6 Module

Treatment

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6.3.6. Managing vaginal stenosis

Vaginal stenosis is a common problem experienced by women undergoing pelvic radiotherapy, and women who have undergone some surgeries for gynaecological cancer.

Evidence on prevention and management strategies is controversial. This has led to a number of significant variations in practice across health care settings.

Using vaginal dilators - evidence

Some evidence suggests using vaginal dilators to prevent vaginal stenosis.[1]

The rationale proposed for using a dilator is that it:

  • may assist with enabling sexual relations to continue or recommence post treatment
  • may reduce the incidence of discomfort or painful intercourse
  • may reduce potential difficulties with future partners if not in a sexually active relationship at the time of treatment
  • allows the medical team to accurately examine and assess the vaginal vault or cervix as part of ongoing medical follow up, care and support
  • offers the opportunity to discuss sexual fears / myths associated with pelvic radiotherapy.

Vaginal dilators may also help women as they learn to control tension and relaxation in their pelvic floor muscles. [2]

However, the consensus is that more research is needed before health care professionals can give women definitive guidance. [3]

Dilation may separate the adhesions formed by the denuded epithelium, thus possibly preventing stenosis. [4] It’s also possible that interfering with the vagina during the inflammatory phase of radiation treatment may:

  • cause additional scarring
  • promote additional damage, both physically and psychologically. [4]

The latest Cochrane review of studies into dilator use advises against using dilators during treatment. This is because of the lack of strong evidence for using the treatment. [5]

New resource - International Guidelines on Vaginal Dilation after Pelvic Radiotherapy. International Clinical Guidelines Group, 2012.

Using vaginal dilators - Australian practice

Evidence to support the use of vaginal dilators is equivocal. However, dilator use following pelvic radiation treatment is commonly recommended in Australia. There’s also wide variation in clinical practice and the information given to women on the subject. [6] [7] [8]

It is important for health professionals to consider the advantages and possible risks highlighted in the evidence reviews described above.  Where a decision to use dilators is recommended, some of the following points are commonly recommended by experts in the field:

When to use a dilator

  • Most commonly recommended for women undergoing radiotherapy.
  • Women with gynaecological cancer whose vaginal depth or caliber has been reduced by surgery may benefit from using dilators.
  • It’s unknown whether dilators can help postmenopausal women regain elasticity of the vagina. However, using dilators may give women confidence that they can have an object inserted into their vagina, including a speculum, without pain. [2]

Timing dilator use

There’s no clear evidence on the best time to start vaginal dilatation.

Some cancer centres encourage women to use dilators during treatment, but most centres advise women to start using dilators following their treatment.

Until there’s more research on dilator use, it’s common for health care professionals to advise women to use dilators after radiation treatment for an indefinite period and provide them with the rationale for dilator use. [6] [8]

How to use a dilator

For women who decide to use a dilator, the following is current best practice:[1]

The minimum a woman should use a dilator is 3 times per week for an indefinite period of time.

Dilators can be combined with sexual intercourse for frequent vaginal dilation. Tell the woman to find a private and comfortable place where she can relax and use the dilator.

She can use the dilator in the shower or bath if this offers her some privacy and / or relaxes her pelvic floor muscles. This will let her use the dilator more successfully. If applicable, encourage the woman to involve her partner.

  • Before it’s inserted, a water-soluble lubricant should be rubbed on the dilator and around the entrance to the vagina.
  • There are various positions the dilator can be used in. Advise the woman to either:
    • lie down on her back with knees slightly apart and bent
    • or, stand with a leg raised on the side of the bed or bath to insert the dilator.
  • Inserting the dilator into the vagina requires a firm, gentle pressure. Advise the woman to insert the dilator as deeply as is comfortable, without forcing it.
  • Once the dilator is inside the vagina it should be moved in a forward and backward motion, then a left to right motion. If possible, the dilator should be gently rotated using the handle.
  • There's a range of dilator sizes that can be used depending on the woman’s needs. It’s usual for a woman to start with the smallest size and move to the largest size in the days / weeks following treatment - depending on what’s comfortable.
  • If the woman has manual dexterity problems or other physical restrictions, health care professionals should tailor dilator information to her needs. For instance, she may find it difficult to rotate the dilator.
  • The woman should use the dilator for 5-10 minutes each time.
  • The woman should be encouraged to use pelvic floor exercises when inserting the dilator.
  • The dilator should be removed slowly and be rotated in a clockwise / anti-clockwise movement when being removed.
  • Vibrator use may also be combined with dilator use.
  • Slight vaginal blood loss is not uncommon when using dilators. If the woman experiences heavy vaginal blood loss, or pain, then she should seek advice and on-going follow-up and support from the appropriate health care professional providing care.
  • Douching isn’t usually advised as a part of dilator treatment.

Adhering to dilator use - the strategies

A range of factors may influence a woman’s willingness to use a dilator.[9]

These include:

  • uncertainty about use
  • negative experiences
  • lack of time
  • inability to find privacy
  • association with sex aids.

To encourage the woman to follow advice on using a dilator, follow this guidance:

  • Discuss stenosis and dilators before her treatment.
  • When providing the woman with the dilator, talk to her about using it and give her written material on the subject. To avoid information overload, this should be done in a separate nurse-led consultation.
  • Use ongoing examinations to monitor and encourage dilator use.
  • Help the woman plan how to incorporate dilator use into her normal weekly routine.

References

1 Best practice guidelines on the use of vaginal dilators in women receiving
pelvic radiotherapy

Author: National Forum of Gynaecological Oncology Nurses (2005).
From: Owen Mumford.

2 Simple strategies for vaginal health promotion in cancer survivors
Authors: Carter, J, Goldfrank, D & Schover, LR (2010).
In: J Sex Med, 8(2): 549-559.

3 Interventions for the physical aspects of sexual dysfunction in women
following pelvic radiotherapy

Authors: Denton, AS & Maher, EJ (2003).
In: Cochrane Database of Systematic Reviews, Issue 1.

4 Sexuality in cancer and palliative care 1: Effects of disease and treatment
Author: Rice, A. (2000).
In: International Journal of Palliative Nursing, 6(8): 392-397.

5 Vaginal dilator therapy for women receiving pelvic radiotherapy
Authors: Miles, T & Johnson, N (2010).
In: Cochrane Database of Systematic Reviews, Issue 9.

6 Preventing vaginal stenosis after brachytherapy for gynaecological cancer:
an overview of Australian practices

Authors: Lancaster, L (2004). 
In: European Journal of Oncology Nursing,8(1): 30–39.

7 Delivering sensitive healthcare information: challenging the taboo of
women’s sexual health after pelvic radiotherapy

Authors: Faithfull, S & White, I (2008). 
In: Patient Education Counselling, 71: 228-233.

8 Vaginal dilation associated with pelvic radiotherapy: a UK survey of current practice
Authors: White, ID & Faithfull, S (2006).
In: Int J Gynecol Cancer, 16: 1140-1146.

9 Turning a chore into a priority: barriers and facilitators affecting vaginal dilator use after radiation therapy for gynaecological cancer
Poster presented at COSA ASM Melbourne. 2010
Authors: Bonner, C, Nattress, K, Carter, J, Anderson, C & Juraskova, I (2010).
Abstract in: Asia-Pacific Journal of Oncology.

 

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