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Human Reproduction Update 2014In women with vaginal hypoplasia, such as in Mayer-Rokitansky-Küster-Hauser syndrome (MRKH) and in Complete Androgen Insensitivity Syndrome (CAIS), surgical... (Review)
Review
BACKGROUND
In women with vaginal hypoplasia, such as in Mayer-Rokitansky-Küster-Hauser syndrome (MRKH) and in Complete Androgen Insensitivity Syndrome (CAIS), surgical vaginoplasty and non-surgical self-dilation treatments are available to lengthen the vagina and facilitate sexual intercourse, but the best treatment remains controversial. Vaginal dilation has been recommended as a first-line treatment, because of its less invasive character and high success rate. However, the exploration of factors associated with compliance and long-term outcome is incomplete, including whether psychological counselling needs to be embedded in treatment to maximize efficacy. It is not known if failed vaginal dilation therapy jeopardizes further surgical success outcomes, especially because in a number of these procedures ongoing vaginal dilation is required. In addition, if surgery is needed, there is a lack of evidence to inform physicians regarding the optimum surgical technique to use. Also, it is unclear whether maintenance dilation therapy in case of sexual inactivity is crucial to ensure functional success.
METHODS
In view of this ongoing debate, we performed a search of all published literature (English language only) restricted to the management of vaginal hypoplasia in patients with MRKH or CAIS from 1898 to March 2013 using Pubmed, Cochrane Library and Web of Science. Of the 6700 articles initially identified, a total of 190 studies are analysed. More specifically, by establishing the risk/efficacy profile (vaginal capacity, complications and long-term durability in terms of sexual function) of the different surgical and non-surgical reconstruction techniques, we evaluate if vaginal dilation proposed as the first-line technique is justified based on the evidence.
RESULTS
When anatomical success was defined as a length of ≥7 cm and functional success as coitus, all vaginoplasty techniques yielded significantly higher success rates (>90 versus 75% after vaginal dilation), irrespective of underlying diagnosis or start vaginal length. When functional success was defined as 'satisfaction with sex', including non-genital sex, differences disappeared. Failed dilation therapy does not preclude anatomical (nor functional) success if vaginoplasty afterwards is necessary. Traction vaginoplasty seems to have the highest anatomical (99%) and functional success rates (96%), whereas both split- and full-thickness skin graft procedures and intestinal procedures have the lowest successful outcomes (83-95%). Overall, complication rates were significantly lower within the vaginal dilation groups when compared with the different vaginoplasty techniques. Although no randomized control data exist regarding maintenance dilation, the available evidence suggests that continued dilation is needed to maintain patency in periods of coital inactivity. Despite the expectancy that the probability of further positive outcomes is maximized with psychological counselling, this could not be confirmed.
CONCLUSIONS
As the medical literature lacks high-quality comparative outcome studies and prospective, longitudinal studies are scarce, no evidence-based treatment guidelines can be provided. However, because of the physically low complication rate and an overall success chance of 75%, vaginal dilation as first choice treatment seems to be justified. Overall, the laparoscopic Vecchietti procedure, becoming more and more available in specialized centres, is considered an appropriate surgical option in patients who are poorly compliant and failed dilation therapy, or for those who do not want to start with vaginal dilation therapy. Future approaches need to raise a wider range of psychosexually oriented questions, elucidate the relationship between vaginal depth and satisfactory outcomes and gain additional experience concerning the format of acceptable and efficient psychological care.
Topics: 46, XX Disorders of Sex Development; Coitus; Congenital Abnormalities; Diagnosis, Differential; Dilatation; Female; Humans; Laparoscopy; Mullerian Ducts; Sexual Behavior; Treatment Outcome; Vagina
PubMed: 24899229
DOI: 10.1093/humupd/dmu024 -
Clinical Oncology (Royal College of... Feb 2019Women treated with pelvic radiation therapy (PRT) for gynaecological or anorectal cancer report a high number of sexual problems and unmet post-treatment psychosexual... (Randomized Controlled Trial)
Randomized Controlled Trial
A Psychosexual Rehabilitation Booklet Increases Vaginal Dilator Adherence and Knowledge in Women Undergoing Pelvic Radiation Therapy for Gynaecological or Anorectal Cancer: A Randomised Controlled Trial.
