Non-ablative Er:YAG laser therapy effect on stress urinary incontinence related to quality of life and sexual function: A randomized controlled trial

Efficacy and safety of non-ablative ErYAG laser for mild to moderate stress urinary incontinence: a prospective, multicenter, randomized, sham-controlled clinical trial

This study evaluated the efficacy and safety of a non-ablative vaginal Er: YAG laser device in treating stress urinary incontinence (SUI). We conducted a prospective, multicenter, randomized, sham-controlled clinical trial in which women with SUI received either active treatment with Er: YAG laser therapy or sham control with a non-therapeutic handpiece. Patients underwent three treatments spaced one month apart. The primary endpoint measure was the treatment success rate at three months post-treatment. A total of 126 participants with SUI were recruited, with 84 in the active arm and 42 in the sham arm. One participant in the sham arm was excluded due to not using research instruments. The treatment success rate at three months post-treatment was 36.59% in the sham arm and 71.43% in the active arm, with an absolute difference of 34.84% (95% CI: 17.2-52.5%). Incontinence quality of life questionnaire (I-QOL) score and incontinence questionnaire short form (ICIQ-SF) score demonstrated significant improvement in the both arms with no substantial difference between the groups. Non-ablative vaginal ErYAG laser therapy demonstrated a significant improvement in objectively measured SUI symptoms compared to sham treatment. The non-ablative Er: YAG laser therapy seems to be a promising non-surgical treatment option for SUI patients. The limitations of this study are the short follow-up and limited sample size, so additional studies with longer follow-up and larger number of patients are needed to further elucidate the role of this therapy for SUI.

The Efficacy and Safety of Erbium-Doped Yttrium Aluminum Garnet Laser Therapy for Stress Urinary Incontinence: A Systematic Review and Meta-Analysis

OBJECTIVES

The erbium-doped yttrium aluminum garnet(Er:YAG) laser therapy has recently emerged as a novel treatment for stress urinary incontinence (SUI) in women. The purpose of this meta-analysis was to evaluate the efficacy and safety of Er:YAG laser therapy in the management of SUI.

MATERIALS AND METHODS

We conducted a search in the databases MEDLINE, EMBASE, and the Cochrane Library, up to December 2024, to identify randomized controlled trials (RCTs) that mentioned the use of Er:YAG laser therapy for the treatment of SUI. A systematic review and meta-analysis was conducted.

RESULTS

The meta-analysis included four publications with a total of 390 patients diagnosed with SUI. Posttreatment analysis revealed statistically significant improvements in the Er:YAG laser therapy group for the 1-h pad test (mean difference [MD]: -10.42; 95% confidence interval [CI], -17.32 to -3.53; p = 0.003) and the number of subjective cures as assessed by the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) (odds ratio [OR]; 6.21, 95% CI; 1.55-24.84, p = 0.01). However, no significant differences were observed in the change of ICIQ-SF scores (MD: -0.15; 95% CI, -0.77 to 1.07; p = 0.75) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) scores (MD: 0.81; 95% CI, -0.24 to 1.85; p = 0.13). In terms of comfort, pain visual analog score (VAS) was higher in the laser therapy versus sham therapy following both treatment sessions (The pain VAS after session one (MD; 3.72, 95% CI; 3.24-419, p < 0.00001). The pain VAS after session two(MD; 2.64, 95% CI; 2.12-3.15, p < 0.00001). Regarding adverse events, there were no statistically significant differences between the Er:YAG laser group and the sham group in terms of increased vaginal discharge (OR; 4.64, 95% CI; 0.27-78.30, p = 0.29), vaginal discomfort (OR; 1.31, 95% CI; 0.62-2.73, p = 0.48), and suspected urinary tract infection (UTI) (OR; 3.44, 95% CI; 0.57-20.58, p = 0.18).

CONCLUSIONS

Our meta-analysis indicates that the Er:YAG laser appears to be a safe and effective treatment option for SUI.

Vaginal Erbium Laser Versus Pelvic Floor Muscle Training for Stress Urinary Incontinence: A Randomised Controlled Trial

INTRODUCTION AND HYPOTHESIS

Current studies on vaginal laser therapy for the management of stress urinary incontinence (SUI) are inconclusive, and many lack comparison with another conservative treatment. Therefore, we compared the efficacy of Er:YAG laser for SUI with that of pelvic floor muscle training (PFMT).

METHODS

Single-centre, randomised controlled trial comparing laser treatment (3-6 applications) with PFMT (9-18 sessions) in women with mild to moderate SUI. Main outcome measures included subjective change in urinary incontinence symptoms by change from baseline to 4 months after randomisation by Urogenital Distress Inventory-6 (UDI-6; primary), adverse events, and other subjective and objective outcomes up to 24 months. A priori sample size calculation for a non-inferiority study resulted in 28 patients per arm. Because of a higher than expected dropout early in the study, we increased our sample size from 56 to 60, without unblinding of the data.

RESULTS

Sixty women were enrolled. Two participants discontinued their allocated treatment (one in each group). At 4 months, mean difference in change in UDI-6 scores was -6.99 (95% CI = -22.34; 8.37), demonstrating non-inferiority of laser to PFMT (p = 0.023). Within groups, most patients improved, yet subjective cure was reached in only a minority (laser: 11% [3 out of 28]; PFMT: 8% [2 out of 26]). The mean number of treatment visits was 4.25 (SD 1.17) in the laser group and 10.04 (SD 6.36) in the PFMT group. There were no subjective or objective inter-group differences. At 24 months, the majority of patients requested additional, yet alternative treatment. There were no serious adverse events at any time point.

CONCLUSIONS

Treatment effect of vaginal laser and PFMT in patients with mild and moderate SUI were comparable, limited and short lasting. No adverse events were reported.

Exploring the role of laser therapy for stress urinary incontinence: a literature review

Stress urinary incontinence (SUI) significantly impacts the quality of life, necessitating innovative treatment options beyond conventional approaches. This comprehensive review aimed to evaluate laser therapy as a promising intervention for SUI management. A systematic search was conducted using the keywords "laser" and "stress urinary incontinence" in the PubMed, Scopus, Web of Science, and Embase databases. The search covers studies from January 1, 2014, to November 30, 2024. A comparative analysis with traditional treatments, such as pelvic floor exercises and medications, underscores the potential advantages and limitations of laser therapy. Clinical studies and research findings are examined to evaluate the efficacy and safety profile of laser therapy, including its short-term success rates and potential complications. Patient experiences and perspectives provide a qualitative dimension, offering insights into the real-world impact and challenges associated with laser therapy for SUI. This review also explores the cost-effectiveness of laser therapy and compares its long-term and short-term effects, positioning it within the broader landscape of SUI management. Future trends and ongoing research are outlined, highlighting the potential integration of laser therapy with multimodal approaches. Recommendations for clinical practice emphasize patient selection criteria and address concerns and expectations, ensuring laser therapy is adopted as a valuable and evidence-based addition to SUI management.

