T1 Vaginal Dilation

3/28/2016
Vaginal Dilation 101
Heather Appelbaum, MD, FACOG
Anne‐Marie Anne‐
Marie Amies Oelschlager, Amies Oelschlager, MD, FACOG
g MD, FACOG
Disclosures
Dr. Heather Appelbaum and Dr. Anne‐Marie Amies Oelschlager have
g
no financial conflicts with this topic
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OBJECTIVES
• Understand the embryology of development of the vagina
• Learn the history of vaginal dilation
• Understand the outcomes of dilation versus surgery
• Learn methods of dilation
• Know how to manage dilation therapy
Disorders associated with vaginal agenesis
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MRKH
Androgen Insensitivity
Isolated vaginal atresia
Anorectal malformations
MURCS
VACTRL/VATER
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Mayer‐Rotitansky‐Kuster‐
Hauser Syndrome (MRKH)
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Primary amenorrhea
Absent or hypoplastic uterus, vagina
Normal ovarian function
Normal secondary sexual characteristics
46, XX karyotype
Sporadic inheritance but may be associated with WNT4 gene mutation
g
MRKH
TYPE I
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IIsolated Mullerian duct l t d M ll i d t
anomaly
TYPE II
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•
•
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Renal anomalies
Renal
anomalies
MURCS with renal and cervical somite anomalies
Klippel‐Feil syndrome (vertebral loss and scoliosis)
Auditory, Cardiac and Digit anomalies
Ano‐rectal malformations
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Androgen Insensitivity
Androgen receptor defect
46 XY
High serum testosterone
Regression of mullerian structures
Distal vagina present
Inguinal or abdominal testes
Breast development at puberty
Complete or Partial
www.cbs.dtu.dk
“I have no vagina.”
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Embryology
Emans and Laufer, 2012
How do we measure the vagina? Vaginal length • Insert a cotton bud into the vagina and record the length from the posterior fourchette to the most distal part of the blind ending vagina
g
p
y
Vaginal capacity
• Note the size of the largest dilator that can be fully inserted
Callens et al. Human Reproduction Update 2014
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Coital dilation Serial
Serial intermittent mechanical self dilation
intermittent mechanical self dilation
Continuous mechanical dilation
Vecchietti procedure
Balloon vaginoplasty
Graft vaginoplasty
Split thickness skin graft
Amnion
Buccal mucosa
Bowel
Peritoneum
Williams labial flap vulvovaginoplasty
Sheares , Creastas
Complications
Dilation
 < 1% urinary complaints, bleeding, prolapse Surgery
• Intraoperative
Intraoperative Bladder or rectal peroration (1‐4%)
UTI (4‐7%)
• Post operative
Graft necrosis (1‐3.5%)
Neovaginal granulation tissue (9%)
Fistulae (1‐3%)
• Long term
Reoperation rate 40%
R
4 %
Vaginal stenosis or strictures (4‐9%)
Neovagina hair growth (1‐6%)
Persistent discharge (3%)
Prolapse (3%)
Callens et al. Human Reproduction Update 2014
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History of vaginal dilation
Amussat 1935: Apply strong digital pressure
The Frank Method
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
Frank RT. The formation of an artificial Frank RT. The formation of an artificial vagina without operation. Am J Obstet
Gynecol 1938; 35: 1053. Gynecol
1938; 35: 1053
Rock JA, Reeves LA, Retto H, et al. Success Rock JA, Reeves LA, Retto H, et al. Success following vaginal creation for Mullerian agenesis. Fertil Steril 1983;39:809. 7
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Mechanical intermittent self dilation:
Technique
 Dilators of gradual sizes are used to
sizes are used to create a vaginal space 
Dilator is placed by the patient at the g
p
vaginal dimple The Ingram Method
Ingram JM. The bicycle seat I
a JM The bi y le eat
stool in the treatment of vaginal agenesis and stenosis: a preliminary report. Am J Obstet Gynecol 1981; 140:867. 8
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Coital dilation
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20 patients, starting vaginal length 0
20 patients, starting vaginal length 0‐
0‐4.5 cm
4.5 cm
Ages 16‐‐25
Ages 16
Ending length 7‐‐12 cm
Ending length 7
Average 2‐
verage 2‐12 months after coitarche
95% success 19/20 One patient had narrowing of proximal vagina p
g p
g
with 8.5 cm depth; underwent Davydov.
