# Vaginal introital laxity

Vaginal introital laxity is a symptom of pelvic floor dysfunction characterised by a sensation of looseness at vaginal external opening, also known as the vaginal introitus. Possible causes include pelvic organ prolapse (POP), post-pregnancy and vaginal delivery and menopause. Consequences may include experiencing sexual dysfunction, ranging from dyspareunia (i.e. painful intercourse), increased vaginal “wind” to overactive bladder (OAB). These consequences may lead to adverse significant impacts on women’s sexual health, body image and quality of life. Vaginal laxity is often underreported, with approximately 80% of women not seeking treatment or discussing their concerns.
Diagnosis is based on physical examination, including pelvic examination, as well as validated questionnaires such as vaginal laxity questionnaire (VLQ) and sexual satisfaction questionnaire (SSQ). Possible treatments include nonsurgical treatment with energy-based devices, vaginoplasty repairs and dynamic quadripolar radiofrequency treatment. More severe cases may require surgical introital reduction procedures after the failure of conservative measures. Outcomes following these treatments are generally positive, with reported significant and sustainable long-term effectiveness and improved sexual life quality.

## Signs and symptoms
### Dyspareunia

Vaginal introital laxity is often associated with a decrease in sensation during sexual intercourse. It may also lead to reduced production of natural lubricating substances in the female body, such as vaginal fluid and cervical mucus, resulting in reduced friction and pressure. Sexual experience may become less enjoyable and may even lead to discomfort. In some serious cases of VIL, the vagina and vaginal introitus may become especially vulnerable during sexual activities when the male penis rubs against the vaginal wall at the external opening. Risks of microtears and vaginal tissue trauma may therefore increase significantly during sexual intercourse, resulting in pain, the feeling of burning and even injuries.

### Increased vaginal "wind"

The loosened vaginal walls caused by vaginal introital laxity may not seal the vaginal canal as strongly as a normal one, resulting in the entering of air into the canal during certain activities, such as during vigorous movements, sexual activities or even childbirth. VIL may also lead to weakened pelvic floor muscles and cause improper closure of the vaginal introital, allowing easier entering of air into the vagina. During certain movements and physical activities, the release of this trapped air will result in vaginal “wind” and produce a sound similar to passing a gas or a “popping” sound.

### Overactive bladder (OAB)

Although vaginal introital laxity may not cause OAB directly, there are still some indirect relationships between them that may relate these two conditions. Pelvic floor muscle, being the major muscle supporting the pelvic organs such as the bladder and uterus, is especially vulnerable during vaginal delivery. During childbirth, women are more likely to develop vaginal introital laxity, eventually leading to the weakening of pelvic floor muscles and may develop urinary symptoms such as OAB.
Vaginal introital laxity may also weaken the support structures around the urethra, which is the tube that helps carry urine outside of the body from the bladder. The weakened urethra supporting structures will subsequently cause the urethra to move much more than usual, such as during physical exercise or even coughing. This will contribute to urinary leakage, a symptom of OAB.

## Pathophysiology
### Pelvic organ prolapse (POP)

Vaginal introital laxity is usually suggested to be associated with pelvic organ prolapse, which refers to the descent of one or more of these organs from the normal position. Constant stretching and elongation of the vaginal canal caused by POP may be a cause of vaginal introital laxity. However, the association between this type of prolapse and vaginal introital laxity is still unclear due to the lack of related data.
POP includes (a) the falling out of vagina, bladder and other genito-pelvic structures, (b) vaginal tissue bulging into and through the introitus, or (c) the prolapse of rectal tissues into the vaginal area. It is differentiable between POP and vaginal introital laxity as pelvic organ prolapse involves the descent of one or more pelvic structures, whereas vaginal introital laxity specifically pertains to the looseness of the vaginal introitus.

### Vaginal delivery

Being one of the most dominant causes of vaginal introital laxity, vaginal childbirth in women may cause trauma to the genito-pelvic floor musculature and vagina by stretching the introitus. Along with the hormonal changes that lead to the relaxation of pelvic ligaments and vaginal tissues during pregnancy, these body parts will be further stretched and weakened. During childbirth, a huge pressure may be exerted onto the vaginal tissues during the passing of the baby through the birth canal, especially onto the introitus, causing laxity. In some cases, when the size of the baby is too large, the excessive stretching of the vaginal opening during childbirth may even cause tearing.

### Menopause

Another cause of vaginal introital laxity is menopause. Estrogen and progesterone are two of the primary sex hormones, and their levels are directly associated with the thickness and elasticity of the vagina. During menopause, the significant decline of estrogen and progesterone levels may cause reduced production of collagen and elastin, leading to thinner and less rigid vaginal walls. The weakening of pelvic floor muscles due to these sudden hormonal changes is also a contributing factor to potential vaginal introital laxity. Especially for estrogen, its significant decline during menopause may result in a condition known as vaginal atrophy, which refers to the thinning of vaginal walls. This reduces the elasticity of the vaginal introitus. Menopausal women who have given birth may face increased risks compared to younger women due to the combined effects of childbirth-related excessive stretching and menopause-caused hormonal level reduction. These combined factors may eventually weaken the vaginal external opening and cause laxity.

