Laser Therapy in the Treatment of Female Urinary Incontinence and Genitourinary Syndrome of Menopause: An Update

Current Treatment of Stress Urinary Incontinence by Bulking Agents and Laser Therapy-An Update

Stress urinary incontinence (SUI) affects around 20% of women. In addition to the established suburethral sling insertion, two less invasive approaches are of interest today: urethral bulking agents and vaginal laser therapy. This review discusses articles through December 2023 identified by a PubMed literature search using the keywords "incontinence" and "bulking" or "laser". Although the two approaches are less effective than sling insertions, there are specific conditions in which one or the other technique is more advantageous. Injecting bulking agents into the urethra only takes some minutes and works without general anesthesia. The method is particularly suited for elderly, frail, or obese patients with multiple comorbidities, but is also applicable for all patients and in combination with other therapies. Generally, the safety profile is good but differs between bulking materials. Two laser types-the Erbium:YAG laser with SMOOTH-mode and the fractional ablative CO2 laser-deliver heat into the tissue to induce tissue tightening and regeneration. Intravaginal laser therapy improves mild to moderate SUI, while studies describe how intraurethral laser therapy is also beneficial for severe SUI. Young women between childbirths, as well as postmenopausal women, may benefit from laser therapy. The method is safe, can be performed on an outpatient basis, and does not require any artificial material.

Radiofrequency as the New Opportunity in Treating Overactive Bladder and Urge Urinary Incontinence-A Single-Arm Pilot Study

Background and Objectives: Until now, overactive bladder (OAB) with or without urge urinary incontinence (UUI) has been treated mainly in two ways: with behavioral methods and patient education, or using antimuscarinic drugs and/or beta-3 adrenergic receptor agonists. Unfortunately, these drugs may cause side effects in some women or are insufficiently effective, so patients abandon them. Therefore, in this pilot study, radiofrequency was evaluated as a new option in the treatment of OAB and UUI. Materials and Methods: Nineteen patients were enrolled in this pilot study using radiofrequency (RF), where the level of OAB and UUI was assessed using the validated ICIQ-OAB questionnaire. RF was applied four times for 20 min, once a week. Two weeks after treatment, the level of OAB and UUI was reassessed and processed statistically and the treatment effect evaluated. Results: Using the ICIQ-OAB, the severity of OAB and UUI was assessed: 0-3 mild symptoms; 4-7 moderate symptoms; 8-11 severe symptoms; 12-16 very severe symptoms. Before treatment, 10.5% of patients had mild symptoms, 21.1% moderate symptoms, 63.2% severe symptoms and 5.3% very severe symptoms. After treatment, 42.9% had mild symptoms, 50% moderate symptoms and 7% severe OAB and UUI symptoms. All four main symptoms-frequency, nocturia, urgency and incontinence-decreased statistically significantly, with the best results being found in urgency (p = 0.002). Conclusions: Based on this pilot study, RF seems a very promising method in the treatment of OAB and UUI. To extend our initial findings, it is necessary to perform a prospective, randomized and placebo-controlled study in order to obtain reliable results and to determine for how long one set of treatment maintains the results obtained immediately after the end of that treatment. In this way, we may determine how often the treatment needs to be repeated, if necessary, and when.

Comparative study of two different rat models of stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

The purpose of this study was to compare the success rate and urodynamic characteristics of the rat model of stress Urinary incontinence established by ovariectomy at different times after vaginal dilation.

METHODS

Eighty female rats were randomly divided into three groups: the control group (n = 20), model group A (n = 30), i.e., the animals received colpectasis and bilateral oophorectomy within 1 day; model group B (n = 30), i.e., the animals received bilateral oophorectomy 1 week after colpectasis. The sneeze test and urodynamics were tested.

RESULTS

There was no significant difference between the model group A and the model group B (p > 0.05) in the sneeze test. The leak point pressure (LPP) of model groups A and B was lower than that of the control group (p < 0.05). The LPP value of model group A was lower than that of model group B (p < 0.05). There was no significant difference in maximum bladder capacity (MBC) between model group A and the control group (p > 0.05); the MBC value of model group B was lower than that of the control group and model group A (p < 0.05).

CONCLUSIONS

Models of stress urinary incontinence in rats can be successfully established by both modeling methods. In terms of LPP, model groups A and B had lower values than the control group, and model group A had lower values than model group B. In terms of MBC, there was no difference between model group A and the control group, and model group B had lower values than the control group and model group A.

