Impact of vaginoplasty on hiatal dimensions measured by translabial ultrasonography

Abstract

Vaginal laxity (VL), characterized by a sensation of vaginal looseness, is a condition that can adversely affect quality of life. Vaginoplasty is a surgical intervention aimed at addressing VL by enhancing both functional support and aesthetic appearance. The outcomes of vaginoplasty have frequently been reported as favorable based on self-reported questionnaires; however, such results are inherently subjective and reflect individual perceptions of satisfaction. This study aimed to objectively evaluate the effectiveness of vaginoplasty in treating VL by using translabial ultrasonography to measure changes in the levator ani muscle hiatus before and after surgery. This prospective study included 36 women aged 18 to 45 years who underwent vaginoplasty at the Cosmetic Gynecology and Sexual Dysfunction Clinic, Ankara Bilkent City Hospital, between June and December 2024. Preoperative and postoperative assessments were performed using translabial ultrasonography to measure the levator ani muscle hiatal area and anteroposterior diameter at rest, during the Valsalva maneuver, and at maximum pelvic floor contraction. Postoperative ultrasonographic evaluations demonstrated significant reductions in both the anteroposterior diameter and hiatal area (P < .01). The hiatal area during Valsalva decreased from 29.14 ± 2.68 cm² preoperatively to 23.51 ± 3.41 cm² postoperatively, indicating a measurable improvement in pelvic floor support and a reduction in vaginal laxity. Vaginoplasty significantly improves vaginal laxity, as evidenced by objective ultrasonographic measurements of the levator ani muscle hiatus. These findings provide objective support for the effectiveness of vaginoplasty, complementing previous subjective outcomes. However, further studies with larger sample sizes are needed to confirm the long-term effects of the procedure.

1. Introduction

Vaginal laxity (VL) is defined as the sensation of excessive vaginal looseness, most commonly experienced as a reduction in vaginal sensation during intercourse.^[1–3] This condition not only affects physical intimacy but also profoundly impacts a woman’s quality of life, leading to both physical and emotional consequences.^[2] The exact pathophysiology of vaginal laxity is not yet fully understood; however, factors such as pregnancy, vaginal delivery, menopause, connective tissue diseases, and aging are recognized risk factors contributing to its development.^[3,4] Studies investigating its prevalence among women attending urogynecology clinics have reported rates ranging between 24% and 38%.^[5,6]

Currently, there is no standardized objective diagnostic test specifically designed to evaluate vaginal laxity.^[7] Therefore, a thorough evaluation including a detailed patient history, a physical examination, and an assessment of pelvic floor integrity to ensure an accurate diagnosis.^[8] Various diagnostic methods are employed depending on the patient’s symptoms, including patient interviews, questionnaires, physical or digital examinations, and translabial ultrasonography.^[8,9] It is widely accepted that trauma to the pelvic floor, particularly the levator ani muscle, is associated with an increased diameter of the levator ani muscle hiatus.^[6] Several studies have demonstrated an association between vaginal laxity and levator ani hyperdistensibility, as indicated by measurements of the genital hiatus, perineal body, and levator hiatal area during the Valsalva maneuver.^[4,6] Notably, the measurement of the hiatal area during the Valsalva maneuver using translabial ultrasonography has been identified as one of the most predictive indicators for vaginal laxity.^[4]

A broad range of treatment options exists for symptomatic vaginal laxity, ranging from conservative approaches to more invasive surgical interventions.^[10] Conservative treatments may include noninvasive options, such as behavioral therapy, pelvic floor physical therapy, coordinated Kegel exercises, and outpatient laser or radiofrequency treatments.^[8,10] Vaginoplasty, a surgical procedure designed to improve the integrity of vaginal tissue, is often considered to reshape the vaginal walls and/or enhance overall sexual function. Vaginoplasty is a minimally invasive procedure, typically performed under local or regional anesthesia, with a short recovery period. It provides long-term aesthetic and functional improvements and is associated with a low incidence of both acute and long-term complications.^[10–13] While vaginoplasty outcomes have been reported as successful through self-reported questionnaires, these results are often subjective and based on individual perceptions of satisfaction.

