Genital Aesthetics — Frequently Asked Questions

It is most often seen as part of the picture of the genitourinary syndrome that appears with menopause. Tissue changes after childbirth, episiotomy scars and skin conditions such as lichen sclerosus can also affect the quality of the tissue in the area.

The main approach described in the sources is the person's own fat tissue (autologous fat graft). The fat is passed through filters and turned into microfat and nanofat forms; microfat is the one suitable for giving volume. Nanofat contains no mature fat cells but is rich in stem cells.

PRP is the plasma fraction obtained from the person's own blood with a high concentration of platelets (the cell fragments in blood that start clotting). When added to fat tissue it has been shown to preserve the structure of the fat cells better, to create a strong blood supply and to create a favourable environment for the multiplication of stem cells. Its purpose, in other words, is to improve the likelihood of the graft taking.

In one of the published examples the result at 18 months was reported in a 54-year-old person; in another, the volume gained was reported to have been maintained. But these are reports of a limited number of cases — that the long-term effects need to be assessed further is the source's own wording.

It is necessary to be clear: the source text states that the effectiveness of microfat and nanofat grafting in this field has not previously been assessed, and that further studies are needed for the results to be confirmed. Most of the favourable results reported rest on subjective scoring scales, and the source accepts that subjectivity as a limitation. This does not mean the method does not work — it means it has not yet been measured in large comparative studies.

The source states that the fat tissue integrates naturally with the host tissue and that no notable side effect has been reported. Even so, this is a report resting on a limited number of cases; as with every interventional procedure, results may vary from person to person.

No, and this should be known plainly. ACOG states that G-spot augmentation procedures have no medical justification whatsoever and that there is no long-term scientific evidence of their effectiveness and safety; it warns doctors not to offer these procedures under the name of "sexual rejuvenation". The FDA has given no official approval and regards the applications as off-label.

In the medical literature there is no agreement. While some studies report that a particular part of the front wall of the vagina is rich in nerves and vessels, many independent studies, including twin studies, argue that no such separate structure has a physiological reality and that the sensitivity arises from the proximity of the clitoris to this area.

No. Clinical data establish this plainly: the application may help increase intensity and duration only in people who have previously experienced vaginal orgasm but whose sensitivity has decreased over time. In people who have never experienced orgasm in their lives it cannot start a new orgasmic function.

It depends on the material used. Hyaluronic acid is the temporary material most often chosen and generally lasts between 4 and 9 months. Collagen is fully absorbed in 6–8 months. The person's own fat tissue and materials that are not absorbed can also be used.

Yes, and they should not be taken lightly. Although very rare, life-threatening pulmonary embolism has been reported after filler was inadvertently delivered into the network of veins in the area. Too much filler can also prevent urination and a temporary catheter may be needed. Lasting loss of sensation, pain during intercourse, infection and firm inflammatory lumps around the filler are also among the risks reported.

It is carried out in the outpatient setting, usually takes less than 30 minutes and requires no rest period. The area is prepared with local numbing. After the procedure, abstaining from intercourse for 2–3 days is advised.

Rather than choosing a procedure directly, the cause needs to be assessed first. ACOG recommends that before moving to surgery or filler, the psychosexual situation and the context of the relationship be examined carefully. There may also be causes such as the clitoris being covered by a thick hood, or dryness due to menopause — causes that have well-established treatments.

The skin of this area is naturally darker than the surrounding skin. The most common causes of darkening that increases over time are friction and tight clothing, hair removal methods such as waxing or shaving, hormonal changes such as pregnancy, menopause and PCOS, insulin resistance and excess weight, and age and genetics.

A gynaecologist or a dermatologist (skin specialist) is suitable for the first visit; when needed, both assess it together. First, the doctor checks whether there is a medical cause for the darkening: skin diseases of the vulva, suspicious spots, insulin resistance and hormonal conditions such as PCOS are ruled out. Lightening is discussed only after this assessment.

Laser (fractional CO2 or Q-switched laser) and chemical peeling (peeling off the top layer of the skin with an acid solution) are used most often. The procedure is done in the practice after a numbing cream is applied to the area and takes a short time. The number of sessions and the method are set according to skin type.

How long it lasts varies from person to person and cannot be predicted with certainty. If the factors causing the darkening (friction, hair removal, hormonal changes, pregnancy, insulin resistance) continue, the colour can darken again over time. Avoiding friction and tight clothing, protecting the area from the sun and sunbeds, and treating underlying causes help the result last longer.

