a type of sexual activity involvin ...

rectal The rectum is the final straight portion of the large intestine in humans and some other mammals, and the gut in others. The adult human rectum is about long, and begins at the rectosigmoid junction (the end of the sigmoid colon) at the le ...

and

cervical cancer Cervical cancer is a cancer arising from the cervix. It is due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body. Early on, typically no symptoms are seen. Later symptoms may include abnormal ...

s are often treated with pelvic

(RT), most commonly

external beam radiation therapy External may refer to: * External (mathematics), a concept in abstract algebra * Externality In economics, an externality or external cost is an indirect cost or benefit to an uninvolved third party that arises as an effect of another party' ...

(EBRT) or

brachytherapy Brachytherapy is a form of radiation therapy where a sealed radiation source is placed inside or next to the area requiring treatment. ''Brachy'' is Greek for short. Brachytherapy is commonly used as an effective treatment for cervical, prosta ...

. Radiation-induced vaginal stenosis can be a side effect of treatment. It is one of the most prevalent side effects, affecting about one third of people undergoing pelvic

. Radiation-induced stenosis can be a late reaction to treatment. Damage to the vaginal

epithelium Epithelium or epithelial tissue is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. It is a thin, continuous, protective layer of compactly packed cells with a little intercellul ...

causes abnormal collagen production that leads to

atrophy Atrophy is the partial or complete wasting away of a part of the body. Causes of atrophy include mutations (which can destroy the gene to build up the organ), poor nourishment, poor circulation, loss of hormonal support, loss of nerve supply t ...

, loss of muscle, decreased blood flow, hypoxia, and

fibrosis Fibrosis, also known as fibrotic scarring, is a pathological wound healing in which connective tissue replaces normal parenchymal tissue to the extent that it goes unchecked, leading to considerable tissue remodelling and the formation of perma ...

Pallor Pallor is a pale color of the skin that can be caused by illness, emotional shock or stress, stimulant use, or anemia, and is the result of a reduced amount of oxyhaemoglobin and may also be visible as pallor of the conjunctivae of the eyes o ...

adhesions Adhesions are fibrous bands that form between tissues and organs, often as a result of injury during surgery. They may be thought of as internal scar tissue that connects tissues not normally connected. Pathophysiology Adhesions form as a natural ...

, and fragility can be observed along with loss of elasticity. These can all contribute to sexual dysfunction that affects more than half of gynecological cancer survivors. Some people who have reduced ovarian function and an estrogen shortage after RT can have an even thinner vaginal mucosal lining that worsens vaginal stenosis.

Risk factors

While the severity of vaginal stenosis depends largely on the type of

received, several risk factors can contribute to the development of vaginal stenosis. People over the age of 50 with

tend to have a higher risk of vaginal stenosis from

Tobacco use Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or simply released from the mouth, as is generally done with pipes and cigars. The practice is believed ...

is also associated with a higher risk of vaginal stenosis. There is also a high correlation between vaginal stenosis and vaginal

pallor Pallor is a pale color of the skin that can be caused by illness, emotional shock or stress, stimulant use, or anemia, and is the result of a reduced amount of oxyhaemoglobin and may also be visible as pallor of the conjunctivae of the eyes o ...

reactions, which is when the mucous membranes thin and dry out, leading to inflammation and fibrosis.

Surgical procedures

Several types of surgical procedure are hypothesized to cause vaginal stenosis.

Episiotomies Episiotomy, also known as perineotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or obstetrician. Episiotomy is usually performed during second stage of labor to quickly enlarge the opening ...

, which are surgical incisions sometimes used to assist childbirth, can lead to narrowing of the vaginal opening and long-term dyspareunia: there is approximately 13% chance of experiencing dyspareunia for at least 6 months after having undergone a routine episiotomy. When the tissue from the

does not heal properly, complications can include mucosal damage and scarring, which can contribute to the development of vaginal stenosis. Vaginal stenosis is the most common post-operative complication in people with

who have genital reconstructive surgery in infancy or childhood. Vaginal stenosis can be an immediate complication or may arise later in

adolescence Adolescence () is a transitional stage of physical and psychological development that generally occurs during the period from puberty to adulthood (typically corresponding to the age of majority). Adolescence is usually associated with the t ...