This study aimed to compare preoperative and postoperative translabial ultrasonography and measurements of the levator ani muscle hiatal area in patients undergoing vaginoplasty, thereby enabling an objective assessment of the procedure’s effectiveness.

2. Materials and methods

This study was approved by the Ankara Yildirim Beyazit University Research and Ethics Committee (01/1076), and was conducted in accordance with the ethical standards outlined in the Declaration of Helsinki. The study included 36 patients aged 18 to 45 years who presented to the Cosmetic Gynecology and Sexual Dysfunction Clinic at Ankara Bilkent City Hospital between June and December 2024 and subsequently underwent vaginoplasty. Participants who were postmenopausal, had pelvic organ prolapse or connective tissue disease, a history of previous vaginal surgery, or did not attend the postoperative follow-up were excluded from the study. Demographic data included patients’ age, number of births, additional diseases, body mass index and history of previous surgery. Vaginal laxity was evaluated through pelvic examination and self-reported symptoms such as vaginal looseness, vaginal sound during intercourse, and gas discharge. Physical examination was conducted using the Modified Oxford Scale. Evaluation of pelvic floor muscle contractility according to the Modified Oxford Score grading system was carried out by the same experienced examiner for all patients to avoid inter-investigator bias. Patients were instructed to contract their pelvic floor muscles, and muscle strength was assessed subjectively by inserting the examiner’s index finger approximately 4 cm into the vagina. The Modified Oxford Score was used to grade pelvic floor muscle strength on a scale from 0 to 5, with 0 indicating no contraction, 1 representing minor muscle contraction, 2 denoting weak muscle contraction, 3 reflecting moderate muscle contraction, 4 indicating good muscle contraction, and 5 signifying strong muscle contraction against resistance.^[14] Translabial ultrasonography measurements were conducted within a week prior to the procedure and repeated at the 3-month postoperative follow-up. Four-dimensional translabial pelvic floor ultrasonography was performed with the patient in the supine position and an empty bladder using a GE Voluson S10 system (GE Ultrasound Korea Ltd.) with an 8 to 4 MHz curved array volume transducer at an acquisition angle of 85°. Volume acquisition was carried out at rest, during the maximum Valsalva maneuver, and at maximum pelvic floor muscle contraction. As previously described, the levator hiatal area and anteroposterior diameter (APD) were measured in the plane of minimal hiatal dimensions using the rendered-volume technique.^[6] The vaginoplasty procedure was carried out using the posterior colporrhaphy technique, with dissection extending from the introitus to the vaginal apex. The dissection and tissue removal were planned to achieve the optimal vaginal width.

The data obtained in the study were statistically analyzed using SPSS ver. 24 (Statistical Package for the Social Sciences, IBM, USA). In evaluating the study data, categorical variables were presented as numbers and percentages, while numerical variables were presented as mean ± standard deviation. The Kolmogorov–Smirnov test was used to assess the normality of data distribution. In comparing quantitative data, a paired sample t test was used to assess pre- and postoperative differences. Results were considered statistically significant at P < .05, with a 95% confidence interval.

3. Results

The mean age of the 36 patients included in the study was 35.65 ± 3.11 (28–45). The mean body mass index of the patients was 26.92 ± 4.12 (21–32). The median parity was 3.00 ± 0.79 (range: 1–5), while the median of vaginal delivery was 2.00 ± 1.30 (range: 0–5). Of the 36 patients included in the study, 33 (91.66%) had at least 1 vaginal delivery. Demographic characteristics are summarized in Table 1.

Table 1.

Demographic characteristics of patients undergoing vaginoplasty.

Variable (n = 36)	Value
Age (yr)	35.65 ± 3.11 (28–45)*
BMI (kg/m2)	26.92 ± 4.12 (21–32)*
Gravida	3.00 ± 1.68 (1–7)†
Parite	3.00 ± 0.79 (1–5)†
Vaginal delivery	2.00 ± 1.30 (0–5)†

BMI = body mass index.