Thermo-Ablative Fractional CO2 Lasers Combined with 1540 nm Wavelengths Is a Promising Treatment Option in Stress Urinary Incontinence

Background/Objectives: Stress urinary incontinence (SUI) is a common and often under-reported condition that significantly impacts quality of life. SUI is more than just a physical issue; it can also affect social interactions, mental health, and emotional well-being due to the embarrassment and limitations it can cause. SUI is often acquired during pregnancy and childbirth as a result of pelvic floor muscle weakness. The aim of this study was to evaluate the effectiveness of an innovative dual-wavelength laser system (CO2 + 1540 nm) in SUI management. Methods: A total of 56 women affected by SUI were enrolled in this study. Half of the patients were treated with CO2 alone, while the other half were treated with the combination of CO2 + 1540 nm wavelengths. The patients were split into four groups based on the type of treatment they received and their menopausal status. Data were acquired at baseline and at various follow-ups (T1, T2, and T3, respectively, after the first, second, and third treatment). The Visual Analog Scale (VAS) (score 0-10) was used. Cystoscopic images were acquired before and at the end of the laser treatment cycle. Results: At the end of the treatment, the patients in each group were very satisfied, on average. In each group, the treatment led to a statistically significant improvement in the SUI VAS score between baseline and follow-up after the first treatment; in both groups 3 and 4, the treatment led to a significant change in the dryness score, both from baseline to T1 (p < 0.05) and also for T2 and T3 compared to baseline. Finally, cystoscopic photos showed an evident increase in mucosa epithelial thickness after the laser treatment cycle. Conclusions: The use of a dual-wavelength laser system (CO2 + 1540 nm) was proven to be well tolerated and safe, with promising outcomes in reducing SUI symptoms, especially in non-menopausal patients.

The Effect of Vaginal Er:YAG Laser Therapy on Pelvic Floor Symptoms in Women With Stress Urinary Incontinence: A Single-Center Cohort Study

OBJECTIVES

To examine the effect of vaginal erbium:yttrium-aluminum-garnet (Er:YAG) laser therapy on pelvic floor symptoms in women with stress urinary incontinence (SUI).

METHODS

This was a prospective, single-arm interventional study applying three Er:YAG laser treatments to patients with SUI. The German version of the validated Australian Pelvic Floor Questionnaire was used to quantify pelvic floor symptoms (bladder function, bowel function, sexual function, pelvic organ prolapse) over different time points (baseline, posttreatment, 3 months, and 6 months after treatment). Subgroups were compared to examine which factors influenced symptom development after the treatment.

RESULTS

A total of 50 women received three Er:YAG laser treatments and had their symptoms evaluated at all time points of the study. All symptom complex scores, especially bladder function and sexual function, showed statistically significant improvements lasting for the whole study period. However, score improvements of bowel function and prolapse symptoms were likely not clinically meaningful, as they were below the minimal important difference (MID) of this questionnaire. Moreover, sexual function scores improved less when women additionally had urgency symptoms (i.e., mixed urinary incontinence [MUI]; p = 0.036).

CONCLUSION

Vaginal Er:YAG laser therapy has the potential to improve pelvic floor symptoms linked to bladder function and sexual function in women with SUI. However, the positive effect on sexual function was lower if the women had MUI.

Exploring the Impact of Non-Ablative Erbium Laser Therapy on Recurrent Vaginal Candidiasis

OBJECTIVES

To assess the effect of non-ablative Er:YAG laser therapy on the symptoms and microbiological conditions of women with recurrent vulvovaginal candidiasis (RVVC).

MATERIALS AND METHODS

One hundred and sixty-seven women (mean age 34.1 ± 8.57 years) participated in this cohort study. Women diagnosed with RVVC received four vaginal laser therapies within 4 months. At baseline, 3 months, and 9 months after the last laser therapy microbiological assessment, improvement of five bothersome symptoms related to vaginal infection (burning, itching, dyspareunia, dysuria, and abnormal discharge), and the safety of the laser therapy and overall patient satisfaction were assessed.

RESULTS

Non-ablative vaginal Er:YAG laser therapy resulted in improvements of all bothersome symptoms and was statistically significant at 3 and 9 months following the therapy. A complete resolution in symptoms (VAS = 0) was observed in 38%-74% of women, depending on the symptom. Nine months after therapy, the prevalence of Candida albicans dropped from 80% to 30%, and a complete elimination of pathogens was detected in 64% of the women. The laser therapy appeared to be effective in the elimination of non-albicans Candida species. A total of 86% of the patients reported being satisfied or very satisfied with the therapy. Only minor and transient adverse effects were recorded during the study.

CONCLUSION

Non-ablative vaginal Er:YAG laser therapy proved to be a promising treatment for RVVC in women. The effect was achieved by improving their vaginal health by lowering the load of pathogenic yeast and by promoting the restoration of a favorable environment for normal microflora.

Hyaluronic acid and erbium laser for the treatment of genitourinary syndrome of menopause

OBJECTIVE

This study aimed to evaluate the effect of the vaginal erbium laser (VEL) in association with vaginal hyaluronic acid (HA) in postmenopausal women suffering from genitourinary syndrome of menopause (GSM).

METHODS

One hundred sexually active postmenopausal women were selected and divided into three groups using a block randomization method; 10 women declined to participate. The remaining women received three laser applications at 30-day intervals; 22 women dropped out for personal reasons or protocol violations. Group 1 (n = 25) received VEL treatment (XS Fotona Smooth®; Fotona, Slovenia) alone; Group 2 (n = 22) received daily vaginal HA tablets for 10 days after VEL treatment, followed by a twice a week administration during the follow-up period; and Group 3 (n = 21) received daily HA tablets for 10 days before the first VEL treatment and for 10 days after each laser application, followed by a twice a week administration for the follow-up period. Vaginal dryness and dyspareunia were assessed at the screening visit, before VEL treatment, after 1 and 3 months from the last laser treatment, using the visual analog scale. Data were analyzed using one-way analysis of variance and a linear mixed model for repeated measures. The post-hoc test for the interaction between time and treatment was performed using Bonferroni correction.

