Reply "Vaginal rejuvenation": comparative effectiveness studies are needed.

Abstract

We thank Dr. Dietz for his interest 1 in our commentary 2 on female genital cosmetic surgery (FGCS). He maintains that we have mixed up two distinct phenomena: introital cosmetic surgery and “vaginal rejuvenation” procedures. We agree with Dr. Dietz that the reasons for seeking these two types of surgical interventions might differ substantially: the former ones have more evident aesthetic goals and may represent the epiphenomenon of a mental disorder, such as body dysmorphic disorder, whereas “vaginal rejuvenation” procedures are used to treat vaginal laxity and have a functional (rather than aesthetic) objective, that is sexual pleasure enhancement. However, both surgical procedure types have been defined as FGCS by the Royal College of Obstetricians and Gynaecologists 3 and are not medically indicated. As pointed out in our commentary, “vaginal rejuvenation” procedures may sometimes be considered modifications of traditional surgical interventions, such as anterior or posterior compartment vaginoplasty and perineoplasty, that are routinely performed in the case of genital prolapse or stress urinary incontinence 2. This type of surgery is medically indicated to treat different types of pelvic floor dysfunctions and cannot be referred to as FGCS. A problem may arise when these procedures are performed to treat a sensation of “wide vagina”. In fact, the notion of “wide vagina” or “vaginal relaxation” is vague and subjective. Does it refer to a low-grade anterior or posterior compartment prolapse, or to an over-distension of the puborectalis muscle, or simply to a relaxation of the vaginal walls? A clear definition of the terminology used and quantification of the condition is necessary to facilitate the understanding of research findings and the development of clinical practice recommendations. It was not our intention to suggest that surgical treatment of vaginal laxity is irrational, or even inappropriate 2. However, we have underlined that there is limited evidence of effectiveness to support it, although some authors have shown an improvement in sexual satisfaction after surgical correction of vaginal relaxation 4. Robust data are also lacking regarding the effectiveness of alternative procedures performed to tighten the vagina, such as laser vaginal rogation or perineal mesh insertion. According to an American College of Obstetricians and Gynecologists Committee Opinion 5, the safety and effectiveness of vaginal rejuvenation procedures have not yet been documented. Therefore, women undergoing this type of surgery should be informed that these techniques are still experimental and their value undefined. In conclusion, excessive expectations with vaginal rejuvenation procedures are currently unwarranted. If “vaginal laxity” is the result of an over-distension of the puborectalis muscle, as Dr. Dietz suggests 1, it might be better managed with pelvic floor training rather than surgery, and comparative trials are needed here. Women's sexuality is not a mechanistic process, as it results from the interaction of multiple physical and psychosocial dimensions 2. Surgery focuses exclusively on the anatomical and biomechanical component. Therefore, the very nature of sexual dysfunctions must be carefully investigated before resorting tout court to narrowing vaginal procedures. This message should be clearly conveyed to all women seeking “vaginal rejuvenation” and, when appropriate, they should be invited to consider pelvic floor training or sexual counseling before surgery. Patients' complaints must always be taken seriously, but because sexual dysfunction is often multifactorial, restoring a “tight vagina” may only provide a partial answer.