Vaginal relaxation syndrome is a gynecological disorder characterized by a decrease in muscle tone and elasticity of the vaginal mucosa. Objectively, the disease is manifested by flabbiness of the walls of the vagina, gaping of the genital slit, subjectively – a decrease in erogenous reactivity, dyspareunia, difficulty in achieving orgasm. The diagnosis is made on the basis of anamnestic data, patient complaints, visual examination results using functional tests, vaginodynamic measurements, ultrasonography. The most common method of treatment and prevention is physical exercise, recently vaginoplasty has been widely used.
N81.8 Other forms of female genital prolapse
Vaginal relaxation syndrome is an early form of genital prolapse, expressed in an increase in the volume of the vagina, incomplete closure of the vulvar ring, due to insufficiency of the pelvic floor muscles (IPFM). In domestic gynecology, the disease is more commonly known as “wide vagina syndrome”, “vaginal weakness”, “vaginal atony”. The frequency of occurrence reaches 77% in the female population. In a quarter of patients, pathology develops after the first birth, is registered at any age, but women over 40 are most susceptible to the disease.
Vaginal relaxation syndrome has a polyethological nature. The main causes of its occurrence are lesions (including degenerative–dystrophic) of the connective tissue of structures supporting the pelvic organs in a normal position, chronic increased load on the musculoskeletal apparatus of the pelvic floor, violation of the nervous regulation of the muscles of the vagina. Significant risk factors include:
- Vaginal delivery. Of particular importance is not so much the quantity as the quality of childbirth through natural ways. Severe childbirth (large fetus, with the use of obstetric aids), accompanied by perineal injuries, is the main trigger factor for the development of vaginal weakness. In this case, the pathology is caused by traumatic muscle damage.
- Increased intra-abdominal pressure. This condition is caused by activities related to weight lifting, obesity, pregnancy (especially multiple). It is possible to note chronic diseases of the lower respiratory tract (obstructive bronchitis, bronchial asthma), accompanied by cough, chronic constipation. Constant heavy load depletes muscle tissue.
- Deficiency of sex hormones. Estrogens provide the tone of the smooth muscles of the vagina, the production of collagen and elastin, therefore, hypoestrogenism is accompanied by atony of the vaginal wall. This explains the frequent manifestation (or rapid progression) of IPFM in peri- and postmenopause. Young women in surgical or drug-induced menopause are particularly susceptible to pathology.
In addition, starvation, exhaustion and some pathologies (collagenosis, violation of innervation, blood circulation of the perineum of the pelvis) can lead to the insolvency of the pelvic muscles, weakness of the vagina. Hypodynamia increases the likelihood of developing the disease. Early – upon reaching puberty – the development of the syndrome is facilitated by a number of congenital anomalies (organic and functional diseases of the central nervous system, Marfan syndrome).
Vaginal weakness does not develop in all women who have had a difficult birth or are engaged in heavy physical labor, it can occur for no apparent reason. The main predisposing condition is the presence of systemic connective tissue dysplasia caused by mutation of genes responsible for the synthesis of elastin and collagen. Often such mutations are inherited. The risk group includes patients with varicose veins developed at a young age (especially before the first pregnancy), hemorrhoids, daughters of women suffering from genital distension.
The muscular layer of the vaginal wall is represented by longitudinal smooth and annular muscles. In the lower part of the vaginal tube there are bundles of striated fibers forming the vaginal locking muscle (vaginal sphincter, or kuni constrictor). The sphincter is formed by deep (pubic-vaginal, which is part of the pubic-coccygeal and levator of the anus) and external (part of the bulbous-spongy) pelvic floor muscles.
The close relationship between the muscles of the pelvic floor and the vagina causes contractile insufficiency of the latter when the muscles of the perineum are damaged. Smooth muscles that support the elasticity of the upper thirds of the vagina are innervated by neurons that are highly sensitive to estrogen, so the amount of hormone produced affects muscle tone. Pelvic muscles provide closure of the sphincter of the vagina, as well as the tone of the rectum and urinary tract, so vaginal weakness can be combined with disorders of urination, defecation.
Smooth muscles are regulated only by the autonomic nervous system, they contract involuntarily (tonic contractions). The striated muscles of the vaginal sphincter are capable of both tonic and volitional contraction. Kinesiotherapy of vaginal weakness is based on this property. The maximum reduction is achieved by involuntary and volitional influence. Such a phenomenon during sexual intercourse leads to the formation of an “orgasmic cuff” and orgasm. Accordingly, with insufficient musculature of the sphincter, achieving orgasm is difficult.
