Radiofrequency for the treatment of stress urinary incontinence in women

Bipolar Radiofrequency and Non-Crosslinked Hyaluronic Acid Plus Calcium Hydroxyapatite in the Treatment of Stress Urinary Incontinence

BACKGROUND

Stress urinary incontinence (SUI) causes both physical and psychological problems to women and their partners. Recently, vaginal radiofrequency (RF) application, as well as the administration of non-crosslinked hyaluronic acid (NCLHA) together with calcium hydroxyapatite (CaHA), has attracted attention for SUI treatment. The current, comparative study evaluated the efficacy and safety of these technologies acting separately and in a combined treatment.

METHODS

Sixty women with mild to moderate SUI, aged between 46 and 76 years (mean age 63.2) were divided into three groups intended for different treatments: group I, RF vaginal treatment only, group II, NCLHA plus CaHA periurethral injection only, group III, combined treatment including a single periurethral injection of NCLHA plus CaHA followed by four vaginal applications of RF at intervals of 3-5 days. The clinical effects of the treatments were evaluated by ICIQ-LUTSqol (Polish version) and UDI-6.

RESULTS

The obtained results suggest that the symptoms of SUI and the quality of life of the patients improved significantly in each group after the therapies compared to the pre-treatment levels and were more persistent in the third HA + RF group compared to the HA or the RF group.

Comparison of Low-Energy Radiofrequency Thermal Vaginal Therapy with Sham Treatment for Stress Urinary Incontinence in Postmenopausal Women: A Randomized Controlled Trial

Introduction and Hypothesis

Low-energy radiofrequency (RF) thermal vaginal therapy for vaginal laxity and the genitourinary syndrome of menopause denatures collagen fibrils in the endopelvic fascia; fiber tightening during healing may stabilize the urethra and bladder neck, thereby resolving female stress urinary incontinence (SUI), especially in postmenopausal women. This study compared RF vaginal therapy with sham treatment for mild to moderate SUI.

Methods

This double-blinded, randomized controlled trial, conducted at a tertiary center from September 2018 to April 2021, recruited postmenopausal women with mild to moderate degree of SUI who had never undergone surgery, energy-based therapy, or vaginal estrogen treatment. The intervention group received vaginal RF laser treatment; the sham group did not. The primary outcome was the 1-hour pad-weight test (PWT) result. Secondary outcomes were Incontinence Quality of Life (I-QOL), Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7), Patient Global Impression of Improvement (PGI-I), percentage of improvement among all participants, and adverse events. Data were analyzed using STATA 17.0.

Results

Forty-nine participants randomized to RF (n = 23) and sham (n = 26) groups were eligible for analysis. PWT decreased during follow-up in the RF group but remained stable in the sham group; PWT did not significantly differ between groups. The 1-year post-treatment success rate was higher in the RF group (69.6%) than in the sham group (38.5%). At 1 year post-treatment, there were no statistically significant differences in any secondary outcomes.

Conclusion

Low-energy RF vaginal therapy is an alternative treatment for mild to moderate SUI in postmenopausal women without serious adverse events. Larger randomized controlled trials should be conducted.

CO2 Laser and radiofrequency compared to a sham control group in treatment of stress urinary incontinence (LARF study arm 3). A randomized controlled trial

INTRODUCTION AND HYPOTHESIS

Female stress urinary incontinence (SUI) is a prevalent condition, and conservative treatment options are needed. Were evaluated CO₂ laser and radiofrequency as treatment for SUI.

METHODS

One hundred thirty-nine women with SUI were eligible and randomized in a three-arm double-blind randomized controlled trial into radiofrequency (RF), laser (LS) and sham control (SCT) groups, with 3-monthly outpatient treatment sessions. One hundred fourteen women were included, 38 in each group, during a 12-month follow-up. The primary outcomes were: subjective improvement of SUI, evaluated on a Likert scale, and objective cure, which was a composite outcome defined according to negative stress tests, voiding diary and pad test. Questionnaires were also applied. The sample size was calculated to provide 80% power to identify a 20% difference between groups, p < 0.05.

