EffIcacy of Intracavitary Manual Lymphatic Drainage as a Treatment for Vaginal Stenosis in Women With Sequelae of Post-Breast Cancer Treatment

Experimental group: Intracavitary Manual Lymphatic Drainage (IMLD) treatment. The intervention in the experimental group will be carried out by a specialised physiotherapist. The treatment will consist of IMLD, one session per week lasting 20 minutes, for 8 weeks. The patient will be placed in supine decubitus with hip flexion of 90o and knee flexion greater than 90o in both lower limbs. If the protocol is performed on a gynaecological examination couch, the patient is placed in the lithotomy position, the usual position for gynaecological examination, in which the patient is in the supine decubitus position, with 90o flexion of both coxofemoral joints and the knees, maintaining abduction of both lower limbs, with the possibility of support on leg supports or a heel stirrup, which allows the lower limbs to relax. The physiotherapist is positioned on one side of the couch or in front of the patient in the case of the gynaecological examination couch. The physiotherapist places his hand in neutral wrist flexion-extension and introduces his index finger and middle finger into the vaginal cavity, after lubrication with a gel, placing his forearm in neutral pronation-supination position. Once the fingers have been inserted approximately 5 centimetres into the vaginal cavity, a slow pronation movement of the forearm is performed. With this prior positioning of the patient and the physiotherapist, we begin the technique, the time for manual intracavitary and external genital lymphatic drainage will be 20 minutes. Technique: The IMLD technique is an adaptation of the resorption manoeuvre described by Leduc(138) to the anatomical area of application. The technique is performed with the index and middle finger, starting the manoeuvre from the proximal phalanx and pushing towards the distal phalanx, in the form of a blotting tampon. The approach areas are the posterior wall of the vagina, and both lateral walls, repeating the manoeuvre on each wall several times. The purpose of this manoeuvre is to reduce oedema and vulvar congestion, draining the lymphatic load in the direction of the inguinal and external iliac nodes. Once the intracavitary treatment has been completed, we will perform a Manual Lymphatic Drainage (MLD) on the external genitalia, supra pubic and inguinal areas, carrying out the following manoeuvres: - Vodder's fixed circles - Classic Leduc resorption To assess adherence to the intervention, several strategies will be employed. Attendance will be recorded at each treatment session, and participants will be asked to sign a session log. In addition, medical records will be reviewed to verify relevant clinical history and continuity of care. Personalized follow-up will be conducted, either in person or by phone, to reinforce adherence and identify any potential barriers. Any incidents, missed sessions, or changes in the treatment plan will be documented by the treating physiotherapist. The technique used will be Intracavitary IMLD, specifically applied via the vaginal route. The maneuver will consist of gentle, rhythmic, and slow manual mobilizations within the vaginal canal, following the physiological direction of lymphatic flow toward the inguinal lymph nodes. The intervention will be performed exclusively by physiotherapists specialized in pelvic floor rehabilitation and lymphatic drainage. The specific application of the technique, including intensity, duration, and frequency, will be tailored to each patient based on clinical evaluation, the degree of vaginal stenosis, and always under medical indication and consent, in coordination with the oncology and gynecology teams.