A numbing cream is applied before the procedure. Most people tolerate it well; however, there may be a mild pricking, warm or burning sensation. Mild redness and peeling are expected in the first days.

It is not advised without medical advice. Some over-the-counter lightening products may contain hydroquinone (a lightening substance that should be used only on prescription), mercury or corticosteroids. On thin genital skin these substances can cause irritation, thinning, paradoxical darkening and harms such as mercury poisoning.

Temporary redness, burning and peeling are common. The most important risk is paradoxical darkening caused by irritation (post-inflammatory hyperpigmentation, darkening that remains after irritation); this risk is higher in people with darker skin. Scarring, lighter patches or infection are uncommon. Scientific evidence on these procedures is limited.

Darkening of areas such as the genital area and nipples during pregnancy is common and linked to hormones. It often partly fades after birth. Lightening procedures are not done during pregnancy and breastfeeding; if the darkening continues after birth, it can be assessed.

On the surgical side Labiaplasty, Clitoral Hood Reduction, Vaginal Tightening (Vaginoplasty) and Hymenoplasty; on the energy and filler side Genital Laser, Labia Majora Filler, PRP to the Genital Area and G-Spot Injection. Their levels of evidence differ greatly from one another.

It helps to think in three groups. Those correcting a functional problem (discomfort from the size of the inner labia, repair of support after childbirth) have defined findings and established techniques. For changes caused by the menopause, moisturisers, local oestrogen and hormone therapy come first. For injections aimed at sexual function there are explicit warnings from ACOG and the FDA.

Because whether a result is found acceptable depends not only on the anatomical finding but on the balance between that finding and the distress it causes. In people whose finding is small but who perceive it as very large, no result may feel sufficient. This assessment is meant to protect you from possible disappointment.

Because it is not rare: its frequency among people presenting for aesthetic surgery has been found to be 13.2%. The critical finding is that more than 90% of people with this condition are still not happy after surgery, and surgery can make the situation worse. The right course is psychological assessment and treatment first.

Yes. One of the source texts puts it this way: “A patient cannot consent to a flawed procedure.” If the examination findings do not support it, the procedure is not recommended — the scarring and risks would outweigh the change that could be achieved. This stands however keen the person may be.

For two reasons. First, the sources' own warning: images must not be presented in a way that suggests an “expected result”; healing and scarring vary from person to person. Second, the regulation in force: information about the cost of procedures, promotional announcements, accounts of other people's experiences, before-and-after images and product brands do not appear on this site.

A chaperone who is a health professional must always be present during the examination; this rule applies to female doctors and female patients too. A family member is not considered suitable for this role.

The main condition is the genitourinary syndrome of menopause (GSM): vaginal dryness, burning, irritation, reduced lubrication, laxity and pain during intercourse. These in turn can lead to vaginal infection, inflammation of the bladder and burning on passing urine.

Up to 50% of women who have gone through menopause experience at least one GSM complaint. After menopause, vaginal dryness is reported at 27–55%, pain during intercourse at 32–42% and urinary tract infection at 4–15%. So it is not rare — but because it is a difficult subject to talk about, it is seldom mentioned.

No, and this matters. The source lists moisturisers and lubricants, hormone therapy (if nothing stands in the way) and local oestrogen preparations as the conventional treatments. Hyaluronic acid, PRP and laser are among the tools that can be used. Laser is not described as replacing the others or as being superior to them.

Medical lasers work through a photo-thermal effect: the beam is absorbed by the tissue component able to absorb it (the chromophore) and heat is released. The target chromophore of the CO2 and Er:YAG lasers used in genital applications is water. In their fractional forms (which deliver the energy to spot areas) the energy is given not to the whole surface but to spot areas; the intact tissue in between acts as the source of healing.

Er:YAG has a wavelength of 2940 nm and acts mainly on the upper skin layer. The CO2 laser reaches both the upper and the middle skin layer; it is a stronger laser that works more deeply. Both have fractional forms.

This should be known clearly: the US Food and Drug Administration (FDA) and the American College of Obstetricians and Gynecologists (ACOG) have stated that there is no official approval for marketing energy-based devices for "vaginal rejuvenation" or for the treatment of menopausal complaints, urinary incontinence and sexual function problems, and that unsupervised use may carry a risk of burns, scarring and lasting pain. Clinical studies, on the other hand, report favourable results in GSM complaints. The picture is not one-sided — you need to know both sides when you decide.