Moen MH Int J Gynaecol Obstet 2014
Nonsurgical vaginal elongation
DISADVANTAGES:
ADVANTAGES:
ADVANTAGES:
Requires self motivation
• Requires self motivation
• Highly successful Highly successful
(85‐90%)
• Delayed results
• Lower cost • Sociocultural barriers
• $796 versus $
796 versus $18520
18520 • Limited success after surgical • Patient controlled
attempts
• Less discomfort
• Inadvertent dilation of the Inadvertent dilation of the
• Non surgical
urethra or rectum
• Few side effect
• Mucosal injury
Edmonds 2011, Rock 1983, Broadbent 1984, Roberts 2001, Gargollo 2009, Nadarajah 2005, Edmonds 2005, Routh 2010
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ACOG: Management of patients with vaginal agenesis 1. Psychosocial counseling to address the functional and emotional effects of vaginal agenesis
2. Nonsurgical creation of the vagina is the appropriate first‐
appropriate first‐line approach in most patients
3. Discuss reproductive potential
ACOG Committee Opinion #562 Mullerian agenesis: diagnosis, management, and treatment; May 2013
Case 1
Your 15 yo patient recently diagnosed with MRKH
diagnosed with MRKH presents and states that she wants to start dilating. She denies any current plan to have intercourse, but wants to have a “normal vagina” like her friends. 10
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The psychosocial impact of Vaginal agenesis
Sexual identity
Sexual identity
Infertility
Social isolation
Coital competency
Fear of surgery/treatment
Is she ready? 
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What is her personal motivation?
I h i th
id t f
l l ti
hi
Is she in the midst of a sexual relationship or anticipating one soon? Is it a healthy relationship?
Ask about her body image/self esteem
Is she dealing with a mood disorder?
Is her family is supportive?
Does she have privacy?
Does she anticipate any barriers to Does she anticipate any barriers Does she anticipate any barriers to dilation? If so, how to dilation? If so, how dilation? If so how
would she solve them?
How confident does she feel that she would succeed? If she has low confidence, address why.
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Advantages of dilating
Disadvantages of dilating
Advantages of not Disadvantages of dilating
not dilating
Can have a normal/pain free sex life
sex life
Chore/Boring
Be “normal” for a day
Won’t be able to have “normal” sex
Feel better as a woman
Discomfort/Pain
Saves time
Lose progress already made
Feel confident to pursue a relationship
Reminder of being No advantage
“abnormal”
Will worry about pursuing relationships
To have a vagina/to avoid i /
id
surgery/to treat
anxiety
Fear of causing h
harm/dilators
/dil
not comfortable/ weird/sex still painful
Have to have
surgery/won’t be a /
’ b
“normal” woman
Avoid pain/discomfort
i /di
f
Liao et al. J Obstet Gynecol 2006
Does age matter?
Age < 18 versus > 18 Lower anatomic success 47% versus 78%
47% versus 78%
Equal functional success 78% versus 76% Callens et al. Human Reproduction Update 2014, BYMRKH photo
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Psychosocial
Motivational problems and poor compliance
Unstable relationship
Interpersonal conflict
Parental misunderstanding of diagnosis
Sociocultural factors
M t l health
h lth issues
i
Mental
Cognitive issues impacting comprehension
Young age
Underlying learning disability
Lack of knowledge of process
Logistical
Lack of privacy
a e d
sta ce to cclinic
c
Travel
distance
Anatomic
Discomfort and pain
Prior scar from “hymenectomy”
Absence of dimple
Multiple congenital anomalies
Reasons for failure
Strategies for support
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Engage the family
Engage the family
Provide detailed information on anatomy and physiology of menstruation and fertility
Discuss sexuality
Review treatment options including risks and benefits
db
fit
Allow for gradual acceptance
Provide professional and peer support
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The vaginal agenesis team
The patient
Family/friends
Nursing
Gynecologist
Social worker and psychologist
On‐Line Support
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Beautiful You MRKH foundation www.beautifulyoumrkh.org/
AIS DSD Support Group http://aisdsd.org
http://aisdsd.org//
Center for Young Women’s Health
http://youngwomenshealth org/2013/10/02/mrkh/
http://youngwomenshealth.org/2013/10/02/mrkh/
The MRKH Organization: http://www.mrkh.org/
Accord Alliance: http://www.accordalliance.org
American Surrogacy Center www.surrogacy.com
MRKH Support and
Awareness: https://www.facebook.com/groups/squirrellhill/
Embrace MRKH
Foundation: https://www.facebook.com/embrace.mrkh
AskaboutMRKH: http://health.groups.yahoo.com/group/askaboutM
RKH/
MRKH girls: http://health.groups.yahoo.com/group/mrkh-grrls/
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“You a e i o t ol ”
“You are in control.”
