Long-Term Outcomes of Surgical Correction for Acquired Vulvovaginal Constriction or Obliteration

INTRODUCTION: Acquired vulvovaginal constriction or obliteration requiring surgical management is rare but profoundly impacts sexual function, gynecologic health, and quality of life. Common etiologies include vulvovaginal dermatoses (VVD), postsurgical adhesions, and scarring. Data on surgical outcomes of this entity remains limited. OBJECTIVE: This study aimed to evaluate clinical characteristics, long-term operative outcomes, recurrence, and quality-of-life measures in patients undergoing corrective surgery. METHODS: A retrospective cohort of 59 patients undergoing surgical correction between 2002 and 2023 was reviewed, excluding congenital anomalies and post-radiation cases. Demographics, disease characteristics, operative findings, postoperative outcomes, recurrence, and current vulvovaginal health were collected via chart review and mailed out questionnaire (VSQ-21). Disease severity was a composite outcome classified as mild (flimsy adhesions, single site, caliber >2 cm, length ≥6 cm), moderate (dense adhesions, multiple sites, caliber 1–2 cm, or length 4–5.9 cm), or severe (scar tissue, circumferential/obliterative involvement, caliber <1 cm, or length <4 cm). Kaplan–Meier estimated recurrence-free survival. Logistic regression identified predictors of vulvovaginal health. Longitudinal symptoms were assessed at baseline, 3 months, and most recent follow-up. Mean follow-up was 6.3 (5.5) years. Logistic regression was performed to identify predictors of regaining sexual function after surgery. RESULTS: The leading etiology was VVD (33/59, 55.9%). Most patients were White (55/59, 93.2%), postmenopausal (42/59, 71.2%), and nonsmokers (42/59, 71.2%). The most common complaint was inability to have vaginal intercourse (25/59, 42.4%). VVD patients had more preoperative topical steroid use (27/33, 81.8%), presented with vulvar agglutination (23/33, 69.7%), shorter mean vaginal length (3.6 cm), and smaller mean vaginal caliber (0.6 cm). Prior hysterectomy was associated with scar tissue adhesions (8/10, 80%) and vaginal constriction (7/10, 70%). Severe disease correlated with postmenopausal status (25/35, 71.4%; p=0.025) and preoperative topical steroid use ≥6 months (24/34, 70.6%; p=0.003). Recurrence occurred in 16 patients (27.1%), which included 10 (30.3%) with VVD, of whom 4 required reoperation. Kaplan–Meier (Figure 1) demonstrated 25% recurrence at 2.38 years in VVD and 2.67 years overall. Use of postoperative systemic biologic therapy alone was associated with higher recurrence (HR 3.25, 95% CI 1.12–9.41; p=0.03). Use of topical steroids or dilators did not influence recurrence rate (p>0.05). In 38 patients with longitudinal symptom data, inability to have intercourse reduced significantly from 27/38 (71.1%) preoperatively to 21/38 (55.3%) at 3 months (p=0.041). No further statistically significant reduction was observed at current follow-up. Logistic regression showed positive association between sexual function regain and use of dilator size 9 (OR 8.7, 95% CI 1.5–9.9; p=0.012). VSQ-21 responses revealed higher emotional distress (p=0.001), worse symptoms (p=0.003), greater negative life impact (p=0.04), and overall lower vulvovaginal health (p=0.0003) in patients using topical steroids. Overall worse vulvovaginal health (p=0.003) was associated with using systemic estrogen alone. In contrast, combined topical therapy with ongoing dilator use was associated with lower symptoms (p=0.008), emotional distress (p=0.033), and better overall vulvovaginal health (p=0.017). CONCLUSIONS: Surgical correction restores sexual activity in most patients, with initial benefit but limited durability, and recurrence remains substantial, particularly in VVD. Severe disease is linked to VVD. Sustained multimodal therapy, including combined topical therapy with dilators, may optimize long-term outcomes.Figure 1Table 1Table 2