The common protocol is 3 sessions 4–6 weeks apart; in some situations this may go up to 5 sessions. But it is not done once and finished: because the collagen production stimulated by the laser declines over time, a reminder session once a year is recommended, and depending on the state of the tissue the whole course may need to be repeated every two years. It is worth taking sustainability into account when you decide.

In the first 24 hours there may be mild redness, swelling and pinpoint bleeding; in the first 7–10 days mild stinging, itching and mild burning on passing urine. Discharge is expected: a light pink watery discharge for the first few days, then a heavy, clear discharge lasting 7–15 days — this is the result of the shedding surface cells, not a sign of infection. On the day of the procedure there may also be flu-like symptoms such as tiredness and a slight fever.

The procedure is done in the outpatient setting and usually does not require anaesthesia; a local numbing cream may be applied to the vaginal entrance. Afterwards, in the first 7–10 days, there may be mild stinging, soreness and mild burning on passing urine.

After a treatment inside the vagina it is recommended that you avoid intercourse for at least 7–10 days. For a Turkish bath, sauna, jacuzzi, bathtub, pool and sea you should also wait until healing is complete (7–10 days on average); wet and warm settings can increase the risk of infection.

Both are non-surgical methods that heat the tissue. The CO2 laser produces a controlled peeling of the surface; radiofrequency heats deeper tissue without peeling the surface. The FDA/ACOG warning applies to both, and neither replaces the usual treatments. Which one is suitable is assessed according to your complaints and examination findings.

So as not to suppress the process that starts the healing, paracetamol is recommended during this period rather than medicines such as ibuprofen or aspirin. Ask your doctor about the medicine you are going to use.

Active infection (vaginitis, urinary tract infection, thrush, herpes), an abnormal smear result within the past year, gynaecological cancer or bleeding whose cause has not been established, pregnancy and the first 3 months after birth, moderate to advanced prolapse (in which case the tears cannot be repaired with a laser and the only option is surgery), active inflammatory skin disease in the area, uncontrolled diabetes, use of blood thinners, use of oral isotretinoin within the past 12 months, and unrealistic expectations.

With tissue-removing (ablative) lasers the healing time may be longer, and there is a risk of darkening of colour and of scarring. For this reason cooling before and after the procedure is important. The procedure also needs to be carried out by an operator trained in the protective measures appropriate to the wavelength used.

Yes. The function of the outer lips is to surround and protect the other external genital structures. When they lose volume and flatten with age, the inner lips, the vagina and the urinary tract are left unprotected; this contributes to infection, inflammation of the bladder and discomfort. For details you can see the Labia Majora Filler page.

The application is referred to in promotional material by a brand name. Because the Turkish Regulation on Advertising and Information Activities in Health Services excludes the advertising of products and brands (Article 5/1-h) and popular-culture names (Article 5/1-c), the clinical name is used on this page. The content describes the same application.

PRP (platelet-rich plasma) is obtained from the person's own blood. The blood is separated by rapid spinning (centrifugation); first the red cells are separated, then the platelets are concentrated. Platelets contain growth factors able to stimulate mesenchymal stem cells (cells able to turn into different tissues); this is the reasoning on which the application rests.

The aim is to deliver the growth factors to the clitoral area and to the Skene glands around the urinary tract, in order to stimulate the formation of new nerves in the clitoris and an increase in the secretion-producing cells in the Skene glands. These are the intended mechanisms — it has not been shown in large studies that they actually occur.

The source gives no clear answer to this question: it states that it is very difficult to say how long it will take for new nerve formation or an increase in secretion, and therefore a change in sexual satisfaction, to appear.

No. According to the report of the authors who perform the method, at 3 months about 10% of patients reported no improvement at all in their sexual satisfaction. The source also states plainly that this datum is unpublished.

It is limited. In the source's own words, follow-up studies with larger numbers of patients and over longer periods are needed for the results to be established more soundly. In addition, whether one of the areas the application targets — the G-spot — is a real anatomical structure present in every woman is disputed in the literature; the same literature contains reviews describing it as "a modern gynaecologic myth".

The source states that the legislation governing PRP injection differs from country to country and that in some places it is not permitted in the outpatient setting. You need to consult your doctor about your own situation and the current legislation.

The first step is not to choose a procedure but to have the cause of the complaint assessed. There may be genitourinary syndrome due to menopause, vaginal dryness, hormonal changes or other conditions causing pain — most of these have well-established treatments. After assessment, the appropriate course is decided together.

