Patients with disorders of sexual development (DSD) requiring vaginal reconstruction are complex and varied in their presentation. Enlargement procedures for vaginal hypoplasia include self-dilation therapy or surgical vaginoplasty. There are many vaginoplasty techniques described, and each method has different risks and benefits. Reviewing the literature on management options for vaginal hypoplasia, the results show a number of techniques available for the creation of a neovagina. Studies are difficult to compare due to their heterogeneity, and the indications for surgery are not always clear. Psychological support improves outcomes. There is a paucity of evidence to inform management regarding the optimum surgical technique to use, and long-term data on success is lacking, particularly with respect to sexual function. In conclusion, vaginal dilators remain the cornerstone of treatment of women with vaginal hypoplasia and should be used as the first-line technique. Surgical vaginoplasty has a role in complex patients with previous failed dilation and surgical intervention, particularly those cases where there is significant scarring from previous surgery. Regardless of the vaginal reconstruction technique, patients should be managed in a multidisciplinary team where there is adequate emotional and psychological support available.

Keywords:
Disorders of sexual development, Surgery, Vaginal hypoplasia
1.
ACOG Committee on Adolescent Health Care: ACOG Committee Opinion. Number 274, July 2002. Nonsurgical diagnosis and management of vaginal agenesis. Obstet Gynecol 100:213–216 (2002).
2.
Alizai NK, Thomas DF, Lilford RJ, Batchelor AG, Johnson N: Feminizing genitoplasty for congenital adrenal hyperplasia: what happens at puberty? J Urol 161:1588–1591 (1999).
3.
Baldwin J: The formation of an artificial vagina by intestinal transplantation. Ann Surg 40:398–403 (1904).
4.
Boyle ME, Smith S, Liao LM: Adult genital surgery for intersex: a solution to what problem? J Health Psychol 10:573–584 (2005).
5.
Brindeau A: Creation d’un vagin artificial a l’aide des membranes ovulaires d’un oeuf a terme. Gynecol Obstet (Paris) 29:385–392 (1934).
6.
Brucker S, Gegusch M, Zubke W, Rall K, Gauwerky JF, Wallwiener D: Neovagina creation in vaginal agenesis: development of new laparoscopic Vecchietti-based procedure and optimized instruments in a prospective comparative interventional study in 101 patients. Fertil Steril 90:1940–1952 (2008).
7.
Creatsas G, Deligeoroglu E: Vaginal aplasia: creation of a neovagina following the Creatsus vaginoplasty. Eur J Obstet Gynecol Reprod Biol 131:248–252 (2007).
8.
Creatsas G, Deligeoroglu E, Makrakis E, Kontoravdis A, Papadimitriou L: Creation of a neovagina following Williams vaginoplasty and the Creatsas modification in 111 patients with Mayer-Rokitansky-Küster-Hauser syndrome. Fertil Steril 76:1036–1040 (2001).
9.
Creighton SM, Minto CL, Steele SJ: Objective cosmetic and anatomical outcomes at adolescence of feminising surgery for ambiguous genitalia done in childhood. Lancet 358:124–125 (2001).
10.
Crouch NS, Minto CL, Liao LM, Woodhouse CR, Creighton SM: Genital sensation after feminizing genitoplasty for congenital adrenal hyperplasia: a pilot study. BJU Int 93:135–138 (2004).
11.
Davies MC, Creighton SM, Woodhouse CR: The pitfalls of vaginal construction. BJU Int 95:1293–1298 (2005).
12.
Davydov SN: Colpopoesis from the peritoneum of the uterorectal space. Akush Ginekol (Moscow) 45:55–57 (1969).
13.
Davydov SN, Zhvitiascvili OD: Formation of vagina (colpopoesis) from peritoneum of Douglas pouch. Acta Chir Plast 16:35–41 (1974).
14.
El Saman AM: Retropubic balloon vaginoplasty for management of Mayer-Rokitansky-Küster-Hauser syndrome. Fertil Steril 93:2016–2019 (2010).
15.
El Saman AM, Fathalla MM, Nasr AM, Youssef MA: Laparoscopically assisted balloon vaginoplasty for management of vaginal aplasia. Int J Gyneacol Obstet 98:134–137 (2007).
16.
Engert J: Surgical correction of virilised female external genitalia. Prog Pediatr Surg 23:151–164 (1989).
17.
Fedele L, Busacca M, Candiani M, Vignali M: Laparoscopic creation of a neovagina in Mayer-Rokitansky-Küster-Hauser syndrome by modification of Vechietti’s operation. Am J Obstet Gynecol 171:268–269 (1994).
18.
Fedele L, Bianchi S, Frontino G, Fontana E, Restelli E, Bruni V: The laparoscopic Vecchietti’s modified technique in Rokitansky syndrome: anatomic, functional and sexual long-term results. Am J Obstet Gynecol 198:377e1–6 (2008).
19.
Frank RT: The formation of an artificial vagina without operation. Am J Obstet Gynecol 35:1053–1055 (1938).
20.
Giannesi A, Marchiole P, Benchaib M, Chevret-Measson M, Mathevet P, Dargent D: Sexuality after laparoscopic Davydov in patients affected by congenital complete vaginal agenesis associated with uterine agenesis or hypoplasia. Hum Reprod 20:2954–2957 (2005).
21.
Hensle TW, Reiley EA: Vaginal replacement in children and young adults. J Urol 159:1035–1038 (1998).
22.
Hensle TW, Shabsigh A, Shabsigh R, Reiley ES, Meyer-Bahlburg HF: Sexual function following bowel vaginoplasty. J Urol. 176:2283–2285 (2006).
23.
