What are the treatment options for vaginal laxity complaints?

Treatment of Vaginal Laxity

Pelvic floor muscle training (PFMT) should be the first-line treatment for women with vaginal laxity, as it demonstrates sustained improvement in sexual function, vaginal symptoms, and pelvic floor muscle contraction at 6 months, with superior long-term outcomes compared to radiofrequency treatments. 1

Understanding Vaginal Laxity

Vaginal laxity is a complaint of excessive vaginal looseness affecting 24-38% of women, with vaginal delivery being the primary risk factor. 1, 2 This condition negatively impacts sexual function and quality of life, yet remains underreported and understudied. 3, 2

First-Line Treatment: Pelvic Floor Muscle Training

PFMT is the evidence-based first-line intervention for vaginal laxity. 1

• PFMT involves instruction on voluntary contraction of pelvic floor muscles (Kegel exercises). 4
• Women treated with PFMT show significant improvement in pelvic floor muscle contraction at both 30 days (P < .001) and 6 months (P < .001) post-treatment. 1
• Sexual function, vaginal symptoms, and urinary symptoms all improve with PFMT, with better sustained results at 6 months compared to other modalities. 1
• PFMT has low risk for adverse effects and is more cost-effective than pharmacologic or device-based therapies. 4

PFMT Implementation

• PFMT can be enhanced with biofeedback using vaginal EMG probes to provide visual feedback on proper pelvic floor muscle contraction. 4
• For women with concurrent urinary incontinence symptoms, PFMT combined with bladder training is recommended. 4
• Pelvic floor physiotherapy should be offered to women with pain or other pelvic floor dysfunction issues. 4

Second-Line Treatment: Radiofrequency

Radiofrequency (RF) can be considered when PFMT is unsuccessful or as an adjunct therapy. 1, 5

• RF was noninferior to PFMT in improving sexual function scores at 30 days post-treatment (mean difference -0.08 [95% CI, -2.58 to 2.42]). 1
• However, RF's noninferiority was NOT maintained at 6 months, making it less suitable as a standalone long-term solution. 1
• RF works through heating effects that stimulate collagen and elastin fibers in vaginal tissue. 5
• In one study of 27 women, all subjects reported improvement in vaginal laxity perception, from "very loose" (2.19±1.08 points) to "moderately tight" (5.74±0.76 points) at 1-month follow-up. 5
• RF treatments are well-tolerated with no reported adverse events in clinical studies. 5

Important Caveat About RF

The long-term effectiveness and safety profile of RF for vaginal laxity remain unknown, which restricts its widespread application. 2 RF should be viewed as a shorter-term intervention or bridge therapy rather than definitive treatment.

Surgical Options

Colpoperineorraphy with levator ani myorrhaphy can be considered for refractory cases. 2

• This surgical approach is associated with high success rates when evaluated in women with genital prolapse. 2
• Major risk: High incidence of postoperative dyspareunia, which may worsen sexual function despite anatomical correction. 2
• Surgery should be reserved for women who fail conservative measures and understand the dyspareunia risk. 2

Additional Emerging Modalities

Several noninvasive treatments are under investigation but lack sufficient evidence for routine recommendation. 6

• CO2 laser, high-intensity focused ultrasound, and combined multipolar RF with pulsed electromagnetic fields show preliminary promise. 6
• These modalities appear to have lower success rates than surgical treatments but are less invasive. 2
• Critical gap: Insufficient high-quality clinical trials exist to establish efficacy, optimal protocols, or long-term safety. 6

Concurrent Management Considerations

For Obese Women

Weight loss and exercise should be recommended for obese women with vaginal laxity, particularly if concurrent urinary incontinence is present. 4

For Women with Vaginal Atrophy Symptoms

If vaginal dryness accompanies laxity complaints, follow this stepwise approach: 4

• Start with lubricants for sexual activity and vaginal moisturizers for daily comfort. 4
• For non-responders or severe symptoms, low-dose vaginal estrogen can be used. 4
• For women with hormone-positive breast cancer, low-dose vaginal estrogen can be considered after thorough risk-benefit discussion. 4

For Women with Pelvic Floor Dysfunction

Vaginal dilators may benefit women with vaginismus and/or vaginal stenosis, particularly those treated with pelvic radiation therapy. 4

Common Pitfalls to Avoid

• Failing to ask about vaginal laxity: At least half of women with pelvic floor complaints do not report symptoms to physicians. 4, 7 Proactively inquire about vaginal looseness, sexual satisfaction, and urinary symptoms during routine examinations.
• Jumping to invasive treatments: Conservative PFMT should always be attempted first given its superior long-term outcomes and safety profile. 1
• Overlooking concurrent conditions: Identify and manage urinary tract infections, constipation, and medications that may worsen pelvic floor symptoms. 4
• Inadequate follow-up: Assess treatment response at both short-term (30 days) and long-term (6 months) intervals, as some modalities lose effectiveness over time. 1