Comparison between laser and transobturator tape therapy in the treatment of stress urinary incontinence and role of overweight in treatment: a prospective observational study

INTRODUCTION AND HYPOTHESIS

Stress urinary incontinence (SUI) is treated with transobturator tape (TOT) sling procedures, but problems arise with artificial mesh in certain instances. Hence, non-invasive laser therapy may be useful under such circumstances. The current study was aimed at comparing the effects of these two treatments and at checking their applicability in various body mass index (BMI) groups.

METHODS

Seventy-nine patients, who were clinically diagnosed with SUI, were divided into two groups, those who preferred TOT and those who preferred the transvaginal fractional micro-ablative CO2 laser system. The SUI symptoms and International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) scores of the patients were determined before and at the 12th month after the treatment. General linear model, Stuart-Maxwell, and Bonferroni correction for pairwise comparison analyses were performed to compare the efficacy of the treatment type.

RESULTS

The ICIQ-SF score decreased by 56.8% for laser therapy and 43.5% for TOT therapy (mean ± SE = 5.97 ± 0.16 and 5.09 ± 0.14 respectively). Laser therapy had a better effect on ICIQ-SF than TOT therapy (η2p: 0.176, ptime*group < 0.001). Regardless of the types of treatment, the ICIQ-SF scores of healthy-weight participants decreased more than those of overweight participants (η2p:0.050, ptime*group = 0.045). In the TOT group, healthy-weight participants were more than twice as likely to recover fully from SUI symptoms as overweight participants, 1 year after the treatment. In the laser group, the majority of healthy-weight participants (88.8%) did not report any SUI symptoms after the treatment.

CONCLUSIONS

The efficacy of laser therapy for urinary incontinence was confirmed. Furthermore, it was observed that being overweight may be a risk factor for the failure of laser therapy.

Fractional CO2 laser treatment for women with stress predominant urinary incontinence: a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

To evaluate the efficacy of vaginal CO2 laser in women with stress predominant urinary incontinence (SUI) compared with the sham treatment.

METHODS

A randomized controlled trial with sham treatment was conducted between January 2019 and April 2021. Women with predominant SUI were recruited and randomized into two groups: the CO2 laser group (n = 29) and the sham group (n = 30). The International Consultation on Continence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) was used to evaluate the efficacy at 3 months postoperatively. All participants in both groups were advised to perform pelvic floor muscle training (PFMT) after the intervention.

RESULTS

A total of 59 women were studied. A total of 29 women were included in the CO2 laser group and 30 women were included in the sham group. The baseline scores of the ICIQ-UI SF were similar in both groups. A significant improvement in urinary incontinence scores was found in both groups 3 months after treatment (p < 0.001). However, there were no statistically significant differences between the two groups at 3 months (p = 0.8281). There were no changes in bladder neck descent or levator hiatal area immediately after intervention or 3 months after completion of treatment in either group. Most participants who received the active intervention reported mild vaginal pain during the procedure that resolved spontaneously at the end of treatment.

CONCLUSIONS

Fractional CO2 laser treatment does not provide any benefit over the sham technique in alleviating SUI symptoms. The improvement in SUI symptoms in both groups might be related to PFMT. This study was registered with the Thai Clinical Trial Register (TCTR20190131004).

Efficacy and safety of intraurethral Erbium:YAG laser treatment in women with stress urinary incontinence following failed intravaginal laser therapy: a retrospective study

Urinary incontinence (UI) is a prevalent condition affecting 25-45% of women and is linked to factors such as menopause, parity, high body mass index, and radical pelvic surgery. Among the three types of UI, stress incontinence (SUI) is the most common, accounting for almost 50% of cases, followed by urgency and overflow incontinence. UI has been found to be associated with reduced quality of life and mental stress. Non-invasive laser treatment is the safest and most effective option for managing SUI, with intraurethral Erbium SMOOTHTM laser treatment holding promise for patients experiencing SUI even after undergoing previous failed intravaginal Erbium:YAG laser treatment. The study recruited 93 female patients with mild to moderate SUI who had received two courses of intravaginal Erbium:YAG laser between January 2015 and June 2018. Of these, 22 patients (23%) who continued to experience SUI after a four-week interval for a second intravaginal Erbium:YAG laser were selected for intraurethral laser treatment in January 2019. The efficacy of the treatment was evaluated by comparing the pre- and post-treatment ICIQ-UI SF score. The urethral length was measured before the procedure. The main procedure involved delivering non-ablative laser energy using Erbium SMOOTHTM technology 2940 nm via a 4-mm cannula with personalized length and fluence was 1.5 J/cm. The 22 female patients with persistent SUI received intraurethral Erbium:YAG laser treatment. Their average age was 47.5 years, with an average of 2 parities and a mean body mass index of 20.97. All patients completed the ICIQ-SF questionnaire before and 3 months after the procedure. Of the patients, 77% reported improvement in symptoms, with 6 reporting strong improvement and 11 reporting improvement. The treatment was well-tolerated, with mild and transient adverse effects such as urinary infection in 1 patient (4.5%) and mild pain in 7 patients (31.8%). Intraurethral laser treatment may be helpful for Taiwanese women with persistent SUI after vaginal laser treatment. However, patients with prior pelvic surgery or pelvic organ prolapse history may limit the efficacy of intraurethral laser. Additional research is necessary to comprehensively investigate the advantages of intraurethral laser therapy. However, using intraurethral Erbium SMOOTHTM laser treatments to rejuvenate tissues and enhance structural support could be a promising avenue for managing stress urinary incontinence in Taiwanese women.

