Evaluation of the effects of non-ablative radiofrequency on vaginal dilation in a trans woman after sexual reassignment: a case report

doi:10.21203/rs.3.rs-2747734/v1

Introduction:

Sex reassignment surgeries (CRS) are surgical interventions that can be performed aiming at the adequacy of the anatomical sex to the gender that the subject recognizes. These patients can be offered CRS, such as neovaginoplasty, which can present clinical complications, such as stenosis, atrophy, loss of vaginal elasticity and dyspareunia. The conservative approach to treating these disorders is vaginal dilation. Radiofrequency (RF) is a technique indicated for these vaginal tissue changes.

Objectives:

to describe the non-ablative radiofrequency (RF)-associated vaginal dilatation process regarding its functional outcome in a transgender woman after vaginoplasty.

Methods:

this is a 31-year-old intersex transgender woman, with skin reassignment surgery and other vaginal correction surgeries. The current complaint was a short vaginal canal and dyspareunia. The patency of the vaginal canal was 2.5 cm wide and 7 cm deep. Intervention: The radiofrequency protocol was performed in the extension of the vaginal cavity. Then, the standard protocol of vaginal dilation was performed. The program consisted of 6 radiofrequency sessions lasting 5 minutes at a temperature of 39 degrees, with an interval of 4 weeks.

Results:

There was progression of vaginal dilation during therapy, with a change from 2.5 to 3.5 cm in diameter (40%) and from 7 to 12 cm (71.4%) in length. As for sexual satisfaction on the EVA-S scale, there was an improvement from 2.5 (dissatisfied) to 7.5 (satisfied).

Conclusion:

This study suggests that radiofrequency followed by dilation was effective in enlarging the vaginal canal, reducing pain and increasing comfort during penetration.

Vaginal Dilation

Physiotherapy

Neovagina

Sexual Reassignment

Transgender

Sexual Reassignment Surgeries (CRS) or transgenitalizations are surgical interventions that can be performed to achieve body changes, aiming at the adequacy of the anatomical sex to the gender that the subject recognizes^{[1, 2]} .

Not all transgender people feel the need to perform these procedures, and they can use other interventions that can meet different demands, such as facial and vocal feminization surgeries, for example^[3]. Those who want and need genital modifications can be offered CRS, such as neovaginoplasty (consisting of the reconstruction of a neovagina) and neophalloplasty (consisting of the formation of a neophallus)^[4] .

In Brazil, both neovaginoplasty and neophalloplasty are available at public healthcare system (SUS), but the process is still lengthy and bureaucratic^[2]. One of the most performed surgeries is bilateral orchiectomy with amputation of the penis, construction of a neovulva and neovagina (neovulvovaginoplasty) and other procedures to correct possible complications^[4] .

Neovaginoplasty in the transsexualization process can present clinical and surgical complications as well as changes in the pelvic floor (PF), since several important structures of are sectioned. Indeed, incorrect use or non-use of the vaginal mold, which is placed after the surgical process, can cause changes or complications, which may present immediately or later^[5] .

The most cited complications in the literature are stenosis, atrophy and loss of vaginal elasticity, cyclic or chronic pelvic pain, sexual dysfunctions (dyspareunia and anorgasmia), genital prolapses, fistulas, dryness, laxaty of the vaginal wall and urinary incontinence^{[4–6, 8, 9]}. The conservative approach for treating some of those disorders is vaginal dilatation^[10].

Radiofrequency (RF) is a technique indicated in degenerative processes that imply a decrease or delay in metabolism, irrigation and nutrition, generally in chronic diseases. It has been studied for vaginal alterations, such as dense fibrous tissue of the vaginal cavity, surgical adhesions, atrophy, atrophic scarring, among others. It has been used in dermatology as a treatment option for late fibrosis after cosmetic surgery, atrophic scarring or epithelial rejuvenation. It is also indicated for causing increased vasodilatation and irrigation in the treated area, in addition to tissue oxygenation and nutrition^[11] .

The RF effect occurs when the current passes through the tissues, generating a slight friction and a thermal rise in tissue temperature. So, there is opening of the capillaries, which improves tissue trophism, the reabsorption of excessive intercellular fluids and the increase in circulation, promoting improved oxygenation and nutrients for the tissues. There is also an improvement in the drainage system of cellular waste (toxins and free radicals). These effects provide the possibility of producing better quality elastic fibers^[11] .