“There is no rush.”
Case 2
An 18 yo with MRKH presents to your office for a new consult with her h
d
h d l
mother and wants to schedule surgery. Her referring doctor told her that she needs surgery because she has no vagina. She was given dilators when she was 14 in the clinic and said that they didn’t work when she tried them. She has a boyfriend and wants to be sexually intimate with him. 15
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Results
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360 patients between 1998‐2010 with MRKH
245 patients requesting vaginal dilation
Mean age of dilating patients:18.6 years (16‐22 years)
Successful length (6 cm length) and sexual Successful length (6 cm length) and sexual
function 232 (94%)
13 patients did not complete treatment

1 lost to follow‐up
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Dilation program
Components of success
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Patient readiness
Knowledgeable, accessible, positive multidisciplinary team
Comfortable surroundings
E
Engagement of family support
f f il
Patient pace driven
Active support of staff
What increases confidence in dilating? •
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Knowing exactly where the dilators are going and what they are doing
going and what they are doing
Evidence that it works
• information about the time it takes
• how to assess progress
Knowing about others’ experience
Being more organized
B i
i d
Making it more fun
Making it more comfortable
Liao et al. J Obstet Gynecol 2006
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Is her vagina too small for dilator therapy to work?
• Starting length is correlated with end vaginal length and duration of dilator therapy
• Not correlated with anatomic correlated with anatomic
success
Vaginal length in 26 women with vaginal agenesis before
and after dilation therapy as first line treatment.
Ida S. Ismail-Pratt et al. Hum. Reprod. 2007;22:2020-2024
© The Author 2007. Published by Oxford University Press on behalf of the European Society of
Human Reproduction and Embryology. All rights reserved. For Permissions, please email:
[email protected]
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Getting started
1)
2)
3)
4)
Tour of the anatomy with the patient
Tour
of the anatomy with the patient
Demonstrate appropriate angle
Start with smallest dilator
Talk about how to avoid the urethra
4) Discuss the levators/Kegels 5) Discuss how to softening the vagina: coconut oil, bath, sexual /
activity/orgasm
6) Privacy strategies
7) Building your team: partner, support group
,
p
,
8)) Review condoms, STI prevention, and HPV vaccine 9) Schedule follow up and make sure she knows the clinic number to call
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Dilation methods
• Patients instructed to place a 0.8 cm tube or p
extra small dilator in a downward angle towards the sacrum one to three times per day for 10 to 30 minutes • When some depth has been reached, change to a more cranial angle and tube is changed to a 2 cm tube or small dilator
t b
ll dil t
• Twice per day for 10 to 30 minutes • Return to clinic next day, two weeks, four weeks, 6‐8 weeks
Does frequency or duration matter?
• Frequency matters more than duration
• 3X per day for 10 minutes better than 3X per day for 10 minutes better than
once for 30 minutes
• Dilation 2‐4 times per day versus 1 X per day
• anatomic success 76% versus 46%
• functional success 78% versus 84%
functional success 78% versus 84%
Callens et al. Human Reproduction Update 2014
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Which one to recommend?
Dilator websites
Pure Romance
http://www.vaginismusmd.com/aidsproducts/dilators/pure‐
romance‐vaginal‐dilators‐set‐of‐6‐dilators/
http://pureromance.com
*Pure Romance will give a discount if you mention AISDSDSG.
Lelo Liv vibrator p //
g
/
p
/
/
http://www.vaginismusmd.com/aidsproducts/vibrators/lelo
‐liv‐vibrating‐dilator/<https://www.lelo.com/liv‐2> I Vibrators in graduated sizes
www.goodvibrations.com
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She returns to clinic 8 weeks later and states that she only has time to dilate once a day She She reports pain, reports pain
dilate once a day. light vaginal bleeding, and urinary frequency. On exam, her vagina is 4 cm in length and 2 cm in width. Troubleshooting: Bleeding
• Physical exam to assess for f
perforation
• Encourage more lubrication
• Prescribe estrogen cream
• Increase width of dilator
• Take a rest day
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Troubleshooting: Pain
Lidocaine jelly
Pelvic floor physical
Pelvic floor physical therapy
Increasing width of the dilator
Estrogen cream
g
Coconut oil
Switch to softer dilator or vibrator
McVearry ME , Warner WE. Use of physical therapy to augment dilator treatment for vaginal agenesis. Female Pelvic Med Reconstr Surg. 2011
Troubleshooting: Urinary symptoms
Urinalysis and culture
Test for gonorrhea and chlamydia
Estrogen cream
y p
Review baseline symptoms
Review dilating technique
Review Kegels and voiding habits
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Pretreatment
%
Posttreatment Normative data
%
Hesitancy
Urgency
Bladder pain
53
53
37
53
63
58
25
20
10
Intermittent stream
Burning
Incomplete emptying
Wearing protection
Urge incontinence
37
42
37
16
15
53
37
58
33
21
30
15
25
0
5
Stress incontinence
Abnormal strength of stream
16
16
21
37
25
0
Michala et al. Int Urogynecol J 2013
She returns to clinic 6 weeks later. She has been dilating 2‐3 times per day and she is wondering when intercourse is safe. Her vagina is now 5 is safe Her vagina is now 5
cm in length
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What is the definition of success?
