Vaginal Adhesions

Vaginal adhesions are fibrous bands that join opposing vaginal walls and narrow or close the vaginal canal.

• Causes include postmenopausal atrophy, desquamative inflammatory vaginitis, erosive lichen planus, radiotherapy, vaginal surgery, trauma, childbirth and prolonged pessary use.
• Complete closure can trap blood or secretions.
• Treatment is by oestrogen, lysis and dilators.

Dyspareunia, vaginal shortening, difficulty with examination, discharge, bleeding and, if the vagina closes, cyclical pain or retained secretions.

• Bands are felt or seen on speculum examination, and the vagina may end blindly with the cervix out of sight.
• Differential diagnosis: vaginal stenosis, transverse vaginal septum, vaginismus, atrophic vaginitis, vaginal agenesis, vaginal tumour.
• Complications: haematocolpos, pyocolpos, apareunia, impaired screening, urinary retention.

Diagnosis is by gentle examination, with ultrasound to exclude trapped blood or pus.

• Gentle vaginal examination, with sedation if painful.
• Pelvic ultrasound to exclude trapped blood or pus.
• Biopsy of any erosion, white striae or suspicious lesion.
• Culture of discharge; exclude lichen planus by examining the mouth and skin.
• Pregnancy test if in the reproductive age.

Treat the cause, lyse the bands and keep the vagina open with dilators.

• Supportive: vaginal dilators with water-based lubricant, 5 to 10 minutes, 3 times weekly after lysis; lubricant during intercourse; pelvic floor physiotherapy.
• Pharmacological: oestriol 0.1 percent cream 0.5 g intravaginal nightly for 2 weeks then twice weekly for 8 to 12 weeks in postmenopausal women. For erosive lichen planus: hydrocortisone 10 percent intravaginal cream 5 g (compounded) nightly for 4 weeks, then twice weekly. For desquamative inflammatory vaginitis: clindamycin 2 percent cream 5 g intravaginal nightly for 2 to 4 weeks. Analgesia with paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours).
• Procedures: lysis of bands under anaesthesia or sedation by blunt dissection or sharp division of thin bands, followed by dilators within a week. Drainage of retained secretions if the vagina is closed.
• Special groups: in women with breast cancer use non-hormonal moisturisers first and local oestrogen only after specialist advice.
• Red flags: bleeding, a closed vagina with cyclical pain, suspicion of malignancy, urinary retention.
• Follow-up: review at 2 weeks after lysis, then monthly for 3 months to confirm patency.