Vaginal stenosis

Last updated
Vaginal stenosis
Specialty Gynecology

Vaginal stenosis is an abnormal condition in which the vagina becomes narrower and shorter due to the formation of fibrous tissue. [1] [2] Vaginal stenosis can contribute to sexual dysfunction, dyspareunia and make pelvic exams difficult and painful. [1] The lining of the vagina may also be thinner and drier and contain scar tissue. This condition can result in pain during sexual intercourse or a pelvic exam. Vaginal stenosis is often caused by radiation therapy to the pelvis, an episiotomy, [3] or other forms of surgical procedures. [4] [5] [6] Chemotherapy can also increase the likelihood of developing vaginal stenosis. [7] Vaginal stenosis can also result from genital reconstructive surgery in people with congenital adrenal hyperplasia. [8]

Contents

Signs and symptoms

Common indicators of vaginal stenosis include pain and bleeding during sexual intercourse along with other types of sexual dysfunction. [1] This can lead to challenges such as difficulty engaging in intercourse and decreased sex drive. [9] Severe forms of vaginal stenosis can be associated with a complete inability to participate in sexual intercourse. [1]

Atrophy, scarring, and damage to the vaginal tissue due to vaginal stenosis can lead to dryness, inflammation, and decreased elasticity of the tissue. [10]

Lasting effects of vaginal stenosis could include impacts on psychological well-being in addition to physical limitations. [1] Symptoms can worsen from post treatment ovarian failure or menopausal status, leading to reduced lubrication and increased thinning of the vaginal tissue. [1]

Causes

Radiation-induced

Uterine, vaginal, anal, rectal and cervical cancers are often treated with pelvic radiation therapy (RT), most commonly external beam radiation therapy (EBRT) or brachytherapy. [1] Radiation-induced vaginal stenosis can be a side effect of treatment. [11] It is one of the most prevalent side effects, affecting about one third of people undergoing pelvic radiation therapy. [12] [13] Radiation-induced stenosis can be a late reaction to treatment. Damage to the vaginal epithelium causes abnormal collagen production that leads to atrophy, loss of muscle, decreased blood flow, hypoxia, and fibrosis. Pallor, adhesions, and fragility can be observed along with loss of elasticity. [1] These can all contribute to sexual dysfunction that affects more than half of gynecological cancer survivors. [10] Some women who have reduced ovarian function and an estrogen shortage after RT can have an even thinner vaginal mucosal lining that worsens vaginal stenosis. [10]

Risk factors

While the severity of vaginal stenosis depends largely on the type of radiation therapy received, several risk factors can contribute to the development of vaginal stenosis. Women over the age of 50 with cervical cancer tend to have a higher risk of vaginal stenosis from radiation therapy. [10] Tobacco use is also associated with a higher risk of vaginal stenosis. [10] There is also a high correlation between vaginal stenosis and vaginal pallor reactions, which is when the mucous membranes thin and dry out, leading to inflammation and fibrosis. [10] [14]

Surgical procedures

Several types of surgical procedures are hypothesized to cause vaginal stenosis. Episiotomies, 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. [15] When the tissue from the episiotomy does not heal properly, complications can include mucosal damage and scarring, [16] which can contribute to the development of vaginal stenosis. Vaginal stenosis is the most common post-operative complication in people with congenital adrenal hyperplasia who have had genital reconstructive surgery in infancy or childhood. [17] Vaginal stenosis can be an immediate complication or may arise later in adolescence. [8] Additionally, in people undergoing a male-to female gender-affirming surgical procedure, such as vaginoplasty, vaginal stenosis has been shown to be a common post-surgical complication. [18]

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'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). [1] The CTCAE v4.0 assesses vaginal strictures 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. [1] However, this scale is not specific to just vaginal injuries alone. [10] The LENT-SOMA grading scale for vaginal stenosis is based on the assessment of subjective symptoms, analytical tests, and observed clinical manifestations. [1] 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. [10]