AIMS
Women treated with pelvic radiation therapy (PRT) for gynaecological or anorectal cancer report a high number of sexual problems and unmet post-treatment psychosexual information needs. Currently, there is suboptimal adherence to recommended rehabilitation aids, such as vaginal dilators, and a paucity of resources to facilitate post-radiation rehabilitation and reduce distress in this population. This randomised controlled trial aimed to evaluate the effectiveness of a study-developed psychosexual rehabilitation booklet in this setting.
MATERIALS AND METHODS
Eighty-two women scheduled for PRT to treat gynaecological/anorectal cancer were randomised to receive the intervention booklet (n = 44) or standard information materials (n = 38). Self-report questionnaires administered at pre-treatment baseline and at 3, 6 and 12 months post-treatment assessed adherence with rehabilitation aids, booklet knowledge, anxiety, depression and sexual functioning/satisfaction.
RESULTS
Dilator adherence and booklet knowledge were significantly higher in the intervention group than in the control group (averaged over time points), with scores significantly increasing over time. Younger age and gynaecological cancer were significant predictors of greater dilator adherence. No significant group differences were found on psychological and sexual measures.
CONCLUSIONS
The psychosexual rehabilitation booklet was effective in educating women with gynaecological and anorectal cancers about PRT-related psychosexual side-effects and rehabilitation options, as well as promoting uptake of vaginal dilator use. Future research should elucidate the effectiveness of this booklet in women with greater psychological and sexual functioning needs.
Topics: Anus Neoplasms; Female; Genital Neoplasms, Female; Humans; Middle Aged; Pamphlets; Pelvis; Rectal Neoplasms; Vagina
PubMed: 30580905
DOI: 10.1016/j.clon.2018.11.035 -
Sexual Medicine Reviews Oct 2022Vaginal stenosis is a distressing side effect of radiation therapy that can impair quality of life. Dilator therapy is an option for patients undergoing pelvic...
INTRODUCTION
Vaginal stenosis is a distressing side effect of radiation therapy that can impair quality of life. Dilator therapy is an option for patients undergoing pelvic radiotherapy to mitigate vaginal stenosis. Currently, the dilators given to patients by most hospitals are made of plastic, compared to silicone dilators which are available on the market for purchase.
OBJECTIVES
We conducted a systematic literature review to find information to guide clinical recommendations to pelvic radiotherapy patients on potential differences regarding the use of plastic vs silicone dilators with regard to efficacy, cost, and patient preferences.
METHODS
A systematic literature review was conducted in Embase, MEDLINE, and PubMed using Emtree terms. To be included in the review, papers needed to: focus on female patients undergoing radiation therapy, assess a vaginal dilator, measure any dilator intervention outcome, and specifically compare plastic vs silicone dilators for any measured outcome (either qualitative or quantitative).
RESULTS
The initial search yielded 195 articles. Two area experts, with a third expert for arbitration, read each article and found that none met all review inclusion criteria. No studies were found that compared silicone to plastic dilators with regard to efficacy in treating vaginal stenosis due to radiation therapy, no studies were found that compared cost or cost-effectiveness of the 2 dilator types, and no studies were found comparing patient preferences or experiences (eg, comfort, adherence, ease of use) between the 2 dilator types.
CONCLUSION
The materials used to create dilators have never been rigorously compared in the context of radiotherapy-related vaginal stenosis. Institutions and patients have no data to guide their choice. Significantly more research at the patient and institutional level is needed to explore the potential long-term quality of life and cost benefits of improved adherence with silicone dilator use, and to guide shared decision-making regarding dilator choice.
Topics: Humans; Female; Vagina; Constriction, Pathologic; Quality of Life; Genital Neoplasms, Female
PubMed: 37051960
DOI: 10.1016/j.sxmr.2022.06.008 -
Journal of Minimally Invasive Gynecology Jan 2019To evaluate the efficacy of different surgical treatments for cesarean scar pregnancy (CSP).
STUDY OBJECTIVE
To evaluate the efficacy of different surgical treatments for cesarean scar pregnancy (CSP).
