Fractional CO2 laser treatment for vaginal laxity: A preclinical study

[Vaginal laxity: Semiology, diagnosis and treatments]

OBJECTIVES

Vaginal laxity concerns 24 to 38% of women but it's still poorly understood and studied. The objective of this study is to do an inventory of current scientific knowledge about its definition, its diagnostic criteria, and treatments.

METHODS

We conducted a non systematic review of literature including original articles in French and English about the definition, diagnostic criteria and treatments of vaginal laxity using data bases such as Cochrane, Embase, Medline, PubMed et Science Direct.

RESULTS

It is a feeling of excessive looseness that can alter the quality of sexual intercourses. The main risk factor is vaginal delivery. The feeling of vaginal laxity appears to be linked to an excessive distensibility of the levator ani muscle that can be evaluated during physical examination by the measure of the genital hiatus and the perineal body (GH and PB measures from the POP-Q classification) during vasalva or by the measure of genital hiatus area by translabial sonography during valsalva. Although pelvic muscle training is currently prescribed as a first line treatment, data are limited to confirm its effectiveness in this affection. Colpoperineorraphy with levator ani myorraphy which was mostly evaluated in case of genital prolapse is associated with a high success rate but is at risk of dyspareunia. New nonsurgical treatments such as radiofrequency and vaginal laser seems to lead to lower success rate than surgical treatments but they are less invasive. Their effectiveness and long-term effects are still unknown which restrict their application in this condition.

CONCLUSION

Vaginal laxity is a frequent condition that impacts on the quality of life and sexual function. Further studies should be conducted to better understand its physiopathology and the optimal treatment.

Treatment of Vulvovaginal Laxity by Electroporation: The Jett Plasma Medical for Her II Study

INTRODUCTION

Vaginal laxity is a widespread and undertreated medical condition associated especially with vaginal parity.

AIM

To evaluate the efficacy and safety of electroporation therapy treatment of vulvovaginal laxity by the Jett Plasma for Her II device.

METHODS

The Jett Plasma for Her II Study is a multicentric, prospective, randomized, single-blinded, and controlled study. Women presenting with vaginal laxity were randomized to receive electroporation therapy delivered to the vaginal tissue (active-82 patients) vs. therapy with zero intensity (placebo-9 patients).

RESULTS

A total of 91 subjects whose average age was 48.69 ± 10.89 were included. Due to the results of a one-way analysis of variance, it may be concluded that in the case of the vaginal laxity questionnaire (VLQ), there is a statistically significant difference between actively treated patients and the placebo group (F1,574 = 46.91; p < 0.001). In the case of the female sexual function index (FSFI), a one-way ANOVA test also showed a statistically significant difference between the actively treated patients and the placebo group (F1,278 = 7.97; p = 0.005). In the case of the incontinence impact questionnaire-7 (IIQ-7), a one-way ANOVA test showed a statistically significant difference between the actively treated patients and the placebo group (F1,384 = 15.51; p < 0.001). It confirms that improvement of vaginal laxity is conjoined with benefits in symptoms of urinary incontinence. Biopsy performed after the end of the treatment shows an increase in the vaginal mucosa thickness by an average of 100.04% in the active group. The treatment was well tolerated with no adverse events. No topical anesthetics were required.

CONCLUSIONS

Treatments of vulvovaginal laxity by electroporation therapy achieved significant and sustainable 12-month effectiveness. Responses to the questionnaires also suggest subjective improvement in self-reported sexual function, incontinence, sexual satisfaction, and urogenital distress.

Vaginal epithelial histology before and after fractional CO2 laser in postmenopausal women: a double-blind, sham-controlled randomized trial

BACKGROUND

Postmenopausal vaginal symptoms affect over 60% of women and may substantially impact a woman's quality of life. Since 2012, fractional CO2 laser has been suggested as a treatment for this indication. Structural assessment of vaginal epithelium using microscopic biopsy examination has been used as a primary outcome measure and surrogate determinant of success of vaginal laser in previous clinical studies.

OBJECTIVE

This study aimed to report the effects of laser compared with sham treatment on human vaginal epithelium from postmenopausal women using microscopic examination of tissue biopsies.