RESULTS

Subjective improvement and objective cure of SUI were identified respectively in 72.6% and 45.2% in LS and in 61.7% and 44.7% in RF, both significantly higher than the 30.0% and 14.0% in SCT. Considering only mild cases (pad test < 10 g), objective cure was achieved in 66.7% in LS, 63.6% in RF and 22.2% in SCT. Significant reduction in the number of episodes of urinary incontinence was found according to voiding diaries (p = 0.029) and pad weight (p = 0.021). A significant reduction in urgency and urinary loss during sexual intercourse was observed only with LS and RF. Improvement in quality of life was also verified by the I-QoL and ICIQ-SF in favor of the energy-treated groups.

CONCLUSIONS

CO₂ laser and radiofrequency are outpatient options for SUI treatment, with no major complications. They had similar results and presented better results than in the sham control group.

Intravaginal Pulsed Contractile Radiofrequency for Stress Urinary Incontinence Treatment; A Safety Study

Introduction: Radiofrequency (RF)-based stress urinary incontinence (SUI) treatment, which has quickly attracted attention, is administered in an office setting. This pilot-safety study assessed the efficacy of transvaginal RF treatment in the quality of life (QOL) and frequency of incontinence episodes in women with SUI. Methods: Twenty-eight women suffering from SUI were treated with an intravaginal quadric applicator while a grounding pad was attached in front of their pubes. The first phase is thermic, which will heat up the vaginal wall up to 40°C for 10 minutes. The second step is contraction to stimulate an aerobic exercise of pelvic floor muscles for 20 minutes (pulsed contractile RF at 20-40 watts and 1000-300 kHz with a modulation of 1 to 300 Hz for muscle exercise). It was scheduled for one session per week for 3 sessions. Patients had follow-up visits before and 1, 6 and 12 months following the treatment for one-day voiding diary, Persian version of urinary incontinence QOL questionnaire (I-QOL), Q-tip test, 24 hours-pad test and daily incontinence episodes' number. Results: The patients' mean age, duration of incontinence and median vesical leak point pressure were 41.6±9.6 years, 5.48±6.84 years and 140 cm H₂ O respectively. Significant changes were observed in the mean I-QOL total score and the pad test. Also, a notable reduction was observed in the number of daily leakage episodes and the Q-tip test at any follow-up visit (P=0.001). Conclusion: Preliminary results suggest that transvaginal RF is a convenient method of SUI treatment. Significant changes were observed in the mean I-QOL total score and the pad test. Also, a notable reduction was observed in the number of daily leakage episodes.

Vaginal Bipolar Radiofrequency Treatment of Mild SUI: A Pilot Retrospective Study

Background and Objectives: This retrospective study investigates the action of a bipolar, temperature controlled, endovaginal RF handpiece for the treatment of mild, moderate, and severe stress urinary incontinence with a minimally invasive approach. Stress urinary incontinence (SUI) is a common condition resulting in involuntary urine leakage, with an associated social and psychological impact. SUI is the most common type of urinary incontinence in women. Materials and Methods: We retrospectively studied 54 patients for this study. The bipolar radiofrequency energy used in all patients was 50 W, with temperatures maintained between 41 °C and 44 °C. Two sessions were performed four weeks apart. In order to monitor all patients before the first treatment and 4 months after the second treatment, the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) was used. Paired Student's t test was used to elaborate the statistical data. Results: The average frequency of urine leak improved from "2-3 times a week" (2.1 ± 1.3 points before the treatment) to "once a week" (0.8 ± 1.3 points 4 MFU post-treatment). The average volume improved from "small/moderate quantity" (3.2 ± 1.6 points before the treatment) to "none" (0.9 ± 1.4 points 4 MFU post-treatment). No adverse events or side effects were found. Conclusion: Our preliminary results represent a good starting point to check the effectiveness and validity of the bipolar radiofrequency temperature-controlled method in the treatment of SUI.

