Fig. 16.1
Femmax® Dilators/Trainers, MDTI product
The process is considered successful and complete when the patient is able to comfortably insert the third size dilator or when she is able to engage in penetrative sexual intercourse with no problems.
In the 1980s, Ingram modified the technique by attaching dilators to a bicycle saddle stool and asking the patient to position herself on the stool for 30 min to an hour a day. By this modification, the woman uses her body weight to exert pressure on the vagina, leaving her hands free, thus allowing her to engage in other activities during the dilation process, supposedly improving compliance with treatment [3]. The Ingram method, used mostly in America, is not widely available in Europe.
The appropriate time to commence vaginal dilation should be individualised. In most patients this will correspond with late adolescence to early adulthood. Professional psychological counselling will help identify the best time for initiating vaginal dilation, depending on time availability, motivation or the presence of a partner. Following completion of vaginal dilation, maintenance dilation is likely to be required, unless the patient is able to engage in regular sexual activity and this should be a factor to take into consideration when deciding whether to start vaginal dilation or not.
Interestingly, some women will present with a vagina of normal size, having achieved this through sexual intercourse alone. This may be an option for some patients that have a good starting vaginal length. However, it would not be reasonable to promote dilation through sexual intercourse as a first line approach for all, as pain at penetration may be traumatic enough to put the woman off from future sexual activity.
In patients with Complete Androgen Insensitivity Syndrome (CAIS), a commonly identified problem is vaginal dryness, due to decreased oestrogenisation, which may cause local irritation and discomfort during dilation. Symptoms will improve by using topical oestrogen regularly, alongside systemic oestrogen replacement.
Results
There are relatively few studies that look at outcome rates of vaginal dilation, particularly when compared to surgical vaginoplasty methods. The available literature suggests an anatomical success rate between 40 and 90 % [4–6]. It is unclear why some women are successful at vaginal dilation whereas some others are not. There is no evidence that a smaller starting size of the blind ending vagina would affect vaginal dilation success [4]. Also, there are no studies at present looking at anatomical or structural factors such as collagen or elasticity tissue levels that may play a role in vaginal dilation success (Table 16.1).
Table 16.1
Details of studies looking at vaginal dilation since 2000
Type of study | Place of study | Cause of vaginal agenesis | Year of publication | Range of age of participants | No. of participants | Successful | Success rate (%) | Median time required to achieve vaginal length (months) | |
|---|---|---|---|---|---|---|---|---|---|
Robson and Oliver [15] | Retrospective | Australia | MRKH | 2000 | 14–19 | 39 | 25 | 64 | |
Ismail-Pratt et al. [4] | Prospective | UK | MRKH and CAIS | 2007 | 18–24 | 26 | 21 | 81 | 5.2 |
Jasonni [16] | Retrospective | Italy | MRKH and CAIS | 2007 | 13–18 | 104 | 41 | 40 | 6 |
Gargollo [17] | Retrospective | USA | MRKH | 2009 | 14–35 | 69 | 50 | 72 | 18.7 |
Bach [5] | Retrospective | UK | MRKH | 2011 | 16–27 | 32 | 25 | 78 | 5.6 |
Edmonds et al. [18] | Retrospective
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