Other specialized medical options: vaginal dilations

VAGINAL DILATION

Vaginal structure
The degree of vaginal agenesis (partial or total absence of the vagina) is variable, and there are different medical and surgical treatments available. The vagina, especially in young people, is made up of elastic tissue which, if subjected to adequate and constant pressure, can be modelled until it becomes long enough to allow penetrative vaginal sexual intercourse. The vaginal wall, in fact, is made up of 3 layers, each of which contains elastic fibres or smooth muscle cells that are easily stretchable.

Medical treatment of vaginal agenesis 
According to the most recent international recommendations, if the person with postpubertal vaginal agenesis is interested in penetrative vaginal intercourse, the first line of treatment is the non-surgical option of vaginal dilation, since it is successful in over 90-96% of cases. Treatment must be personalized and proposed or started when the person has the desire and the disposition to undergo it. A psychological support path should always be offered as well.

What do vaginal dilations consist of? 
Vaginal dilations involve the use of a special kit, easily found in pharmacies or online. This kit contains dilators of increasing calibre and length. After being trained by expert doctors, the person will continue to use them at home, by themselves. Water-based gel or lubricants are prescribed to facilitate insertion of the dilator.

Doctors recommend the gynaecological position, possibly supporting the lumbar area. The person must be taught to locate the vaginal introitus (the entrance to the vagina) to avoid inserting the dilator in the urethral opening and, causing injury to the urethra. For effective use, the dilator must be inserted into the vaginal dimple with a direct inclination towards the rectum/coccyx, following the normal course of the vagina. The pressure exerted should cause a bearable “discomfort”. When the “discomfort” subsides, the person must switch to a larger dilator.

There is no standard schedule, but the final result actually depends on how often the dilators are used: constant use, even daily, leads to better results in a shorter time (3-6 months). Physicians recommend performing these exercises 1-3 times a day for 10–30 minutes (frequency is considered to be more important than duration). 

Once a satisfactory vaginal length is reached, it is just as critical to maintain it. Penetrative sexual activity helps to keep and improve results. 

Support from the medical staff is crucial; they should be available to shed any doubts or for repeated training to help the person face this intimate and delicate path fearlessly. It is also essential to count on psychological support.

Definition of success rate
As we said before, the available literature shows that vaginal dilations can achieve anatomical and functional success in 90-96% of cases. Although some studies define a vaginal length of at least 6 cm as an anatomical success, the best definition of success is a vagina that guarantees comfortable penetrative sexual activity. Again, the best benchmark is the person’s own comfort and satisfaction. As there is no specific length associated with functional success, people with even minimal vaginal dimpling should be encouraged to use dilation as a first-line treatment.

Many factors affect the success rate of the technique. The person must be strongly motivated and start the process of vaginal dilation only when they are emotionally and physically ready. They should be supported by a reliable, trained, multidisciplinary team that will provide proper counselling and instruction on the use of vaginal dilators. There are multiple reasons for dilation failure, and most of them are not anatomical. Low motivation, sociocultural factors, limited understanding of diagnosis and anatomy, young age, inadequate knowledge of the dilation process, lack of privacy/comfortable setting, and limited ability to attend follow-up visits can negatively impact outcomes.

Complications
Reported adverse effects of vaginal dilation are rare (< 1% of cases) and include urinary symptoms (urethritis, cystitis, urinary incontinence), bleeding (vaginal abrasions/urethral lesions), and pain. If these symptoms occur, a gynaecological examination is needed to assess the lesions and retrain the person on the use of dilators. Disorders of micturition, and vaginismus should also be evaluated. Solutions are easy to carry out and include resting until the lesion heals, using more lubricant, switching to a softer dilator. 

Advantages and disadvantages
No actual disadvantages of conservative therapy have emerged to date: compared with surgery, it is unequivocally safer, since surgery of any kind always entails risks. In this case, specific complications are vesicovaginal/rectovaginal fistula, bladder perforations, keloid scars and abnormal healing of the skin graft site. There have also been reports of malignancy in surgical neovaginoplasty, but never in the case of a non-surgical approach.

Bibliography
Committee on Adolescent Health Care. ACOG Committee Opinion No. 728: Müllerian Agenesis: Diagnosis, Management, And Treatment. [Abstract]. Obstetrics and gynecology. 2018 Jan;131(1):e35-e42
Callens N et al. An update on surgical and non-surgical treatments for vaginal hypoplasia. Human  reproduction update. 2014 Sep-Oct;20(5):775-801
Edmonds DK, et al. Mayer-Rokitansky-Küster-Hauser syndrome: a review of 245 consecutive cases managed by a multidisciplinary approach with vaginal dilators. Fertility and Sterility. 2012 Mar;97(3):686-90
Ismail-Pratt IS et al.. Normalization of the vagina by dilator treatment alone in Complete Androgen Insensitivity Syndrome and Mayer-Rokitansky-Kuster-Hauser Syndrome. Human reproduction. 2007 Jul;22(7):2020-4
Gargollo PC et al. Should progressive perineal dilation be considered first line therapy for vaginal agenesis? [Abstract]. Journal of Urology. 2009 Oct;182(4 Suppl):1882-9
Roberts CP, Haber MJ, Rock JA. Vaginal creation for müllerian agenesis. [Abstract]. American Journal of Obstetrics and Gynecology. 2001 Dec;185(6):1349-52; discussion 1352-3
Routh JC, eet al. Management strategies for Mayer-Rokitansky-Kuster-Hauser related vaginal agenesis: a cost-effectiveness analysis. Journal of urology. [Abstract]. 2010 Nov;184(5):2116-21