A pathological condition occurs when the tone of the vaginal sphincter does not allow for a tight closure of the entrance to the vagina and the genital slit. The severity of vaginal atony is determined based on the results of an instrumental study of the contractility of the locking muscle according to the following parameters: the strength of tonic contraction (norm ≥15 gds), volitional contraction (norm ≥55 gds), maximum contraction (norm ≥70 gds), the duration of arbitrary contraction (norm ≥5 s). There are three degrees of sphincter insufficiency:
- I degree. It is diagnosed if the contractility of the sphincter is maintained at 70% of the norm. Quantitative characteristics: tonic reduction – 14-10 grs, volitional reduction – 54-40 grs, maximum reduction – 59-50 grs, duration – 5-3 s.
- II degree. It is characterized by maintaining the tone of the locking muscle by 40-70%. Quantitatively: tonic contraction – 9-6 grs, volitional – 39-16 grs, maximum – 49-21 grs, duration – 3-2 s.
- III degree. It is defined as maintaining contractility by less than 40%. The indicators of the main parameters are: tonic contraction ≤ 5 gds, arbitrary contraction ≤15 gds, combined maximum contraction ≤20 gds, duration ≤ 1 s.
In addition, there is a qualitative classification of the “dilated vagina” syndrome – according to the presence of functional disorders, according to which two forms of pathology are distinguished: simple and complicated. With a simple form, there are no violations of defecation and urination, sexual disorders. The complicated form is characterized by the addition of any one complication (dysfunction of the bladder, rectum, sexual dysfunction) or several at once.
The majority (86%) of women with vaginal relaxation syndrome complain of pathological sounds (mostly “squelching”) during sexual contact and physical education, caused by air entering the vagina. 30-50% have pain and discomfort during sexual intercourse, difficulty or inability to achieve orgasm. Complaints about the deterioration of the quality of sexual life are also made by the sexual partners of the patients. In 20-40% of patients, urination disorders are observed (urine splashing, weak jet, stress incontinence), in 22% – constipation, fecal incontinence.
Pathology itself does not pose a threat to life, but it can significantly affect its quality. Sexual dysfunction leads to a feeling of inferiority, leads to neurosis, violation of harmony in marriage. The result of constant sexual dissatisfaction is stagnation in the pelvic organs and, as a consequence, the development of varicose veins, bacterial vaginosis, gynecological inflammatory diseases. The risk of genital infections is also caused by a loose closure of the genital slit. Women with vaginal weakness need mandatory treatment.
In some patients with untreated vaginal atony, IPFM progresses, leading first to distention of the pelvic organs (internal genitals, rectum, lower urinary tract), and then prolapse of the vagina and uterus. Severe degrees of prolapse are accompanied by persistent pronounced disorders of urination and defecation, entail the impossibility of sexual life, infertility, disability. If the earliest stages of prolapse are quite successfully amenable to conservative treatment, then correction of significant anatomical changes is carried out only surgically.
The diagnosis of vaginal relaxation syndrome is carried out by a gynecologist and is not particularly difficult. When examined on the chair, incomplete closure of the genital slit, atonic walls of the vagina are visually detected. Palpation and simple functional tests reveal increased extensibility of the vulvar ring, contractile weakness of the locking muscle of the lower third of the vagina, lowering of the walls of the vagina when straining. To clarify the diagnosis, they resort to hardware methods:
- Assessment of muscle tone. Vaginodynamic studies (computer vaginotensometry, vaginal perineometry) allow us to determine quantitative indicators of the contractility of the vaginal sphincter, its volume. According to the results of the study, insufficiency of the vaginal musculature is diagnosed, the degree of its severity. In some cases, it is possible to assume the cause of the pathology.
- Ultrasonography. With the help of transvaginal and trans-interventional ultrasound, increased mobility of the pelvic floor is revealed (one of the main signs of the presence of an early stage of genital prolapse), defects of the levator muscles. With the help of elastosonography, the failure of connective tissue is detected.
To verify connective tissue insufficiency, morphological and immunohistochemical analyses of the content of matrix proteins in the epithelium can additionally be prescribed. Differential diagnosis should be carried out with more pronounced degrees of genital prolapse, sexual infantilism, vaginal tumors. In doubtful cases, a consultation with an oncogynecologist may be required.
Treatment of vaginal relaxation syndrome
Therapeutic methods are less effective than operative ones, their advantage is noninvasiveness and safety. Conservative treatment is aimed at restoring the tone of the muscles of the perineum, improving blood supply, microcirculation of the pelvic organs, normalization of the psychoemotional state of the patient. Physiotherapy solves these tasks most effectively, in some cases female sex hormones may be prescribed.
