P J S Randombage, P S Hettipathirana, M Akurugodagama
Evidence remains low-certainty, short-term and mainly subjective. Pelvic floor muscle training should be first-line; devices and surgery require cautious counseling, explicit harm discussion and stronger comparative research.
INTRODUCTION AND HYPOTHESIS: Vaginal laxity is a heterogeneous symptom complaint rather than a standardized diagnosis. Interventions are promoted despite inconsistent definitions, variable outcomes and limited long-term safety data. The objective was to synthesize evidence on conservative and surgical interventions for symptomatic vaginal laxity and quantify study-defined responses where pooling was feasible.
METHODS: MEDLINE/PubMed, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, ClinicalTrials.gov, and the World Health Organization's International Clinical Trials Registry Platform were searched up to 1 April 2026. Two reviewers independently screened studies, extracted data and assessed bias. The primary outcome was study-defined binary laxity response. Secondary outcomes included Female Sexual Function Index total score, pelvic floor muscle strength, symptom burden, sexual distress, objective endpoints and adverse events. Random-effects pairwise meta-analysis was used.
RESULTS: From the literature search, 24 reports informed qualitative synthesis and 7 contributed to quantitative models. Three sham-controlled radiofrequency-based studies favored active treatment for study-defined laxity response versus sham (risk ratio 3.15, 95% confidence interval 2.17-4.58; I2 = 14.6%). Two sham-controlled radiofrequency-based trials showed a modest Female Sexual Function Index gain (mean difference 1.64, 95% confidence interval 0.31-2.98; I2 = 0%). The only pelvic floor muscle training versus radiofrequency trial showed radiofrequency non-inferiority at 30 days but favored pelvic floor muscle training at 6 months. Surgical cohorts reported improved sexual function and perceived tightness, but certainty was very low and harms included dyspareunia, over-correction, worsened vaginismus and reoperation.
CONCLUSIONS: Evidence remains low-certainty, short-term and mainly subjective. Pelvic floor muscle training should be first-line; devices and surgery require cautious counseling, explicit harm discussion and stronger comparative research.