Vaginal Laser Treatment for the Genitourinary Syndrome of Menopause in Breast Cancer Survivors: A Narrative Review

Vulvovaginal atrophy (VVA) is a chronic condition resulting from reduced estrogen levels during menopause. The North American Menopause Society and the International Society for the Study of Women's Sexual Health suggested the term "genitourinary syndrome of menopause" (GSM) to indicate the broader aspects of VVA. Breast cancer treatments, such as chemotherapy and endocrine therapy, can induce early and abrupt menopausal symptoms, including GSM, which negatively affects sexual function and the quality of life of the survivors. Vaginal laser therapy has emerged as a safe and effective option for the management of GSM in breast cancer survivors (BCSs). Two main types of lasers, the non-ablative erbium:YAG laser and fractional microablative CO2 vaginal laser, have been evaluated for GSM treatment. While there are few randomized controlled trials (RCTs) on the subject of BCSs, a wealth of prospective and retrospective studies have highlighted the beneficial effects of vaginal laser therapy on the symptoms of VVA, vaginal health, sexual function, and overall quality of life. More comprehensive research is essential to confirm its enduring effectiveness and safety, with a focus on conducting standardized and meticulously controlled investigations. This study is a narrative review that summarizes clinical trials ranging from the earliest to the most recent ones on laser treatment for GSM in BCSs.

Comparison of Er:YAG and CO2 laser therapy for women with stress urinary incontinence

OBJECTIVE

To compare the effectiveness of Er:YAG and CO2 laser therapies for treating female stress urinary incontinence (SUI).

METHODS

This retrospective study included 139 women who were divided into four groups: group 1 received two therapy sessions with the Er:YAG laser, group 2 received two therapy sessions with the CO2 laser, group 3 received one therapy session with the Er:YAG laser, and group 4 received one therapy session with the CO2 laser. Patients completed three questionnaires to assess SUI symptom severity at baseline, 1 month, and 3 months after laser therapy.

RESULTS

Urinary incontinence symptoms significantly improved in groups 1 and 2 at both the 1- and 3-month follow-up evaluations compared to the baseline (p < 0.001). Symptoms improved after one therapy session in groups 3 and 4 at the 3-month follow-up (p < 0.001). The Er:YAG laser was more effective than the CO2 laser in improving SUI symptoms (Urogenital Distress Inventory 6 and Incontinence Impact Questionnaire 7) 3 months after treatment, regardless of the number of sessions. Both Er:YAG and CO2 laser therapies were found to be effective in reducing symptoms associated with an overactive bladder, as demonstrated by improvements in overactive bladder symptom scores. Two sessions of laser therapy were more effective than one.

CONCLUSION

Vaginal laser therapy could be an effective alternative treatment for mild to moderate SUI. The Er:YAG laser was more effective than CO2 laser therapy, with results lasting for at least 3 months. However, further large-scale, randomized, controlled trials are needed to confirm our findings.

A randomized trial comparing vaginal laser therapy and pelvic floor physical therapy for treating women with stress urinary incontinence

INTRODUCTION

Female stress urinary incontinence (SUI) is considered a major public health issue. Physical therapy is an important conservative treatment; however, it is primarily limited by poor long-term compliance. Furthermore, surgical treatment entails significant risks. Therefore, new treatment techniques must be identified.

OBJECTIVE

To compare the use of laser therapy and pelvic floor (PF) physical therapy for treating postmenopausal women with SUI.

METHODS

This pilot study enrolled 40 women with a clinical and urodynamic diagnosis of SUI who were randomized into two groups: those who received erbium-doped yttrium-aluminum-garnet (Er:YAG) laser therapy implemented over three sessions with a 1-month interval (n = 20) and those who received physical therapy with supervision twice a week for 3 months (n = 20). In total, 16 women completed the treatment in each group. The patients were assessed for PF function using the modified Oxford scale and for pelvic organ prolapse using the Pelvic Organ Prolapse Quantification System. The 1-h pad test and quality of life questionnaires, King's Health Questionnaire (KHQ), and Incontinence Quality of Life (IQOL) were also administered. Patients were re-evaluated at 1, 3, 6, and 12 months after treatment.