Hrabovszky Z, Hutson JM: Surgical treatment of intersex abnormalities: a review. Surgery 131:92–104 (2002).
24.
Hughes IA, Houk C, Ahmed SF, Lee PA: Consensus statement on management of intersex disorders. Arch Dis Child DOI: 10.1136/adc.2006.098319.
25.
Imparato E, Alfei A, Aspesi G, Meus AL, Spinillo A: Long-term results of sigmoid vaginoplasty in a consecutive series of 62 patients. Int Urogynecol J Pelvic Floor Dysfunct 18:1465–1469 (2007).
26.
Ismail-Pratt IS, Bikoo M, Liao LM, Conway GS, Creighton SM: Normilization of the vagina by dilator treatment alone in Complete Androgen Insensitivity Syndrome and Mayer-Rokitansky-Küster-Hauser Syndrome. Hum Reprod 22:2020–2024 (2007).
27.
Kapoor R, Sharma DK, Singh KJ, Suri A, Singh P, et al: Sigmoid vaginoplasty: long-term results. Urology 67:1212–1215 (2006).
28.
Keser A, Bozkurt N, Taner OF, Sensöz O: Treatment of vaginal agenesis with modified Abbé-McIndoe technique: long-term follow-up in 22 patients. Eur J Obstet Gynecol Reprod Biol 121:110–116 (2005).
29.
Kim C, Campbell B, Ferrer F: Robotic sigmoid vaginoplasty: a novel technique. Urology 72:847–849 (2008).
30.
Klingele CJ, Gebhart JB, Croak AJ, DiMarco CS, Lesnick TG, Lee RA: McIndoe procedure for vaginal agenesis: long-term outcome and effect on quality of life. Am J Obstet Gynecol 189:1569–1572 (2003).
31.
Lee PA, Houk CP, Ahmed SF, Hughes IA: Consensus statement on management of intersex disorders. Pediatrics 118:753–757 (2006).
32.
Liao LM, Doyle J, Crouch N, Creighton SM: Dilation as a treatment for vaginal agenesis and hypoplasia: a pilot exploration of benefits and barriers as perceived by patients. J Obstet Gynaecol 26:144–148 (2006).
33.
Liguori G, Trombetta C, Bucci S, Salame L, Bortul M, et al: Laparoscopic mobilization of neovagina to assist secondary ileal vaginoplasty in male-to-female transsexuals. Urology 66:293–298 (2005).
34.
McIndoe AH, Banister JB: An operation for the cure of congenital absence of the vagina. J Obstet Gynaecol Br Emp 45:490–494 (1938).
35.
Michala L, Cutner A, Creighton SM: Surgical approaches to treating vaginal agenesis. BJOG 114:1455–1459 (2007).
36.
Minto CL, Liao LM, Woodhouse CR, Ransley PG, Creighton SM: The effect of clitoral surgery on sexual outcome in individuals who have intersex conditions with ambiguous genitalia: a cross-sectional study. Lancet 361:1252–1257 (2003).
37.
Mizia K, Bennett MJ, Dudley J, Morrisey J: Müllerian dysgenesis: a review of recent outcomes at Royal Hospital for Women. Aust N Z J Obstet Gynaecol 46:29–31 (2006).
38.
Mobus VJ, Kortenhorn K, Kreienberg R, Friedberg V: Long-term results after operative correction of vaginal aplasia. Am J Obstet Gynecol 175:617–624 (1996).
39.
Money J, Hampson JG, Hampson JL: Hermaphroditism: recommendations concerning assignment of sex, change of sex, and psychologic management. Bull Johns Hopkins Hosp97:284–300 (1955).
40.
Nisolle M, Donnez J: Vaginoplasty using amniotic membranes in cases of vaginal agenesis or after vaginectomy. J Gynecol Surg 8:25–30 (1992).
41.
O’Connor JL, DeMarco RT, Pope JC, Adams MC, Brock JW: Bowel vaginoplasty in children: a retrospective review. J Pediatr Surg 39:1205–1208 (2004).
42.
Panici PB, Bellati F, Boni T, Francescangeli F, Frati L, Marchese C: Vaginoplasty using autologous in vitro cultured vaginal tissue in a patient with Mayer-Rokitansky-Küster-Hauser syndrome. Hum Reprod 22:2025–2028 (2007).
43.
Parsons JK, Gearhart SL, Gearhart JP: Vaginal reconstruction utilizing sigmoid colon: complications and long-term results. J Pediatr Surg 37:629–633 (2002).
44.
Rajimwale A, Furness PD, Brant WO, Koyle MA: Vaginal construction using sigmoid colon in children and young adults. BJU Int 94:115–119 (2004).
45.
Schober JM: Cancer of the neovagina. J Paed Urol 3:167–170 (2007).
46.
Seccia A, Salgarello M, Strula M, Loreti A, Latorre S, Farello E: Neovaginal reconstruction with the modified McIndoe technique: a review of 32 cases. Ann Plast Surg 49:379–384 (2002).
47.
Syed HA, Malone PS, Hitchcock RJ: Diversion colitis in children with colovaginoplasty. BJU Int 87:857–860 (2001).
48.
Vecchietti G: Le neo-vagin dans le syndrome de Rokitansky-Küster-Hauser. Rev Med Suisse Romande 99:593 (1979).
49.
Warne G, Grover S, Hutson J, Sinclair A, Metcalfe S, et al: A long-term outcome study of intersex conditions. J Pediatr Endocrinol Metab18:555–567 (2005).
50.
Williams EA: Congenital absence of the vagina: a simple operation for its relief. J Obstet Gynaecol Br Commonw 71:511–514 (1964).
© 2010 S. Karger AG, Basel
2010
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.