Vaginal Stenosis

Vaginal stenosis is narrowing or shortening of the vagina that makes intercourse, speculum examination or pelvic examination painful or impossible.

• Causes are pelvic radiotherapy, vaginal or pelvic surgery, severe atrophy after menopause, genital tract injury, female genital mutilation, severe lichen planus, graft-versus-host disease and congenital anomalies.
• Early treatment with dilators and local oestrogen prevents fixed scarring.
• Late, dense stenosis needs surgery.

Dyspareunia, apareunia, vaginal tightness, bleeding with examination and inability to pass a speculum.

• Short, narrow vagina with scarring, bands and loss of rugae.
• Differential diagnosis: vaginismus, atrophic vaginitis, vaginal adhesions, vaginal agenesis, transverse vaginal septum, lichen planus, vaginal cancer recurrence.
• Complications: sexual dysfunction, impaired cancer surveillance, haematocolpos or pyocolpos from obstruction, psychological distress.

Diagnosis is by gentle examination, with biopsy to exclude recurrent cancer.

• Gentle pelvic examination, measuring vaginal length and calibre.
• Review of treatment history including radiotherapy and surgery.
• Biopsy of any suspicious area to exclude recurrent cancer.
• Ultrasound or MRI when obstruction or a congenital anomaly is suspected.
• Test for vaginal infection if there is discharge.

Start dilators and local oestrogen early, and reserve surgery for dense scarring.

• Supportive: vaginal dilators of increasing size, used for 5 to 10 minutes, 3 times weekly, with water-based lubricant; regular sexual intercourse when comfortable; pelvic floor physiotherapy; counselling. Start dilators 2 to 4 weeks after radiotherapy finishes.
• Pharmacological: oestriol 0.1 percent cream 0.5 g intravaginal nightly for 2 weeks then twice weekly, or oestradiol 10 micrograms vaginal tablet nightly for 2 weeks then twice weekly, used for as long as needed. Vaginal moisturiser (polycarbophil) 2 to 3 times weekly. For erosive lichen planus: hydrocortisone 10 percent intravaginal cream 5 g (compounded) nightly for 4 weeks under specialist care.
• Procedures: lysis of bands and adhesions under anaesthesia followed by early dilator use; vaginal reconstruction or vaginoplasty for dense stenosis; resection of the septum for transverse septum. Incision to drain haematocolpos or pyocolpos.
• Special groups: in women with breast cancer use non-hormonal lubricants and moisturisers first, and local oestrogen only after specialist advice. In women on tamoxifen avoid local oestrogen unless the treating team approves.
• Red flags: bleeding from the stenosis, suspicion of cancer recurrence, cyclical pelvic pain from obstruction, urinary or faecal leakage.
• Follow-up: review at 4 to 6 weeks, then every 3 months while using dilators; continue dilators for at least 1 year after radiotherapy.