The lack of a well-established grading scale has potentially led to poor vaginal dilator therapy and long-term vaginal stenosis. [19] Vaginal stenosis is most often diagnosed with subjective parameters. [19] These subjective parameters in combination with the variety of different grading scales used, cannot be interchanged in clinical practice. [20] This makes it harder to properly diagnose the condition and establish a standard treatment. [20]

Treatment

Vaginal Dilator Therapy (VDT)

Stenosis of the vagina is typically treated with vaginal dilator therapy (VDT), but evidence is lacking for its efficacy. [21] [22] Vaginal dilators are smooth, cylindrical-shaped devices that promote stretching and relaxation of the vaginal tissue. [23] Vaginal dilator therapy requires a consistent routine and may cause physical and/or psychological discomfort, which makes adherence to treatment difficult. [19] It may be difficult to evaluate the efficacy of vaginal dilation therapy as measures of sexual function and quality of life are hard to quantify and control for. [21] Optimal duration of vaginal dilator therapy and its improvements on sexual function and cancer-related outcomes remain unclear. [24]

Although there is no high level evidence, many guidelines and reviews suggest the use of vaginal dilator therapy after pelvic radiation therapy. [10] It is believed that this therapy stretches vaginal tissues and the vaginal canal, leading to epithelial cell growth, and decreasing potential circumferential fibrosis. [10] Some studies have even suggested correlations between VDT and preventing risk of severe vaginal stenosis. [10]

Some studies have suggested positive patient outcomes when VDT was coupled with a longer dilation duration. [23] Using VDT with meditation and soothing music has also been shown to increase effectiveness, though evidence for this is not high grade. [23] Regular psychosocial support and regular follow up visits should occur in order to support this therapy and optimize the treatment. [1]

Other treatments

Recent treatment advances include local hyaluronic acid application, laser therapy, and vaginal estrogen treatment but further investigation is needed. [10] Hyaluronic acid helps treat vaginal stenosis by retaining moisture to promote vaginal tissue repair. [25] There are currently no known contraindications and is commonly used in clinical practice due to its high safety profile. [10]

Laser therapy 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. [10] A 2020 study demonstrated an improvement in vaginal length as well as the Vaginal Health Index, though more studies are needed to establish efficacy. [26]

There are limited studies around vaginal estrogen therapy in people with radiotherapy-induced vaginal stenosis due to concerns around an increased risk of tumor recurrence. [10] Similarly, there has been one study conducted that suggests people treated with high dose radiation therapy have a lower likelihood of responding to estrogen treatment. [10]

Epidemiology

The reported incidence of radiotherapy-induced vaginal stenosis varies widely, ranging from 1.2% to 88%. [10] 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 or brachytherapy). [1] In addition, symptoms may not occur until a year after radiation therapy and can increase in severity over the course of three years. [10] Vaginal stenosis may also be underreported due to stigma and discomfort around discussion of sexual dysfunction. [1] The estimated incidence of vaginal stenosis in people undergoing radiation therapy is 50% for people with endometrial cancer and 60% for people with cervical cancer. [10] The incidence of vaginal stenosis in people undergoing radiation therapy for anal cancer or colorectal cancer is not well-reported, but is estimated to be up to 80%. [10] [27]

See also

Related Research Articles

<span class="mw-page-title-main">Radiation therapy</span> Therapy using ionizing radiation, usually to treat cancer

Radiation therapy or radiotherapy is a treatment using ionizing radiation, generally provided as part of cancer therapy to either kill or control the growth of malignant cells. It is normally delivered by a linear particle accelerator. Radiation therapy may be curative in a number of types of cancer if they are localized to one area of the body, and have not spread to other parts. It may also be used as part of adjuvant therapy, to prevent tumor recurrence after surgery to remove a primary malignant tumor. Radiation therapy is synergistic with chemotherapy, and has been used before, during, and after chemotherapy in susceptible cancers. The subspecialty of oncology concerned with radiotherapy is called radiation oncology. A physician who practices in this subspecialty is a radiation oncologist.