Pharmaceutical and Energy-Based Management of Sexual Problems in Women

This article summarizes and critiques the evidence for use of available pharmacotherapies (vasoactive, psychoactive, and hormonal medications) and energy-based therapies (laser, radiofrequency, shockwave, and neurostimulation) for treatment of female sexual dysfunction. The enthusiasm with which energy-based treatments for sexual dysfunction have been adopted is disproportionate to the amount of data currently available to support their clinical use. Pharmacotherapy for female sexual dysfunction has considerably more research evidence to justify its use. Patients must be empowered to make an informed, autonomous determination as to whether the risk/reward ratio favors the use of pharmacotherapy, energy-based therapy, or some other treatment intervention.

Transvaginal radiofrequency energy for the treatment of urinary stress incontinence: A comparison of monopolar and bipolar technologies in both pre- and post-menopausal patients

AIM

A study to compare the effect of two different radio frequency energy models (mono polar and bipolar) for the treatment of urinary stress incontinence.

METHODS

Retrospective chart review, which was conducted at 2 sites, 69 patients received treatment with a bipolar radiofrequency device. Out of those 69 patients, 13 patients received bipolar in conjugation with CO₂ laser treatment, while 32 patients received monopolar frequency. The study protocol normally consists of three sessions of treatment. Each session was four weeks apart with a whole 6-month duration follow-up. Results were evaluated by urogenital distress inventory (UDI)-6 questionnaire before and after treatment.

RESULTS

The bipolar group improved UDI-6 scores across time more so than did the monopolar group with some evidence suggesting that the bipolar radiofrequency treatment was more effective compared to the monopolar radiofrequency. Three months after treatment, the bipolar group UDI-6 values were lower than those of the monopolar group. Six months after treatment, the UDI-6 scores increased in both groups, suggesting decrease efficacy with time however, the bipolar group's UDI-6 scores were consistently lower than the monopolar group's scores.

CONCLUSION

This study shows benefit of both monopolar and bipolar radiofrequency device in patients with stress urinary incontinence and mixed UI, with bipolar RF more efficacious than monopolar RF. More randomized prospective studies are needed to confirm these findings.

Clinical utility of radiofrequency energy for female genitourinary dysfunction: past, present, and future

INTRODUCTION AND HYPOTHESIS

Radiofrequency (RF) energy has been delivered in a variety of methods to the vagina, bladder, and periurethral tissue to improve myriad genitourinary complaints. Currently, practitioners are promoting transvaginal RF treatments with a minimal understanding of the various platforms and data to support or refute their utilization. This review explores how various RF technologies create desired tissue effects, review the published literature reporting outcomes of various treatment regimes, and peer into potential future uses of this technology in urogynecology.

METHODS

A comprehensive literature review was performed for articles pertaining to RF energy use in women for genitourinary complaints with regard to stress urinary incontinence (SUI), genitourinary syndrome of menopause (GSM), female sexual dysfunction (FSD), and overactive bladder (OAB).

RESULTS

Radiofrequency energy devices heat tissues via direct or micro-needling applications with the goal of stimulating collagen remodeling, neovascularization, and potentially modulation of nerve function. By altering the approach and location of energy application, many new devices have been marketed for treatment of conditions such as SUI, GSM, FSD, and OAB. Available studies demonstrate promising efficacy and favorable safety; however, interpretation of studies is greatly limited by poor study quality and reporting.

CONCLUSIONS

Despite a lack of high-quality evidence for efficacy, safety, and durability in the literature, practitioners around the world continue to promote RF technology for a variety of genitourinary complaints. Currently, it appears that RF energy can potentially treat a variety of genitourinary conditions, but more robust data are needed to substantiate evidence-based use.

Vaginal rejuvenation: From scalpel to wands

Vaginal rejuvenation procedures are increasing in popularity in terms of types of treatment offered, number of patients undergoing them, clinical studies, and in the controversy surrounding them. Both non-invasive and invasive solutions are being developed by pharmaceutical and technological companies. Radiofrequency devices and lasers are spearheading the energy-based device space, and fillers and platelet-rich plasma are used to address several concerns surrounding vaginal health. In this review, an overview of the growing field of vaginal rejuvenation is presented, as well as the authors’ personal view and analysis of this clinical space.