RESULTS

The mean patient age was 62.7 ± 9.1 and 57.9 ± 6.1 years, median Oxford score at baseline was 3 (2-4.5) and 4 (3-4), mean IQOL score was 79.8 ± 17 and 74.6 ± 18 for physical therapy group (PTG) and laser group (LG), respectively. For the amount of urine leak in the 1-h pad test evaluation, we found significance for the interaction of group and time points only for the Laser intragroup. The cure rate, that is, the rate of reaching an insignificant score in the pad test, at 6 and 12 months was 43.75% and 50% in PTG and 62.5% and 56.25% in the LG, respectively (p > 0.05). IQOL scores demonstrated considerable improvement in both groups (p > 0.05). Upon comparing the initial and follow-up results, the LG showed an improvement at all consultations, whereas the PTG showed improvements at 1, 3, and 6 months but not at 12 months after treatment. KHQ analysis revealed a considerable improvement in the quality of life (QOL) of patients over time, with no substantial difference between the groups. QOL comparison before and after treatment revealed that the vaginal LG improved more consistently in some domains. Only the PTG showed a significant increase in the mean Oxford score from pretreatment to 1 and 3 months after treatment (p < 0.001 and p = 0.002, respectively). However, no statistically significant difference was observed between the groups.

CONCLUSION

Both treatments are safe and have a positive influence on the impact of UI on patients' QOL. The laser caused a greater reduction in the urinary loss, as measured using the weight of pad test, at 6-month and 12-month after treatment without difference with PTG at the end of the follow-up.

Sexual function after energy-based treatments of women with urinary incontinence. A systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI) affects approximately 50% of adult women worldwide and is associated with declining sexual function (SF). Energy-based devices emerged as a minimally invasive alternative treatment. Nevertheless, their effect on sexuality is uncertain. We hypothesize that the UI energy treatment can lead to sexual function improvement.

METHODS

A search was performed in PubMed, Cochrane Library, Web of Science, Embase, and Scopus for randomized clinical trials (RCTs) and nonrandomized studies of intervention, which treated incontinent women using energy, with UI and sexual function (SF) as outcomes. Severe comorbidities, pelvic organ prolapse (POP)> grade 2, and use of medication to treat UI or that affects SF were excluded. Quality assessment and meta-analysis were performed.

RESULTS

From 322 articles, 11 RCTs were included for qualitative analysis. UI symptoms improved in all studies. Regarding SF, RCT with premenopausal women showed improvement in SF in the Er:Yag group (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 and Female Sexual Function Index). A prospective study showed improvement in SF independent of the grade of SUI. RF showed benefits for SF but was not superior to pelvic floor muscle training. One nonrandomized study of intervention with a High-Intensity Focused Electromagnetic Field showed significant improvement of SF in the Golombok Rust Inventory of Sexual Satisfaction total score, a decline in pain and dissatisfaction domains. Meta-analysis with 4 RCTs and 2 nonrandomized studies found no difference between groups (0.26 (95% CI -0.67 to 1.20, and -0.74 (95% CI -3.78 to 2.30) respectively).

CONCLUSIONS

This meta-analysis did not confirm that energy equipment improved the SF of women with UI.

The evidence behind the use of LASER for genitourinary syndrome of menopause, vulvovaginal atrophy, urinary incontinence and lichen sclerosus: A state-of-the-art review

In recent years, LASER has been introduced as a minimally invasive treatment for a broad range of vaginal and vulvar symptoms and diseases. However, the efficacy and safety of vaginal and vulvar LASER has continuously been questioned. The aim of this study is to create an overview of the current literature and discuss the controversies within the use of LASER for genitourinary syndrome of menopause, vulvovaginal atrophy, urinary incontinence and lichen sclerosus. A search string was built in PubMed. The search was commenced on August 25, 2021 and closed on October 27, 2021. Two authors screened the studies in Covidence for inclusion according to the eligibility criteria in the protocol. The data were extracted from the studies and are reported in both text and tables. This review included 114 papers, of which 15 were randomized controlled trials (RCTs). The effect of LASER as a vaginal treatment was investigated for genitourinary syndrome of menopause in 36 studies (six RCTs), vulvovaginal atrophy in 34 studies (four RCTs) and urinary incontinence in 30 studies (two RCTs). Ten studies (three RCTs) investigated the effect of vulvar treatment for lichen sclerosus. Half of the included RCTs, irrespective of indication, did not find a significant difference in improvement in women treated with vaginal CO₂ or Er:YAG LASER compared with their respective controls. However, most non-comparative studies reported significant improvement after exposure to vaginal or vulvar LASER across all indications. Included studies generally had a short follow-up period and only a single RCT followed their participants for more than 6 months post treatment. Adverse events were reported as mild and transient and 99 studies including 51 094 patients provided information of no serious adverse events. In conclusion, this review found that the effect of vaginal and vulvar LASER decreases with higher study quality where potential biases have been eliminated. We therefore stress that all patients who are treated with vaginal or vulvar LASER should be carefully monitored and that LASER for those indications as a treatment should be kept on a research level until further high-quality evidence is available.