<span class="mw-page-title-main">Vagina</span> Part of the female reproductive tract

In mammals and other animals, the vagina is the elastic, muscular reproductive organ 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. At the deep end, the cervix bulges into the vagina. The vagina allows for copulation and birth. It also channels menstrual flow, which occurs in humans and closely related primates as part of the menstrual cycle.

<span class="mw-page-title-main">Cervical cancer</span> Cancer arising from the cervix

Cervical cancer is a cancer arising from the cervix or in the any layer of the wall of 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 vaginal bleeding, pelvic pain or pain during sexual intercourse. While bleeding after sex may not be serious, it may also indicate the presence of cervical cancer.

<span class="mw-page-title-main">Brachytherapy</span> Type of radiation therapy

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, prostate, breast, esophageal and skin cancer and can also be used to treat tumours in many other body sites. Treatment results have demonstrated that the cancer-cure rates of brachytherapy are either comparable to surgery and external beam radiotherapy (EBRT) or are improved when used in combination with these techniques. Brachytherapy can be used alone or in combination with other therapies such as surgery, EBRT and chemotherapy.

<span class="mw-page-title-main">Endometrial cancer</span> Uterine cancer that is located in tissues lining the uterus

Endometrial cancer is a cancer that arises from the endometrium. 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 often vaginal bleeding not associated with a menstrual period. Other symptoms include pain with urination, pain during sexual intercourse, or pelvic pain. Endometrial cancer occurs most commonly after menopause.

<span class="mw-page-title-main">Vaginectomy</span> Surgical removal of the vagina

Vaginectomy is a surgery to remove all or part of the vagina. It is one form of treatment for individuals with vaginal cancer or rectal cancer that is used to remove tissue with cancerous cells. It can also be used in gender-affirming surgery. Some people born with a vagina who identify as trans men or as nonbinary may choose vaginectomy in conjunction with other surgeries to make the clitoris more penis-like (metoidioplasty), construct of a full-size penis (phalloplasty), or create a relatively smooth, featureless genital area.

Cervical stenosis means that the opening in the cervix is more narrow than is typical. In some cases, the endocervical canal may be completely closed. A stenosis is any passage in the body that is more narrow than it should typically be.

<span class="mw-page-title-main">Vaginal dilator</span> Medical instrument used to stretch the vagina

A vaginal dilator is an instrument used to gently stretch the vagina. They are used when the vagina has become narrowed, such as after brachytherapy for gynecologic cancers, and as therapy for vaginismus and other forms of dyspareunia.

Hematocolpos is a medical condition in which the vagina is pooled with menstrual blood due to multiple factors leading to the blockage of menstrual blood flow. The medical definition of hematocolpos is 'an accumulation of blood within the vagina'. It is often caused by the combination of menstruation with an imperforate hymen. It is sometimes seen in Robinow syndrome, uterus didelphys, or other vaginal anomalies.

Vaginal cancer is an extraordinarily rare form of cancer that develops in the tissue of the vagina. Primary vaginal cancer originates from the vaginal tissue – most frequently squamous cell carcinoma, but primary vaginal adenocarcinoma, sarcoma, and melanoma have also been reported – while secondary vaginal cancer involves the metastasis of a cancer that originated in a different part of the body. Secondary vaginal cancer is more common. Signs of vaginal cancer may include abnormal vaginal bleeding, dysuria, tenesmus, or pelvic pain, though as many as 20% of women diagnosed with vaginal cancer are asymptomatic at the time of diagnosis. Vaginal cancer occurs more frequently in women over age 50, and the mean age of diagnosis of vaginal cancer is 60 years. It often can be cured if found and treated in early stages. Surgery alone or surgery combined with pelvic radiation is typically used to treat vaginal cancer.

Radiation enteropathy is a syndrome that may develop following abdominal or pelvic radiation therapy for cancer. Many affected people are cancer survivors who had treatment for cervical cancer or prostate cancer; it has also been termed pelvic radiation disease with radiation proctitis being one of the principal features.