DESIGN
Retrospective study (Canadian Task Force classification II-3).
SETTING
Affiliated university hospitals.
PATIENTS
Women (n = 313) with CSP.
INTERVENTIONS
Dilation and curettage under ultrasound guidance (DCUS, n = 124), dilation and curettage with hysteroscopic guidance (DCH, n = 103), vaginal excision (n = 55), laparotomy (n = 12), and laparoscopy (n = 19).
MEASUREMENTS AND MAIN RESULTS
Undetectable serum human chorionic gonadotropin (hCG) levels and thickness of the uterine scar were measured before and after surgery. Success rates of the 5 surgical treatments of CSP (DCUS, DCH, vaginal excision, laparotomy, and laparoscopy) ranged between 89% and 100%. Postoperative treatment was not needed in the vaginal and laparotomy groups, and vaginal treatment was associated with shorter operative time than laparotomy and laparoscopy and shorter time to undetectable hCG levels than DCUS and DCH. Serum hCG levels on day 3 after surgery were significantly lower than baseline levels in all groups of patients, but there was no significant difference between levels on days 3 and 5 postoperatively. Median scar thickness after surgery in the vaginal surgery, laparotomy, and laparoscopy groups was thicker than that in the DCUS and DCH groups.
CONCLUSION
In certain circumstances, CSP can be treated simply by DCH or DCUS. However, time to undetectable hCG levels is prolonged compared with more invasive techniques.
Topics: Adult; Cesarean Section; Chorionic Gonadotropin, beta Subunit, Human; Cicatrix; Dilatation and Curettage; Female; Humans; Hysteroscopy; Laparoscopy; Laparotomy; Operative Time; Postoperative Period; Pregnancy; Pregnancy Complications; Pregnancy, Ectopic; Retrospective Studies; Treatment Outcome; Ultrasonography; Uterine Diseases; Uterus
PubMed: 29758363
DOI: 10.1016/j.jmig.2018.03.035 -
The European Journal of Contraception &... Apr 2022The aim of the study was to evaluate pain following overnight osmotic cervical dilator placement for second trimester dilation and evacuation (D&E).
OBJECTIVE
The aim of the study was to evaluate pain following overnight osmotic cervical dilator placement for second trimester dilation and evacuation (D&E).
METHODS
A retrospective cohort study surveyed pain and quantified prescription opioid use among 100 women who underwent overnight osmotic cervical dilator placement for D&E. Participants were given opioid and non-steroidal anti-inflammatory (NSAID) prescriptions and were asked to rate their level of pain on a Likert scale (1-10). Demographic and medical information was abstracted from electronic medical records. Bivariate analyses of demographic and clinical characteristics by pain score and opioid use were conducted. Multivariate linear regression analyses were performed for pain score. A multivariate logistic regression model was fitted for factors associated with opioid use.
RESULTS
Gestational age ranged from 14 to 23 weeks (average 19 ± 3 weeks). The mean score of worst pain experienced was 5.3 out of 10. Participants reported 3.4 h of moderate pain (4-6 out of 10) and 1.0 h of severe pain (7-10 out of 10); 54% of women took at least one opioid (mean 2.8 ± 1.5). Multivariate analysis showed that higher pain was associated with younger age ( = .0363) and no prior vaginal delivery ( = .0296). The number of osmotic cervical dilators was associated with pain in the bivariate analysis ( = 0.216, = .0311) but was not significant in the multivariate analysis ( = .0634). An increasing number of cervical dilators ( = .0323) and a higher pain score ( = .004) were associated with opioid use.
CONCLUSION
Most participants with overnight cervical dilators for D&E experienced at least moderate pain and used opioid pain medication in addition to NSAIDs when available. A shared decision-making model may be appropriate for determining which patients may benefit from opioids.
Topics: Abortion, Induced; Analgesics, Opioid; Dilatation; Female; Humans; Infant; Misoprostol; Pain; Pregnancy; Pregnancy Trimester, Second; Retrospective Studies
PubMed: 34528856
DOI: 10.1080/13625187.2021.1975266 -
Patient Preference and Adherence 2018Vaginal dilator (VD) therapy is often recommended for women receiving pelvic radiation therapy or experiencing pain and discomfort during intercourse, as well as for...
