Repair of a constricted or shortened vagina: What works?

Patients who want to be sexually active but suffer iatrogenic vaginal constriction or shortening, or both, are a surgical challenge. Their condition may require any of a variety of nonsurgical and surgical procedures to restore the ability to have gratifying sexual intercourse, and they may need considerable preoperative and postoperative counseling and management.

What is the basis of this problem?

The cause of vaginal shortening or constriction is most often surgical. Rarely is systemic disease or a localized condition, such as urogenital atrophy, responsible.

Prolapse procedures. Most procedures that result in vaginal shortening or constriction are ones performed to correct pelvic organ prolapse (POP), notably:

• posterior colpoperineorrhaphy with levatorplasty
  
• hysterectomy, whether abdominal or vaginal, during which too much of the upper vagina is taken with the cervix
  
• anterior and posterior colporrhaphy in which vaginal plication and trimming are performed overzealously.
  

Radiation therapy to the pelvis can result in vaginal shortening, constriction, and obliteration.

How do you avoid creating these problems?

Techniques to avoid vaginal shortening and constriction during vaginal reconstructive surgery include appropriate use of levatorplasty during posterior colpoperineorrhaphy. Although levatorplasty is, at times, the only way to decrease the size of a large vaginal hiatus, it should be used only in the distal third of the vagina. Levatorplasty above this area often creates vaginal constriction that results in postoperative dyspareunia.

Also, avoid 1) overzealous trimming during anterior and posterior colporrhaphy and 2) removing too much vagina at vaginal or abdominal hysterectomy.

Last, it is important that a patient who has undergone vaginal reconstructive surgery have a vaginal exam within 2 weeks after surgery. This will ensure that the vaginal incisions do not fuse, thus creating vaginal scarring, closure, and constriction.

How is correction approached?

Various modifications of a McIndoe procedure have been described for vaginal agenesis, but surgical correction of iatrogenic vaginal shortening or constriction is not well described; few case series exist in the literature. Consensus is lacking on what the minimal length of a vagina must be to preserve normal sexual function, and no standard exists in regards to either normal vaginal caliber or the relationship of the perineum and perineal body to the distal posterior vagina.

That being said, we have recognized the following correlates of a successful return to sexual function after surgery for vaginal constriction or shortening:

• The vagina should, at minimum, be 7 cm long to have the potential for normal function
  
• The vaginal opening should easily admit two fingers during examination
  
• The relationship of the posterior vagina and the perineum should be a perpendicular one, in which a built-up perineum attaches to the posterior vagina at the posterior fourchette at a 90° angle
  
• There should be no buildup of perineal skin above and beyond the posterior fourchette.
  

Is surgery the first intervention?

No. The patient should first undergo an attempt at nonsurgical management. This usually involves:

• vaginal estrogen cream in a postmenopausal patient
  
• appropriate utilization of a vaginal dilator.
  

What are options for surgery?

If nonsurgical management of vaginal constriction or shortening is unsuccessful or unsatisfactory, next choose an operation based on the needs of the individual patient. Some procedures involve placement of a skin graft or, possibly, other biologic material in the vagina to close over defects after constriction has been taken down or the vagina has been appropriately opened up. (It is fortunate that the vagina heals well by secondary intention; often, simply taking down the constriction and allowing the vagina to heal by secondary intention is successful.)