The vagina that leads to many important events to take place in a woman's life is a tube-shaped organ 8-10 cm in length that shows structural and functional variability throughout life due to hormonal, environmental and traumatic events.
The vagina, an organ which makes sexual intercourse possible; which becomes the first step in the path that mediates the fusion of the sperm and egg; which enables the birth of a baby; and which allows for the discharge of the menstrual blood that is the proof of a woman's fertility, has very special structures that enable it to perform all these functions.
Vagina has the capacity to stretch up to twice its length and width thanks to the accordion-like mucosal folds called “ruga” on the inside and its connective tissue and elastic fibers. On the other hand, the strong muscular structure surrounding the outer part enables it to resist gravity.
The vagina, as an organ with a dynamic structure, can change due to both hormonal and mechanical effects. These changes are sometimes structural such as expansion and contraction, and sometimes functional such as dryness or indistinction of the rugae.
The vagina is affected by almost all important events in a woman’s life (birth, sexual intercourse, aging, menopause, etc.). Generally vaginal relaxation and the treatment of this condition are focused on and discussed in detail. Well, can the vagina sometimes expand and sometimes contract? Can it be possible that the vagina has been narrow from birth?
The vagina can be narrow due to congenital or acquired conditions.
Congenital vaginal absence or vaginal stenosis can be seen due to some genetic diseases, hormonal disorders and tumors. In such cases, patients are evaluated considering their entire life from their early childhood in a versatile way and corrective (reconstruction) surgical procedures are performed. With the latest surgical techniques, it is possible to create a vagina that normally functions in many patients.
Conditions which develop after vaginal delivery and episiotomy repair, vaginoplasty, autoimmune diseases such as lichen sclerosis, menopausal period, pelvic cancer surgeries, and post-radiotherapy and chemotherapy periods can be given as examples of acquired conditions.
Difficulty during sexual intercourse when getting a foreign body (tampon, suppository, and finger) into the vagina is the first finding in most women with vaginal stenosis. The situation, which initially cannot be clearly realized is generally considered to be temporary and is left to time. However, vaginal contractions accompanied by pain and ache may occur in the forthcoming periods, especially during sexual intercourse, which can further increase the complaints (secondary vaginismus). After a while, it may become impossible to insert anything into the vagina.
Inability to have a complete sexual intercourse, painful sexual intercourse, inability to insert a speculum or an ultrasound probe during gynecological examination are some the general symptoms of vaginal stenosis. Some patients learn this during the examination.
Depending on the underlying cause that leads to vaginal stenosis, complaints such as vaginal dryness, itching, and burning sensation may also be the early symptoms.
Permanent stenosis may occur at the vaginal introitus and in the vaginal canal, especially as result of improper repair or excessive vaginal tightening after vaginal deliveries performed with episiotomy (incision).
Painful sexual intercourse (dyspareunia) after the postpartum period, vaginismus secondary to dyspareunia (secondary vaginismus) and lack of sexual drive that arises as a natural consequence of all these problems are some of the most common reasons for why our patients with vaginal stenosis apply to our clinic.
Vaginal stenosis and episiotomy scars can be detected during the examinations of our patients who have a history of difficult vaginal delivery. After the vaginal relaxation and perineoplasty (corrective perineal surgery) operations, our patients no longer suffer from their stenosis problem. However, especially patients with secondary vaginismus may need the rehabilitation of their pelvic floor muscles with behavioral therapy techniques after 6 postoperative weeks on average.
Vaginal relaxation and vaginal prolapse are common problems, especially in old women and in those who have had vaginal delivery. Many women undergo surgical operations due to this problem that can affect a woman’s both sexual and social lives. However, after some surgeries performed without sufficient experience, excessive vaginal narrowing may be much more than it should be.
The amount of tissue to be removed during vaginoplasty surgery is the most important point of the surgery. When excessive amount of tissue is removed, the vaginal canal and vaginal introitus become too much narrow; and this situation causes the person to have painful sexual intercourse or prevent her from having sexual intercourse, despite the surgical operation that she has undergone with intent to get much sexual pleasure. Moreover, sometimes gynecological examinations become impossible for these patients. This situation becomes considerably annoying for patients.
We perform revision (correction) surgery for our patients who apply to our clinic with the complaint of excessive stenosis after vaginoplasty. However, it should be remembered that revision surgeries are always more difficult than the surgical operations performed before them. Therefore, it is the most important point to set out with a surgeon experienced in vaginoplasty operations, as in all genital cosmetic operations.