Effect of Single-Session, Cryogen-Cooled Monopolar Radiofrequency Therapy on Sexual Function in Women with Vaginal Laxity: The VIVEVE I Trial

Objective: This subanalysis of the VIVEVE I trial aimed to evaluate the impact of cryogen-cooled monopolar radiofrequency (CMRF) therapy, for the treatment of vaginal laxity, on the domains of sexual function included in the Female Sexual Function Index (FSFI).

Materials and Methods: The VIVEVE I clinical trial was prospective, randomized, single-blind, and Sham-controlled. Nine clinical study centers in Canada, Italy, Spain, and Japan were included. This subanalysis included premenopausal women with self-reported vaginal laxity who had ≥1 term vaginal delivery and a baseline FSFI total score ≤26.5, indicating sexual dysfunction. Enrolled subjects were randomized (2:1) to receive CMRF therapy [Active (90 J/cm²) vs. Sham (≤1 J/cm²)] delivered to the vaginal tissue. Independent analyses were conducted for each FSFI domain to evaluate both the mean change, as well as the clinically important change for Active- versus Sham-treated subjects at 6 months post-intervention.

Results: Subjects randomized to Active treatment (n = 73) had greater improvement than Sham subjects (n = 35) on all FSFI domains of sexual function at 6 months postintervention. The analysis of covariance change from baseline analyses showed statistically significant improvements, in favor of Active treatment, for sexual arousal (p = 0.004), lubrication (p = 0.04), and orgasm (p = 0.007). In addition, Active treatment was associated with clinically important and statistically significant improvements in sexual desire [Odds ratio (OR) = 3.01 (1.11–8.17)], arousal [OR = 2.73 (1.06–7.04)], and orgasm [OR = 2.58 (1.08–6.18)].

Conclusions: This subanalysis showed CMRF therapy is associated with statistically significant and clinically important improvements in sexual function in women with vaginal laxity. These findings provide the first randomized, placebo-controlled energy-based device evidence for functional improvements associated with a nonsurgical modality for a highly prevalent and undertreated condition.

Emerging Trends in Nonsurgical Female Genital Rejuvenation

BACKGROUND

Aging, childbearing, and hormonal changes can lead to vulvovaginal laxity and mucosal atrophy that negatively affect a woman's quality of life. As more minimally and noninvasive options for genital rejuvenation become available in the outpatient setting, it becomes increasingly important for the dermatologic surgeon to be familiar with these popular procedures.

OBJECTIVE

To familiarize dermatologists with the nonsurgical options available for female genital rejuvenation, patient motivations for pursuing these procedures, relevant anatomy, and potential adverse events.

MATERIALS AND METHODS

A MEDLINE search was performed on nonsurgical female genital rejuvenation from 1989 to 2015, and results are summarized.

RESULTS

Reports of nonsurgical female genital rejuvenation procedures using fractional carbon dioxide lasers, nonablative lasers, monopolar radiofrequency devices, hyaluronic acid fillers, and fat transfer are concisely summarized for the practicing dermatologist.

CONCLUSION

Review of the literature revealed expanding options for nonsurgical female genital rejuvenation.

Vaginal rejuvenation using energy-based devices

Physiologic changes in a woman's life, such as childbirth, weight fluctuations, and hormonal changes due to aging and menopause, may alter the laxity of the vaginal canal, damage the pelvic floor, and devitalize the mucosal tone of the vaginal wall. These events often lead to the development of genitourinary conditions such as stress urinary incontinence; vaginal atrophy; dryness; and physiologic distress affecting a woman's quality of life, self-confidence, and sexuality. Various treatment modalities are currently available to manage these indications, varying from invasive vaginal surgery to more benign treatments like topical vaginal hormonal gels or hormone-replacement therapy. A new trend gaining momentum is the advent of energy-based devices for vaginal rejuvenation that apply thermal or nonthermal energy to the various layers of the vaginal tissue, stimulating collagen regeneration contracture of elastin fibers, neovascularization, and improved vaginal lubrication. This review aims to present the available technologies offering vaginal rejuvenation and the scientific evidence that underlines their safety and efficacy for this indication.