BACKGROUND
Vaginal dilator (VD) therapy is often recommended for women receiving pelvic radiation therapy or experiencing pain and discomfort during intercourse, as well as for women with a congenital malformation of the vagina. VD use has both physical and psychological benefits; however, it often causes pain, discomfort, and adverse emotions, including embarrassment and loss of modesty, which often result in low adherence to therapy.
OBJECTIVES
The aims of this study were to explore the use and adherence of VD therapy in women, identify barriers and facilitators of therapy adherence, and suggest improvement strategies from the theoretical perspective of symbolic interactionism.
METHODS
A systematic review of the literature was conducted using PubMed, CINAHL, and Scopus databases, with no year restrictions. Articles addressing the experience of women using VD therapy, as well as barriers and facilitators of therapy adherence were selected and analyzed. Then, the theoretical perspective of symbolic interactionism was introduced and applied to synthesize the results.
RESULTS
A total of 21 articles were selected for the review. Most of the reviewed studies explored VD therapy in women who had undergone pelvic radiation therapy for gynecological cancer. Women's adherence to the therapy ranged between 25% and 89.2%, with great variance in definitions and methods for assessing therapy adherence. Among the five categories of identified barriers to therapy adherence, "unhelpful circumstances" and "negative perceptions toward the VD" were the two most frequently mentioned. The two most frequently reported facilitators of adherence among the six identified categories were "supportive interactions with health care providers" and "risk perception and positive outcome expectancies". On the basis of the perspective of symbolic interactionism, strategies for strengthening interactions with others (eg, health care providers, significant others, and support groups) are discussed in detail.
CONCLUSION
Strategic intervention regarding the decisive factors identified in the review can benefit women by enhancing their experience and adherence to VD therapy.
PubMed: 29695897
DOI: 10.2147/PPA.S163273 -
Current Opinion in Urology Jul 2015Female urethral stricture disease is increasingly recognized as an uncommon but important cause of lower urinary tract symptoms in women, which is amenable to surgical... (Review)
Review
PURPOSE OF REVIEW
Female urethral stricture disease is increasingly recognized as an uncommon but important cause of lower urinary tract symptoms in women, which is amenable to surgical treatment. Several new reconstructive techniques have recently been described. The purpose of this review is to summarize the past literature with a focus on more recent contributions.
RECENT FINDINGS
Several new studies have recently been published investigating previously described reconstructive techniques including vaginal flap urethroplasty using the ventral approach, ventral labial graft, dorsal vaginal graft and dorsal buccal mucosal graft urethroplasty. Success rates, variably defined, ranged from 57.1 to 100% in these new contributions. No incidences of stress urinary incontinence were described. There continues to be lack of robust evidence to advocate one technique of urethroplasty for female urethral stricture disease over another, surgeon experience is likely to be an important factor.
SUMMARY
Urethroplasty using a flap or graft augmentation is a feasible treatment for female urethral strictures with good reported success rates and a minimal risk of stress of incontinence. Further studies are required to define the optimal technique and approach.
Topics: Dilatation; Female; Humans; Mouth Mucosa; Predictive Value of Tests; Recovery of Function; Risk Factors; Sex Factors; Surgical Flaps; Treatment Outcome; Urethra; Urethral Stricture; Urologic Surgical Procedures; Vagina
PubMed: 26049879
DOI: 10.1097/MOU.0000000000000186 -
Journal of Clinical Research in... Feb 2020In patients with Mayer-Rokitansky-Küster-Hauser syndrome and complete androgen insensitivity syndrome (CAIS), management of vaginal hypoplasia includes non-surgical or...
In patients with Mayer-Rokitansky-Küster-Hauser syndrome and complete androgen insensitivity syndrome (CAIS), management of vaginal hypoplasia includes non-surgical or surgical vaginal elongation techniques. For these patients, primary vaginal dilation is considered a first-line option to avoid the risks of having surgery and complications that may occur due to these procedures. Non-surgical dilation is a highly successful treatment if treatment is initiated when the patient is emotionally mature and ready. Here, we present a case of CAIS with vaginal hypoplasia managed successfully with non-surgical dilation therapy.