RESULTS

A significant (p < 0.001) improvement in both vaginal dryness and superficial dyspareunia was evident, with greater (p < 0.001) improvement in Group 2 and Group 3.

CONCLUSIONS

The results suggest that vaginal HA administration can improve the VEL effects on GSM in postmenopausal women.

Conservative treatments for women with stress urinary incontinence: a systematic review and network meta-analysis

Objective

This study aimed to compare the effectiveness of various conservative treatment strategies for women with stress urinary incontinence.

Methods

A comprehensive search of PubMed, Web of Science, Embase, and the Cochrane Library was conducted from their inception through March 2024, without restrictions on language or location. Randomized controlled trials (RCTs) comparing the efficacy of conservative treatments for stress urinary incontinence, using short-term pad test or the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) score as outcome measures, were included. We conducted a network meta-analysis using a random-effects model to compare the effectiveness of different conservative treatment strategies, employing prediction interval plots and league tables, and ranked them according to the surface under the cumulative ranking curve (SUCRA). The quality of the included studies was assessed following the Cochrane Handbook for Systematic Reviews of Interventions.

Results

A total of 31 RCTs involving 1,900 patients across 8 intervention categories were included in the analysis. SUCRA rankings indicated that electrical stimulation (SUCRA = 95.9%) was the most effective therapy for improving ICIQ-UI SF scores, followed by biofeedback electrical stimulation (SUCRA = 84.9%), radiofrequency (SUCRA = 77.5%), biofeedback (SUCRA = 57.8%), magnetic stimulation (SUCRA = 45.3%), pelvic floor muscle training (SUCRA = 38.4%), Er: YAG laser (SUCRA = 37.4%), and CO2 laser (SUCRA = 7.4%). In terms of reducing urine leakage, the treatments were ranked in descending order as follows: Er: YAG laser (SUCRA = 97.5%), biofeedback electrical stimulation (SUCRA = 83.4%), biofeedback (SUCRA = 67.0%), radiofrequency (SUCRA = 59.5%), electrical stimulation (SUCRA = 48.4%), pelvic floor muscle training (SUCRA = 43.0%), magnetic stimulation (SUCRA = 27.8%), and CO2 laser (SUCRA = 21.4%). Based on the clustered rankings of the two metrics, biofeedback electrical stimulation was identified as the most effective therapy for improving stress urinary incontinence.

Conclusion

Based on the combined analysis of two indicators, we found that biofeedback electrical stimulation may be the optimal therapy for the conservative management of stress urinary incontinence.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42024569845.

The efficacy and feasibility of fractional CO2 laser therapy for the treatment of urinary incontinence: a multicentric case-control study

BACKGROUND

Female urinary incontinence is a significant public health problem. Conservative treatments require high patient compliance, while surgery often leads to more complications and recovery time. Our aim is to evaluate the efficacy of microablative fractional CO2 laser (CO2-laser) therapy in women with urinary incontinence (UI).

METHODS

This is a retrospective analysis of prospectively collected data on women with stress urinary incontinence (SUI) and mixed urinary incontinence (MUI) with predominant SUI subjected to four sessions of CO2-laser therapy performed once a month, between February 2017 and October 2017, with a 12-month follow-up. The subjective Visual Analogue Scale (VAS) 0-10 was used to score and variables were evaluated at baseline and at one, six and 12 months after initiation of therapy. Finally, results were compared to a control group.

RESULTS

The cohort consisted of 42 women. The proportion of patients with vaginal atrophy among those younger than 55 years was substantially lower (3/23; 13%) than among those older than 55 years (15/19; 78.9%). CO2 laser treatment was associated with a significant improvement in VAS scores recorded one-month, six-months, and one-year, after conclusion of therapy (P<0.001). VAS scores improved significantly in patients with either SUI (26/42; 61.9%) or mixed UI (16/42; 38.1%). No major post treatment complications were registered. Women with vaginal atrophy demonstrated significantly better results (P<0.001).

CONCLUSIONS

Results confirm the efficacy and a good safety profile, for CO2 laser treatment in SUI, mostly in women with postmenopausal vaginal atrophy and should be considered as a treatment option for female patients with concomitant SUI and vaginal atrophy.

Double-blind randomized controlled trial of Er: YAG vaginal laser to treat female stress urinary incontinence

BACKGROUND

Stress urinary incontinence affects approximately 40% of adult females and is often treated surgically. Minimally invasive vaginal laser therapy to treat stress urinary incontinence has become widely available, but the efficacy of this novel therapy is unclear.

OBJECTIVE

This study aimed to determine the efficacy of erbium-doped yttrium aluminum garnet laser as a therapy for stress urinary incontinence.

STUDY DESIGN

This was a double-blind randomized sham-controlled trial with 6-week and 6-month follow-ups at a single tertiary hospital setting with 144 adult female patients with symptomatic stress urinary incontinence. Each participant received 2 vaginal laser therapies 6 weeks apart, with patients randomized to either laser or sham. The primary outcome was patients' subjective reporting of no urinary incontinence at 6 months after treatment on question 3 of the International Consultation on Incontinence Questionnaire-Short Form. The secondary outcomes included objective measures of urine loss with 24-hour pad tests, 3 incontinence symptom questionnaires (Urogenital Distress Inventory-6, Incontinence Impact Questionnaire-7, and International Consultation on Incontinence Questionnaire-Short Form), 1 quality-of-life questionnaire (King's Health Questionnaire), and 1 sexual function questionnaire (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire).

RESULTS

Of 263 individuals approached, 76 of 144 individuals were randomized to the laser treatment group, and 68 of 144 individuals were randomized to the sham treatment group. There was no difference in the reported cure rate and the primary outcome at 6 months after treatment between the groups (laser treatment group: 0.0136; 95% confidence interval, 0.0006-0.0811; sham treatment group: 0.0000; 95% confidence interval, 0.0000-0.0666). Apart from a statistically significant difference noted at 6 weeks after treatment in 1 of 3 incontinence questionnaires and 3 of 9 domains of the quality-of-life questionnaire, there were no other significant differences in our subjective or objective measures between the 2 groups at 6 weeks and 6 months after treatment.

CONCLUSION

Er: YAG laser was no more effective than sham for curing or improving female stress urinary incontinence at 6 months.

Update on Genitourinary Syndrome of Menopause: A Scoping Review of a Tailored Treatment-Based Approach

This scoping review explores the therapeutic strategies available for managing genitourinary syndrome of menopause (GSM), a condition often underdiagnosed and undertreated despite significantly affecting women's quality of life. GSM results from decreased estrogen levels during menopause, leading to a range of symptoms including vulvovaginal atrophy and urinary tract issues.

