Shortened Vagina due to Surgery

Vaginal shortening is also known to occur following surgery in the vagina or the pelvis including hysterectomy, and/or repair of vaginal relaxation or prolapse (ie cystocele, rectocele, uterine prolapse etc). It is not common, however can be very devastating to the woman when it occurs. This can occur due to the vaginal walls scarring together during healing, or too much vagina being removed during a vaginal repair or following hysterectomy. Patients may complain of pain with intercourse or not being able to achieve intercourse secondary to the vagina being shortened and not able to accommodate the penis during penetration or can only have partial penetration secondary to pain or limited length. Most patients will state that they had no problem with sexual intercourse prior to their surgery, however when they attempted it following their surgery they were not able to have it at all, or had extreme pain with every attempt. Many times they see their original surgeon and are told, “don’t worry, keep trying, it will get better or improve." Occasionally this will be true, however if the scarring is complete, it will not improve without intervention. Even worse, some are told that there is nothing that can be done about it, and this is far from the truth!

Pain following hysterectomy:

Many women complain of pain with deep intercourse following hysterectomy. Most did not have this pain prior to surgery, however develop it after. Sometimes this can be due to scar tissue or nerve damage that with time and healing will improve and resolve. Many times, however, the pain may persist and could be due to vaginal shortening and scarring at the apex of the vagina.

As reconstructive pelvic surgeons, vaginal shortening can be one of the most challenging conditions to deal with as in the past it has been very difficult to achieve extra vaginal length once it has been shortened. We have attempted in the past to utilize various techniques to achieve extra length including skin grafts, cadaveric human skin or fascial grafts, cadaveric animal grafts, muscle flaps etc all with very limited success. In most cases further surgery causes more scar tissue and the vagina scars back down or gains very minimal length. Dr Miklos and Moore have done extensive work and research in this field and published some of the first papers in the literature on the use of biologic grafts in vaginal reconstructive surgery.  They are known throughout the world for their work in the field of graft use,  however they too had very limited success in creating extra length for women with shortened vaginas when using biologic grafts.

More recently Dr Moore and Miklos have utilized a modification of a procedure used to create Neovagina for young women born without a vaginal canal or uterus in women with shortened vagina due to scar tissue. This is a laparoscopic procedure (Laparoscopic Neovagina) that utilizes the patient’s own peritoneal lining of the pelvis to create extra length and they have achieved excellent success rates, better than any other technique ever described. They have been using this technique for many years in women born without vaginas as it is the least invasive and most successful method to create a vagina in this patient group, and have been some of the first in the world to use it successfully in women with shortened vaginas due to surgery. Compared to other treatment options it is the least invasive with fastest recovery, requires no grafts or foreign bodies and has highest success rates!

Traditional Treatment options for Short Vagina

Non-surgical Techniques for Short Vagina

Self-dilation:

The first step if a shortened vagina is found following vaginal surgery or hysterectomy is to use vaginal dilators to try to gain extra length manually. Vaginal dilators come in various length and sizes and are used one to two times daily to try to stretch the caliber and length of the vagina. Depending on the extra length required as well as the amount of scar tissue present will determine how successful the technique is. If the vagina is shortened to less than 7cm, this technique rarely works, however is always a good option to start with.

Pelvic floor physical therapy:

If available in the patients region, this is typically completed at the same time as dilator use. The physical therapist will actually help the patient with dilation, utilize soft tissue techniques, myofascial release in the vagina and on the vaginal muscles to attempt to soften the scar tissue, gain extra length and also try to help decrease the pain in the vagina. Many times with vaginal pain, the pelvic muscles will also tighten and spasm and this can lead to more pain with intercourse and the therapists will work to help release this tension as well.

Surgical Techniques for Short Vagina:

Vaginal release of scar tissue:

This is the simplest surgical technique that is utilized to try to gain extra vaginal length. Simply, the surgeon will go in through the vagina and try to separate the scar or the fusion of the walls together at the top of the vagina. The difficulty with this approach is that if the vagina was surgically shortened secondary to loss of vaginal tissue, or if the scar is thick, the amount of length to be gained is minimal. Additionally, any length that is gained is raw tissue (ie not true skin with a smooth epithelial surface, it would be like severely scraping the palm of your hand or your knee and removing the outer layer of skin, leaving a raw bloody surface) and there is a high probability the two raw surfaces will heal together again. Vaginal packing must be used post operatively for an extended period of time and then aggressive vaginal dilation must be used as well. Typically, the most length to be gained by this approach would be 1-2 cm at the most.

