Expanding treatment horizons for vaginal stenosis

Vaginal stenosis (VS), a narrowing and/or shortening of the vaginal canal, is a common adverse event associated with pelvic radiotherapy and other therapies used in the management of gynecologic and pelvic gastrointestinal malignancies.¹ While it has been nearly 50 years since vaginal dilators were introduced as a therapy to decrease VS, the medical community still knows very little about the potential impact on long term outcomes.

A recent systematic review was conducted by Haddad et al looking at articles published over the last 10 years focused on the use of vaginal dilators to treat VS. After eligibility criteria were applied, 28 articles were examined.

Despite the depth of research, the authors noted an overarching challenge in gaining global insights on best practices in vaginal dilator use due to the inconsistency in study design, lending to a breakdown in viable comparative data.

Common study variables included fluctuating cohort sizes, measurement of vaginal volume, assessment of partner support, assessment of sexual enjoyment or dyspareunia, menopausal status at the time of the recommended vaginal dilation therapy, and use of a control group. An additional challenge involved use of compliance with vaginal dilator therapy; Only 18 of the 28 studies included this metric in their analysis.

The inconsistency in study design echoes previous findings from other review articles. A 2019 review concluded that monitoring for an extended time period seems to be critical to proper assessment of the effects of vaginal dilators in patients with VS as biological changes alter VS for years following treatment.²

Clinicians are presented with numerous barriers to achieving improved health outcomes. For patients dealing with VS, diagnostic assessments are primarily subjective, and there is a significant lack of uniformity in evaluation. According to the review by Haddad et al, whether it be interview (face-to-face or via phone/video) or use of a validated assessment tool such as the Female Sexual Function Index questionnaire, the overall lack of objective standardized testing can impact diagnosis of VS and available long-term data outcomes.

Patient adherence is often problematic and has been shown to significantly decline over time. While strategies such as regular sexual intercourse or vaginal dilator therapy have been recommended to prevent or minimize VS, several issues impact adherence. This review found that patients continue to be challenged with issues such as vaginal dilator frequency of use, duration of dilation, and incorporation of vibration in tandem with dilation.

There are also psychological and emotional components that influence the implementation of vaginal dilator therapy. This invasive method of improving vaginal health must take into consideration the patient’s overall interest in sexual activity, their existing or needed support system, and potential shame due to pre-existing taboos about objects utilized in a sexual manner.

“Women's nonadherence to dilator use may reflect an attempt to avoid unwanted negative feelings such as emotional and/or physical pain, or to reduce humiliation and shame, thereby preventing further damage to their view of self,” the study authors wrote. “There is a need for future studies on whether an objective demonstration of stenosis or educational programs can increase compliance, or whether dilation can actually prevent stenosis and how often [vaginal dilators] must be used.”

Clinical feedback has also been observed to play a role in adherence rates. Some studies found that women were motivated to incorporate use of a vaginal dilator into their treatment plan when their doctor examined them and gave positive feedback. On the flip side, data showed that they were discouraged if their doctor did not talk about dilator use and follow-up pelvic examinations were uncomfortable.³

There are many considerations for the ob-gyn community for treatment for VS, and future research must become more targeted and standardized. The expansion of study groups to include high-risk populations, address socioeconomical disparities, and involve patients with varying cancers and a high rate of VS after treatment are necessary to expand knowledge, according to the study authors.

Assessment standardization will further assist in the identification of future improvements in practice that positively impact patient care.

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References

1. Haddad NC, Soares Brollo LC, Pinho Oliveira MA. Diagnostic methods for vaginal stenosis and compliance to vaginal dilator use: A systematic review. J Sex Med. 2021;18:493e514.

2. Damast S, Jeffrey D, Son C, et al. Literature review of vaginal stenosis and dilator use in radiation oncology. Pract Radiat Oncol. 2019;9(6):479-491.

3. Bakker RM, Vermeer WM, Creutzberg CL, Mens JW, Nout RA, Ter Kuile MM. Qualitative accounts of patients’ determinants of vaginal dilator use after pelvic radiotherapy. J Sex Med. 2015;12:764-773.