Gynecologic oncology is a specialized field of medicine that focuses on cancers of the female reproductive system, including ovarian cancer, uterine cancer, vaginal cancer, cervical cancer, and vulvar cancer. As specialists, they have extensive training in the diagnosis and treatment of these cancers.

Intraoperative radiation therapy (IORT) is radiation therapy that is administered during surgery directly in the operating room.

Gynecologic cancer is a type of cancer that affects the female reproductive system, including ovarian cancer, uterine cancer, vaginal cancer, cervical cancer, and vulvar cancer.

Uterine clear-cell carcinoma (CC) is a rare form of endometrial cancer with distinct morphological features on pathology; it is aggressive and has high recurrence rate. Like uterine papillary serous carcinoma CC does not develop from endometrial hyperplasia and is not hormone sensitive, rather it arises from an atrophic endometrium. Such lesions belong to the type II endometrial cancers.

Treatment for prostate cancer may involve active surveillance, surgery, radiation therapy – including brachytherapy and external-beam radiation therapy, proton therapy, high-intensity focused ultrasound (HIFU), cryosurgery, hormonal therapy, chemotherapy, or some combination. Treatments also extend to survivorship based interventions. These interventions are focused on five domains including: physical symptoms, psychological symptoms, surveillance, health promotion and care coordination. However, a published review has found only high levels of evidence for interventions that target physical and psychological symptom management and health promotion, with no reviews of interventions for either care coordination or surveillance. The favored treatment option depends on the stage of the disease, the Gleason score, and the PSA level. Other important factors include the man's age, his general health, and his feelings about potential treatments and their possible side-effects. Because all treatments can have significant side-effects, such as erectile dysfunction and urinary incontinence, treatment discussions often focus on balancing the goals of therapy with the risks of lifestyle alterations.

Neuroendocrine carcinoma of the cervix is best defined separately:Neuroendocrine: Of, relating to, or involving the interaction between the nervous system and the hormones of the endocrine glands.Carcinoma: An invasive malignant tumor derived from epithelial tissue that tends to metastasize to other areas of the body.

<span class="mw-page-title-main">Hegar dilators</span> Medical implement

Hegar dilators are dilators used to treat vaginismus and induce cervical dilation, and for inflatable penile implant procedures, though for penile implants it has been shown that outcomes are better without dilation.

<span class="mw-page-title-main">Squamous cell carcinoma of the vagina</span> Medical condition

Squamous cell carcinoma of the vagina is a potentially invasive type of cancer that forms in the tissues of the vagina. Though uncommonly diagnosed, squamous cell cancer of the vagina (SCCV) is the most common type of vaginal cancer, accounting for 80-90% of cases as well as 2% of all gynecological cancers. SCCV forms in squamous cells, which are the thin, flat cells lining the vagina. SCCV initially spreads superficially within the vaginal wall and can slowly spread to invade other vaginal tissues. Because of its slow growth, this cancer may cause no symptoms, or it may present with signs like irregular bleeding, pain, or a vaginal mass. This carcinoma can metastasize to the lungs or less frequently to the liver, bone, or other sites. SCCV has many risk factors in common with cervical cancer and is similarly strongly associated with infection with oncogenic strains of human papillomavirus (HPV). Diagnosis of SCCV is done by pelvic exam and biopsy of the tissue. Treatment and prognosis will depend on the stage, location, and characteristics of the cancer.

