Prevention and treatment
Some small, single institution studies have looked at the use of topical oestrogens, benzydamine douches, hyperbaric oxygen and surgical reconstruction, however larger randomised trials are needed to assess their effectiveness.r
There is fairly strong evidence to support the use of vaginal dilators and/or sexual intercourse to prevent the development of, and as treatment for, vaginal stenosis.r
In cases of severe stenosis vaginal reconstruction may also be an option.r As surgery of irradiated tissue may lead to poor and delayed wound healing, there are potential risks and benefits of reconstruction which need to be considered.r
The use of vaginal dilators has been a widely accepted part of the prevention and management of vaginal stenosis.rr The rationale for dilator use is that the breakdown of adhesions and stretching of the vagina will assist in maintenance of vaginal patency.r This in turn will facilitate vaginal examinations for ongoing clinical follow-up and allows patients to continue to have intercourse if desired.
Evidence supports the commencement of dilation after the completion of radiation therapy and once acute inflammation has resolved.rr Dilation should not occur during radiation therapy.rr
Dilation therapy may include the use of dilators, vibrators, fingers, or similar shaped devices.r Continuing gentle penetrative sexual activity may serve the same purpose as using dilators or accelerate the dilation process.rrr
Frequency and duration of dilation
Recommendations about when and how to use vaginal dilators are inconsistent.r There is a lack of evidence for the ideal frequency and duration for dilation.rr Frequency of dilation has been shown to be more important than duration of therapy.r Some guidelines recommend dilation 1-3 times per day for 10-30 minutes.r Patients should be encouraged to dilate as frequently as is convenient and acceptable to them.rr
There is no definitive evidence on the ideal timeframe for ongoing dilation.r Ongoing dilation for at least 2 years and potentially indefinitely may be recommended where the risk of stenosis is high.r
Guidelines for dilator use
Patients are generally offered a range of dilator sizes and are recommended to commence dilation with the smallest size and progress to larger sizes as dilation becomes more comfortable.rr
Different shapes of dilator maybe available and suitable for use in different patients depending on the tumour site treated. For example, a pointed end dilator for anal, low rectal and vaginal cancer or a flat end dilator for endometrial and cervical cancer.r
The principles for dilator use are:rr
- Insert the dilator gently into the vagina using a lubricant.
- The dilator should be inserted to a comfortable point to the top of the vagina, gently rotated and then withdrawn.
- To avoid damage to the vagina and mucosa, the dilator use should be gentle and with no force.
Some patients may experience pain and discomfort during dilator use. This may be managed by increasing lubrication or the use of topical or oral analgesics.r
A small amount of bleeding or ‘spotting’ after using a dilator is normal.r Large amounts of bleeding or pain should be investigated.
Some women find using dilators stressful and there can be poor compliance with the treatment.rr As the treatment is patient-driven, it is critical that patients are willing, motivated and prepared to dilate.r Identification of any psychosocial, logistical and anatomic barriers is key.r Women who wish to dilate should be given adequate information on how to use dilators.r Ongoing support to ensure continuation of dilation therapy is also important.
Clinicians who are not able to fully support patients through the dilation process should consider referral to a physiotherapist specialising in women’s health or pelvic physiotherapy.r