. Additionally, in people undergoing a male-to female gender affirmation surgical procedure, such as

vaginoplasty Vaginoplasty is any surgical procedure that results in the construction or reconstruction of the vagina. It is a type of genitoplasty. Pelvic organ prolapse is often treated with one or more surgeries to repair the vagina. Sometimes a vaginoplas ...

, vaginal stenosis has been show to be a common post-surgical complication.

Diagnosis

There are currently several grading scales that exist to assess vaginal stenosis but none have been well established. Two common grading scales are the

National Cancer Institute The National Cancer Institute (NCI) coordinates the United States National Cancer Program and is part of the National Institutes of Health (NIH), which is one of eleven agencies that are part of the U.S. Department of Health and Human Services. ...

's Common Terminology Criteria for Adverse Events (CTCAE) v4.0 and the Late Effects in Normal Tissues-Subjective, Objective, Management and Analytic Score (LENT-SOMA). The CTCAE v4.0 assesses vaginal

strictures A stenosis (from Ancient Greek στενός, "narrow") is an abnormal narrowing in a blood vessel or other tubular organ or structure such as foramina and canals. It is also sometimes called a stricture (as in urethral stricture). ''Stricture' ...

based on three grades based upon shortening or narrowing of the vagina, its interference with physical examination, and its interference with use of tampons or sexual activity. However, this scale is not specific to just vaginal injuries alone. The LENT-SOMA grading scale for vaginal stenosis is based on the assessment of subjective symptoms, analytical tests, and observed clinical manifestations. This scale was invented by the European Organization for the Research and Treatment of Cancer (EORTC) along with the Radiation Therapy Oncology Group (RTOG) from the US. The lack of a well-established grading scale has potentially led to poor vaginal dilator therapy and long-term vaginal stenosis. Vaginal stenosis is most often diagnosed with subjective parameters. These subjective parameters in combination with the variety of different grading scales used, cannot be interchanged in clinical practice. This makes it harder to properly diagnose the condition and establish a standard treatment.

Treatment

Vaginal Dilator Therapy (VDT)

Stenosis of the vagina is typically treated with

vaginal dilator A vaginal dilator (sometimes called a vaginal trainer) is an instrument used to gently stretch the vagina. They are used when the vagina has become narrowed ( vaginal stenosis), such as after brachytherapy for gynecologic cancers, and as therapy ...

therapy (VDT), but evidence is lacking for its efficacy. Vaginal dilators are smooth, cylindrical-shaped devices that promote stretching and relaxation of the vaginal tissue. Vaginal dilator therapy requires a consistent routine and may cause physical and/or psychological discomfort, which makes adherence to treatment difficult. It may be difficult to evaluate the efficacy of vaginal dilation therapy as measures of

sexual function Sexual function is how the body reacts in different stages of the sexual response cycle, or as a result of sexual dysfunction. Relevant aspects of sexual function are defined on the basis of a modified version of Masters and Johnson's work. The aspe ...

and

quality of life Quality of life (QOL) is defined by the World Health Organization as "an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards ...

are hard to quantify and control for. Optimal duration of vaginal dilator therapy and its improvements on sexual function and cancer-related outcomes remain unclear. Although there is no high level evidence, many guidelines and reviews suggest the use of vaginal dilator therapy after pelvic radiation therapy. It is believed that this therapy stretches vaginal tissues and the vaginal canal, leading to

epithelial Epithelium or epithelial tissue is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. It is a thin, continuous, protective layer of compactly packed cells with a little intercellula ...

cell growth, and decreasing potential circumferential

. Some studies have even suggested correlations between VDT and preventing risk of severe vaginal stenosis. Some studies have suggested positive patient outcomes when VDT was coupled with greater length of dilation duration. Using VDT with meditation and soothing music has also been shown to increase effectiveness, though evidence for this is not high grade. Regular psychosocial support and regular follow up visits should occur in order to support this therapy and optimize the treatment.