STUDY DESIGN

This single-center double-blind, sham-controlled randomized controlled trial was performed in a tertiary hospital in Sydney, Australia. A total of 49 postmenopausal women who were symptomatic of at least 1 vaginal symptom (vaginal dryness, burning, itching; dyspareunia; or dryness) were randomized to either laser or sham treatment. For this nested histologic study, participants had a pre- and post-treatment vaginal wall biopsy collected. Biopsy samples were analyzed by 3 independent specialist gynecologic pathologists and categorized as Type 1 (well-estrogenized), 2 (poorly estrogenized), or 3 (combination) mucosae. Other outcomes assessed included symptom severity (visual analog scale for symptoms including most bothersome symptom, and Vulvovaginal Symptom Questionnaire) and Vaginal Health Index. Prespecified secondary analyses of data were performed. Categorical data were analyzed using the Pearson chi-square test (or Fisher exact test if <5 in any category) or related-samples McNemar test for paired nonparametric data. Nonparametric, continuous variables were assessed using Wilcoxon signed-rank test or Mann-Whitney U test, and parametric variables with t test or 1-way analysis of variance as appropriate. All analyses were performed using SPSS software version 26.0 (IBM Corp, Armonk, NY).

RESULTS

There was no significant difference in microscopic features of vaginal epithelium following laser or sham treatment (P=.20). Further subgroup analyses of age, menopause type, duration of reproductive life, time since menopause and BMI, still demonstrated no significant difference between laser and sham groups in histological category of vaginal epithelium. Microscopic features at pre-treatment vaginal biopsy were Type 1 in 27% (13/49). There was no significant difference in VAS score for overall vaginal symptom between those classified as Type 1 vs. Type 2/3 (VAS score overall: Type 1 vs. Type 2/3, (48.1 [95% CI 27.0, 69.2] vs. 61.5 [95% CI 49.8, 73.3]; P=.166).

CONCLUSION

Data from this double-blind, sham-controlled randomized controlled trial demonstrate that fractional CO2 laser and sham treatment have a comparable histologic effect on vaginal tissue that is not significantly different. Fractional CO2 laser is not significantly different from sham treatment and should not be recommended for clinical use for postmenopausal vaginal symptoms.

Fractional carbon dioxide vaginal laser treatment of stress urinary incontinence: Remodeling of vaginal tissues and improving pelvic floor structures

OBJECTIVE

To demonstrate remodeling of vaginal biomechanical and physiological properties using vaginal fractional carbon dioxide (CO₂ ) laser treatment of stress urinary incontinence (SUI).

MATERIALS AND METHODS

The study cohort included 26 patients with SUI between October 2019 and November 2020. Patients were treated with two sessions of FemTouch vaginal fractional CO₂ laser with a one-month interval. Three subjective assessments were administered to all patients: female sexual function index (FSFI), vaginal health index score (VHIS), and international consultation on incontinence questionnaire-short form (ICIQ-SF). Vaginal tissue biopsies were taken from 6 patients before treatment and one-month after the final treatment. Vaginal tactile imaging (VTI) measurements, ultrasonography, and magnetic resonance imaging (MRI) scans were performed before treatment and 10-12-months after treatment in 10, 9, and 6 patients, respectively.

RESULTS

The average age of the cohort was 39.5 ± 12.0 years. The overall scores for FSFI, VHIS, and ICIQ-SF significantly improved in patients after each treatment sessions as compared with baseline scores. VTI showed significantly increased pressure resistance of both the anterior and posterior vaginal walls after treatment. Ultrasonography showed significant decreases in bladder neck mobility and urethrovesical angle during the Valsalva maneuver after treatment. MRI scans showed significant decreases in the length of the vaginal anterior wall after treatment. Histological examination confirmed that the laser treatment led to a thicker stratified squamous epithelium layer as compared to the baseline.

CONCLUSIONS

Our results demonstrated that vaginal fractional CO₂ laser treatment can restore vaginal biomechanical and physiological properties by increasing vaginal tightening and improving pelvic floor structures.

Fractional Carbon Dioxide Laser Improves Vaginal Laxity via Remodeling of Vaginal Tissues in Asian Women