Transurethral radiofrequency collagen denaturation for the treatment of women with urinary incontinence

BACKGROUND

Transurethral radiofrequency collagen denaturation is a relatively novel, minimally invasive device-based intervention used to treat individuals with urinary incontinence (UI). No systematic review of the evidence supporting its use has been published to date.

OBJECTIVES

To evaluate the efficacy of transurethral radiofrequency collagen denaturation, compared with other interventions, in the treatment of women with UI.Review authors sought to compare the following.• Transurethral radiofrequency collagen denaturation versus no treatment/sham treatment.• Transurethral radiofrequency collagen denaturation versus conservative physical treatment.• Transurethral radiofrequency collagen denaturation versus mechanical devices (pessaries for UI).• Transurethral radiofrequency collagen denaturation versus drug treatment.• Transurethral radiofrequency collagen denaturation versus injectable treatment for UI.• Transurethral radiofrequency collagen denaturation versus other surgery for UI.

SEARCH METHODS

We conducted a systematic search of the Cochrane Incontinence Group Specialised Register (searched 19 December 2014), EMBASE and EMBASE Classic (January 1947 to 2014 Week 50), Google Scholar and three trials registries in December 2014, along with reference checking. We sought to identify unpublished studies by handsearching abstracts of major gynaecology and urology meetings, and by contacting experts in the field and the device manufacturer.

SELECTION CRITERIA

Randomised and quasi-randomised trials of transurethral radiofrequency collagen denaturation versus no treatment/sham treatment, conservative physical treatment, mechanical devices, drug treatment, injectable treatment for UI or other surgery for UI in women were eligible.

DATA COLLECTION AND ANALYSIS

We screened search results and selected eligible studies for inclusion. We assessed risk of bias and analysed dichotomous variables as risk ratios (RRs) with 95% confidence intervals (CIs) and continuous variables as mean differences (MDs) with 95% CIs. We rated the quality of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

MAIN RESULTS

We included in the analysis one small sham-controlled randomised trial of 173 women performed in the United States. Participants enrolled in this study had been diagnosed with stress UI and were randomly assigned to transurethral radiofrequency collagen denaturation (treatment) or a sham surgery using a non-functioning catheter (no treatment). Mean age of participants in the 12-month multi-centre trial was 50 years (range 22 to 76 years).Of three patient-important primary outcomes selected for this systematic review, the number of women reporting UI symptoms after intervention was not reported. No serious adverse events were reported for the transurethral radiofrequency collagen denaturation arm or the sham treatment arm during the 12-month trial. Owing to high risk of bias and imprecision, we downgraded the quality of evidence for this outcome to low. The effect of transurethral radiofrequency collagen denaturation on the number of women with an incontinence quality of life (I-QOL) score improvement ≥ 10 points at 12 months was as follows: RR 1.11, 95% CI 0.77 to 1.62; participants = 142, but the confidence interval was wide. For this outcome, the quality of evidence was also low as the result of high risk of bias and imprecision.We found no evidence on the number of women undergoing repeat continence surgery. The risk of other adverse events (pain/dysuria (RR 5.73, 95% CI 0.75 to 43.70; participants = 173); new detrusor overactivity (RR 1.36, 95% CI 0.63 to 2.93; participants = 173); and urinary tract infection (RR 0.95, 95% CI 0.24 to 3.86; participants = 173) could not be established reliably as the trial was small. Evidence was insufficient for assessment of whether use of transurethral radiofrequency collagen denaturation was associated with an increased rate of urinary retention, haematuria and hesitancy compared with sham treatment in 173 participants. The GRADE quality of evidence for all other adverse events with available evidence was low as the result of high risk of bias and imprecision.We found no evidence to inform comparisons of transurethral radiofrequency collagen denaturation with conservative physical treatment, mechanical devices, drug treatment, injectable treatment for UI or other surgery for UI.

AUTHORS' CONCLUSIONS

It is not known whether transurethral radiofrequency collagen denaturation, as compared with sham treatment, improves patient-reported symptoms of UI. Evidence is insufficient to show whether the procedure improves disease-specific quality of life. Evidence is also insufficient to show whether the procedure causes serious adverse events or other adverse events in comparison with sham treatment, and no evidence was found for comparison with any other method of treatment for UI.