Vaginal or Abdominal use of skin grafts:

Various techniques have been described and attempted through the years to gain vaginal length with the use of autologous skin grafts (ie skin take from another part of the patient, like her legs or her buttocks) or biologic grafts such as human cadaveric skin grafts, or from animals such as pigskin. Dr Miklos and Moore have been on the forefront of the research and use of grafts in vaginal reconstructive surgery and have extensively published in this field. They were some of the first to use cadaveric grafts to help support vaginal prolapse, repair fistulas, or lengthen/widen vagina with them.  Unfortunately, these techniques have not been proven to be very successful at all to lengthen the vagina. Most are very extensive procedures, some require placing a skin graft over a vaginal stent or balloon and leaving this in the vagina for up to 3 months. In many cases the walls still scar down, or the graft is rejected or does not take. These procedures have not been the answer for vaginal shortening.

More recently, Dr Miklos and Moore have been utilizing a procedure in women with surgically shortened vaginas that has been described and they have used very successfully to create a full new vagina for women born without a vaginal canal. This is called vaginal agenesis or MRKH syndrome (click here for more information). The procedure was originally described through an abdominal approach with a large incision, however Dr Moore and Miklos have utilized their skills as laparoscopic reconstructive surgeons to be able to do the surgery through a laparoscopic approach (ie mini-incsions in the belly) which makes it an outpatient type surgery with a very rapid recovery.  They typically can extend the vagina up to 10 or 11 cm, no matter what length the vagina starts out, using this very minimally invasive approach.

NEW Laparoscopic Approach to lengthen the vagina

The Davydov Procedure is a surgical procedure used to create a full length vagina in young women that are born without a vaginal canal. It is one of the most successful procedures described for this condition and utilizes the patients own peritoneum (the cellular layer that lines the walls of the pelvis and the abdominal cavity) as the new vaginal canal. Traditionally completed via open abdominal incision, the laparoscopic approach was developed in Russia in the late 1990’s and early 2000’s. The advantage of this procedure is that it utilizes the pelvic peritoneum as the lining of the new vagina, which has been shown to transform into histologic vaginal epithelium in approximately 6 months time. That means if one biopsies the new vagina 6 months after it was created, the skin appears as normal vaginal skin under the microscope! Additionally, it creates more length than any of the other procedures and is one of the least invasive techniques available, has a very quick recovery, has minimal risk of scarring down and typically requires very little dilating after surgery.

Dr Moore and Miklos utilize a laparoscopic modification of the Davydov procedure not only to create new vaginas in women born without one, but also now in women that have surgically shortened vaginas. This makes it even more minimally invasive than the original procedure. The doctors travelled to Russia and were trained by Dr L.V. Adamyan, who developed this original technique. They have used their laparoscopic expertise and suturing skills to modify the procedure even more and to do more of it laparoscopically (it is a combined laparoscopic and vaginal procedure) as they do most of the suturing required through the mini-incisions in the belly button and abdomen while working off of High-Definition large screen TV’s. In a recent study the procedure had a 96% functional success rate with sexual function scores in the good to very good rate. Typically, patients are able to have normal sexual function including arousal, lubrication, orgasm and satisfaction. The procedure itself is much less invasive than most of the alternative surgical options and achieves better length with less risk of scarring down.

The procedure usually takes between 1 and 2 hours and is completed in an outpatient surgical setting (or a 23 hour stay facility). Recovery is rapid and intercourse is able to be achieved in as little as 2 weeks post-operatively. A vaginal pack is typically left in for just 36-48 hours (in some procedures that require skin grafting of the vagina, the pack is left in for up to 4 weeks), however in some cases it may need to be changed and left in for approximately a week. Pain is usually minmal and return to normal activities such as work is usually very rapid.

Dr Miklos and Moore have utilized this laparoscopic technique on women throughout the US, including many women that have had attempts of neovagina or vaginal lengthening by other techniques and other surgeons and have failed. They are still able to utilize their laparoscopic skills even in this more complicated subset of patients to create extra vaginal length and a new vaginal cuff (ie top of the vagina) with the pelvic peritoneum and still operate through mini-incisions and give the patient the benefit of very minimally invasive surgery. Patients that have had previous surgery cannot believe how much easier the approach was with Dr Moore and Miklos and the results they achieved after the procedure resulting in a normal, full length, functioning vagina!

Drs Miklos and Moore are considered world leaders in the laparoscopic approach for vaginal reconstruction, including  shortened vaginas and are asked from experts throughout the world to come and lecture and teach on the subject.  They just returned from Dubai (put link to the flyer here, or put the flyer in the text) where they taught surgeons from throughout Europe and the Middle East their laparoscopic techniques. For more information on the procedure, please click here.