<span class="mw-page-title-main">Radiation-induced lumbar plexopathy</span> Type of nerve damage

Radiation-induced lumbar plexopathy (RILP) or radiation-induced lumbosacral plexopathy (RILSP) is nerve damage in the pelvis and lower spine area caused by therapeutic radiation treatments. RILP is a rare side effect of external beam radiation therapy and both interstitial and intracavity brachytherapy radiation implants.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Morris L, Do V, Chard J, Brand AH (2017). "Radiation-induced vaginal stenosis: current perspectives". International Journal of Women's Health. 9: 273–279. doi: 10.2147/IJWH.S106796 . PMC   5422455 . PMID   28496367.
  2. ↑ "Vaginal stenosis". TheFreeDictionary.com. Retrieved 2018-03-11.
  3. ↑ Venes D (2017-01-25). Taber's Cyclopedic Medical Dictionary - Episiotomy. F.A. Davis. ISBN   9780803659407.
  4. ↑ "Vaginal Outlet Stenosis Repair". www.atlasofpelvicsurgery.com. Retrieved 2018-03-11.
  5. ↑ "NCI Dictionary of Cancer Terms -Vaginal Stenosis". National Cancer Institute. Retrieved 2018-03-14.PD-icon.svg This article incorporates text from this source, which is in the public domain .
  6. ↑ Rosa LM, Hammerschmidt KS, Radünz V, Ilha P, Tomasi AV, Valcarenghi RV, et al. (2016). "Evaluation and Classification of Vaginal Stenosis After Brachytherapy". Texto & Contexto - Enfermagem. 25 (2). doi: 10.1590/0104-07072016003010014 . ISSN   0104-0707.
  7. ↑ "How to Manage Vaginal Stenosis" (PDF). Uhn.ca. Retrieved 2022-03-14.
  8. 1 2 Merke DP, Poppas DP (2013). "Management of adolescents with congenital adrenal hyperplasia". The Lancet. Diabetes & Endocrinology. 1 (4): 341–352. doi:10.1016/S2213-8587(13)70138-4. PMC   4163910 . PMID   24622419.
  9. ↑ Huffman LB, Hartenbach EM, Carter J, Rash JK, Kushner DM (2016). "Maintaining sexual health throughout gynecologic cancer survivorship: A comprehensive review and clinical guide". Gynecologic Oncology. 140 (2): 359–368. doi:10.1016/j.ygyno.2015.11.010. PMC   4835814 . PMID   26556768.
  10. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Varytė G, Bartkevičienė D (2021). "Pelvic Radiation Therapy Induced Vaginal Stenosis: A Review of Current Modalities and Recent Treatment Advances". Medicina. 57 (4): 336. doi: 10.3390/medicina57040336 . PMC   8066324 . PMID   33915994.
  11. ↑ Harkenrider MM, Block AM, Alektiar KM, Gaffney DK, Jones E, Klopp A, et al. (2017). "American Brachytherapy Task Group Report: Adjuvant vaginal brachytherapy for early-stage endometrial cancer: A comprehensive review". Brachytherapy. 16 (1): 95–108. doi:10.1016/j.brachy.2016.04.005. PMC   5612425 . PMID   27260082.
  12. ↑ Clinical trial number NCT03090217 for "Pelvic Physiotherapy in the Prevention of Vaginal Stenosis Secondary to the Radiotherapy" at ClinicalTrials.gov PD-icon.svg This article incorporates text from this source, which is in the public domain .
  13. ↑ "Management of radiation induced vaginal stenosis eviQ; (Australian, evidence-based health information)". www.eviq.org.au. Retrieved 2018-03-11.
  14. ↑ Yoshida K, Yamazaki H, Nakamura S, Masui K, Kotsuma T, Akiyama H, et al. (2015). "Role of vaginal pallor reaction in predicting late vaginal stenosis after high-dose-rate brachytherapy in treatment-naive patients with cervical cancer". Journal of Gynecologic Oncology. 26 (3): 179–184. doi:10.3802/jgo.2015.26.3.179. PMC   4510333 . PMID   25925294.
