Vaginal Relaxation Syndrome (VRS) generally includes changes in the vaginal wall caused by age-related decrease in the amount of vaginal connective tissue.
Vaginal Relaxation Syndrome (VRS) generally includes changes in the vaginal wall caused by age-related decrease in the amount of vaginal connective tissue. VRS is the underlying problem in many patients consulting the physician for vaginal tightening with complaints such as a feeling of relaxation in the vagina, insensitivity and difficulty in achieving orgasm. We can also define it as “vaginal enlargement”.
A healthy, satisfying sexual life is unquestionably the most important part, the core of a relationship. Not only the sensual intimacy provided by sexuality, but also hormones such as “oxytocin” secreted during and after sexual intercourse psychologically strengthen the couple’s emotional attachment to each other, and enable them to live their relationship more happily.
Although we say orgasm is not the purpose of sexual intercourse but a natural consequence, any decrease in the pleasure in the way to orgasm, and any difficulty in achieving orgasm cause a gradual decrease in sexual drive and desire. Many patients come to our clinic with the complaint of vaginal relaxation saying that their sex life is not the same as before. In such cases, we often encounter vaginal relaxation syndrome.
How is the normal structure of the vagina; what does this structure provide; and by what factors do changes occur in the vagina over time? Let's look for answers to these questions.
The vagina is a genital organ. It is also a transfer organ (birth, menstrual bleeding). Contrary to popular belief, there are no sebaceous and sweat glands in the vagina. Vaginal lubrication triggered by sexual stimulation is provided through the surrounding glands and the enlargement of the vaginal blood vessels (venous congestion).
The vagina is basically a canal composed of muscle and connective tissue. Although it is 8-10 cm in length on average, it has a great stretching and extending capacity, which enables it to tolerate any size of penis during intercourse, and allows for easy delivery of a baby during childbirth. Some hormones secreted during sexual intercourse further increase this stretching capacity.
“Vaginal rugae” are other crucial structures responsible for the enlargement and stretching of the vagina. The rugae, which make the inner structure of the vagina look like an accordion, are responsible for expanding the vaginal surface and providing stretching. It has also the function of gripping the penis tightly and providing friction to increase sexual pleasure during sexual intercourse. Especially age-related ruga deficiency can be accompanied by a decrease in the sensation during sexual intercourse.
If we are talking about vaginal relaxation syndrome, we should definitely mention the pelvic floor muscles, as well. The pelvic floor muscles, which are main responsible to enable the internal genital organs to resist gravity, in other words, prevent sagging, and ensure urinary continence, also surround the vagina and provide the necessary muscle tone. Inadequate contraction, i.e. hypotonicity of the pelvic floor muscles, will cause many problems experienced during sexual intercourse.
The conditions that affect all these factors I described above can appear to be a cause of vaginal relaxation syndrome. Vaginal deliveries are undoubtedly the most common cause of vaginal relaxation. Especially if the person has had more than one vaginal delivery, she is at a greater risk; but sometimes a single childbirth or even just pregnancy (without vaginal delivery) can cause vaginal relaxation. Weakness of the pelvic floor muscles that may be observed after pregnancy and childbirth can lead to flattening of the vaginal rugae, and episiotomy scars that may not be properly repaired can cause many sexual problems.
Flattening of the vaginal rugae that can occur due to childbirths both decreases the sensation by reducing the sensitivity of the vagina and weakens its ability to grip the penis. When not properly repaired, episiotomy scars can cause sometimes loss of sensation and sometimes painful sexual intercourse (dyspareunia).
Hypotonicity, i.e. muscle weakness, reduces the contractive force of the vagina felt when wrapping the penis, and sometimes can cause sagging in the pelvic organs or urinary incontinence problems. As a result of this condition, the male partner feels like that the penis is almost lost inside the vagina, while the female partner usually states that there is a general vaginal insensitivity, that she feel nothing during sexual intercourse, that the sexual pleasure gradually decreases, and that achieving orgasm becomes quite difficult.
Weakness of the pelvic floor muscles can also lead to vaginal gaping. Vaginal gaping, which is a disorder usually occurs develops after childbirth, is mostly caused by hypotonicity of the bulbocavernous muscle. A gaping vaginal introitus both makes the inside of the vagina visible and an aesthetically disturbing when viewed from the outside, and paves the way for recurrent vaginal infections.
The most common complaints include flatus (expulsion of gas from the vagina) due to vaginal air intake in patients with vaginal gaping, recurrent vaginitis due to impaired flora, insensitivity during sexual intercourse, and aesthetically unpleasant appearance.