Laxity of the vaginal introitus after childbirth: nonsurgical outpatient procedure for vaginal tissue restoration and improved sexual satisfaction using low-energy radiofrequency thermal therapy

INTRODUCTION

Vaginal childbirth may result in vaginal introital laxity, altered genital sensation during sexual intercourse, and reduced sexual satisfaction. We report the long-term effectiveness of a single nonsurgical procedure with radiofrequency (RF) energy for laxity at the vaginal introitus.

MATERIALS AND METHODS

Prospective single-arm study of 30 premenopausal women (21-52 year) with one 30-minute office procedure using RF applied to the vaginal introitus; 12-month outcome assessments included the linguistic validated Japanese versions of the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised (FSDS-R) and the Vaginal Laxity and Sexual Satisfaction Questionnaires.

RESULTS

Sexual function improved significantly throughout 6 months (30 subjects); mean FSFI total score was 22.4±6.7 before treatment and then improved to mean 26.0±5.8 at month 6 (P=0.002), inclusive of improved scores in five of six FSFI domains except desire (P<0.001 -<0.01). In the 22 of 30 subjects remaining evaluable at 12 months, the mean was 26.0±5.2 (P=0.08). Distress related to sexual activity decreased significantly; baseline FSDS-R mean score of 15.8±11.7 improved to 9.8±8.0 at one month and was sustained throughout 12 months (P<0.001 - 0.002). Subjects reported decreased vaginal laxity within the first month after the procedure (P<0.001); responses peaked, and effectiveness was sustained through 12 months (P<0.001).

CONCLUSIONS

A single nonsurgical office-based RF procedure for vaginal introital laxity achieved significant and sustainable 12-month effectiveness with respect to improved integrity at the vaginal introitus and improved sexual satisfaction. Treatment was well-tolerated with no adverse events.

Radiofrequency treatment of vaginal laxity after vaginal delivery: nonsurgical vaginal tightening

INTRODUCTION

All women who have given birth vaginally experience stretching of their vaginal tissue. Long-term physical and psychological consequences may occur, including loss of sensation and sexual dissatisfaction. One significant issue is the laxity of the vaginal introitus.

AIM

To evaluate safety and tolerability of nonsurgical radiofrequency (RF) thermal therapy for treatment of laxity of the vaginal introitus after vaginal delivery. We also explored the utility of self-report questionnaires in assessing subjective effectiveness of this device.

METHODS

Pilot study to treat 24 women (25-44 years) once using reverse gradient RF energy (75-90 joules/cm(2) ), delivered through the vaginal mucosa. Post-treatment assessments were at 10 days, 1, 3, and 6 months.

MAIN OUTCOME MEASURES

Pelvic examinations and adverse event reports to assess safety. The author modified Female Sexual Function Index (mv-FSFI) and Female Sexual Distress Scale-Revised (FSDS-R), Vaginal Laxity and Sexual Satisfaction Questionnaires (designed for this study) to evaluate both safety and effectiveness, and the Global Response Assessment to assess treatment responses.

RESULTS

No adverse events were reported; no topical anesthetics were required. Self-reported vaginal tightness improved in 67% of subjects at one month post-treatment; in 87% at 6 months (P<0.001). Mean sexual function scores improved: mv-FSFI total score before treatment was 27.6 ± 3.6, increasing to 32.0 ± 3.0 at 6 months (P < 0.001); FSDS-R score before treatment was 13.6 ± 8.7, declining to 4.3 ± 5.0 at month 6 post-treatment (P < 0.001). Twelve of 24 women who expressed diminished sexual satisfaction following their delivery; all reported sustained improvements on SSQ at 6 months after treatment (P = 0.002).

CONCLUSION

The RF treatment was well tolerated and showed an excellent 6-month safety profile in this pilot study. Responses to the questionnaires suggest subjective improvement in self-reported vaginal tightness, sexual function and decreased sexual distress. These findings warrant further study.