Radiofrequency could be used by physiotherapists in the post -surgical sex reassignment surgery for helping the rehabilitation of the vagina, acting on pelvic floor dysfunctions as well as on the dilatation process, in order to obtain a neovagina of functional length and diameter.

This case reports the use of radiofrequency and vaginal massagers in the late postoperative period of a trans woman dissatisfied with the surgical outcome.

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of UNIFESP - Federal University of São Paulo /Brazil, date 06/07/22 num. 5.453.749. It took place at the Genital Malformations Outpatient Clinic of the Gynecology Sector of the Escola Paulista de Medicina and Informed Consent Term was signed with the assignment of rights to use images for this study.

This is an intersex transsexual woman, 32 years old, white, in a stable relationship, with a complaint of excess skin and engorgement in the mount of Venus during sexual arousal, associated with a short vagina, dyspareunia and difficulty reaching orgasm, which brought impairment of her sexual activity.

She identified herself as trans in childhood and began the transition at age 13, undergoing reassignment surgery with skin vaginoplasty at age 20 in 2010 using the Cury YX technique. In the following year, she underwent correction of labia minora hypertrophy, followed by excision of excess skin and anteriorization of the vaginal introitus in 2013, enlargement of the neovagina introitus in 2016 and urethroplasty with removal of the right bulbocavernosus muscle in 2020.

During the post-operative period of neovaginoplasty in 2010, she used a vibrator for three months in order to not reduce the vaginal canal. She was instructed on dilatation, but she did not feel confident about the progression of the canal for fear of skin rupture and pain during dilatation.

During the first consultation at the Genital Malformations Outpatient Clinic of the Gynecology Sector of the Escola Paulista de Medicina, the sociodemographic data and a complete clinical history were collected. A gynecological examination was performed, assessing the patency and measurements of the vaginal cavity in length and diameter, as well as the presence of pain on palpation.

To measure sexual satisfaction, the Visual Analogue Scale (VAS-S) adapted for satisfaction^[13] was used. It consists of a 10 cm long line, ranging in scale from 0 (very dissatisfied) to 10 (very satisfied)^[13] .

The FSFI (Female Sexual Function Index) questionnaire was applied, which aims to assess the female sexual response in relation to sexual desire, sexual arousal, vaginal lubrication, orgasm, sexual satisfaction and pain. For this, it presents 19 questions that assess sexual function in the last four weeks^[15] scored from 0 to 5. The score is reversed only for pain-related questions^[22].

For the functional evaluation of the pelvic floor (FEPF), the instrument described by Ortiz^[16] was used. With the patient in the gynecological position, the examiner introduces the index and middle fingers into the vagina, or just the index finger, and asks the patient to contract the pelvic floor muscles (PFM) and maintain this contraction for a few seconds. The FEPF graduation ranges from 0 to 4^{[16, 17]}.

The vaginal dilatation sessions followed the dilatation protocol for vaginal agenesis suggested by ACOG^[18]. Initially, a thorough examination with a mirror was performed so that the patient could identify the clitoris, urethra, and distal vagina with the aim of understanding and demonstrating the appropriate location and angle for placement of the dilator.

For radiofrequency, an Energy Compact® Radiofrequency electrical transfer device, brand DGM Eletrônica Ltda, under ANVISA registration nº 80108300019 was used. The RF procedures were performed in the lithotomy position in the region of the vaginal mucosa and monopolar electrodes were introduced into the vaginal cavity. The application time was 5 minutes with a temperature of 39º degrees (measured by a digital thermometer) and the frequency was 1 Mhz. The speed of movement of the probe was a cycle of one round trip every two seconds marked through beep sound.

After these procedures, the vaginal introitus was evaluated for dilator eligibility, which varies in diameter and length. ®Absoloo brand vaginal dilators, numbers 4 (2.5 x 10.9cm), 5 (3.1 x 13.2cm) and 6 (3.5 x 14.5cm) were used.

For analgesia and proprioception of the perivaginal region, a ®Peridell 12.5 x 2.8cm perineal massager with a convex tip was used.

Dilatation using vibrocompression was performed for 20 minutes, alternating every two minutes in vibration and 2 minutes without vibration (2:2). At the end, the patient was reassessed for maintenance or progression to a major dilator to continue home therapy. Images were collected in the first and last session to record the therapeutic evolution.