Changes in sexual function and vaginal topography using transperineal ultrasound after vaginal laser treatment for women with stress urinary incontinence

We aim to assess the changes in sexual function and vaginal topography using 3-D transperineal ultrasound in stress-incontinent women treated with Er:YAG vaginal laser. Two hundred and twenty women with stress urinary incontinence (SUI) treated with Er:YAG laser were recruited. Assessment before and 6 months after the treatment included vaginal topography using 3-D transperineal ultrasound and sexual function using female sexual function index questionnaire (FSFI). A total of 50 women with complete data showed that the symptomatic improvement was noted in 37 (74%) women. After Er:YAG vaginal laser treatment, significantly decreased width and cross-sectional area in proximal, middle, and distal vagina were found in women with SUI. Nearly all of the domains of FSFI improved significantly after the vaginal laser treatment, except sexual desire. In conclusion, 3-D transperineal ultrasound can be used to conduct vaginal topography. After Er:YAG vaginal laser treatment, the anatomical changes of vaginal shrinkage and the improvement of female sexual function were both noted. The favorable outcome of sexual function partly related to the tightening of vagina, as evidenced by the measurements of the 3-D transperineal ultrasound.

Effect of electroacupuncture on the degradation of collagen in pelvic floor supporting tissue of stress urinary incontinence rats

INTRODUCTION AND HYPOTHESIS

To examine the changes induced by electroacupuncture in stress urinary incontinence (SUI) rats, including the urodynamics and collagen degradation-related cytokine molecular biological expression changes, and to explore the effect and mechanism of EA treatment in SUI.

METHODS

Female SPF Sprague-Dawley rats were randomly assigned to five groups (n = 10): sham, model, electroacupuncture control, electroacupuncture, and blocker. The leak point pressure (LPP) and maximum bladder capacity (MBC) were measured for each group of rats, and collagen I, collagen III, matrix metalloproteinases (MMPs), and tissue inhibitor of metalloproteinase (TIMPs) in the anterior vaginal wall of rats in each group were determined by reverse transcription-polymerase chain reaction and western blotting. The data were analyzed by one-way analysis of variance or Kruskal-Wallis test.

RESULTS

Electroacupuncture Shenshu (BL23) and Huiyang (BL35) increased the LPP and MBC in SUI rats (P < 0.05). Electroacupuncture treatment significantly increased the protein expression of collagen I and collagen III in the anterior vaginal wall of SUI rats (P < 0.05) and significantly reduced the protein expression of MMP1, MMP2, and MMP9 (P < 0.05).

CONCLUSIONS

Electroacupuncture stimulation can alleviate the signs of SUI, and its mechanism is related to the degradation of collagen in the anterior vaginal wall.

Comparison of urethral sling surgery and non-ablative vaginal Erbium:YAG laser treatment in 327 patients with stress urinary incontinence: a case-matching analysis

Stress urinary incontinence (SUI) occurs when abdominal pressure, such as from coughing or sneezing, causes urine leakage. We retrospectively compared tension-free vaginal tape (TVT) and non-ablative vaginal Erbium:YAG laser treatment (VEL) by propensity score (PS) analysis in women with SUI. No PS analysis studies have investigated urethral sling surgery using polypropylene TVT and VEL for SUI. Data from patients aged 35-50 years who were treated for SUI and registered at several institutions were selected. Patients with medical records covering 1 year for the 1-h pad test, who completed the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and the Overactive Bladder Symptom Score (OABSS), were included. We analyzed 102, 113, and 112 patients in the TVT, VEL, and control groups, respectively. Compared with the control group, the TVT and VEL groups exhibited significant improvement in the 1-h pad test and ICIQ-SF. In the PS analysis, the TVT and VEL groups similarly improved in the 1-h pad test and ICIQ-SF. As for the OABSS, the VEL group showed significantly greater improvement than the TVT group. In the odds ratio analysis for the 1-h pad test, no differences in any of the parameters were observed between TVT and VEL. VEL may be considered an alternative to TVT for SUI treatment.