MATERIAL AND METHODS

we screened the literature for original studies with "menopause", "hormonal therapy", "vulvovaginal atrophy", "urinary incontinence", "urinary infections", "genitourinary syndrome".

RESULTS

A total of 451 relevant articles were retrieved. After screening, 19 articles were included in this scoping review.

DISCUSSION

First-line treatments typically include lubricants and moisturizers for short-term symptom relief, while unresolved or severe cases may warrant hormonal treatment. Topical hormonal treatments often have fewer side effects than systemic alternatives. Special attention is given to selective estrogen receptor modulators like ospemifene and steroid hormones like dehydroepiandrosterone (DHEA), which have shown beneficial effects on GSM symptoms. Moreover, innovative therapeutic approaches, such as laser treatment, are discussed in the context of their efficacy and accessibility. The safety of GSM hormonal therapy in women with a history or risk of cancer is also addressed, noting the need for more definitive research in this area. While there is a growing demand for tailored therapy, this scoping review emphasizes the importance of effective communication and counseling to allow women to make informed decisions about their treatment. Overall, this review underscores the need for increased awareness and further research into effective treatment options for GSM.

The Therapeutic Effect of Monopolar Radiofrequency Therapy on Urinary Symptoms and Sexual Function

Objectives: Stress urinary incontinence (SUI) negatively affects the quality of life and sexual function in women. This study aimed to evaluate the efficacy of radiofrequency (RF) therapy in reducing SUI symptoms and its impact on sexual function. Methods: Thirty-four women with SUI were enrolled and underwent a single RF treatment session using the Viveve® System (Viveve Medical Inc., USA) with parameters of 90 J/cm2 and 220 pulses per hour. Assessments at baseline and 6 months post treatment included perineal ultrasound and personal interviews to evaluate lower urinary tract symptoms and sexual function. Urodynamic studies, voiding diaries, and questionnaires such as the Female Sexual Function Index (FSFI), Overactive Bladder Symptom Score (OABSS), Urogenital Distress Inventory-6 (UDI-6), Incontinence Impact Questionnaire-7 (IIQ-7), and International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) measured outcomes. Results: RF therapy significantly improved sexual function, with higher FSFI scores in all domains except pain at 6 months. SUI symptoms were significantly reduced, as indicated by improved scores on OABSS, UDI-6, IIQ-7, and ICIQ-SF, alongside better voiding diary results. Anatomical changes included reduced bladder neck mobility, decreased vaginal width, and a reduced rotation angle of the proximal urethra. Conclusions: RF therapy is effective and safe for treating mild to moderate SUI and enhances sexual function, potentially due to changes in vaginal topography. These results suggest RF therapy as a viable non-surgical option for managing SUI and improving sexual health.

Lasers in Gynecology

The first published reports on the use of laser for cervical pathology date back to 1973. Technical advancements in flexible and rigid laser fibers revolutionized video laser laparoscopy in the 1990s. Fractionated lasers have been used to treat vulvovaginal symptoms associated with genitourinary syndrome of menopause, lichen sclerosus, and urinary incontinence. Review of available data suggests that fractionated lasers can improve both subjective and objective signs of vaginal atrophy and lichen sclerosus, but the evidence is weak because most of the trials are underpowered, are at risk for bias, and lack long-term follow-up. There is no strong evidence to support fractionated laser therapy for urinary incontinence or low-level laser therapy for chronic pelvic pain. Although short-term, single-arm trials suggest benefit of fractionated laser therapy for genitourinary syndrome of menopause, lichen sclerosus, and urinary incontinence, additional adequately powered, prospective, randomized, and longer-term comparative trials are needed before lasers can be recommended for these specific conditions. The purpose of this Clinical Expert Series is to review basic laser biophysics and the mechanism of action for modern fractionated lasers as relevant to the gynecologist. We also summarize safety and effectiveness data for lasers used for some of the most commonly studied gynecologic conditions: the vulvovaginal atrophy component of genitourinary syndrome of menopause, lichen sclerosus, and urinary incontinence.

The Treatment Selection for a 36-Year-Old Woman With Stress Urinary Incontinence Using a Discrete Mathematical Approach: A Case Report

This case report describes the treatment selection process for a 36-year-old woman with stress urinary incontinence (SUI) and an overactive bladder (OAB) who desired pregnancy. The patient had comorbidities of hypertension and type 2 diabetes, which required consideration to improve her quality of life and reproductive health. A recently developed decision support tool using a discrete mathematical approach was used to select a treatment method tailored to the patient's individual situation. The analysis determined that vaginal erbium laser (VEL) treatment (Renovalase SP Dynamis Fotona d.o.o, Ljubljana, Slovenia) was the most suitable for this patient. VEL treatment significantly improved both SUI and OAB and changing antihypertensive medication eliminated nocturia. This case suggests the potential application of graph theory in treatment selection for SUI patients.

Vaginal erbium laser treatment for stress urinary incontinence: A multicenter randomized sham-controlled clinical trial

OBJECTIVE

To evaluate the efficacy and safety of non-ablative vaginal Er:YAG laser device in stress urinary incontinence (SUI) treatment.

METHODS

We conducted a multicenter blinded randomized sham-controlled trial in which women with urodynamic SUI were randomization to active arm using Er:YAG laser therapy, and sham arm using sham handpiece. Patients received two treatments 1 month apart. The primary outcomes measure was 1 h pad weight test measured at 6 months. Secondary outcomes were durability of treatment success at 12 months, and questionnaires for assessment of SUI severity (ICIQ-UI SF), sexual function (PISQ-12) and HRQoL (KHQ), and incidence and severity of device related adverse events and pain (VAS).

RESULTS

A total of 110 participants with SUI were recruited; 73 in the active arm and 37 in the sham arm. Two participants were excluded; one was assigned the wrong treatment and one withdrew their consent. Treatment success was observed in 36% of the sham arm and 59% of the active arm; in the latter, odds of achieving treatment success were more than three-fold higher (OR 3.63, 95% CI: 1.3-11.2, P = 0.02). HRQoL by KHQ showed significant improvement in the active versus the sham arm (OR 0.36, 95% CI: 0.15-0.87, P = 0.003). Similarly, subjective patient assessment of general and sexual function improvement with PISQ-12 and PGI-I showed superior effect over sham (OR 2.8, 95% CI: 1.2-7.0, P = 0.02 and OR 0.13, 95% CI: 0.05-0.36, P < 0.001, respectively).