According to the initial evaluation, a diagnosis of canal shortening, and vaginal stenosis was made. The patient's expectation was to obtain a functional vagina and, for that, a protocol of 6 sessions of radiofrequency intervention and vaginal dilatation was proposed, being carried out every 4 weeks.

At the first consultation, the patient showed a patent vaginal canal with 2.5 cm in diameter and 7cm in length. The muscle strength level was FEPF 4, Visual Analogue Scale (Satisfaction) score was 2.5 (Dissatisfied) and FSFI score was 20.2 (Table 1).

Table 1

FSFI scores
Domain	Question	Score Variation	Multiplication Factor	Minimum Score	Punctuation maximum	total score
Desire	1,2	1–5	0.6	1.2	6.0	5.4
Excitement	3,4,5,6	0–5	0.3	0	6.0	4.2
Lubrication	7,8,9,10	0–5	0.3	0	6.0	3
Orgasm	11,12,13	0–5	0.4	0	6.0	2.8
Satisfaction	14,15,16	0 ( or 1) − 5	0.4	0.8	6.0	3.2
Pain	17,18,19	0–5	0.4	0	6.0	1.6
Total				2.0	36.0	20.2

The patient attended the six proposed sessions. In the first session, she reported difficulty in penetration and dyspareunia, performing dilatation with a dilator 5. The length was 7 cm (Fig. 1) and after the radiofrequency protocol, it reached 9 cm, allowing progression to a larger dilator, n. 6 (Fig. 2).

In the second session, the patient reported assiduously maintaining the home exercises, with good tolerance, maintaining dilator n.6. There was good acceptance, with only brief discomfort when introducing the dilator. In this session, there was a progression of vaginal length from 9 cm to 12 cm at the end of radiofrequency therapy.

In the next session, the patient reported home dilatation every two days due to the discomfort of the vaginal introitus, but reported improvement in sexual response and intercourse. There was progression of the vaginal canal from 12 to 14 cm after RF, and the home dilator 6 was maintained.

In the fourth session, the patient remained motivated and reported a significant reduction in dyspareunia. She performed home dilation 2–3 times a week with no bleeding or discomfort. She reported experiencing painless intercourse. Vaginal measurements remained the same as in the previous session, 14 cm, and therapy was maintained for vaginal introital dilation, still with the dilator n.6.

In the fifth session, the patient reported interruption of dilatation for 15 days due to a respiratory infection. In this session, the initial length was 11 cm and after radiofrequency it was 12 cm. The home protocol was maintained with a 6 dilator.

In the sixth session, the patient maintained the home dilatation with significant improvement of dyspareunia, stenosis, and vaginal length, but referred the desire to increase the vaginal length to 16 cm. In this session, the length has increased from 12 cm (Fig. 3) to 14.5 cm (Fig. 4). The degree of muscle strength was FEPF 4 and sexual satisfaction by VAS-S score was 7.5. The results are described in Figs. 3 and 4 and shown in Tables 2 and 3.

Table 2. Results of vaginal dilatation in diameter and length

*Session*	*Vaginal canal measurements (cm)*
	Diameter			Length
	Pre	Post	Result	Pre	Post	Result
1	2,5	3	0,5	7	9	2
2	3	3,5	0,5	9	12	3
3	3,5	3,5	0	12	14	2
4	3,5	3,5	0	12	14	2
5	3,5	3,5	0	11	12	1
6	3,5	3,5	0	12	14	2
Mean	3,5	3,5	0	11,5	13	2
SD	0,42	0,20	0,26	2,07	1,97	0,63

Cm centimeters Pre Pre radiofrequency, Post Post radiofrequency SD standard deviations,

Table 3. Scores obtained at the beginning and end of treatment

*Scale*	*Pre*	*Post*	*Result*	*Mean*	SD
VAS-S	2,5	7,5	5	5	3,54
FSFI	20,2	-	-	-	-
FEPF	4	4	0	4	0

VAS-S Visual Analogue Scale (Satisfaction), FSFI Female Sexual Function Index , FEPF Functional Evaluation of the Pelvic Floor , SD standard deviations

Male-to-female transsexual surgical techniques are well defined and present good aesthetic and functional results with satisfaction rates of up to 90%. Techniques include creating a normal-looking female introitus and a neovagina that allows for sexual intercourse and the ability to orgasm^[20] .