- Physical therapy. Patients with initially diagnosed vaginal weakness are prescribed gymnastics (according to Kegel, Yunusov, Atarbekov) to restore the tone of the musculoskeletal system of the pelvic floor. At the initial stage, it is important to do exercises under the supervision of a doctor, since their inadequate performance (with tension of antagonist muscles) leads to the opposite result, aggravation of the problem.
- Electrical stimulation of muscles. Electromyostimulation (EMS) of the perineal muscles is prescribed as an alternative to physical therapy for patients who have difficulty performing exercises (often they have difficulty with isolated contraction of the perineal muscles). Treatment can be carried out at home using a portable device. A number of patients complain of unpleasant sensations when using vaginal electrodes, which limits the use of the method.
- Non-ablative lifting. Shown to young women. A good, but transient therapeutic effect is noted after a course of Rf-lifting, erbium laser therapy in thermal (non-ablative) mode. Heating the tissues to 40-50 ° C leads to the reduction of old collagen fibers and the production of new protein molecules, which contributes to an increase in the tone and elasticity of the vaginal tissues, their gradual reduction, and, ultimately, to a decrease in the volume of the vagina.
- Medical treatment. Estrogen therapy is indicated for patients with hypoestrogenism under the close supervision of a gynecologist due to an increased risk of endometrial and breast carcinomas. The effectiveness of pharmacotherapy is a subject of debate – some clinicians note its complete failure, others believe that treatment allows to stop symptoms in 20% of patients.
A good result is achieved with long-term therapy. Exercises should be performed regularly for life, and hardware lifting courses should be repeated periodically. The therapeutic effect of non-ablative lifting lasts about a year, gradually weakening, so the optimal interval between courses is six months. Complex treatment is especially successful – a combination of physical therapy or EMS with radiofrequency or laser therapy, surgical correction.
The use of biofeedback techniques (behavioral therapy) with the use of simulators significantly increases the effectiveness of training, when the patient, observing the results of her efforts, actively participates in the treatment process. This allows you to learn how to perform exercises correctly, helps to increase motivation for further treatment, increases the psychoemotional status of the patient.
Surgical treatment provides a quick and longer-term result, but often entails complications: persistent sexual dysfunction, vaginal and urethral stenosis, neuritis of the locking nerve. In modern aesthetic gynecology, there are both minimally invasive non-surgical and operative methods of vaginoplasty. Intervention is prescribed if the use of conservative methods has not led to a decrease in symptoms (usually with involutive changes or congenital defects of connective tissue).
- Ablative lifting. It is carried out using laser or radio wave radiation. It differs from non-ablative methods in the heating temperature of the submucosal layer of connective tissue (up to 150 ° C), its traumatization (destruction of protein fibers). The lifting effect increases within six months and lasts up to five years. Treatment is indicated for patients of the late reproductive period and older.
- Thread lifting. Perineovaginal lifting is performed when stretching the vestibule without pathological changes in the walls of the vagina. A dissolvable thread is inserted into the muscles of the perineum, around which a connective tissue scar (fibrosis) is formed, remaining after its biodegradation. The method allows to eliminate the gaping of the vestibule of the vagina and discomfort during sexual intercourse, increase sexual satisfaction, prevent the progression of IPFM.
- Surgical operation. With atony of the vaginal walls, colporaphy is performed (more often anterior). Surgical intervention includes excision of the oval flap of the corresponding wall, followed by suturing of the edges, if necessary, supplemented by perineoplasty (excision of the perineal area). As a result, the volume of the vagina decreases, the vulvar ring narrows, urination disorders weaken or disappear.
Prognosis and prevention
The prognosis depends on the severity of changes in connective tissue, its ability to self-renew. Since there is no pathogenetic treatment for vaginal relaxation syndrome, relapses are not uncommon. After surgery, their frequency reaches 40%. Clear guidelines for the prevention of pathology have not yet been developed, but this problem is currently being actively investigated. For example, Berlin clinicians are studying the role of wearing ring-shaped perforated vaginal pessaries after childbirth in preventing vaginal atony.
Pelvic muscle training and operative delivery can reduce the likelihood of developing the disease. Reducing the risk of pathology contributes to the fight against excess weight and chronic respiratory diseases, limiting physical activity. Special attention should be paid to preventive measures at the stage of pre-pregnancy preparation, during pregnancy, and the postpartum period. Women with vaginal weakness should be under the supervision of a gynecologist in order to prevent the progression of IPFM.