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.

Effect of electroacupuncture on the intestinal microflora in rats with stress urinary incontinence

OBJECTIVE

To examine the effect of electroacupuncture on the urodynamics and gut microbiota of rats with stress urinary incontinence (SUI).

MATERIALS AND METHODS

Thirty 2-month-old female Sprague-Dawley (SD) rats were randomly assigned to 4 groups: normal (N), model (M), nonacupoint electric acupuncture control (NAAC), and electroacupuncture (EA). An SUI rat model was established through vaginal balloon dilatation and bilateral oophorectomy. After various treatments, urodynamic tests were performed, and feces were collected. 16S rRNA sequencing analysis was used to investigate SUI-related changes in the intestinal flora.

RESULTS

After treatment, compared with those of the M group, the leak point pressure and maximum bladder capacity of the electroacupuncture groups increased (P<0.05). The species community compositions of the N and M groups differed at the genus level, and there were 15 differentially abundant bacterial genera (P<0.05). The Blautia proportion was increased by electroacupuncture treatment (P<0.05) and was significantly positively correlated with the electroacupuncture treatment of SUI (according to Spearman correlation analysis).

CONCLUSION

Electroacupuncture treatment can improve signs of urine leakage in rats with SUI rats by increasing the leak point pressure and maximum bladder capacity. The enrichment of Blautia by electroacupuncture treatment enrichment may be related to SUI sign improvement.

Female Genitourinary Treatments in Aesthetics

Female genitourinary treatments in aesthetics utilize energy-based treatments and other non-invasive modalities. These include CO2 and Er:YAG lasers, radiofrequency (RF), high-intensity focused electromagnetic energy (HIFEM), hyaluronic acid (HA) injection, platelet-rich plasma (PRP), and silicone thread treatments with an objective to treat sexual dysfunction and symptoms of genitourinary syndrome associated with menopause (GSM), which include atrophic vaginitis, urinary incontinence, and vulvovaginal laxity that is characterized by vaginal dryness, thinning of the epithelium, laxity, prolapse, incontinence, dyspareunia, and increased bacterial infections. The body of evidence is growing for the use of these modalities to improve signs and symptoms of GSM and sexual function, as well as rejuvenate the appearance of external female genitalia. We reviewed the currently available modalities in this rapidly advancing area of expertise.

Use of a vaginal CO2 laser for the management of genitourinary syndrome of menopause in gynecological cancer survivors: a systematic review

Genitourinary syndrome of menopause (GSM) may arise from the hypoestrogenism caused by ovarian function destruction following gynecological cancer treatments. GSM may also be present in menopausal women and its symptoms might be exacerbated by cancer treatments. Historically, patients with hormone-dependent gynecological cancer and physicians have been less comfortable using vaginal estrogen due to fear of recurrence. CO₂ vaginal laser therapies have demonstrated efficacy as a non-hormonal alternative for GSM treatment in healthy menopausal patients. The objective of this study was to evaluate the data on the effect of a CO₂ vaginal laser for the management of GSM in gynecological cancer patients. Databases searched included MEDLINE, Embase, PubMed, Cochrane and Google Scholar. Selected studies assessed use of a CO₂ vaginal laser in gynecological cancer patients with GSM. A total of 269 studies were retrieved. Four studies met the inclusion criteria. Each study followed a different type of CO₂ vaginal laser protocol for the management of GSM in gynecological cancer patients. There are no randomized controlled trials that assess the use of a CO₂ vaginal laser in gynecologic cancer patients. The number of published gynecological cancer patients treated with a CO₂ laser for the management of GSM is extremely limited (N < 100). There is a lack of literature on the impact and safety of vaginal CO₂ laser use to manage GSM in gynecologic cancer patients.

[Therapeutic options in female stress urinary incontinence]

Stress urinary incontinence in female patients is characterised by loss of urine without the need to urinate. Causes are manifold and require a good knowledge of the pelvic floor structures and the functionality of the bladder's occlusion system. Before any treatment can be initiated, differentiated diagnostic investigation must uncover the causes in order to be able to show incontinent women the ideal therapeutic options. In addition to conservative treatment strategies, there are several surgical alternatives available that can be used depending on the functional and/or anatomical deficit. Surgical correction produces good results, although a minor rate of possible complications must be accepted.

Comparison of topical fractional CO2 laser and vaginal estrogen for the treatment of genitourinary syndrome in postmenopausal women: a randomized controlled trial

OBJECTIVE

To compare the efficacy of fractional CO2 laser therapy with topical estrogen therapy for the treatment of postmenopausal genitourinary syndrome of menopause.