## Diagnosis

Diagnosis of vaginal introital laxity involves a comprehensive evaluation of the patient's symptoms and medical history, which may include physical examination and response to several validated questionnaires. Since vaginal introital laxity is usually a patient self-reported condition based on subjective perceptions, there are no objective measurements to quantify its severity.

### Physical examination

Healthcare providers will perform pelvic examinations to assess the vaginal tissue. Patients are first asked to empty their bladders to improve access to the pelvic organs, and to alleviate any discomfort or pressure that may arise from a full bladder during the examination. They are then placed in a supine position, usually lying on their back on birthing chairs at 45 degrees with their feet in stirrups, allowing the legs to be comfortably positioned. This position is called the dorsal lithotomy position, which is most commonly used in genital examination. In some cases, alternative positions such as the supine frog leg position or the prone knee chest position may be used.
Next, inspection of external genitalia, including the labia majora and minora, clitoris, perihymenal tissue (vestibule), hymen, posterior fourchette, vagina, and cervix will proceed. Healthcare providers may gently palpate the vaginal introitus and surrounding tissues. Speculum examination is also conducted by inserting a lubricated speculum into the vagina to visualise the vaginal walls and cervix for assessing the vaginal introitus and measuring any laxity or looseness. The speculum is available in different sizes and shapes to accommodate individual anatomy.
Moreover, pelvic floor assessment may be used to evaluate the strength and tone of the muscles. This may involve requesting patients to perform specific movements, such as contracting and relaxing the pelvic floor muscles, coughing, or bearing down. This helps evaluate the muscle function and identify any issues or weaknesses.

### Vaginal Laxity Questionnaire (VLQ)

Vaginal Laxity Questionnaire (VLQ) is designed to evaluate the degree of vaginal looseness, which helps guide treatment decisions and monitor the effectiveness of interventions aimed at improving vaginal laxity. The questionnaire covers several aspects:
* Physical symptoms: sensations of looseness, lack of tightness, or reduced friction during sexual intercourse
* Sexual function: changes in sexual satisfaction, orgasmic intensity, or sexual desire due to vaginal laxity
* Impact on quality of life: impact of vaginal laxity on self-esteem, body image, and overall well-being
* Emotional well-being: feelings of embarrassment, discomfort, or distress related to vaginal introital laxity

### Sexual Satisfaction Questionnaire (SSQ)

Sexual Satisfaction Questionnaire (SSQ) is used to assess sexual quality of life and sexual function. Since vaginal introital laxity (VIL) may cause decreased genito-pelvic sensation during sexual intercourse, which in turn is associated with decreased sexual desire, arousal difficulties, and orgasmic dysfunction, it can adversely impact the sexual quality of life. Due to this potential cause-and-effect, SSQ can indirectly reveal the occurrence and severity of VIL.
The questionnaire consists of multiple items that individuals can rate on a scale to indicate their level of satisfaction. This method has great reliability due to the high consistency score measured. The questionnaire result can be used to cross-check with physical examinations for inferring the severity extent of VIL.

## Treatment
### Surgery with energy-based devices

There are two main types of laser modalities – the ablative CO$_2$ and the non-ablative Erbium Yag. The former renders collagen- and elastin-fibre remodelling by denaturing the tissue, while the latter has a deeper secondary thermal effect and controlled heating of the target mucous membrane of the vaginal wall due to a higher affinity of water absorption. Both aim to remodel the subepithelial connective tissue. The safety and efficacy need further investigation.

### Vaginoplasty Repairs

In vaginoplasty repairs, a modified anterior and/or high posterior colporrhaphy and/or the excision of lateral vaginal mucosa are used to remove sections of the mucosa from the vaginal fornices. The goal of this procedure is to tighten a rather lax upper vagina.

### Dynamic Quadripolar Radiofrequency Treatment

The radiofrequency device emits focused electromagnetic waves that generate 40 °C to 45 °C heat upon tissue impedance. The high temperature stimulates the fibroblasts' production of collagen by activating heat-shock proteins and initiating the inflammatory cascade. With the treatment biophysics, the operator can significantly lower the amount of energy administered by defining the target vulvar area's volume and depth. To provide strict tissue temperature control, it also permits electronic movement and temperature sensor control within the radiofrequency device.

### Surgical Introital Reduction Procedures

Perineorrhaphy is a common technique that is involved in the procedure, which aims to repair the perineum (i.e. the area between the vagina and anus) surgically. It can be performed with or without levator ani plication to tighten the pelvic floor muscles.