Vaginal dilator therapy for women receiving pelvic radiotherapy.
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.


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


METHODS
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).


METHODS
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.


METHODS
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.


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.


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.
Miles
Tracie
T
Gynaecological Oncology, Royal United Hospital NHS Trust, Combe Park, Bath, UK, BA1 3NG.
Johnson
Nick
N
D003251:Constriction, Pathologic / Q000209:etiology / Q000628:therapy; D004106:Dilatation / Q000009:adverse effects / Q000295:instrumentation*; D005260:Female; D006801:Humans; D010388:Pelvis; D011878:Radiotherapy / Q000009:adverse effects / Q000379:methods; D012421:Rupture / Q000209:etiology; D013997:Time Factors; D014621:Vagina / Q000293:injuries / Q000528:radiation effects*
Control Clin Trials. 1986 Sep;7(3):177-88
3802833
Cancer. 1972 Aug;30(2):426-9
5051667
Int J Radiat Oncol Biol Phys. 1997 May 1;38(2):373-80
9226326
South Med J. 1982 Oct;75(10):1195-7
7123286
Psychooncology. 2004 Aug;13(8):577-92
15295778
Oncol Nurs Forum. 1995 Sep;22(8):1227-32
8532547
BJOG. 2010 Apr;117(5):522-31
20163407
Br J Obstet Gynaecol. 1991 Jun;98(6):564-8
1873246
Int J Radiat Oncol Biol Phys. 1993 Nov 15;27(4):825-30
8244811
Int J Radiat Oncol Biol Phys. 1995 Mar 30;31(5):1281-99
7713788
Int J Radiat Oncol Biol Phys. 1999 Jun 1;44(3):497-506
10348277
Br J Nurs. 1996 Feb 22-Mar 13;5(4):239-44
8704455
Int J Radiat Oncol Biol Phys. 2006 Jun 1;65(2):404-11
16542794
Radiother Oncol. 2003 Sep;68(3):241-7
13129631
Clin Oncol (R Coll Radiol). 1999;11(1):46-8
10194586
Health Psychol. 1996 Mar;15(2):114-23
8681919
Int J Palliat Nurs. 2000 Sep;6(8):392-7
12411851
J Clin Epidemiol. 1997 Jun;50(6):683-91
9250266
BMJ. 1994 Apr 2;308(6933):869-70
8173361
Radiother Oncol. 1995 Apr;35(1):11-5
7569011
Obstet Gynecol. 2003 May;101(5 Pt 2):1125-6
12738124
J Obstet Gynecol Neonatal Nurs. 2000 Jul-Aug;29(4):413-21
10929845
Eur J Gynaecol Oncol. 2006;27(4):356-8
17009625
Clin Oncol (R Coll Radiol). 2000;12(6):347-53
11202086
Int J Gynaecol Obstet. 1980 Sep-Oct;18(2):90-2
6108259
Am J Obstet Gynecol. 1974 May 15;119(2):181-9
4856712
Obstet Gynecol. 1958 Apr;11(4):403-14
13517747
Clin J Oncol Nurs. 2001 Mar-Apr;5(2):59-63
11899777
J Psychosom Obstet Gynaecol. 1993 Mar;14(1):51-63
8358523
Dan Med Bull. 1983 Dec;30 Suppl 2:31-4
6673914
Cochrane Database Syst Rev. 2003;(1):CD003750
12535485
Eur J Oncol Nurs. 2004 Mar;8(1):30-9
15003742
Int J Gynecol Cancer. 2006 May-Jun;16(3):1140-6
16803497
BMJ. 2003 Sep 6;327(7414):557-60
12958120