One of the factors that can cause late complications in vaginoplasty is the incorrect use or non-use of the vaginal mold, placed after the surgical process to avoid changes in elasticity, vaginal lubrication, closure or significant narrowing of the formed vaginal canal. Such complications can cause sexual dysfunctions^[5] .

Difficulty in penetration is a common complaint, the main one being dyspareunia, directly affecting mental and physical health and relationships with partners, and can lead to sexual dysfunctions, such as decreased sexual desire and arousal, and even anorgasmia ^[20]

Neto et al.^[7], have studied 332 patients who underwent vaginoplasty, observing dyspareunia in 15% of them. They also observed loss of vaginal length in 25 cases, which corresponds to 8% of women.

These data corroborate our patient's report, who was admitted with a complaint of penetration difficulties due to dyspareunia, stenosis and short vaginal canal which caused a decrease in libido and sexual satisfaction. The patient also complained of difficulty and insecurity to perform the dilatation, for fear of breaking the skin, due to the low elasticity of the vaginal tissue. There was also discomfort with the flaccid aesthetic appearance of the vagina.

The radiofrequency was indicated to treat these disorders, based on studies that cited neoelastogenesis and neocollagenesis promoted by the thermal effects, which can contribute to the improvement of tissue quality. The immediate effects of radiofrequency on dilatation were described by the patient, such as pleasant thermal sensation, better comfort and increased tolerance related to the pain threshold for progression of dilatation pressure. This was reflected in the immediate increase observed from the initial (pre-therapy) to final (post radiofrequency therapy) vaginal length measurements.

Although the FSFI questionnaire was applied in the first session with a score of 20.2, it was not possible to assess sexual function after treatment, as the patient was sexually inactive in the last 4 weeks prior to the sixth session. However, she denied pain and discomfort during home dilatation with a dilator 6. However, the VAS (Sexual Satisfaction) scale was applied with an initial score of 2.5 (dissatisfied) with an increase to 7.5 (satisfied).

Another relevant point is that the patient was unaware of the limitations of the auto dilatation process resulting from the use of intravaginal skin during the neovaginoplasty. She was afraid of tearing the tissue from friction, which had hampered the dilator process over the years. The patient considered this factor harmful to her sexual health. With the help of the thermal effects of radiofrequency, vibrocompression for analgesia and orientations regarding neovagina skin distention, it was possible to obtain better results.

At the end of the sixth session, the patient obtained a 14.5 cm vaginal canal and was instructed on how to maintain the therapy at home. Despite having reached the parameters of a functional vagina without discomfort to penetration, she mentions a desire to enlarge the canal to 16 cm or more and continues her treatment in our sector. Regarding the aesthetic appearance, the patient complains of excess skin for the formation of the labia majora and will undergo surgical correction.

In this case, the immediate effects of radiofrequency followed by dilatation suggest efficacy in the formation of the vaginal canal, reduction of pain and better comfort during penetration, favoring the process in the long term. However, due to the scarcity of studies, more research is needed on the duration of these effects and on gynecological physical therapy in this population, ensuring adequate assistance and monitoring during this process, reducing possible late complications.

There is also a need for studies regarding sexual expectations related to vaginal length in transgender women. Histological analysis of the vaginal canal could provide more information.

Ethics approval and consent to participate

Informed consent was obtained from the participants/legal guardians regarding the participation in the study.

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of UNIFESP - Federal University of São Paulo /Brazil, date 06/07/22 num. 5.453.749. It took place at the Genital Malformations Outpatient Clinic of the Gynecology Sector of the Escola Paulista de Medicina and Informed Consent Term was signed with the assignment of rights to use images for this study.

Consent for publication

The patient signed informed consent regarding publishing their data and photographs.

Competing interests

All authors declare no competing interests

Funding

This study was financed in part by the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Finance Code 001.

Availability of Data and Materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Acknowledgments

This study was financed in part by the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Finance Code 001.

Authors' Contribution Description

RAMALHO, AML data collection, tabulation, statistical analysis of data, tables and figures.

SARTORI, MFG project guidance, study design, review of text, data and tables, addition of significant parts

TAKANO, CC project coordination, review of data and tables.

LEITE, MTC review of data and literature.

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No competing interests reported.

Evaluation of the effects of non-ablative radiofrequency on vaginal dilation in a trans woman after sexual reassignment: a case report

Status:

Version 1

Abstract

Figures

Introduction

Case Report

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1