  15. ↑ Jiang H, Qian X, Carroli G, Garner P, et al. (Cochrane Pregnancy and Childbirth Group) (February 2017). "Selective versus routine use of episiotomy for vaginal birth". The Cochrane Database of Systematic Reviews. 2017 (2): CD000081. doi:10.1002/14651858.CD000081.pub3. PMC   5449575 . PMID   28176333.
  16. ↑ "Episiotomy Complications and Side Effects". www.birthinjuryhelpcenter.org. Retrieved 2022-08-01.
  17. ↑ Wang LC, Poppas DP (2017). "Surgical outcomes and complications of reconstructive surgery in the female congenital adrenal hyperplasia patient: What every endocrinologist should know". The Journal of Steroid Biochemistry and Molecular Biology. Genetic Steroid Disorders. 165 (Pt A): 137–144. doi:10.1016/j.jsbmb.2016.03.021. PMID   26995108. S2CID   45876518.
  18. ↑ Li JS, Crane CN, Santucci RA (2021). "Vaginoplasty tips and tricks". International Braz J Urol. 47 (2): 263–273. doi:10.1590/S1677-5538.IBJU.2020.0338. PMC   7857744 . PMID   32840336.
  19. 1 2 3 Haddad NC, Soares Brollo LC, Pinho Oliveira MA, Bernardo-Filho M (2021). "Diagnostic Methods for Vaginal Stenosis and Compliance to Vaginal Dilator Use: A Systematic Review". The Journal of Sexual Medicine. 18 (3): 493–514. doi:10.1016/j.jsxm.2020.12.013. PMID   33526400. S2CID   231766638.
  20. 1 2 de Morais Siqueira T, Derchain S, Juliato CR, Pinto E Silva MP, Machado HC, Brito LG (2022). "Vaginal stenosis in women with cervical or endometrial cancer after pelvic radiotherapy: a cross-sectional study of vaginal measurements, risk for sexual dysfunction and quality of life". International Urogynecology Journal. 33 (3): 637–649. doi:10.1007/s00192-021-04798-8. PMID   33891152. S2CID   233355491.
  21. 1 2 Miles T, Johnson N, et al. (Cochrane Gynaecological, Neuro-oncology and Orphan Cancer Group) (2014). "Vaginal dilator therapy for women receiving pelvic radiotherapy". The Cochrane Database of Systematic Reviews. 2014 (9): CD007291. doi:10.1002/14651858.CD007291.pub3. PMC   6513398 . PMID   25198150.
  22. ↑ White ID, Faithfull S (2006). "Vaginal dilation associated with pelvic radiotherapy: a UK survey of current practice". International Journal of Gynecological Cancer. 16 (3): 1140–1146. doi:10.1111/j.1525-1438.2006.00452.x. PMID   16803497. S2CID   12423507.
  23. 1 2 3 Liu M, Juravic M, Mazza G, Krychman ML (2021). "Vaginal Dilators: Issues and Answers". Sexual Medicine Reviews. 9 (2): 212–220. doi:10.1016/j.sxmr.2019.11.005. PMID   32014450. S2CID   211026055.
  24. ↑ Damast S, Jeffery DD, Son CH, Hasan Y, Carter J, Lindau ST, Jhingran A (2019). "Literature Review of Vaginal Stenosis and Dilator Use in Radiation Oncology". Practical Radiation Oncology. 9 (6): 479–491. doi:10.1016/j.prro.2019.07.001. PMC   7944435 . PMID   31302301.
  25. ↑ Gerdin B, Hällgren R (1997). "Dynamic role of hyaluronan (HYA) in connective tissue activation and inflammation". Journal of Internal Medicine. 242 (1): 49–55. doi: 10.1046/j.1365-2796.1997.00173.x . PMID   9260566. S2CID   30214069.
  26. ↑ Perrone AM, Tesei M, Ferioli M, De Terlizzi F, Della Gatta AN, Boussedra S, et al. (2020). "Results of a Phase I-II Study on Laser Therapy for Vaginal Side Effects after Radiotherapy for Cancer of Uterine Cervix or Endometrium". Cancers. 12 (6): 1639. doi: 10.3390/cancers12061639 . PMC   7352893 . PMID   32575821.
  27. ↑ Miles T. International guidelines on vaginal dilation after pelvic radiotherapy. Brook Hill, Woodstock, Oxon: Owen Mumford Ltd. 2012.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.