Vaginal stenosis

Definition

Vaginal stenosis refers to narrowing and/or shortening of the vaginal vault.^r

Pathophysiology

Brachytherapy and/or external beam radiation therapy to the pelvis for treatments of cervical, endometrial, vaginal, vulval, anal, low rectal and urological cancers can result in radiation injury and damage to vaginal tissue. This damage has an acute phase, consisting of mucosal inflammation and ulceration. This is followed by a chronic phase associated with ischaemic changes, atrophy, scarring, circumferential fibrosis and adhesions.^rr These changes can result in vaginal stenosis.

Vaginal stenosis can inhibit sexual function and the ability for patients to undergo pelvic examinations that may be part of routine follow-up for their cancer or other healthcare needs. Severe cases are rare but can result in the vagina becoming completely obstructed.^rrr

Vaginal stenosis can be further compounded by additional potential side effects of cancer treatments, such as decreased vaginal lubrication (vaginal dryness) and thinning of the vaginal epithelium.^r

Incidence/prevalence

Reported rates of vaginal stenosis vary, ranging from 1.2% to 88%. This wide range may be due to reliance on retrospective evidence, small cohorts, the difficulty in accurate diagnosis and poor documentation of the condition.^rrrrrr In one study, rates of CTCAE grade 1-2 vaginal stenosis were reported in 75% of patients, with grade 3 symptoms reported in only 1% of patients.^r In studies where vaginal stenosis is specifically assessed, reported incidence rates are higher.^r 

Onset/duration

The reported time of onset of vaginal stenosis can vary. The condition usually develops in the first year after treatment, although onset as early as 1 month to over 5 years after treatment have also been reported.^rrr

Risk factors

There is limited evidence about the specific risk factors for the development of vaginal stenosis. Increasing radiation dose and volume of vagina treated is associated with higher risk of all grades of vaginal stenosis.^rrrr

Some evidence exists for an increased risk in patients:

• aged >50 years^r
• with co-morbidities such as diabetes and arterial disease^r
• with large tumour bulk/tumour extension into the vagina at diagnosis^rr
• who use tobacco.^r

The risk of developing vaginal stenosis may be decreased for patients who have regular vaginal intercourse.^r

Symptoms

Symptoms of vaginal stenosis includes dyspareunia (pain during sexual intercourse) and pain during pelvic exams. Sexual dysfunction after radiation therapy is multifactorial and vaginal stenosis can be further compounded by vaginal dryness and atrophic vaginosis, all of which can have negative effects on a patients quality of life.^r

Investigations and diagnosis

Establish baseline, current sexual function and assess the patient for:

• dyspareunia
• pain during pelvic examination.

Grading

If stenosis develops, this should be recorded utilising a recognised grading system.^r There are various published tools for grading vaginal stenosis.^rr The National Cancer Institute Common Toxicity Criteria for Adverse Events (CTCAE) provides grading for vaginal stricture, although this is not specific to radiation-induced injury.^r

Table 1. CTCAE grading for vaginal stricture^r

Definition: A disorder characterised by a narrowing of the vaginal canal.
Common Terminology Criteria for Adverse Events (CTCAE) v5.0

The US-based Radiation Therapy Oncology Group (RTOG) and the European Organisation for the Research and Treatment of Cancer (EORTC) developed the Late Effects on Normal Tissues - Subjective, Objective, Management and Analytic (LENT-SOMA) scale.^r The LENT-SOMA scale is used to assess adverse effects from treatment in terms of subjective symptoms, observed clinical features, management strategies required, and analytical tests performed. Table 2 shows the LENT-SOMA scoring table for injury to the vagina. Stenosis is only one component of this grading system, reflecting the fact that symptoms following radiation therapy may result from a combination of pathologies.

Table 2. RTOG/EORTC LENT-SOMA scoring table for injury to the vagina^r

Abbreviations: HBO₂: Hyperbaric oxygen therapy; MRI: magnetic resonance imaging; EUA: examination under anaesthesia.

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 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

Vaginal dilatation

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 once acute inflammation has resolved and the vaginal mucosa is healed, usually around 4 weeks post radiation therapy.^rrr 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 A range of guidelines recommend dilation 3 times per week for 5-10 minutes per session.^rrr

There is no definitive evidence on the ideal timeframe for ongoing dilation.^r Ongoing dilation for 6-24 months^rand 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 are 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.

Patient support

Some patients 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 Patients who wish to dilate should be given adequate information on how to use dilators.^r Ongoing support and sexual function assessment is important to ensure continuation of dilation therapy and to effectively manage vaginal stenosis.

Clinicians who are not able to fully support patients through the dilation process should consider referral to a specialist pelvic physiotherapist.^r

Prior to the commencement of treatment, it is important to advise patients and their partners about the risk of developing vaginal stenosis and its potential consequences regarding sexual function and post-treatment assessments. It is also valuable to establish baseline sexual function to provide a reference for future comparison.^rFor patients who subsequently develop vaginal stenosis, education and support is critical.^r

Use of vaginal dilators

It is important that patients advised to use vaginal dilators know how to do this correctly. Patients should be advised to:^rr

• commence dilation therapy when they feel ready to, and only after the completion of radiation therapy and resolution of acute inflammation
• use the smallest sized dilator when commencing dilation and gradually increase size as dilation becomes more comfortable
• use water-based lubricant when using the dilator
• use the dilator at a time and place that is private and comfortable to relax
• relax the pelvic floor muscles to make dilation more comfortable
• report significant bleeding or pain when using vaginal dilators
• use non-hormonal vaginal moisturisers if they experience vaginal dryness
• use analgesia appropriately, if required
• avoid irritating the vagina e.g. avoid oil-based lubricants, do not douche, or use products such as soaps or shower gels.

Patients who are not ready or motivated to commence dilator use, or have broader sexual concerns, should be offered further advice, counselling and support where available, for example, referral to a pelvic physiotherapist, a psychotherapist or sex therapist.^rr

Current smokers should be referred to a smoking cessation program.

Written information

Patients should be provided with written information, for example:

• eviQ Vaginal changes after radiation therapy to the pelvis information sheet
• Recovering after Pelvic Radiation Therapy – A guide for women

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