CONCLUSION

Non-ablative vaginal Er:YAG laser therapy significantly improves SUI symptoms versus sham treatment. Er:YAG laser therapy should be considered as a non-surgical treatment option for SUI patients.

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.

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).

SUI in postmenopausal women: advantages of an intraurethral + intravaginal Er:YAG laser

OBJECTIVE

This study aimed to compare the efficacy of concomitant application of an intraurethral (IU) + intravaginal (IV) non-ablative Erbium (Er):YAG laser with IV application in improving the symptoms of stress urinary incontinence (SUI) in women.

METHODS

This observational retrospective cohort study included 122 patients with SUI, 60 women in the IU + IV laser arm and 62 in the IV laser arm. The primary outcome was the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form score at entry and at 3, 6 and 12 months from baseline.

RESULTS

Demographic characteristics were comparable in both arms. Significant improvement in SUI symptoms was seen 3 months after the intervention and was sustained until the end of month 12 in both arms. The women who had severe SUI symptoms initially showed greater improvement. A higher number of women who initially had mild to moderate SUI symptoms were dry after treatment. Patients treated with IU + IV Er:YAG laser showed significant improvement in SUI symptoms compared to IV laser only, especially at postmenopausal state (p = 0.003).

CONCLUSIONS

The Er:YAG laser appears to be an efficient treatment method for SUI. Concomitant application of an IU + IV Er:YAG laser is more effective in relieving SUI symptoms at postmenopausal state.

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.

Applicability of vaginal energy-based devices in urogynecology: evidence and controversy

OBJECTIVE

This study aimed to analyze the evidence and controversies about the use of vaginal energy-based devices (laser and radiofrequency) for treatment of genitourinary syndrome of menopause, recurrent urinary tract infection, urinary incontinence, and genital prolapse through a literature review.

METHODS

A search of literature databases (PubMed, Medline) was performed for publications in December 2022. Keywords included genitourinary syndrome of menopause, vaginal laxity, vaginal/vulvovaginal atrophy, urinary tract infection, urgency incontinence, frequency, urgency, stress urinary incontinence, genital prolapses AND energy-based devices, AND vaginal laser, AND vaginal radiofrequency, AND CO2 laser, AND Er:YAG laser. Publications in English from the last 7 years were reviewed and selected by the authors.

RESULTS

The literature regarding vaginal energy-based devices in the treatment of urogynecological conditions is primarily limited to prospective case series with small numbers and short-term follow-up. Most of these studies showed favorable results, improvement of symptoms with low risk, or no mention of serious adverse events. Consensus statement documents from major medical societies suggest caution in recommending these therapies in clinical practice until more relevant data from well-designed studies become available.

CONCLUSION

The potential of the vaginal laser and radiofrequency as a therapeutic arsenal for the evaluated urogynecological conditions is great, but qualified research must be done to prove their efficacy and long-term safety, define application protocols, and recommend the use of these technologies in clinical practice.

Evaluation of Possible Side Effects in the Treatment of Urinary Incontinence with Magnetic Stimulation

Background and Objectives: Magnetic stimulation is a type of conservative treatment of urinary incontinence. Our aim was to evaluate the possible side effects of this method. Materials and Methods: We conducted a systematic literature review. The key search terms were urinary incontinence, magnetic stimulation, and female. All known synonyms were used. Results: 255 titles and abstracts were retrieved, and 28 articles met our inclusion criteria. Out of 28 studies, 15 reported no side effects, five reported side effects, and eight did not report anything. There was no significant difference in the incidence of side effects between the sham and active treatment groups. Conclusions: Side effects of magnetic stimulation in comparison to other active treatments are minimal and transient. Among the conservative UI treatment methods, magnetic stimulation is one of the safest methods for the patient and as such a suitable first step in treating UI.

The efficacy of CO2 laser in the treatment of genitourinary syndrome of menopause: a systematic review and meta-analysis of randomized controlled trials

CO₂ laser has been proposed as a treatment strategy for genitourinary syndrome of menopause (GSM). In order to assess its efficacy for treating GSM, we conducted a systematic review and meta-analysis. To identify the current state of randomized controlled trials on CO₂ laser therapy for GSM, a literature review was conducted. We systematically searched the following databases: PUBMED, EMBASE and the Cochrane Controlled Trials Register. In addition, a review of the references in the retrieved studies was carried out. Of 562 identified studies, 9 were eligible and were included in our analysis, involving 523 patients in total. Based on our analysis, CO₂ laser has no statistical difference compared with estrogen in VHI (p = 0.87), FSFI total score (p = 0.19), FSFI-Arousal (p = 0.11), FSFI-Desire (p = 0.72), FSFI-Orgasm (p = 0.45) and FSFI-Satisfaction (p = 0.08). The meta-analysis also showed that CO₂ laser significantly improved FSFI-Lubrication scores compared with estrogen therapy (p = 0.0004). Furthermore, compared with the sham group, CO₂ laser group had statistically improved VHI scores (p = 0.003) and FSFI scores (p < 0.00001). CO₂ laser therapy may be an effective alternative to estrogen therapy for GSM both in cases where estrogen is not applicable because of comorbidities and in cases in which women do not desire to take estrogen.

Treating and Managing Urinary Incontinence: Evolving and Potential Multicomponent Medical and Lifestyle Interventions

Incontinence is defined by either ICS 2002 or IUGA/ICS 2010 as the involuntary loss of urine and includes urgency urinary incontinence (UUI), stress urinary incontinence (SUI) or mixed urinary incontinence (MUI). It has a high worldwide prevalence with an associated impact on quality of life. Despite existing management options for the management of urinary incontinence, patients continue to be troubled by symptoms or side effects of existing treatment. There is therefore a requirement for ongoing research into treatment options for the management of UUI and SUI, that are more effective and tolerable to patients. Advances in treatment of UUI include a more selective beta 3 agonist, Vibegron, which has less impact on cardiac function than Mirabegron. Hormonal treatment, including Ospemifene and Prasterone, may improve GSM and in turn symptoms of UUI. There are advances in the types of neuromodulators available, including those that are rechargeable at home and are MRI safe. Laser has shown promising initial results. There is developing interest in the microbiome, and how this may impact future treatment modalities. Advances in treatment of SUI include the use of mobile health applications to support delivery of pelvic floor muscle training. Litoxetine, a selective serotonin reuptake inhibitor, has shown promising results at phase III trials. Functional magnetic stimulation is being developed to improve contractility of pelvic floor muscles. We also discuss interventions that improve tissue elasticity and regeneration, such as platelet rich plasma, autologous stem cell transplantation, laser therapy and radiofrequency treatment, which show short term benefits.