No. In 2018 the FDA announced that it had not approved the safety and effectiveness of energy-based devices for this purpose; ACOG also stated that cosmetic vaginal procedures are not based on adequate evidence. There are studies reporting favourable results, but specialist societies say broader and longer-term studies are needed.

The two work differently. The laser produces controlled peeling at the tissue surface, reaches a higher temperature, and because it depends on the tissue components that absorb light it carries a risk of burns in darker skin types. Radiofrequency does not peel the surface, goes deeper and works at a lower temperature. Which is suitable depends on the complaint, the state of the tissue and the person's other health problems; the evidence for both is limited in a similar way.

The number of sessions varies with the device used: in some systems three sessions 4–6 weeks apart, in others a single session. The main part of the effect does not appear immediately; it begins to be felt after the third week and continues to develop over 3–4 months.

No. Because the device produces an electromagnetic current, it is not applied to those with a pacemaker or another implanted electronic device. An intrauterine device (coil), on the other hand, is not an obstacle; it does not need to be removed.

The type and degree of the leakage need to be established first. Pelvic floor exercises, for which the evidence is stronger, come first. Radiofrequency may come up only in mild cases and after the other options have been assessed; in second-degree prolapse and above it is inadequate, and in that situation surgical repair is recommended.

No, it is definitely not. The sources make this distinction explicitly: clitoral hood reduction has nothing whatsoever to do with female genital cutting, infibulation, cultural or ceremonial practices, or genital piercing. Nor is it a procedure performed on the clitoris — only the excess of the hood skin covering it is reduced.

It can be done, but that is uncommon. According to the sources, hood reduction is rarely performed as a separate procedure; it is most often planned together with inner lip reduction. One reason is aesthetic balance: if the hood is not corrected while the inner lips are reduced, the clitoral area may look disproportionately prominent.

It is necessary to be honest here: according to the sources its functional results are not fully known and its effect on sexual function has not been established. For this reason it is regarded as predominantly a procedure to do with appearance. One exception: if the clitoris is completely covered by an excessively thick hood, this can prevent it from receiving adequate stimulation.

The source gives this list plainly: those expecting orgasm only in a particular position or with no other stimulation at all; those who are currently content and have no examination findings; those with reduced sexual desire (if the cause is psychological or hormonal, surgery does not help); those with pain in the clitoris; those seeking multiple orgasms — such a result cannot be promised.

In these two situations the likelihood of the problem recurring is high. With adhesions due to menopause, the problem recurs if the hormonal situation is not corrected. With scar tissue due to lichen sclerosus, the condition recurs within a few months almost every time. For this reason the underlying condition needs to be addressed first.

This is the most important technical concern of the procedure. The clitoris contains about 8,000 sensory nerves and the under-surface of the hood is also rich in nerves. For this reason surgery does not go down to the deep plane; the dissection is kept in the superficial layer. Aggressive incisions can lead to lasting loss of sensation or to pain during intercourse.

Those with unrealistic expectations, those with untreated psychosexual problems, those with an active infection or inflammatory disease of the external genital area, those with a clotting disorder, and those who smoke. ACOG also recommends that in people presenting with a complaint of sexual dissatisfaction, the psychosexual situation be assessed before surgery.

It is recommended that the excess of the hood be assessed standing. Tissue thickness, excess folds and symmetry are examined; the clitoris is examined by hand and its size assessed; adhesions, narrowing, scarring and pain are recorded. Previous genital surgery is always asked about. The appearance of the hood varies a great deal from person to person and is mostly not symmetrical — for this reason there is no definition of an "ideal" appearance.

No. There is broad agreement in the scientific literature: the assumption that virginity can be identified by examination of the external genitalia is a myth. In one study, 19% of sexually active adolescent girls had no tear, notch or cleft at all in the hymen.

No. It is reported that 40–50% of women from different cultural backgrounds have no blood loss at all at first intercourse. The absence of bleeding is something to be expected.

Yes. The insertion of objects such as tampons, strenuous sporting activity, surgical procedures and falling onto a sharp object are among the reasons listed. The elasticity of the structure also varies from person to person — in some situations it may be elastic enough to allow intercourse without tearing.

Looked at on purely medical grounds, no — the sources state that the procedure is not medically indicated, provides no medical benefit, and that the balance of benefit against risk is not in its favour. Given the World Health Organization's definition of health as "a state of physical, mental and social well-being", it is also noted that a health benefit can be spoken of.