Lichen sclerosus is a chronic, autoimmune skin disease that manifests itself with atrophy (thinning of the skin tissue) in certain parts of the body. The disease that most commonly involves the genital area also often involves the labia minora, labia majora, clitoris, perineum (area between the vagina and anus),anus and vestibulum (vaginal introitus). Itching and burning are its most common symptoms. Over time, color changes (whitening) and thinning develop on the skin in the involved area. “Sclerosis” develops over time, in other words, chronic inflammation causes a pathological hardening in the connective tissue. Sclerosus that develops in the genital area can cause many problems.
When lichen sclerosus involves the vaginal introitus or labia minora, it can cause painful sexual intercourse (dyspareunia) due to narrowing. In some cases, tears, abrasions and bleeding occur in the perineal area after every sexual intercourse.
If it settles around the urethral orifice, it may cause difficult urination as well as problems such as labial fusion. This condition causes problems with both urination and sexual intercourse. In patients with advanced disease, it may even completely close the vaginal introitus, causing problems such as inability to menstruate.
The classical treatment is intended to relieve the symptoms and involves the use of steroid-containing creams. With today’s technology, promising results are obtained with genital laser and genital PRP procedures. In cases where the vaginal introitus is too narrow or there is excessive fusion, surgical procedures can be performed.
In many aspects, menopause can be a challenging period for women. The rapid hormonal decline in women causes many mental and physical changes. The vagina gets its share of these changes, as well.
As a result of the withdrawal of hormonal support, which is the most important underlying factor of the healthy and dynamic structure of the vagina, vaginal pH and flora change, rugae get flattened, the mucosa gets thinned and “atrophy” develops, and vaginal dryness may occur by gradual decline in the moist structure of the vagina. Lack of pleasure and painful sexual intercourse due to all these factors can lead to lack sexual drive in women. As the frequency of sexual intercourse decreases, the vagina will be destitute of both the mechanical effect of the penis and the regenerative effect of the hormones secreted during sexual intercourse and orgasm.
The combination of all these factors makes vaginal stenosis inevitable over time. This problem is seen less commonly in patients who notice vaginal atrophy at an early stage and get hormone treatments in a controlled manner. Both oral systemic hormone treatments and topical vaginal hormones safely stop this destructive effect.
Living a regular sexual life is an important factor in maintaining the healthy and youthful structure of the vagina. When hormone treatments remain inadequate in cases of painful sexual intercourse, urinary problems and vaginal dryness suffered by menopausal women, extremely successful results can be achieved with genital laser and genital PRP procedures.
Vaginal stenosis may develop after ovarian, uterine and colon cancers, which are among the 5 most common types of cancer in women. Especially in patients diagnosed with cancer and treated at an early age, these problems come to the forefront in the long term. Vaginal stenosis may occur after comprehensive surgeries involving complete removal of cancer tissues.
Pelvic radiation therapy (radiotherapy) performed in conjunction with these treatments worsens vaginal stenosis. We perform surgical enlargement procedures on our patients who develop vaginal shortness and stenosis after such treatments. The aim is to achieve full recovery of adequate vaginal canal created with postoperative pelvic floor rehabilitation and sexual therapy.
Vaginal stenosis should be treated based on the degree of the person's complaint, the extent of the vaginal stenosis and the underlying factor. Regardless of the cause of its development, there is a treatment procedure that can create sufficient vaginal relaxation for each patient.
Among the treatment procedures, there were initially medical treatments with hormonal content in particular; however, laser treatments which have entered our lives in recent years with the ever-developing energy modality treatments give very successful results, especially when combined with genital PRP treatments. Cylindrical dilators for blunt dilatation are also among the devices used in the treatment of vaginal stenosis.
For those with severe vaginal fusion and stenosis problems, the definitive solution is corrective surgical operations. Surgical treatment should be performed at an early age, especially in patients with congenital vaginal absence or vaginal shortness. In cases of acquired vaginal stenosis, the stenosis can be eliminated by performing an operation selected among a variety of procedures depending on the underlying factor. PRP treatment to be performed in conjunction with surgery will enhance healing and vaginal rejuvenation.
Especially in patients with long-term sexual dysfunction due to vaginal stenosis; it should be remembered that a sexual therapy intended to solve the sexual dysfunction problem will also be required after the treatment of the stenosis.
In this section, you will find some of the hands-on aesthetic genital surgery (cosmetic gynecology) courses, trainings and meetings given by Assoc. Prof. Süleyman Eserdağ.
Assoc. Prof. Süleyman Eserdağ, MDCosmetic Gynecologist & Sexual Therapist
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