^*Mean ± SD.

^†MoM ± variance.

There were significant improvements in all measured parameters following the vaginoplasty procedure. At rest, the APD decreased from 5.81 ± 0.61 cm preoperatively to 5.01 ± 0.49 cm postoperatively (P < .01). During the Valsalva maneuver, the APD decreased from 7.14 ± 0.61 cm to 5.85 ± 0.81 cm (P < .01), and at maximum pelvic floor contraction, it dropped from 4.91 ± 0.77 cm to 4.25 ± 0.73 cm (P < .01).

Similarly, the levator hiatal area showed a significant reduction postoperatively. At rest, the area decreased from 17.25 ± 3.52 cm² to 15.54 ± 3.45 cm² (P < .01), and during Valsalva, it decreased from 29.14 ± 2.68 cm² to 23.51 ± 3.41 cm² (P < .01). At maximum pelvic contraction, the hiatal area decreased from 15.18 ± 3.48 cm² to 13.50 ± 3.09 cm² (P < .01). Preoperative and postoperative ultrasonographic measurements are presented in Table 2.

Table 2.

Comparison of preoperative and postoperative ultrasonographic measurements.

	Preoperative	Postoperative	P-value*
Rest levator APD (cm)	5.81 ± 0.61	5.01 ± 0.49	<.01
Valsalva levator APD (cm)	7.14 ± 0.61	5.85 ± 0.81	<.01
MPC levator APD (cm)	4.91 ± 0.77	4.25 ± 0.73	<.01
Rest levator hiatal area (cm²)	17.25 ± 3.52	15.54 ± 3.45	<.01
Valsalva levator hiatal area (cm²)	29.14 ± 2.68	23.51 ± 3.41	<.01
MPC levator hiatal area (cm²)	15.18 ± 3.48	13.50 ± 3.09	<.01

APD = anteroposterior diameter, MPC = maximum pelvic contraction.

^*Paired sample t test.

4. Discussion

The sensation of vaginal looseness is increasingly being reported by patients, with this growing concern becoming more pronounced in recent years.^[15,16] This rise in awareness can be attributed to the expanding popularity of aesthetic procedures worldwide, as well as the greater dissemination of information about these treatments, which have allowed individuals to openly voice their concerns about body image and sexual health.^[17] As patients become more informed about available treatment options for vaginal looseness, there is a significant increase in demand for procedures like vaginoplasty.^[13] Consequently, this awareness is expected to lead to a continued rise in the demand for such treatments in the future. Vaginoplasty and vaginal tightening procedures are becoming increasingly popular for the treatment of vaginal laxity.^[18,19] While vaginoplasty results have been shown to be successful through self-reported questionnaires and physical examinations, these results are often subjective and based on individual perceptions of satisfaction.^[20–23] Therefore, there is a growing need for objective data to evaluate the efficacy of these procedures. In our study, we aimed to objectively demonstrate the effects of vaginoplasty by evaluating the changes in the hiatus of the levator ani muscle, which is known to be associated with vaginal laxity, using translabial ultrasonography. As a result of our study, we demonstrated that the hiatal dimensions, including the APD and the hiatal area, were significantly altered after the vaginoplasty procedure.

Studies have demonstrated that vaginal laxity is associated with labor, particularly vaginal delivery.^[6,8,23] Mikhail et al suggested that pelvic hyperdistensibility, characterized by an enlarged hiatal area, is more common in women who have undergone vaginal or forceps delivery, which may help explain the increased vaginal laxity in women who have delivered vaginally.^[23] In our study, it was observed that 91.66% of the patients had at least 1 vaginal birth, further supporting the association between vaginal delivery and the presence of vaginal laxity. In the study by Dietz et al, the mean age of patients with VL was 53.1 years (19–84), while in the study by Talab et al, the mean age of patients was 47.8 ± 11.7 years (23–99).^[6,24] In our study, the mean age was 35.65 ± 3.11 years (28–45), which is attributed to the inclusion of only sexually active patients of reproductive age. Vaginal tightness has been reported to be positively associated with both age and menopausal status.^[3,23] Therefore, the deliberate selection of our patient population was essential to minimize the potential confounding effects of these variables, thereby enhancing the overall reliability and validity of our study outcomes.