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.

Effect of vaginal energy-based treatment on female stress urinary incontinence: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

To evaluate the efficacy and safety of vaginal energy-based therapies in treating female SUI.

METHODS

The PubMed, EMBASE, Web of Science, and Scopus databases were searched up to September 2022 to identify RCTs comparing energy-based therapies with placebo intervention in treating female SUI. The primary outcome was International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score. Secondary outcomes included the 1-h pad test and cure rate.

RESULTS

A total of 577 patients from 6 studies were included in the meta-analysis. Energy-based therapies did not significantly improve the ICIQ-SF score at all visits (≤ 1 month: SMD, -0.39; 95% CI - 0.80 to 0.03; P = 0.07; 3 months: SMD, - 1.32; 95% CI - 4.07 to 1.43; P = 0.35; 6 months: SMD, - 0.39; 95% CI - 0.91 to 0.12; P = 0.14). The subgroup analysis showed that there was no significant improvement in ICIQ-SF score in the CO₂ laser group compared to the placebo group at all visits (≤ 1 month: SMD, - 0.13; 95% CI - 0.59 to 0.34; P = 0.59; 3 months: SMD, - 1.50; 95% CI - 3.91 to 0.92; P = 0.22; 6 months: SMD, 0.13; 95% CI - 0.47 to 0.72; P = 0.67). Meta-analysis was not performed in Er: YAG laser and radiofrequency therapy due to insufficient trials.

CONCLUSION

Based on the limited clinical evidence, our meta-analysis showed no prior efficacy of energy-based therapy over placebo intervention. However, the results of this meta-analysis should be taken with caution due to the limited amount of available evidence and the heterogeneity among the included studies.

PROSPERO REGISTRATION NUMBER

CRD42022360471.

Superficial dyspareunia treatment with hyperstacking of erbium:yttrium-aluminum-garnet SMOOTH laser: a short-term, pilot study in breast cancer survivors

OBJECTIVE

This prospective pilot study aimed to evaluate the effects of a modified vaginal erbium laser (VEL) protocol, using the hyperstack mode on the vaginal vestibulum and introitus to treat superficial dyspareunia in postmenopausal breast cancer survivors suffering from the genitourinary syndrome of menopause.

METHODS

In this pilot, prospective, randomized study, two groups of postmenopausal women suffering from superficial dyspareunia were included: 34 women (VEL group) were treated with erbium laser crystal yttrium-aluminum-garnet (XS Fotona SMOOTH; Fotona, Ljubljana, Slovenia) with a wavelength of 2,940 nm; for the other 34 (hyperstack group), a modified second step of the VEL protocol for the treatment of vestibulum and introitus was used, with hyperstacked (repeating a number of) subablative, long pulses with very low fluences. For each group, three laser applications at 30-day intervals were performed. Symptoms were assessed before, after each application, and after 1 and 3 months from the last laser application, using the visual analog scale score for superficial dyspareunia.

RESULTS

Superficial dyspareunia improved in both groups over time (P < 0.001), regardless of age and years since menopause status. The reduction in visual analog scale score after the third laser application was 58% in VEL versus 73.5% in hyperstack. The hyperstack group, since the first laser application, showed a greater (P < 0.001) and persistent improvement of superficial dyspareunia.

CONCLUSIONS

The hyperstack treatment of the introitus and vestibulum in breast cancer survivors leads to a more significant improvement in superficial dyspareunia than the VEL alone.

The efficacy and safety of a single maintenance laser treatment for stress urinary incontinence: a double-blinded randomized controlled trial

INTRODUCTION AND HYPOTHESIS

To evaluate the efficacy and safety of a single carbon dioxide (CO₂) laser maintenance treatment in women previously treated successfully with laser for stress urinary incontinence (SUI), who have demonstrated a decline in treatment effect.

METHODS

Women aged 40-70 years who experienced temporary significant improvement in symptoms following CO₂ laser treatments for SUI were randomized to either the treatment group or the sham treatment control group. Cough test results, 1-h pad weights and scores on the Urogenital Distress Inventory (UDI6), the International Consultation of Incontinence Questionnaire (ICIQ-UI) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) were obtained at baseline and 3 and 6 months.

RESULTS

Of 183 women screened, 131 were included in the final analysis. Demographic characteristics and baseline measures in the outcome tests were similar between the groups. Statistically significant improvements were demonstrated in the study compared to the control group at 3 months post-treatment in positive cough test (44.4% vs. 79.4%, P = 0.002), mean pad weight test (2.3 g ± 1.3 vs. 5.6 ± 1.1, P < 0.001), mean UDI-6(24.7 ± 12.1 vs. 45.1 ± 13.6 SD, P = 0.004), mean ICIQ-UI (16.5 ± 4.3 vs. 10.3 + 3.8, P = 0.003) and mean PISQ-12 (21.3 ± 6.8 vs. 36.6 ± 7.5, P = 0.003). However, values at 6 months post-treatment were similar to those at baseline.

CONCLUSIONS

Our results suggest that a single maintenance laser treatment for reducing symptoms of SUI is transiently effective, well tolerated and safe. This treatment modality provides alternative non-surgical therapy for women with SUI.

Vaginal Laser Therapy for Stress Urinary Incontinence: A Systematic Review of Prospective Randomized Clinical Trials

The most common type of urinary incontinence in women is stress urinary incontinence (SUI) which negatively impacts several aspects of life. The newly introduced vaginal laser therapy is being considered for treating SUI. This systematic review aimed to evaluate the efficacy of vaginal laser therapy for stress urinary incontinence in menopausal women. We searched the following databases: MEDLINE (via PubMed), EMBASE, Cochrane Library databases, Web of Science, clinical trial registry platforms, and Google Scholar, using the MeSH terms and keywords [Urinary Incontinence, Stress] and [(lasers) OR laser]. In our systematic review, prospective randomized clinical studies on women diagnosed with SUI as per the International Continence Society's diagnostic criteria were included. The Cochrane Risk-of-Bias assessment tool for randomized clinical trials was used to evaluate the quality of studies. A total of 256 relevant records in literature databases and registers and 25 in additional searches were found. Following a review of the titles, abstracts, and full texts, four studies involving 431 patients were included. Three studies used CO2-lasers, and one used Erbium: YAG-laser. The results of all four studies revealed the short-term improvement of SUI following both the Erbium: YAG-laser and CO2-laser therapy. SUI treatment with CO2-laser and Erbium: YAG-laser therapy is a quick, intuitive, well-tolerated procedure that successfully improves incontinence-related symptoms. The long-term impact of such interventions has not been well established as most trials focused on the short-term effects.