Background: Vaginal laxity (VL) is characterized by the relaxing of the vaginal wall that affects the quality of life and sexual function of patients. The current management of VL such as Kegel exercises and topical or systemic hormonal replacement results in unsatisfactory outcomes; thus, novel modalities are needed to improve the efficacy. Vaginal fractional carbon dioxide (CO2) laser treatment has shown growing applications for the treatment of VL, but results show nonconformities due to the lack of objective evaluations. In this study, we aimed to validate the clinical efficacy and biophysical benefits of fractional CO2 laser treatment for VL patients with the incorporation of objective approaches. Methods: This is a descriptive study without controls. A total of 29 patients were enrolled and treated with two sessions of FemTouch vaginal fractional CO2 laser, with a one-month interval between sessions. Both subjective and objective measurements, including female sexual function index (FSFI), vaginal health index score (VHIS), vaginal tactile imaging (VTI), and histology were used to validate the clinical efficacy and biophysical benefits after treatment. Results: The overall FSFI scores and VHIS scores after the first and second treatment sessions were significantly higher than the baseline scores (p < 0.01, n = 29). VTI measurements showed a significant increase in maximal pressure resistance (kPa) of both the anterior and posterior vaginal walls at a 10−12-month post-treatment visit compared with pre-treatment controls (p < 0.001; n = 16). Histological examination showed that laser treatment led to increases in the thickness of the stratified squamous epithelium layer and density of connective tissues in the lamina propria. Conclusions: Fractional CO2 vaginal laser treatment can improve both vaginal health and sexual function and restore vaginal biomechanical properties by increasing vaginal tissue tightening and improving vaginal tissue integrity in Asian women. Our data support that fractional CO2 vaginal laser is a valid treatment modality for VL.

Vaginal laser therapy for gynecologic conditions: re-examining the controversy and where do we go from here

Despite significant controversy, vaginal laser therapy continues to be used for treatment of many gynecologic and pelvic conditions including vaginal atrophy, vaginal dryness, dyspareunia, urinary incontinence and pelvic pain. This commentary reviews the controversy surrounding vaginal laser therapy and summarizes the important distinction between ablative and non-ablative vaginal lasers. While much research is still needed, the article describes what is important for healthcare professionals to know before making the decision to integrate this technology into their clinical practice.

Vaginal collagen I and III changes after carbon dioxide laser application in postmenopausal women with the genitourinary syndrome: a pilot study

OBJECTIVE

The aim of the study was to evaluate the clinical response and collagen remodeling in the vaginal wall after three sessions of carbon dioxide (CO₂) laser application.

METHODS

Fourteen postmenopausal women with vulvovaginal atrophy, aged 45-65 years and sexually active, were evaluated with clinical questionnaires, gynecological examinations and histological techniques before and after 20 weeks of treatment (ClinicalTrials.gov NCT03939078). Treatment consisted of 3-monthly sessions of the CO₂ laser. Clinical questionnaires included the Vaginal Health Index, the Female Sexual Function Index and the International Consultation on Incontinence Questionnaires Short Form. Biopsies were taken from the lateral vaginal wall at week 0 (left wall) and week 20 (right wall). Tissue samples were stained with hematoxylin and eosin, Periodic Acid-Schiff, Picrosirius Red Stain and Orcein dyes. Immunohistochemical study was used to quantify collagens I and III in the samples.

RESULTS

The mean age was 54.4 ± 4.5 years, and the average time of amenorrhea was 7.6 ± 5.1 years. The Female Sexual Function Index and the Vaginal Health Index Score values increased while the International Consultation on Incontinence Questionnaire Short Form score decreased after the programmed treatment. There was no significant change in vaginal pH. Histological studies showed increases in the total and superficial epithelial cell layers, and type III collagen fibers (from 10.86 ± 7.66 to 16.87 ± 3.96, p < 0.05), and immunohistochemical studies confirmed the significant increase in collagen III.

CONCLUSION

Histological findings revealed epithelial atrophy reversal and collagen remodeling of the vaginal wall. Immunohistochemical analysis showed an increase in collagen type III fibers.

Fractional CO2 laser treatment effect on cervicovaginal lavage zinc and copper levels: a prospective cohort study

BACKGROUND

The basic principle of vaginal laser therapy is the rejuvenation of the affected tissue. Zinc and copper are essential nutritional trace elements and have a key role in connective tissue homeostasis. We aimed to investigate the effect of vaginal, fractional CO₂ laser treatment on cervicovaginal lavage (CVL) zinc and copper levels.

METHODS

Twenty-nine postmenopausal women with symptoms of vaginal dryness were enrolled in our prospective cohort study. Three treatments with MonaLisa Touch CO₂ laser system were performed four weeks apart. At each treatment CVL was collected, Vaginal Health Index (VHI) was obtained, and Visual Analog Scale (VAS) for vaginal dryness was assigned by patients. Zinc and copper concentrations were measured with optical emission spectrometry before each treatment and six weeks after the 3rd treatment.