Anatomic versus Functional
MOST COMMON DEFINITION:
ANATOMIC LENGTH >
ANATOMIC
LENGTH > 6 cm and ABSENCE OF 6 cm and ABSENCE OF
COMPLICATIONS
If success is:
• ANATOMIC LENGTH > 7 CM
• Vaginoplasty 90% versus dilation 75%
• SATISFACTION WITH SEX” • Vaginoplasty 93% versus dilation 96%
• “ABILITY OF WOMAN TO PROVIDE PLEASURE TO THE PARTNER”
Callens et al. Human Reproduction Update 2014
Overall outcomes for dilation
908 patients
93% MRKH 7% AIS
93% MRKH, 7% AIS
ANATOMIC SUCCESS > 6 CM: 78% > 7 CM: 69%
> 8 CM: 33%
FUNCTIONAL SUCCESS 96%
satisfaction with sex life
satisfaction with sex life
or successful sexual function
COMFORTABLE COITAL AND ORGASMIC FUNCTION 74%
SEXUAL ACTIVITY 86%
Callens et al. Human Reproduction Update 2014
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When is intercourse OK? She returns 6 weeks later and now her vagina is 7 cm in length. She has been using the medium dilator She and her boyfriend have
medium dilator. She and her boyfriend have been having intercourse and she states that it was initially painful but now it is better. She has not had an orgasm with him and she is worried that her clitoris is not working. She reports vaginal dryness and she is scared of having sex. She still doesn’t feel that her vagina is “normal.”
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MSQ Scores before and after dilator therapy
Sexual esteem
CAIS
before
CAIS after MRKH MRKH before after
6
7
2
4
Sexual anxiety
9
6
12.5
7
Sexual assertiveness
8
7
8
6
Sexual depression
11.5
8
11
5
Fear of sex
9
8
9
8
Sexual satisfaction
l
f
2.5
9
5
6
Ida S. Ismail-Pratt et al. Hum. Reprod. 2007;22:2020-2024
Long term sexual function:
Female Sexual Function Index • Women post dilation and surgery have lower scores than women without vaginal agenesis
Arousal
Lubrication
Orgasm
Pain during intercourse • No differences in desire or satisfaction with No diffe e ces i desi e o satisfactio
ith
sex life or relationship
• Those medically treated did not have higher scores than those who were not treated
Callens et al. Human Reproduction Update 2014
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Vaginal perceptions
Ida S. Ismail-Pratt et al. Hum. Reprod.
2007;22:2020-2024
© The Author 2007. Published by Oxford University Press on behalf of the European Society of
Human Reproduction and Embryology. All rights reserved. For Permissions, please email:
[email protected]
Quality of life
Depression symptoms
Doubts about female identity
Body image issues Even post surgery and dilation, f
women feel that their vagina is abnormal.
Minto et al Fertility and Sterility 2003
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Troubleshooting: Addressing sexual dysfunction
Discuss healthy relationships
Discuss lubrication, anatomy
Encourage pelvic floor PT
Discuss psychological issues
Encourage counseling
Encourage support from others
She returns one year later.
She and her boyfriend have broken y
up. She is really busy with school and work and is wondering whether her vagina is going to shrink but she doesn’t really want to dilate due to boredom. boredom
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Is maintenance dilation necessary?
Recommended 2‐3 times per week if no coitus
• 2‐3 times per week if no coitus
• No studies comparing those who did and did not do maintenance dilation
• Women regain length very Women regain length very
quickly with resumption after hiatus
Callens et al. Human Reproduction Update 2014
VIBRATORS!
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Take home points
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Vaginal dilation successful as a first line treatment for vaginal agenesis
Psychological readiness/ evaluation is important
Multidisciplinary support is likely a variable in success
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