Other treatments

Recent treatment advances include local

hyaluronic acid Hyaluronic acid (; abbreviated HA; conjugate base hyaluronate), also called hyaluronan, is an anionic, nonsulfated glycosaminoglycan distributed widely throughout connective, epithelial, and neural tissues. It is unique among glycosaminoglycans ...

application,

laser therapy Laser medicine consists in the use of lasers in medical diagnosis, treatments, or therapies, such as laser photodynamic therapy, photorejuvenation, and laser surgery. Lasers Lasers used in medicine include in principle any type of laser, but ...

, and

vaginal estrogen Vaginal estrogen is a form of estrogen that is delivered by intravaginal administration. Vaginally administered estrogens are thereby exerting their effects mainly in the nearby tissue, with more limited systemic effects compared to orally adminis ...

treatment but further investigation is needed.

Hyaluronic acid Hyaluronic acid (; abbreviated HA; conjugate base hyaluronate), also called hyaluronan, is an anionic, nonsulfated glycosaminoglycan distributed widely throughout connective, epithelial, and neural tissues. It is unique among glycosaminoglycans ...

helps treat vaginal stenosis by retaining moisture to promote vaginal tissue repair. There are currently no known contraindications and is commonly used in clinical practice due to its high safety profile.

Laser therapy Laser medicine consists in the use of lasers in medical diagnosis, treatments, or therapies, such as laser photodynamic therapy, photorejuvenation, and laser surgery. Lasers Lasers used in medicine include in principle any type of laser, but ...

has been shown to improve symptoms for people with menopausal genital atrophy, but there are currently not many studies on its effect on people with radiotherapy-induced vaginal stenosis. A 2020 study demonstrated an improvement in vaginal length as well as the Vaginal Health Index, though more studies are needed to establish efficacy. There are limited studies around

therapy in people with

radiotherapy Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is a therapy using ionizing radiation, generally provided as part of cancer treatment to control or kill malignant cells and normally delivered by a linear accelerator. Radia ...

-induced vaginal stenosis due to concerns around an increased risk of

tumor A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...

recurrence. Similarly, there has been one study conducted that suggests people treated with high dose radiation therapy had a lower likelihood to respond to estrogen treatment.

Epidemiology

The reported incidence of

-induced vaginal stenosis varies widely, ranging from 1.2% to 88%. This is due to past studies being limited to small groups as well as variability due to personal factors such as: type of cancer, age, dose and mode of radiation therapy (

EBRT External beam radiotherapy (EBRT) is the most common form of radiotherapy (radiation therapy). The patient sits or lies on a couch and an external source of ionizing radiation is pointed at a particular part of the body. In contrast to brachyt ...

). In addition, symptoms may not occur until a year after radiation therapy and can increase in severity over the course of three years. Vaginal stenosis may also be underreported due to stigma and discomfort around discussion of

. The estimated incidence of vaginal stenosis in people undergoing

is 50% for people with

endometrial cancer Endometrial cancer is a cancer that arises from the endometrium (the lining of the uterus or womb). It is the result of the abnormal growth of cells that have the ability to invade or spread to other parts of the body. The first sign is most o ...

and 60% for people with

. The incidence of vaginal stenosis in people undergoing

for

anal cancer Anal cancer is a cancer which arises from the anus, the distal opening of the gastrointestinal tract. Symptoms may include bleeding from the anus or a lump near the anus. Other symptoms may include pain, itchiness, or discharge from the anus. ...

colorectal cancer Colorectal cancer (CRC), also known as bowel cancer, colon cancer, or rectal cancer, is the development of cancer from the colon or rectum (parts of the large intestine). Signs and symptoms may include blood in the stool, a change in bowel m ...

is not well-reported, but is estimated to be up to 80%.Miles T. International guidelines on vaginal dilation after pelvic radiotherapy. Brook Hill, Woodstock, Oxon: Owen Mumford Ltd. 2012.

References

{{Female diseases of the pelvis and genitals , state = collapsed Noninflammatory disorders of female genital tract Women's health