RESULTS

The VHI scores significantly improved after each laser treatment (mean ± SD VHI score, 13.03 ± 4.49 before vs. 15.55 ± 4.35 after the 1st, 17.79 ± 4.57 after the 2nd and 19.38 ± 4.39 after the 3rd treatment, P < 0.01). Similarly, VAS scores reflected improvement (mean ± SD VAS score 6.59 ± 2.86 before vs. 4.17 ± 2.86 after the 1st, 2.45 ± 2.43 after the 2nd and 1.41 ± 1.94 after the 3rd treatment, P < 0.01). CVL zinc levels were significantly higher compared to copper levels (0.06 ± 0.04 vs. 0.006 ± 0.006 mg/L, P < 0.01) at baseline. While copper levels remained the same through treatments, the CVL zinc level was significantly higher after the second laser treatment compared to the baseline.

CONCLUSIONS

Fractional CO₂ laser treatment of the vagina impacts CVL zinc and copper levels differently. While CVL copper levels were not different after each laser treatment, zinc levels were significantly higher after the second treatment before returning to baseline values.

Vaginal Fractional Carbon Dioxide Laser Treatment and Changes in Vaginal Biomechanical Parameters

BACKGROUND AND OBJECTIVES

Vaginal fractional carbon dioxide (CO₂ ) laser treatment has emerged in the past two decades as a non-surgical option for vaginal tightening. Mounting evidence supports the effectiveness and safety of this treatment for female sexual dysfunction. A newly developed vaginal tactile imaging (VTI) technique accurately evaluates the biomechanical parameters of the female pelvic floor and vagina, including tissue elasticity, pelvic support, and pelvic muscle function in high definition. In the current study, we evaluated changes in objective biomechanical parameters using VTI, following vaginal CO₂ laser treatment for vaginal tightening and sexual dysfunction.

STUDY DESIGN/MATERIALS AND METHODS

We conducted a prospective cohort between June 2018 and January 2020. Inclusion criteria were vaginal looseness, decreased local sensation during sexual intercourse, and sexual dysfunction. All the participants were treated with a vaginal carbon dioxide laser. They underwent a gynecological evaluation based on the Vaginal Health Index (VHI) and sexual function assessment according to the Female Sexual Function Index (FSFI). Vaginal biomechanical parameters were assessed by VTI. Initial evaluations were performed at the pre-treatment consult visit, 1 week prior to the first treatment and at a 6-month post-treatment follow-up visit.

RESULTS

Twenty-five women were included in the final analysis. Compared with baseline, the post-treatment mean scores for vaginal elasticity and tightening were higher (54.8 ± 5.2 vs. 41.5 ± 6.3, P = 0.0027 and 1.97 ± 0.25 vs. 1.32 ± 0.31, P = 0.0014, respectively). Post-treatment increases were demonstrated in pelvic muscle contraction strength (25.9 ± 3.5 vs. 16.5 ± 4.2, P = 0.0011) and in reflex pelvic muscle contraction (2.93 ± 0.44 vs. 2.12 ± 0.47, P = 0.0022); the mean FSFI and VHI scores were higher following treatment (28.47 ± 1.73 vs. 21.12 ± 1.58, P = 0.036 and 19.15 ± 1.27 vs. 11.6 ± 0.97, P = 0.0032).

CONCLUSIONS

The quantification of vaginal biomechanical parameters using VTI technology offers objective evidence of the beneficial effect of vaginal CO₂ laser treatment. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

The efficacy of erbium-doped yttrium aluminum garnet (Er:YAG) laser in the treatment of decreased sexual sensation: a randomized, placebo-controlled trial

Vaginal laxity, a common cause of decreased sexual sensation, is a common problem affecting the quality of life of women worldwide. Recently, lasers and energy-based devices (EBDs) have been applied in the treatment of this condition. The aim of this study was to compare the efficacy and safety of Er:YAG laser and placebo in treating decreased sexual sensation in Asians. Forty-two patients with decreased sexual sensation were randomized into 2 groups: intervention (laser treatment) and control (placebo treatment). Both groups received two treatments, at 1-month interval. Subjective and objective evaluations were done at baseline, 1-, 3-, and 6-month follow-ups. Pain score and adverse effects were also recorded. In the laser group, there was significant improvement in the patients' vaginal tightness satisfaction at 1- and 3-month follow-ups (P = 0.002 and 0.004) and also in the patients' overall satisfaction at 1- and 3-month follow-ups (P = 0.003 and 0.001). Pelvic floor muscle contraction was significantly better in the laser group after the first treatment (P = 0.043). No serious adverse effects were noted. Er:YAG laser provides improvement of sexual sensation for an average of 3 months following treatment. Mild and transient adverse effects such as leukorrhea, dryness, dysuria, vaginal itching, and spot bleeding were noted in the laser group, and these were not significantly different from the control group.

