Current challenges in the assessment and management of radiotherapy-induced vaginal stenosis

Recommended therapy for cervical and other pelvic cancers relies on external beam radiation therapy with brachytherapy. The total biologically equivalent dose in 2 Gy fractions delivered to the tumor ranges from 60 to 90 Gy. The addition of brachytherapy boosts tumor dose and substantially improves 5-year survival, but unavoidable radiation exposure of surrounding vaginal tissue often induces fibrotic scarring which constricts the vaginal vault and can result in complete occlusion. This condition is termed vaginal stenosis, a serious, chronic syndrome which leads to sexual dysfunction and may obstruct gynecological surveillance for cancer recurrence. Clinical management consists of self-administered vaginal dilation with hard plastic rods, an approach that is effective when applied consistently. However, many women are reluctant to use these dilators because the underlying rationale and the methodology are often inadequately presented, and dilator use can be painful and even injurious. Additional challenges with clinically managing vaginal stenosis include incompletely characterized radiation dosimetry, the absence of widely standardized diagnostic and assessment criteria, and an absence of innovative new therapeutics that are both well tolerated and efficacious. Accordingly, in the present review we begin by describing the pathogenesis of vaginal stenosis and focus on risk factors including irradiation modalities and methods and nonadherence to dilator use. Subsequently, in this context we address the key importance of standardized stenosis assessment and identify current inconsistencies in clinical reporting. Finally, within the above landscape we highlight potential innovations for protecting vaginal tissue and promoting vaginal recovery in pelvic radiotherapy patients.