There is growing evidence indicating an association between pelvic floor hyperdistensibility and vaginal laxity.^[4,6] A study by Manzini et al demonstrated a statistically significant increase in sonographic measurements of pelvic floor distensibility in women with VL.^[4] In their study, the area, APD, and coronal diameter of the levator hiatus were measured both at rest and during the maximum Valsalva maneuver in the plane of minimal hiatal dimension. For the levator hiatal area during maximum Valsalva, the optimal cutoff for predicting vaginal laxity was found to be 26 cm², with a sensitivity of 0.64 and a specificity of 0.60.^[4] In their study, they found that the hiatal area in women with vaginal laxity was 16.29 ± 3.78 cm² at rest, while it increased to 30.45 ± 8.74 cm² during the Valsalva maneuver, showing a significant difference compared to women without vaginal laxity. The APD was 5.79 ± 0.74 cm at rest and 7.24 ± 1.16 cm during Valsalva.^[4] In our study, the preoperative resting hiatal area of the patients was 17.25 ± 3.52 cm², while the Valsalva hiatal area was 29.14 ± 2.68 cm². The APD was 5.81 ± 0.61 cm at rest and 7.14 ± 0.61 cm during Valsalva, which was consistent with the findings of previous studies.

Vaginal laxity is gaining increasing attention, largely due to the growing availability of surgical options such as vaginoplasty and radiofrequency methods. The rate of female genital plastic surgery has increased by nearly 220 percent over the past 5 years.^[25] The most commonly performed female genital aesthetic procedure worldwide is labiaplasty, which targets the labia minora, followed by vaginal tightening (vaginoplasty).^[26] According to data obtained from The International Society of Aesthetic Plastic Surgery, surgical vaginal rejuvenation procedures saw a 19.6% increase in 2023 compared to 2022.^[27] Numerous studies have demonstrated that patients report general satisfaction with their sexual lives following vaginoplasty, with some indicating that this improvement may be associated with improved body image. While the success of the operation is often measured through questionnaires, there remains a lack of objective data to fully support these findings.^[20–23] In our study, the effect of posterior vaginal repair on improving vaginal measurements was evaluated using translabial ultrasonography, Valsalva and maximum pelvic contraction. All ultrasound measurements showed significant improvement in the postoperative period compared to the preoperative period. In particular, the hiatal area measured during Valsalva, which was the best predictor of vaginal laxity according to Manzini et al., was 29.14 ± 2.68 cm² preoperatively, while it decreased to 23.51 ± 3.41 cm² postoperatively, showing a significant reduction compared to the preoperative period.

In conclusion, this study demonstrates a clear and statistically significant improvement in vaginal laxity following vaginoplasty, as evidenced by translabial ultrasonographic measurements of hiatal dimensions. These findings offer objective evidence supporting the effectiveness of the procedure, in contrast to previous studies that primarily relied on subjective questionnaires. Nevertheless, given the limited sample size, additional studies with larger patient populations are warranted to validate these results and to better elucidate the long-term effects of vaginoplasty on vaginal laxity.

Author contributions

Conceptualization: Elcin İslek Secen, Raziye Toksoz.

Data curation: Raziye Toksoz.

Formal analysis: Raziye Toksoz.

Investigation: Elcin İslek Secen.

Methodology: Elcin İslek Secen.

Project administration: Raziye Toksoz.

Resources: Elcin İslek Secen.

Supervision: Raziye Toksoz.

Validation: Raziye Toksoz.

Writing – original draft: Elcin İslek Secen.

Writing – review & editing: Raziye Toksoz.