The Royal College of Obstetricians and Gynaecologists (RCOG) strongly opposes both virginity testing and hymenoplasty; it states that neither is medically necessary under any circumstances and that both reinforce beliefs that wrongly attach a value to women on the basis of their sexual history. RCOG also emphasises that a clinical procedure should not be performed in order to protect someone, and that people at risk of violence should be referred to the relevant agencies.

You should have counselling — and there are data showing how decisive this is: of the 82 women who applied for hymenoplasty, only 24 (29%) decided to go ahead with surgery after detailed counselling. For most of them, the information and self-confidence gained in counselling meant they were able to give up the operation they had initially seen as the only solution.

Wound separation, infection, scarring, distortion of the shape of the vaginal entrance and over-narrowing of the entrance are the risks listed. Over-narrowing may lead to obstruction of the outflow of menstrual blood and to pain during intercourse. In the largest series of 518 people, bleeding requiring surgery in the early period was reported at 0.5%; in the same series no complication related to childbirth was reported.

No — no technique can predict or promise this. There is no accepted surgical standard aimed at restoring the bleeding property of the hymen. While the rate of reporting bleeding after the procedure with one method is given as about 69%, the rate of recalling bleeding at first intercourse among people who have had no procedure at all is only 34%.

Swelling and bruising are to be expected in the first 1–2 days. Desk work can usually be resumed after 3–5 days. For sex, tampon use and heavy sport it is necessary to wait at least 4–6 weeks. The stitches dissolve on their own.

The options are local anaesthetic, local anaesthetic with sedation, or general anaesthetic. The procedure takes about an hour and is a day procedure; you go home the same day.

No. Once healing is complete, it does not prevent pregnancy or a vaginal birth. However, later births may change the shape of the inner labia again.

Because the genital tissues continue to develop until the age of 18, if there is no serious functional problem it is recommended that information is given first and that surgery is postponed until after the age of 18.

It is considered where the inner labia extend outwards, are thickened by mucosa or submucosal tissue, have excess length front to back, or have a ruffled appearance. In the sources it is described as the most frequently performed female genital aesthetic procedure. The decision, however, rests on examination findings — the request alone is not sufficient.

In edge trim, tissue is taken along the free edge of the labium. In the wedge technique a full-thickness slice is taken from the most protruding part. The wedge technique's notable feature is that it preserves the natural edge of the labium, leaves a shorter scar and produces less sensitivity in the scar area. It also preserves the important nerves and maintains the arterial blood supply.

In labia thickened by excess submucosal tissue, edge trim is difficult: thinning the tissue would require removing almost the whole labium. The result is remnants that are very short and have lost their natural edge. The wedge technique, by contrast, allows the amount of submucosal tissue removed to be adjusted.

The wedge technique is usually performed under local anaesthetic and most often takes less than an hour. People are reported to tolerate the procedure well under these conditions.

Notching of the edge, separation of the stitches and a collection of blood are the complications listed, and they are uncommon. Even so, as with any surgical procedure, healing and scarring vary from person to person; possible outcomes should therefore be discussed as a range.

Yes, that is possible. The source states plainly that labiaplasty should not be performed on people whose inner labia are already small on examination: the scarring and risks would outweigh the change in appearance that could be achieved. This assessment stands however keen the person may be.

Because whether a result is found acceptable depends not only on the anatomical finding but on the balance between finding and distress. In people whose finding is small but who perceive it as very large, no result may feel sufficient. This assessment is part of the procedure and is meant to protect you from possible disappointment.

Body dysmorphic disorder is when a person perceives an aspect of their appearance as ugly, although the appearance is usually ordinary. Its frequency among people presenting for aesthetic surgery has been found to be 13.2% — so it is not rare. What matters is this: more than 90% of people with this condition are still not happy after surgery, and surgery may make the situation worse. The right course is psychological assessment and treatment first.

Yes. A chaperone who is a health professional must always be present during the examination; this rule applies to female doctors and female patients too. A family member is not considered suitable for this role.

It is a repair operation on the area between the vaginal entrance and the anus (the perineum). The superficial muscles that separated in the midline during childbirth are rejoined, and a problematic scar from the cut made at delivery, along with excess skin and mucosa (the thin tissue lining the inside of the vagina), is removed. The deep part of the vaginal canal is not operated on.

No. Perineoplasty covers only the vaginal entrance and the perineum. Vaginoplasty narrows the vaginal canal along its length by repairing the deep supporting tissue and muscles. If the laxity is also deeper in the canal, perineoplasty alone may not relieve the complaint; when needed, the two procedures can be done together.

