Radiation-Induced Vaginal Stenosis

Radiation therapy has been utilized to treat cervical cancers for approximately 60 years and colorectal cancers for 20 to 30 years. It is documented that approximately 88 percent of women treated for cervical cancer with radiation will go on to develop vaginal stenosis. Women treated for colorectal cancers go underreported, and thus it is unknown statistically the effect on vaginal patency. Women treated for malignancies such as endometrial, vulvar, or vaginal cancers also may be affected by radiation-induced vaginal stenosis.

During radiation, in the area receiving the maximal dose, there is epithelial loss that may persist for three to six months following the completion of therapy. The re-epithelialization during this time results in thin vaginal skin without a complete basal cell layer.

Women with vaginal stenosis may present with a short or narrowed vagina, which may make vaginal intercourse (and even exams) painful or impossible. Vaginal dryness is also a problem related to a stenotic vagina.

The use of topical estrogen therapy in certain populations may assist in the regeneration of the epithelium. Systemic hormone replacement may also be beneficial in eligible populations. Topical benzydamine may relieve symptoms of acute radiation vaginitis. Vaginal dilators are used to prevent and treat vaginal stenosis, and it is generally recommended that dilators be used two to three times per week for 15 to 20 minutes. One obstacle to compliance with dilator use is the need to "fit" a woman with the appropriate dilator size and shape. Another potential obstacle is the correct use of the dilator.

At times, surgery is necessary to treat vaginal stenosis. However, it is important to note that skin in an irradiated field is less likely to heal, so other measures should be tried before considering treatment with this modality. Most studies report split-thickness skin grafts for vaginal lengthening, while others utilized myocutaneous grafts for vaginal reconstruction in those treated for anal or rectal cancers.

Nurses and nurse practitioners (NPs) play a pivotal role in the treatment of vaginal stenosis, because they are the key in educating patients and keeping the lines of communication open. Maintaining an open relationship with the patient so that these sensitive topics can be discussed is pivotal and underestimated.

I find that asking a patient about sexual health and function outright breaks down the barrier and naturally opens the lines of communication. It is also important to realize that sexual health should be addressed with all women, including lesbians, who may have different needs than heterosexual women with the same disorder.

For those of us who grew up in the 1990s, great advice was given to us by Salt-n-Pepa: "Let's Talk About Sex!"

Case Study

JD is a 52-year-old woman with a history of stage 3 cervical adenocarcinoma treated with concomitant radio-sensitizing cisplatin and radiation therapy. Before her diagnosis, she and her husband had what she considered a healthy sex life with vaginal intercourse at least once weekly. She had no previous problems with dyspareunia, vaginal dryness, or accommodation. During treatment, JD was not sexually active, due to skin changes related to radiation therapy and anemia-related fatigue, which required her to undergo blood transfusions. She was prescribed the use of a medium-sized vaginal dilator with nonhormonal vaginal lubrication. She was instructed to use her dilator at least twice weekly for 15 to 20 minutes. Soon after that, JD began to have vaginal intercourse, which caused her discomfort.

She presented to her GYN ONC NP, who attempted to perform an exam but had to utilize a virginal speculum, due to vaginal wall collapse and pain. She was instructed to continue dilator and vaginal lubrication, and she would try to have vaginal intercourse if possible. During her therapy for stenosis, JD was able to increase the dilator size to large and then extra large. With time, sex became more enjoyable and less painful. Her exams also were less painful, and the NP was able to use a larger speculum, which allowed for better visualization of the cervix and vagina.

This study shows that, with the proper clinician support and teaching, vaginal stenosis at times can be controlled with non-invasive treatment modalities.

What are your experiences with women diagnosed with vaginal stenosis?

Reference

Wolf, Judith. Prevention and treatment of vaginal stenosis resulting from pelvic radiation therapy. October 2006. Community Oncology, Volume 3, Number 10. Accessed on 7/5/12.