Patient reported vaginal laxity, sexual function and stress incontinence improvement following vaginal rejuvenation with fractional carbon dioxide laser

In this study, we have evaluated the efficiency of fractional carbon dioxide laser in the treatment of vaginal laxity and urinary incontinence. Thirty patients with vaginal laxity, sexual dysfunction and urinary incontinence complaints were treated with fractional carbon dioxide laser. Results were evaluated with patient questionnaires relating to comfort during the procedure and general satisfaction following the procedure. In the survey regarding comfort during the procedure, 90% (n:27) of the patients reported that they were comfortable during the procedure. The survey on the level of general satisfaction six months following the procedure revealed high-moderate level of satisfaction in 86% (n:26) of the patients. 66% (n:20) of the patients reported improved vaginal tightness and 63% (n:19) of the patients reported improvement in the quality of their sexual activity. Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire(PISQ-12) scores six months following the procedure were not significantly different when compared to the scores prior to the procedure. The average of Questionnaire for Urinary Incontinence Diagnosis(QUID) score prior to the procedure and six months following the procedure was 7.5 and 0.9 respectively (p < 0.05). Fractional carbon dioxide laser treatment results in high level of satisfaction and improvement in vaginal laxity, sexual dysfunction and urinary incontinence symptoms in patients with genitourinary syndrome.

Treating Vaginal Laxity Using Nonablative Er:YAG Laser: A Retrospective Case Series of Patients From 2.5 Years of Clinical Practice

INTRODUCTION

Vaginal laxity drastically impairs women's quality of life, suggesting there is a need for effective noninvasive treatments.

AIM

The aim was to retrospectively assess the effectiveness and safety of a nonablative Er:YAG IntimaLase laser procedure for vaginal laxity in patients treated in our clinical practice during a 2.5-year period.

METHODS

Laser treatment for vaginal laxity was performed using an intravaginal nonablative Er:YAG laser. Effectiveness was assessed using a Patient Satisfaction Questionnaire and also by independent evaluation of before and after treatment photographs of the patients' introitus. The safety and tolerability of the procedure was monitored in all patients.

MAIN OUTCOME MEASURE

The study showed an improvement of sexual gratification and improvement of vaginal tightness, as assessed by patients. The tightness of the introitus was also improved, as assessed by independent evaluators.

RESULTS

As assessed by the Patient Satisfaction Questionnaire, we show that 92.7% of patients experienced improvement of sexual gratification after IntimaLase laser treatment. The results of the visual evaluation of the grade of laxity improvement in the introitus area, when open introitus photos were evaluated, show that 69% (n = 20/29) of patients had an improvement of laxity. Nonablative Er:YAG treatment seems to be an effective and safe treatment for vaginal laxity. As it is a noninvasive procedure, it should be considered before any vaginoplasty surgery. The study included all the patients treated in clinical practice and observed very few adverse effects. The results were comparable with other published data. Because it is a retrospective study, there is a lack of a control group.

CONCLUSION

The results have confirmed that patients suffering from vaginal laxity can be effectively treated using the nonablative Er:YAG IntimaLase procedure without adverse effects. Mitsuyuki M, Štok U, Hreljac I. Treating Vaginal Laxity Using Nonablative Er:YAG Laser: A Retrospective Case Series of Patients From 2.5 Years of Clinical Practice. Sex Med 2020;8:265-273.

The Rationale for Photobiomodulation Therapy of Vaginal Tissue for Treatment of Genitourinary Syndrome of Menopause: An Analysis of Its Mechanism of Action, and Current Clinical Outcomes

Objective: Light, particularly in the visible to far-infrared spectrum, has been applied to the female genital tract with lasers and other devices for nearly 50 years. These have included procedures on both normal and neoplastic tissues, management of condylomata, endometriosis, and menometrorrhagia, and, more recently, a number of fractional laser devices have been applied for the management of genitourinary syndrome of menopause (GSM) and stress urinary incontinence (SUI), and to achieve so-called vaginal rejuvenation. Photobiomodulation therapy (PBMT) has been proposed as an alternative for use in managing GSM and SUI.

Methods: This article reviews the biological basis, symptoms, and management of GSM, and investigates the current status and rationale for the use of PBMT.

Results and conclusions: Based on the preliminary evidence available, PBMT is safe and appears to be efficacious in treating GSM.