Sunday, November 4, 2012

Vaginal Laxity (Looseness): What does the Woman's Doctor Think?

Stretching of the vagina and its opening (introitus) can occur from vaginal delivery or from pelvic organ prolapse (dropping of the bladder, uterus, rectum), however it may also be a natural process. It is thought that looseness or stretching may contribute to diminished sexual satisfaction from loss of sensation, and affect body image. It is not clear how many women may experience this condition, but 83% of urogynecologists from a recent survey described vaginal laxity as underreported by their patients. These physicians felt that laxity may be a bothersome condition to patients that may impact on “happiness and sexual function”. It is the most obvious physical change that physicians felt women experienced after childbirth.

Some studies conflict about where repair of pelvic organ prolapse improves sexual function. If prolapsing organs are uncomfortable or affect urination or bowel movements, these conditions will be repaired regardless if the woman is sexually active or not. Since prolapse also usually affects an older population of women who may already be less sexually active due to their own libido, health or their partner’s health, it is difficult to sometimes judge whether prolapse surgery improves sexual function. “Vaginoplasty” is the tightening surgery, often done for cosmetic reasons  or with the intention of improving sexual function, but studies measuring whether this actually improves sexual function are poorly designed so a true answer  is elusive.

Conversely, it is also known that with age, hysterectomy and reconstructive surgery for prolapse the length of the vagina shortens. Dyspareunia, or pain with sex, can occur from either being “too tight”, from having a narrow introitus, or from reduced vaginal length. Vaginal dilators can be used to stretch the introital opening after scarring/narrowing develops with age, radiation, and surgery.

So, does the woman’s doctor (urologist or urogynecologist) feel comfortable talking about sexual health to their patients? The vast majority of those surveyed (>90%) feel comfortable discussing sexual health, but often feel than time pressure in the office may limit the depth of the conversation. 83% felt that vaginal looseness was an underreported concern among patients, 57% believed that vaginal laxity directly affects the quality of life of relationship happiness, while only 31% felt that vaginal looseness was an issue driven by the male partners of patients. 4% responded that vaginal laxity was an industry invented condition. Some of the concerns cited about sexual impact were: less confidence, perceived inability to please partner, altered sensation and less satisfaction.

The prime location of looseness was cited as being the introitus, and the most frequently recommended treatments were Kegel muscle exercises and pelvic floor physical therapy, though physical therapy was noted to be more effective. Only 54% of doctors recommended surgery to correct looseness, yet it was felt to be a more effective therapy.

Overall, vaginal laxity is not well studied and may affect sexual quality of life. Yet, there is a keen interest in addressing it, but there is inconclusive evidence to date that any one therapy works well or is the best option. There is debate and scant data, and this means, more study is definitely needed.