Vaginal dilator therapy for women receiving pelvic radiotherapy

Abstract

Background: Many vaginal dilator therapy guidelines advocate routine vaginal dilation during and after pelvic radiotherapy to prevent stenosis (abnormal narrowing of the vagina). The UK Gynaecological Oncology Nurse Forum recommend dilation "three times weekly for an indefinite time period". The UK patient charity Cancer Backup advises using vaginal dilators from two to eight weeks after the end of radiotherapy treatment. Australian guidelines recommend dilation after brachytherapy "as soon as is comfortably possible" and "certainly within four weeks and to continue for three years or indefinitely if possible". However, dilation is intrusive, uses health resources and can be psychologically distressing. It has also caused rare but very serious damage to the rectum.

Objectives: To review the benefits and harms of vaginal dilation therapy associated with pelvic radiotherapy for cancer.

Search strategy: Searches included the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 4), MEDLINE (1950 to 2008), EMBASE (1980 to 2008) and CINAHL (1982 to 2008).

Selection criteria: Any comparative randomised controlled trials (RCT) or data of any type which compared dilation or penetration of the vagina after pelvic radiotherapy treatment for cancer.

Data collection and analysis: The review authors independently abstracted data and assessed risk of bias. We analysed the mean difference in sexual function scores and the risk ratio for non-compliance at six weeks and three months in single trial analyses. No trials met the inclusion criteria.

Main results: Dilation during or immediately after radiotherapy can, in rare cases, cause damage and there is no persuasive evidence from any study to demonstrate that it prevents stenosis. Data from one RCT showed no improvement in sexual scores in women who were encouraged to practice dilation. Two case series and one comparative study using historical controls suggest that dilation might be associated with a longer vaginal length but these data cannot reasonably be interpreted to show that dilation caused the change in the vagina.

Authors' conclusions: Routine dilation during or soon after cancer treatment may be harmful. There is no reliable evidence to show that routine regular vaginal dilation during or after radiotherapy prevents the late effects of radiotherapy or improves quality of life. Gentle vaginal exploration might separate the vaginal walls before they can stick together and some women may benefit from dilation therapy once inflammation has settled but there are no good comparative supporting data.

Figure 1

Sexual function data extracted from the paper by Robinson 1999, reproduced with permission of the International Journal of Radiation Oncology, Biology, and Physics.

Figure 2

Compliance data plotted by age extracted from the paper by Robinson 1999, reproduced with permission of the International Journal of Radiation, Oncology, Biology, and Physics.

Figure 3

Vaginal length data extracted from the paper by Velaskar 2007, reproduced with permission of the the Indian Journal of Occupational Therapy and thanks to Ms. Shruti M. Velaskar.