Topics: Adolescent; Androgen-Insensitivity Syndrome; Conservative Treatment; Dilatation; Female; Humans; Male; Vagina
PubMed: 32041393
DOI: 10.4274/jcrpe.galenos.2020.2019.S0222 -
Journal of Pediatric and Adolescent... Oct 2023To understand variations and experiences of vaginal lengthening internationally in individuals with congenital underdevelopment of the uterus, cervix, and upper vagina...
STUDY OBJECTIVE
To understand variations and experiences of vaginal lengthening internationally in individuals with congenital underdevelopment of the uterus, cervix, and upper vagina or Müllerian agenesis METHODS: In this study, we used a cross-sectional mixed-methods design incorporating quantitative and qualitative questionnaires. Adults with Müllerian agenesis completed questionnaires with quantitative and open-ended qualitative questions about their vaginal lengthening experiences. Data were analyzed using descriptive statistics and inductive thematic analysis.
RESULTS
Of 616 respondents meeting inclusion criteria (representing 40 countries), 46% (n = 284) reported no vaginal lengthening intervention. Vaginal lengthening was commonly reported by participants from North America and Europe (59%) and less commonly by participants from Africa, Asia, and South America (16%). Of those who had undergone vaginal lengthening, 72% reported dilator use, 34% coital dilation, and 39% surgery. Four major themes were identified in response to the open-ended vaginal lengthening experience question: (1) difficult physical symptoms, (2) practical and psychosocial challenges, (3) intimate relationships and sexual satisfaction, and (4) impact of experiences with healthcare providers.
CONCLUSION
This study highlights vaginal lengthening practices internationally and shared themes related to significant challenges and positive experiences. The findings show room for improvement in the counseling and care surrounding vaginal lengthening. Future research should investigate factors that influence decision-making about vaginal lengthening and work toward international consensus on best care practices in Müllerian agenesis.
Topics: Adult; Female; Humans; Cross-Sectional Studies; Treatment Outcome; Vagina; Uterus; 46, XX Disorders of Sex Development; Mullerian Ducts; Congenital Abnormalities
PubMed: 37182810
DOI: 10.1016/j.jpag.2023.05.004 -
Archives of Gynecology and Obstetrics Apr 2022Stress urinary incontinence (SUI) is a pervasive health tissue among women, which seriously affects the quality of life. The etiology of SUI is complex and diverse in...
BACKGROUND
Stress urinary incontinence (SUI) is a pervasive health tissue among women, which seriously affects the quality of life. The etiology of SUI is complex and diverse in women, with past studies having demonstrated that estrogen deficiency plays an important role in pelvic floor muscle atrophy and urethral degeneration. We comprehensively investigated the effects of estrogen in the treatment of SUI in female mice at cellular and animal levels.
METHODS
L929 fibroblasts mechanical injury model was established by four-point bending device, and SUI mouse model was established by vaginal dilation method commonly used to simulate labor injury. After estrogen treatment, the expressions of Collagen I, Collagen III, Elastin, TIMP-1, TIMP-2, MMP-2, and MMP-9 were detected, the leak point pressure (LPP) and abdominal leak point pressure (ALPP) of mice in each group were detected, and both the effect of estrogen on extracellular matrix remodeling of mouse urethra and anterior vaginal wall was observed from the histological level.
RESULTS
The results revealed that an appropriate amount of estrogen can promote the expression of Collagen I, Collagen III, Elastin, TIMP-1, and TIMP-2, decrease the expression of MMP-2 and MMP-9, and maintain the dynamic balance of MMPs/TIMPs at both cellular and animal levels. Meanwhile, we determined that estrogen can increase the LPP and ALPP values of SUI mice. The collagen fibers' content in the mice treated with estrogen was significantly greater than in the control group mice.
CONCLUSIONS
The estrogen may alleviate the symptoms of SUI by reconstituting ECM, thus laying a solid foundation for further exploration of estrogen therapy.
Topics: Animals; Estrogens; Female; Humans; Male; Mice; Quality of Life; Urethra; Urinary Incontinence, Stress; Vagina
PubMed: 35174407
DOI: 10.1007/s00404-022-06435-1