METHODS

We conducted a randomized controlled clinical trial involving 25 postmenopausal women. Participants were aged between 50 and 65 years with at least 1 year of amenorrhea and follicle-stimulating hormone levels of >40 IU/L. The women were randomized into two groups: the laser therapy group (n = 13) and the vaginal topical estrogen therapy group (n = 12). Changes in the vaginal epithelium thickness, Frost index, and cell maturation were analyzed in both the groups. The female sexual quotient of each woman was also evaluated. Subjective evaluation was performed through a physical examination.

RESULTS

Histological analysis showed a significant increase in the vaginal epithelium thickness at the end of treatment in females in both the laser therapy (P < 0.001) and topical estrogen therapy (P = 0.001) groups. The topical estrogen therapy group tended to present a higher maturation index at the end of treatment when compared with that of the other group. Sexual function increased significantly over time in both the topical estrogen therapy (P < 0.001) and laser therapy (P < 0.001) groups. Subjective evaluation through physical examination showed a significant improvement in atrophy in both the groups.

CONCLUSION

Despite the nonequivalence with topical estrogen therapy, our data suggest that laser therapy is an effective method for the treatment of vulvovaginal atrophy.

The use of vaginal lasers in the treatment of urinary incontinence and overactive bladder, systematic review

OBJECTIVES

To evaluate the available literature to assess the safety, efficacy, and outcomes of lasers in the treatment of female stress urinary incontinence (SUI) and overactive bladder (OAB).

METHODS

Pubmed search was conducted up to May 2020, including observational and investigational human studies that documented the effects on laser treatment in SUI and OAB.

RESULTS

A total of 27 studies, recording subjective or objective measures in SUI or OAB were included. Lasers used included Er:YAG and Fractional CO2 lasers. The overall quality of studies was poor, and 23/27 studies were case series (LOE:4). Er:YAG laser showed a modest reduction in mild SUI cases, with benefits lasting a maximum of 13-16 months. Er:YAG laser for OAB showed conflicting results, with a trend to improve OAB symptoms for up to 12 months. Fractional CO2 laser showed an improvement of mild SUI in few studies; however, no long-term data are available. For OAB symptoms, studies showed minimal improvement that was evaluated in short term studies. When reported, adverse events were insignificant, however, they were not reported systematically. Several limitations have been noticed in the current literature of vaginal lasers, including large variation in laser settings and protocols, short term follow up, lack of urodynamic evaluation, and appropriate objective measures.

CONCLUSION

Based on the available literature, lasers cannot be recommended as a treatment option at this time. Future better-quality studies are needed to document the exact mechanism of action, longevity, safety and its eventual place into the current treatment algorithms of SUI and OAB.

Physical methods for the treatment of genitourinary syndrome of menopause: A systematic review

BACKGROUND

Genitourinary syndrome of menopause (GSM) negatively affects sexual function and quality of life. Techniques like laser and radiofrequency are being used to manage GSM, particularly in women with contraindications for hormone therapy.

OBJECTIVES

To verify whether the physical methods of laser and radiofrequency can be recommended as safe and effective options for the treatment of GSM/urinary urgency or incontinence in pre- and postmenopausal women.

SEARCH STRATEGY

Databases were comprehensively searched using combinations of the following keywords in any language: "postmenopause"; "genitourinary syndrome of menopause"; "vaginal atrophy"; "radiofrequency"; and "laser."

SELECTION CRITERIA

Full articles of case-control, cross-sectional, cohort, randomized clinical trials, and quasi-randomized or controlled clinical trials were included.

DATA COLLECTION AND ANALYSIS

All authors independently evaluated the design of the studies for quality of reporting, risk of bias, and quality of evidence.

MAIN RESULTS

Of the included 49 studies, 37 were on the CO₂ laser, 10 on the Erbium laser, and two on radiofrequency.

CONCLUSIONS

Laser and radiofrequency therapy could be promising and safe therapeutic options for GSM/urinary incontinence. However, the study findings cannot be generalized until new randomized clinical trials are performed that confirm the strength of the evidence. This review has been registered with PROSPERO: CRD42020141913.

Vaginal laser treatment of genitourinary syndrome of menopause: does the evidence support the FDA safety communication?

IMPORTANCE

Genitourinary syndrome of menopause (GSM) is a chronic, progressive condition frequently manifesting as vaginal dryness and pain with intercourse. Survey data indicate this is a highly prevalent, likely underreported, condition that profoundly affects quality of life for millions of women. Vaginal lasers demonstrate promise as an effective, nonhormone therapeutic alternative for GSM; however, the risks associated with them may have been overstated.