Clinical Consensus Statement: Vaginal Energy-Based Devices

ABSTRACT

This clinical consensus statement on vaginal energy-based devices (EBDs) reflects an update by content experts from the American Urogynecologic Society's EBD writing group. In 2019, the American Urogynecologic Society's EBD writing group used a modified Delphi process to assess statements that were evaluated for consensus after a structured literature search. A total of 40 statements were assessed and divided into 5 categories: (1) patient criteria, (2) health care provider criteria, (3) efficacy, (4) safety, and (5) treatment considerations. Of the 40 statements that were assessed, 28 reached consensus and the remaining 12 did not. Lack of evidence was among the main reasons that vulvovaginal EBD treatment statements did not reach consensus. In March 2022, these statements were reassessed using the interim literature.

CO2 surgical laser for treatment of stress urinary incontinence in women: a randomized controlled trial

BACKGROUND

Stress urinary incontinence is a common condition that can be treated conservatively and/or surgically. Given the risks of surgery, developing effective nonsurgical treatment options would be beneficial. Some studies have suggested that laser therapy may improve or cure stress urinary incontinence. However, there is a lack of sham-controlled randomized controlled trials to judge treatment efficacy.

OBJECTIVE

This study aimed to compare the effects of CO₂ vaginal laser vs sham therapy for treating stress urinary incontinence.

STUDY DESIGN

This was a multicenter, participant-blinded, sham-controlled, parallel group (1:1) superiority randomized controlled trial performed in outpatient clinics in 2 hospitals. We included women aged 18 to 80 years with objective and subjective stress urinary incontinence. Participants had undertaken or declined supervised pelvic floor muscle training. Intervention was performed using a CO₂ fractionated vaginal laser. Participants underwent 3 treatments, 4 weeks apart, with increasing energy and density settings. Sham treatment was performed using an identical technique with a deactivated pedal. The primary outcome was the subjective stress urinary incontinence rate (proportion with leak with cough, sneeze, or laughter) at 3 months after completion of treatment. Secondary outcomes included objective stress urinary incontinence, change in the disease-specific patient-reported outcomes, health-related quality of life, and adverse effects. Categorical outcomes were compared using the chi square test and continuous outcomes using analysis of covariance, adjusting for the baseline score.

RESULTS

There were 52 participants who received laser and 49 who received sham treatment. One participant in each group withdrew from the study before the endpoint, and 2 participants in the laser group did not participate in the follow-up visits. Participant mean age was 53 (34-79) years. Mean body mass index was 26.1 (18.1-49.6); 90% were vaginally parous. At 3 months, there was no difference between the sham and active treatment arm in subjective stress urinary incontinence (46 [96%] vs 48 [98%]; relative risk, 0.98 [95% confidence interval, 0.91-1.05]; P=.55) or in objective stress urinary incontinence (37 [80%] vs 33 [80%]; relative risk, 0.99 [95% confidence interval, 0.81-1.23]; P=.995). Patient-reported outcomes and health-related quality of life were also comparable between the groups. Vaginal bleeding occurred in 3 participants after laser and 1 participant after sham treatment. Pain during treatment did not differ between laser and sham treatment.

CONCLUSION

We were unable to show an improvement in stress urinary incontinence after CO₂ vaginal laser therapy compared with sham treatment.

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.

Morphological and histological changes in the urethra after intraurethral nonablative erbium YAG laser therapy: an experimental study in beagle dogs

The purpose of this study was to investigate the morphological and histological changes in the urethra in beagle dogs after intraurethral Er:YAG laser irradiation in nonablative mode to confirm the safety of this therapy. Six 2-year-old healthy female virgin beagle dogs (13 ± 1.51 kg) were used in this study. The animals were divided into 2 groups: the sham group, which received sham treatment (n = 3) involving insertion of an intraurethral cannula and laser delivery handpiece into the urethra without laser irradiation, and the experimental group (n = 3), which received intraurethral Er:YAG laser irradiation. The laser irradiation parameters were set according to clinical criteria (4 mm spot size, 1.5 J/cm², 1.4 Hz, and 4 pulses) in nonablative mode. All animals received three sequential sessions at 4-week intervals. Urethrography and urethroscopy were performed in the 12th week and 13th week, respectively, after the first treatment. After urethroscopy, the animals were sacrificed, and urethral tissue was harvested for histological investigations. All procedures were performed under general anesthesia (40 mg/kg 3% sodium pentobarbital, i.v.). Transforming growth factor β1 (TGF-β1) and α-smooth muscle actin (α-SMA) expression levels were measured to evaluate the biochemical characteristics of the scar. Urethral stricture was not found by urethrography or urethroscopy in either group. Urethral epithelium thickness and collagen expression under the urethral mucosa were significantly increased in the experimental group compared with the sham group. However, there were no significant differences in TGF-β1 and α-SMA expression between the experimental group and sham group (p > 0.05). Urethral stricture is not found in beagle dogs after clinically relevant intraurethral nonablative mode Er:YAG laser irradiation. Proliferation of urethral collagen and the urethral mucosa may be one of the mechanisms by which urine leakage symptoms can be improved.

Analysis of Characteristics and Quality of Life of Elderly Women with Mild to Moderate Urinary Incontinence in Community Dwellings

Introduction: The incidence of urinary incontinence (UI) increases with age. Mild and moderate UI have little impact on women and are easily ignored. This study reports the characteristics of non-severe UI and quality of life (QOL) in elderly women using data from a Development and Evaluation of a Senile UI Alert System study. Methods: 926 women aged ≥60 were enrolled from six subcenters across China, among whom 717 SUI patients and 209 UUI/MUI patients were grouped into Group A and Group B, respectively, according to leakage symptoms. Demographic and clinical data, pelvic organ prolapse quantification and pelvic floor muscle strength measurement (PFMS) were collected from participants, followed by evaluation of QOL and sexual life. Result: The major type of UI in community women was SUI (77.4%); MUI and UUI accounted for 20.63% and 1.94%, respectively. Weakened PFMS was detected in 78.2% of the participants. Group B was significantly higher in terms of median age, weight, BMI, waist circumference and menopausal years, and had the greater UI severity and impact on QOL, as well as less active sex live than group A (p < 0.05). Conclusion: SUI distributes dominantly in elderly community women, but UUI/MUI has greater impact on QOL and is related to a less active sex life, which requires more attention from medical staff.

