Vaginal hypoplasia refers to a condition in which the vagina is much smaller than normal, and is not capable of supporting its normal functions. These include sexual penile penetration, allowing the passage of a baby during birth, and providing a protected outlet for menstrual and other uterine secretions to leave the body.
The normal vaginal dimensions vary widely between women. An average length might be between 6 and 12 cm, while the width is variable as well. In vaginal hypoplasia in which only a vaginal dimple is present, the length may be as little as 1-2 cm only.
Treatment of vaginal hypoplasia takes two forms. It depends on the presenting condition, the urgency of providing relief, the skills available to the treating team of physicians, the level of post-operative and psychological care that is probable, and the risks.
This is the first line of treatment for vaginal hypoplasia because of the low risk and very high success rates, unless specifically contraindicated by severe genital scarring. The advantages of dilatation include the fact that the new vagina is lined by natural vaginal epithelium which is therefore sensitive to touch and responsive to sexual cues.
The essentials include a motivated patient who is interested in sexual intercourse. The timing of treatment depends on when the woman is ready to seek a sexual partner and can comply with treatment.
This form of treatment aims to provide a vagina for satisfactory sexual intercourse. It may be used when the woman has no internal female organs, or after surgery to keep the neovagina patent until regular intercourse begins. It depends upon expansion of the potential rectovesical space by the application of pressure, with eventual epithelial growth over the whole of the new space created. The use of vaginal estrogen makes the use of dilators more comfortable and normalizes the vaginal tissue more as well.
The two most commonly used methods include:
- Intermittent dilation with Frank’s dilators which consists of a graduated set of plastic dilators that increase in length and width, and are inserted by the patient for 30 minutes a day until the vagina is long enough, which usually takes a few months. A specialized seat called the ‘bicycle seat’ (Ingram) or even a more modern chair design (Veronikis) lets the patient achieve daily dilation without undressing and while doing other things in the seated position, in as little as 4 weeks, and by gradual increments.
- The Vecchietti procedure is a surgical intervention which involves attaching an acrylic vaginal ovoid that presses against the top of the vaginal dimple through a set of wires held against the anterior abdominal wall. It is wound tighter each day. This is quite a fast procedure and achieves excellent results, but the patient may experience significant pain and need to be admitted for analgesia over the treatment period of 7-10 days.
This route of treatment is a plastic surgery approach to construct a new vagina using tissue from other parts of the body, which is referred to as vaginoplasty. Its success is dependent upon the presence of previous scarring, the skills of the operating team, the associated medical or surgical conditions, and the presence of psychological and post-operative support. It should almost always be performed only after puberty, when the vagina has reached its maximum length.
Several types of vaginoplasty have been described, each with its own advantages and risks. Surgery may always involve complications such as malignancies developing in grafted skin or intestine, vaginal discharge, vaginal dryness, stenosis or shortening of the vagina due to scar contracture, and infection. Dilation must always be used after all surgeries to keep the vagina open until it heals.
Why Dilation is Preferred to Vaginoplasty
Dilation is almost always preferable as the first intervention in vaginal hypoplasia because:
- It is low-risk
- It has high success rates
- It achieves the touch and function of a normal vagina
- It does not introduce foreign tissue
- It can be done only if previous surgical correction has not been attempted, but conversely, previous failed dilation does not adversely affect the outcome of a surgical intervention later
- The pain and effort of primary vaginal dilation are less than that imposed by surgery which, in addition, always requires additional dilation postoperatively
This uses a split-thickness skin graft, often from the buttocks, to cover a mold which is inserted into the previously expanded rectovesical space to fuse to the lateral aspects of the fascia there and form a new tube. The skin may contract and close off the vagina as it heals unless dilators are used post-operatively as advised.
Modifications of this procedure use amnion, full-thickness skin grafts, or non-biological materials to cover the mold or stent.
The Davydov Technique
This employs peritoneum pulled down from the abdominal cavity to line the neovagina formed by expanding the rectovesical space.
The Baldwin Technique
This uses a length of transplanted pedicled colon or ileum to replace the vagina. It is much more high-risk and invasive compared to any of the other techniques in use. Excessive mucous discharge is a possible and disturbing adverse effect of the intestinal vagina.
This originally consisted of suturing the labia majora together. It has been modified, most notably by Creatsas, to include vulval and perineal tissue sutured from both sides to make a new vagina which functions well.
This involves the insertion of a Foley’s catheter into the rectovesical space by laparotomy or laparoscopy, following which it is fixed to the anterior abdominal wall. The inflation of the balloon pushes up the vaginal dimple progressively to a length of up to 12 cm by a week or so.