A 42-year-old woman came to our clinic alone and told in tears that after their third vaginal delivery, nothing about their sex life was the same as before; that she could feel nothing during sexual intercourse and couldn’t achieve orgasm, and that her husband on the other hand said “I cannot understand if the penis goes into your vagina or into the air” My patient, whose youngest child was only 1 year old, began to worry about her gradually deteriorating sexual life, while trying to fulfill her responsibilities at home and take care of her little child. She said that her husband no longer wanted to have sex, that she suspected that her husband was cheating on her, that they began to face problems in their marital life and frequently quarrel due to those lack of sexual drive and doubts,
After vaginal examination, I found advanced vaginal relaxation in my patient. Our diagnosis was vaginal relaxation syndrome (VRS). There was also flattening of the rugae, and the tears caused by childbirth, which were not properly repaired, worsened the appearance. Surgery was the appropriate treatment method was that patient.
I planned vaginal tightening and perineum correction together with my patient. Meanwhile, they accepted my offer and started a marital therapy as a couple. When we reached the end of his recovery period, she and her husband visited me with great happiness and a highly big bunch of flowers. Both she and her husband were very satisfied with the result after the surgery. She made me very happy saying; “We feel just like in the first days of our marriage, doctor... thank you very much.” Meanwhile, the marital therapy they received restored the excitement and freshness of the first days of their relationship, which had worn out over the years. In front of me, there was a happy couple with 3 children and a satisfying sexual life.
I seem to hear you asking whether vaginal relaxation syndrome develop only in women who have had vaginal delivery. I think you would be quite surprised if I tell you that even my patients who have never experienced pregnancy, let alone giving birth, come to my clinic with the complaint of insensitivity during sexual intercourse, feeling of relaxation in the vagina, and vaginal flatus.
I said above that the vagina is a canal structure consisting of muscle and connective tissue. Genetic factors have a great effect on that “connective tissue”. Many patients who under 30 years of age who have not had any vaginal intervention have visited me to find a solution for their vaginal relaxation problem, sometimes alone and sometimes with their male partners affected by that condition. The genetic factors play an important role in the destruction, formation, and structure of “collagen”, which is the main component of connective tissue. Therefore, these factors should be remembered when treating the young patient group, and any patient who comes with the complaint of insensitivity during sexual intercourse should be evaluated in detail.
A 27-year-old female patient said that she had been sexually active for 4 years, but although she had several partners, almost all of them had said “your vagina is wider than normal that I cannot feel tightness", and added that she was very sad due to that situation. She said she could not assess on her own whether this was normal, because she said she didn't know what a normal vagina should be like. When I examined the patient, I found a medium level vaginal relaxation and shared the result with her. My patient was initially very surprised; because she did not women who have not given birth could have vaginal relaxation. After explaining the condition in detail, she stated that many women in her family had poor connective tissue and that her own skin was very elastic. We decided to first try vaginal CO2 laser treatment. After the vaginal laser treatment administered twice at 2-month intervals, my patient was smiling when she came back for control examination in the 4th month. She herself and her partner, with whom she had been together for the last 1 year, were aware of the change, and this not only added an additional excitement to their sexual life, but also enabled my patient to experience an intense pleasure that she had never experienced before. I also verified the success of the treatment during the vaginal examination. In addition to the increase in the vaginal tightness, the sensitivity of the anterior vaginal wall, which is the most sensitive area, was also increased. All I had to do was to happily accept the thanks of my patient, whose treatment was successfully completed.
There are two factors to keep in mind when talking about vaginal relaxation syndrome: Menopause and age factor. As women grow older, especially with the effect of the menopausal process, hormone levels rapidly decrease on the one hand, and destruction of the collagen structure increases on the other. The decrease in hormone levels that may cause lack of sexual drive can weaken the pelvic floor muscles and cause vaginal atrophy, leading to flattening and sexual insensitivity in the rugae.
The underlying cause of vaginal relaxation syndrome as well as its treatment procedure varies from patient to patient. Kegel exercises, which we sometimes teach to our patients, work very well in strengthening the vaginal muscles in the long term, but they remain inadequate to solve the problem on their own in many patients. In such a case, there are a variety of energy modality treatments that we can perform. CO2 and Er:YAG lasers, radiofrequency treatments and vaginal HIFU can be preferred as highly effective non-surgical treatment options. Another advantage of these treatments is that they increase the vaginal sensitivity and the pleasure felt during sexual intercourse by increasing the vaginal blood flow.
A vaginal tightening operation is always the last option. Especially for patients with advanced vaginal relaxation, surgical intervention should be considered as the first option. Vaginal tightening (vaginoplasty, colporrhaphy) operations intended to tighten the vagina can be performed with a variety of techniques. Posterior (posterior vaginal wall) colporrhaphy is the most preferred one among them. Posterior colporrhaphy is often performed in conjunction with a corrective perineal surgery (perineoplasty) (colpoperineoplasty).
As in the treatments of all other diseases, the most important points in the treatment of vaginal relaxation syndrome are a detailed anamnesis taken from the patient and a precision examination. After determining the problem completely, the treatment decision to be made together with the patient will ensure her story to have a happy ending.
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