Vaginal hypoplasia refers to the underdevelopment of the vagina or birth canal. It may be present in various grades, of which the most severe is vaginal agenesis, or complete absence of the vagina.
The vagina is designed to provide a protected outlet for menstrual and other secretions from the uterus to the exterior of the woman’s body. It is also the last part of the passageway through which a fetus is born. Finally, but not least importantly, it is the orifice through which penetrative sexual intercourse occurs.
The vaginal dimensions vary, of course, from woman to woman. However, in most cases, an average length might be between 6 and 12 cm, though this is known to increase during penetration. The length in women with vaginal hypoplasia may range from nil to just 1-2 cm, which is called a vaginal dimple.
Primary amenorrhea is the usual presenting symptom of most women with vaginal hypoplasia. A physical examination is the only way to find out if this condition is present. This may be deferred until after puberty, when the vagina has attained its maximum dimensions, and whenever the patient is ready to consider a sexual relationship. This will of course vary greatly between women.
Too narrow a vagina can lead to obstruction of the menstrual outflow, which leads to the eventual formation of a blood-filled distended uterus and upper vagina, called a hematocolpos. This can lead to secondary endometriosis, a condition in which ectopic or misplaced endometrial tissue is lodged and grows within the abdominal cavity and produces cyclical intraabdominal bleeds, similar to menstrual bleeding. This in turn results in the formation of peritoneal adhesions which may block the tubes and make the woman infertile.
In women who lack a normally developed uterus, as in Rokitansky syndrome or androgen insensitivity syndrome, a hematocolpos does not form but they find sexual intercourse impossible or very painful.
The examination involves measuring the length of the vagina with a cotton-tipped swab, and a single finger is inserted to assess vaginal width and elasticity. If it is very short, further treatment may be advised depending on the patient’s preferences.
Most patients with a hypoplastic vagina and no uterus may receive treatment using Frank’s vaginal dilators. These are usually silicone or plastic, and graduated in length and width. The patient is shown how to introduce these into the vaginal dimple with pressure, for 30 minutes a day. This has a high success rate of above 85%, and maintenance treatment twice or three times per week is sufficient to keep the vagina patent until regular sexual intercourse begins. No anesthesia or surgery is needed but the patient needs to be motivated and compliant to continue with this.
In the remaining 15% of women, surgical correction is required. This is indicated also if the woman already has scarring of the perineum which makes the vagina inelastic and unable to expand as necessary. A simple but highly effective first-line surgical intervention is the Vecchietti procedure. This may be done laparoscopically and uses continuous abdominal traction on an acrylic olive placed in the vaginal dimple. The traction is increased daily, to stretch the vagina to normal dimensions over a week or 10 days. It may cause pain and therefore the patient is usually admitted in hospital for analgesia. Vaginal dilators are then used to keep it patent as usual. This surgery is not possible if previous scarring is present.
Other Surgical Procedures
These are indicated only if dilatation is not possible, as when there is severe scarring following surgeries, or complex reproductive tract anomalies. In these cases, vaginoplasty is resorted to. These include:
- William’s vaginoplasty, in which the labia majora are fused to make a short vaginal pouch
- Creatsas vaginoplasty, in which the perineal and vulval tissue are used to create a longer vagina
- McIndoe-Reed vaginoplasty using split-thickness skin over a mold inserted into the expanded rectovesical space to create a neovagina
- Other modifications using various tissues and materials to line the neovaginal space.