MRKH: Treatment Options

If you’ve been told that you have MRKH and your vagina is incomplete or absent, you have the following options to create a vagina:

1. You can do nothing.
2. You can create a vagina without surgery, using dilators that expand and stretch your existing vagina over time, using intermittent pressure. This is a nonsurgical procedure and a natural approach with no side effects.
3. You can have a surgical procedure, or “vaginoplasty”, or a combination of surgery and dilation.

Remember that YOU are in control of your own body. Deciding to create or not create a vagina should be your decision, and if you decide that you want to, when to do so should be your decision too! If you are not planning to have vaginal intercourse, it is not something you need to do. If you plan to have vaginal intercourse now or in the future, creating a vagina is something you might want to consider.

Aside from doing nothing, there are three basic approaches to help you expand or create a vagina. If you’re considering treatment, we recommend using dilators first. All of the surgical options require general anesthesia and the use of dilators after the operation; therefore, surgery is not a quick fix or a way to avoid the need for using dilators.

Accepted Standards of Care

The American College of Obstetricians and Gynecologists recommends vaginal dilators without surgery as the optimal treatment for creating a vagina. Healthcare providers recognize that this treatment is highly effective and noninvasive, and it does not carry the risks associated with surgery and anesthesia.

Dilators: Sometimes the use of dilators is referred to as the Frank Method, named after the first healthcare provider who became famous for introducing a treatment that a young woman could perform on her own, in the privacy of her own home. The Gynecology Program at Boston Children’s Hospital does not recommend the Ingram method because it is difficult and awkward to use.

Today, hard plastic dilators have replaced glass dilators. There are different kinds of dilators available, but the most widely prescribed dilators come in a set with different sizes ranging from XS-L. The smallest dilator is similar in size to a slender tampon. Starting with the smallest dilator, a young woman learns how to hold it and apply pressure to stretch her vagina. In the beginning, most of the dilator is used as a “handle” (as it can only go in so far). Later, as the vagina stretches, more of the dilator can be inserted into the vagina. If you’re a patient at Boston Children’s Hospital and select this method of treatment, a trained clinician will teach you how to use the dilators. You will take one home with you and should plan to use it twice a day for 20 minutes.

Is dilator treatment successful?

Dilator treatment can be very successful. However, there can be variation in the success of dilator treatment, mainly related to dilator compliance, teaching, and the expertise of the healthcare providers who instruct their patients on this method.

Make sure that you work with a gynecology program that has at least an 85-95% success rate for helping their patients create a functional vagina. You should ask the gynecologist how many patients he/she treat monthly/yearly who have vaginal agenesis (incomplete or absent vagina) and ask about their success rate. If the program or health care provider that you are working with has a low success rate, you will likely get frustrated during treatment, have a poor chance of success using dilators, and thus be at a higher risk of needing a surgical procedure.

How often do I need to see my gynecologist?

If you decide to use dilators to create your vagina, you will be scheduled to return about once every 1-2 months depending on if you have to travel far. At Boston Children’s Hospital we offer the option of Telehealth follow-up visits for patients who qualify. It is VERY important to keep your appointments with your gynecologist so he/she can check your progress to see if you are applying pressure in the right place and at the correct angle. As your vagina stretches, your gynecologist will give you the next (slightly bigger) dilator.

What are the surgical options for creating a vagina?

Surgery to create a vagina, also known as vaginoplasty, can be done in many ways. The type of surgery offered may depend on the surgeon and hospital you attend.

• Laparoscopy-Vecchietti procedure: The Vecchietti procedure combines the use of dilators and a surgical procedure. This technique (named after the physician who developed it) involves applying a traction device to the outside abdomen (stomach) of a young woman. This is done during a laparoscopy while the patient is under general anesthesia. At the same time, a plastic bead (about the size of an olive) is placed in the vaginal space, and is held with string that is threaded up through the vagina, into the abdominal cavity, and out to the traction device (which is secured to the skin outside of the abdomen).The vagina is formed using continuous pressure, 24 hours a day. The tension is set by turning the “crank” that is on the outside of the abdominal wall. The tension pulls the plastic bead upwards, creating vaginal length. The vagina can be created in about a week and requires a long hospital stay to complete the process. Afterwards, a second procedure with anesthesia is necessary to remove the equipment. It’s very important to understand that after this procedure is completed, patients should use vaginal dilators afterwards to maintain vaginal length. The Vecchietti procedure is popular in Europe and is also done at some hospitals in the United States, including Boston Children’s Hospital.
• McIndoe procedure: A vagina is created with a skin graft, usually from your buttocks (bottom) or with a special skin-like material and a vaginal mold. Young women who have this procedure must stay in bed in the hospital after the procedure for about a week so that the newly created vagina will heal. After the operation, a soft dilator must be worn all the time for about 3-6 months, taking it out only to use the bathroom. Even though a vagina is created faster with surgery, it’s still necessary to use a dilator afterwards.
• Williams’s procedure: This procedure is more commonly performed after other surgical procedures have failed and requires the surgeon to cut and dissect tissue to make the vagina. This procedure is more popular in Europe than in the United States. Dilators are necessary following the procedure, but for only about 3-4 weeks, instead of up to 6 months (which is more typical with the McIndoe procedure). This procedure may result in an angle of the vaginal opening.
• Bowel vagina: This is a major operation which involves creating a vagina using a section of your bowel. The recovery involves a minimum of 4-6 weeks of healing from major surgery.. Young women who have this procedure may experience chronic vaginal discharge, requiring the need to wear a pad all the time.
• Davydov procedure: The Davydov operation is a type of surgical procedure to create a vagina using a patient’s own abdominal tissue. The peritoneum is a membrane that lines the walls of the abdominal and pelvic cavities. While the patient is under anesthesia, an incision (cut) is made where the vaginal opening should be. Another incision(s) is made near the belly button to allow a thin instrument to be inserted into the peritoneal cavity. The peritoneal lining is then pulled down and stitched in place at the vaginal opening. The top of the newly created vaginal canal is then sewn closed. The vaginal space is then packed with gauze, which is typically removed several days after the operation. After the packing is removed, the patient must use various size vaginal dilators a few times a day for several months or until she becomes sexually active. Most women who have this procedure stay in the hospital overnight for observation and then return for close follow-ups.

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