OBJECTIVE

Despite reports of improved sexual and vaginal comfort without serious safety concerns, the Food and Drug Administration (FDA) issued a 2018 safety communication warning against it. We conducted a systematic literature review and surveyed both the FDA Manufacturer and User Facility Device Experience (MAUDE) and Bloomberg Law Databases to evaluate risks associated with laser treatment for GSM.

EVIDENCE REVIEW

A systematic literature review identified articles published before September 2019. The MAUDE database was searched by name from 2009 to 2019 for safety claims for 24 vaginal laser devices. The Bloomberg Law database was searched for product liability claims against any vaginal laser device manufacturer before July 2019.

FINDINGS

Literature review revealed 3 publications detailing 29 presumptive laser-associated complications, only 5 of which (17.2%) reported worsening symptoms after treatment. The MAUDE database contained 120 complaints; only 30 (25%) detailed potential adverse patient events, most frequently pain (n = 12) and burning (n = 10). The Bloomberg law database contained no claims asserting harm from device use.

CONCLUSIONS AND RELEVANCE

Lacking strong evidence indicating significant patient risk for vaginal laser treatment of GSM, the FDA safety communication appears unsubstantiated and implies gender bias. Identified complications suggest most reported "adverse events" represent lack of treatment effect. The well-documented benefits and low risk of adverse event suggest laser therapy for GSM is reasonable with appropriate pretreatment counseling. Additional randomized, well-controlled clinical trials are needed to further elucidate both the safety and efficacy of this nonhormone therapy.

The first major complication due to laser treatment for stress urinary incontinence: a short report

AIM

Stress urinary incontinence (SUI) is a common benign disease causing a markedly negative impact on quality of life. Vaginal laser is a minimally invasive treatment and no major complications of this technique have been published to date. The purpose of the article is to present the first major adverse event related to this treatment.

MATERIALS AND METHODS

We present the case of a 48-year-old woman with an important complication after vaginal laser for SUI.

RESULTS

The patient presented a transverse vaginal septum and shortening of vaginal length after two sessions of vaginal erbium:yttrium aluminum garnet laser treatment. She required two surgical interventions, local injections, and pelvic floor physiotherapy, although currently the patient has not experienced complete resolution of symptoms.

DISCUSSION AND CONCLUSIONS

Vaginal laser use can lead to serious adverse events. Selection of patients and treatment must be carried out with caution.

Pixel CO2 Laser for the Treatment of Stress Urinary Incontinence: A Prospective Observational Multicenter Study

BACKGROUND AND OBJECTIVES

Energy-based treatments have been found to be a promising treatment modality for improving stress urinary incontinence (SUI) symptoms. This prospective two-center study was designed to evaluate the efficacy of fractional-pixel CO₂ laser for the treatment of SUI.

STUDY DESIGN/MATERIALS AND METHODS

Eighty-five women with SUI symptoms as per the cough stress test and validated International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI-SF), were treated intravaginally with Pixel-CO₂ laser. Two treatment sessions were performed with a 1-month interval. Safety and treatment tolerance were assessed by the visual analog scale (VAS) immediately and at 1 week after each laser treatment. Associations of age and body mass index (BMI) with the ICIQ-UI-SF score were statistically assessed by the Jonckheere-Terpstra test.

RESULTS

The ICIQ-UI-SF score was 12.0 at baseline, 7.0, after the first treatment, and 3.5 after the second treatment (P = 0.001). For women with BMI (25.0-29.9), the ICIQ-UI-SF score was 9.0 at the baseline, 6.0 after 1 month, and 5.0 at the 6 months follow-up visit (P = 0.04). For women with BMI ≥ 30.0, the ICIQ-UI-SF score was reduced from 14.0 to 8.0 1 month after the baseline and 5.0 at the 6-month follow-up visit (P = 0.001). SUI severity evaluation at baseline showed that 27.1% of women had mild, 24.7% had moderate, 45.9% had severe, and 2.4% had very severe SUI symptoms. SUI severity scores were significantly reduced, with 45.8% of women with no SUI symptoms, 18.8% with mild, 20.8% with moderate, and 14.6% with severe SUI symptoms at the 6-month follow-up. The patient's evaluation of VAS after the first treatment was 1.0-1.5 (0-10) and 0.0 1 week after the second treatment.

CONCLUSION

Fractional-pixel CO₂ laser is safe and effective for treating SUI. No adverse event or significant pain was reported during or after the procedure. Its safety and efficacy are clearly demonstrated. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.