A painful, irregular or raised scar from the cut made at delivery (episiotomy) is one of the defined reasons for perineoplasty. However, pain during intercourse is not always caused by scar tissue; vaginismus (involuntary tightening of the muscles around the vagina) or excessive tension in the pelvic floor muscles can also cause pain. This distinction is made at the examination.

Planning it at least 3–6 months after childbirth is recommended, so that the tissues can heal, the swelling can go down and the discharge after childbirth (lochia) can stop.

If you are planning another vaginal birth in the near future, postponing the operation until after all planned births is recommended. The sources state that in women who have had this operation, a later vaginal birth can undo the repair, and caesarean section is recommended. The decision about how to give birth is made during pregnancy together with your doctor.

When perineoplasty is done on its own it takes about 30–45 minutes. Local anaesthetic (numbing of the area), local anaesthetic with sedation (a light sleep-like state produced by medicine) or general anaesthetic (being fully asleep) can be used. It is a day procedure; you usually go home the same day.

Most women can return to desk work within 3–7 days. Wait at least 6–8 weeks before intercourse and using tampons. Wait 4 weeks for heavy exercise, and at least 6–8 weeks for activities that put pressure on the perineum, such as cycling or horse riding. The stitches dissolve on their own.

The listed risks are painful intercourse due to over-narrowing, wound separation, infection, bleeding and haematoma (a collection of blood under the tissue), and small sacs forming later on. To prevent wound separation, it is important in the early period to avoid constipation and spreading the legs too wide.

There are studies reporting improvement; however, a large share of them are based on case series (reports of groups of patients followed at a single centre) and on expert experience. Randomised controlled studies (in which participants are assigned to groups by lot) are limited. As reported in the sources, ACOG does not regard procedures done only for appearance as a medical necessity; it treats repair done for a functional reason separately.

First the cause is identified. In mild cases pelvic floor (Kegel) exercises done regularly for at least 3 months can improve sensation and bladder control. If childbirth has caused clear muscle separation or prolapse, the lasting solution is surgical vaginal tightening (vaginoplasty).

Pelvic floor exercises are the first non-surgical step. Devices such as laser and radiofrequency are promoted for this purpose, but their long-term effect has not been shown; in 2018 the FDA warned against their use for "vaginal rejuvenation". They do not repair separated muscles or prolapse.

No. The vagina is elastic and returns to its usual state after intercourse. The real causes of looseness are vaginal birth, ageing and tissue changes after menopause.

No — and the source explicitly criticises that idea. Narrowing simply by cutting and stitching skin creates an unnatural band of skin and leads to pain during intercourse. Narrowing with sutures may give a result in terms of appearance but cannot rebuild the perineum. The real aim is to repair the muscles and the supporting structures.

The main aim is to rebuild the perineal body — the point where the perineal muscles and the anal sphincter meet. Because pressure inside the abdomen stays high for a long time in pregnancy and vaginal birth, these muscles weaken, shift and descend; the operation aims to bring them back together.

Yes, this is a common reason. Removing tender scars remaining after repair of the cut made at delivery (episiotomy) is one of the defined uses of perineoplasty.

It is postponed in women planning a vaginal birth. Active infection and undiagnosed skin conditions of the external genital area must be treated first. Vulvodynia (persistent pain in the external genital area) is a relative contraindication — genital surgery may make it worse. If there are problems with bowel movements, the relevant specialist's opinion is obtained first.

Because the outcome depends on function, not only on appearance. Bladder, bowel and pelvic floor function are assessed; open questions are asked about sexual life, comfort, laxity and lubrication. The examination is done both gynaecologically and standing, with coughing and bearing down — because the true degree of prolapse is only seen on straining.

This is deliberately avoided. Over-narrowing leads to a tight introitus and pain during intercourse. The principle followed is "measure twice, cut once": if there is any doubt about how much tissue to remove, removing less is preferred. If a tight introitus does occur it is managed first with dilators and massage, and if that is not enough, with a small release procedure.

Rinse the perineum gently with soap and water four times a day and after every visit to the toilet; do not take sitting baths. Avoid heavy physical activity for 4 weeks, and tampons and intercourse for 6 weeks. Medicine to prevent constipation is given. Follow-up is at day 1, week 1, week 6 and month 3.

Delayed healing and superficial separation are the most common and do not require surgical repair. With deep separation the edges need to be refreshed and rejoined; if there is too much tension, letting the wound heal on its own is preferred. Swelling settles with cold application.