Medical Therapy
Conservative management for patients who complain about an enlarged vaginal introitus includes pelvic floor physical therapy (PFPT). This is a non-invasive treatment method in which specially trained physical therapists perform internal and external therapy aimed at strengthening and relaxing the pelvic floor muscles. PFPT is a structured and comprehensive program that sometimes includes biofeedback therapy, which is visual confirmation the patient is contracting her muscles appropriately. An individualized home exercise program is also prescribed by the patient’s therapist. Coordinating the pelvic floor muscles along with behavioral modification education can lead to improvement and even resolution of many pelvic floor disorders. [12, 13]
Pessary use is another conservative treatment modality that would be appropriate if the enlarged vaginal introitus is due to pelvic organ prolapse. The practitioner may choose from many shapes and sizes of pessaries depending upon the patient’s symptoms and type of prolapse. Patients with an enlarged vaginal introitus may not be able to retain pessaries as well, however, depending on her genital hiatus to total vaginal length ratio. [14] A pessary can be used concurrently with PFPT.
Surgical Therapy
Surgical therapy of an enlarged vaginal introitus includes perineorrhaphy, which may be performed concomitantly with surgery to correct pelvic organ prolapse. There are variations in technique and suture material, but the surgeon is essentially reattaching rectovaginal fascia to the perineal body and reapproximating the perineal body muscle support. By re-creating the perineal body, the enlarged vaginal introitus becomes smaller. [10]
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Delancey's levels of support for the pelvic organs. Note that level I refers to apical (or uterovaginal) support.
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Muscles of the pelvic floor. Courtesy of McGraw-Hill Education.
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Patient who is not symptomatic from her enlarged vaginal introitus.
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Side-by-side photos of asymptomatic patients, one with a 3.5cm vaginal introitus and the other with a 7cm vaginal introitus.
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Multiparous patient with an approximately 3cm vaginal introitus.
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Rectocele characterized by bulging of the posterior vaginal wall at the introitus. Courtesy of McGraw-Hill Education.