Vaginal Laser Therapy for Female Stress Urinary Incontinence: New Solutions for a Well-Known Issue-A Concise Review

Background and Objectives: Insufficient connective urethra and bladder support related to childbirth and menopausal estrogen decrease leads to stress urinary incontinence (SUI). The aim of this review is to narratively report the efficacy and safety of new mini-invasive solutions for SUI treatment as laser energy devices, in particular, the microablative fractional carbon dioxide laser and the non-ablative Erbium-YAG laser. Materials and Methods: For this narrative review, a search of literature from PubMed and EMBASE was performed to evaluate the relevant studies and was limited to English language articles, published from January 2015 to February 2022. Results: A significant subjective improvement, assessed by the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-UI-SF) was reported at the 6-month follow up, with a cure rate ranged from 21% to 38%. A reduction of effect was evidenced between 6 and 24-36 months. Additionally, the 1-h pad weight test evidence a significant objective improvement at the 2-6-month follow up. Conclusions: SUI after vaginal laser therapy resulted statistically improved in almost all studies at short-term follow up, resulting a safe and feasible option in mild SUI. However, cure rates were low, longer-term data actually lacks and the high heterogeneity of methods limits the general recommendations. Larger RCTs evaluating long-term effects are required.

Short-term effects of an erbium/neodymium laser combination in superficial dyspareunia: a pilot study

OBJECTIVE

This prospective pilot study aimed to evaluate the effects of associating a neodymium:yttrium-aluminum-garnet (Nd:YAG) laser with a vaginal erbium laser (VEL), as a non-ablative photothermal therapy for superficial dyspareunia in postmenopausal women (PMW) suffering from genitourinary syndrome of menopause (GSM).

METHODS

Two groups of sexually active PMW reporting superficial dyspareunia were selected: one (15 patients, VEL) was treated using an erbium:yttrium-aluminum-garnet laser crystal (XS Fotona SMOOTH; Fotona, Ljubljana, Slovenia) with a wavelength of 2940 nm; in the other group (15 patients, VEL + Nd:YAG) this treatment was followed by Nd:YAG laser (Fotona SP Dynamis, PIANO mode) treatment. Treatment consisted of three laser applications at 30-day intervals. Symptoms were assessed before, after each laser application and after 1 and 3 months from the end of the treatment, using the subjective visual analog scale (VAS) for superficial dyspareunia.

RESULTS

Both groups showed a rapid and significant improvement of superficial dyspareunia over time (p < 0.001) independently from age and years since menopause. The VEL + Nd:YAG group showed a greater improvement of superficial dyspareunia (p < 0.001); this difference was evident since the first treatment and remained stable over time.

CONCLUSIONS

The addition of Nd:YAG to VEL may induce greater improvement in superficial dyspareunia in PMW with GSM.

Vaginal erbium laser for treatment of stress urinary incontinence: optimization of treatment regimen for a sustained long-term effect

Stress urinary incontinence (SUI) is a common health problem that affects roughly 35% of women in the reproductive period. A prospective uncontrolled study was conducted to assess the long-term efficacy and safety of a non-ablative Er:YAG laser treatment of SUI. Forty-three patients participated in the study. All women underwent three sessions of IncontiLase® procedure, and efficacy of laser treatment was assessed by 1-h pad test, 24-h pad test, 3-day voiding diary, and ICIQ-UI SF questionnaire at multiple follow-ups. Statistical analysis was performed using one-way repeated measures ANOVA. Patients were questioned about discomfort during treatment and any adverse events following the laser procedures. All outcome measures showed a significant change over a period of the entire clinical trial. Eighteen-month follow-up revealed a fading of the effect, which was alleviated by single-session maintenance treatments every 6 months. There were no serious adverse events reported during the study. All reported side effects were mild and transient. The application of non-ablative Er:YAG laser for SUI treatment significantly improves the SUI symptoms. High improvement rates and patient satisfaction can be maintained with single-session maintenance treatments performed every 6 months. Long-term safety profile of multiple non-ablative Er:YAG laser treatment is shown. NCT04348994, 16.04.2020, retrospectively registered.

The placebo and nocebo effects in functional urology

A placebo is an inert substance normally used in clinical trials for comparison with an active substance. However, a placebo has been shown to have an effect on its own; commonly known as the placebo effect. A placebo is an essential component in the design of conclusive clinical trials but has itself become the focus of intense research. The placebo effect is partly the result of positive expectations of the recipient on the state of health. Conversely, a nocebo effect is when negative expectations from a substance lead to poor treatment outcomes and/or adverse events. Randomized controlled trials in functional urology have demonstrated the importance of the placebo and nocebo effects across different diseases such as overactive bladder, urinary incontinence, lower urinary tract symptoms and interstitial cystitis/painful bladder syndrome, as well as male and female sexual dysfunction. Understanding the true nature of the placebo-nocebo complex and the scope of its effect in functional urology could help urologists to maximize the positive effects of this phenomenon while minimizing its potentially negative effects.

The Use of Platelet-rich Plasma as a Novel Nonsurgical Treatment of the Female Stress Urinary Incontinence: A Prospective Pilot Study

OBJECTIVES

The aim of the study was to evaluate the efficacy and safety of platelet-rich plasma (PRP) for the treatment of stress urinary incontinence (SUI).

METHODS

This was a prospective observational pilot study conducted in a tertiary referral unit, enrolling women with SUI booked for SUI surgery. A total of 20 consecutive women met the inclusion criteria and attended all follow-ups. All participants underwent 2 PRP injections into the lower one third of the anterior vaginal wall at 4- to 6-week intervals. At baseline, they underwent urodynamic studies, a 1-hour pad test, and completed the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms and King's Health Questionnaire. At follow-up visits (1, 3, and 6 months), patients underwent the 1-hour pad test and completed the King's Health Questionnaire, International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms, and Patient Global Impression Scale of Improvement. Primary outcome was to evaluate posttreatment SUI. Secondary outcomes included assessment of patient-reported questionnaires, assessment of urine loss (1-hour pad test), and the level of discomfort during injections (visual analog scale score). Statistical analysis was performed before PRP and 1, 3, and 6 months after the last treatment.

RESULTS

A significant improvement in SUI symptoms was observed 3 months after treatment with a further improvement at 6 months. A mean reduction of 50.2% in urine loss was observed in the 1-hour pad test. At the 6-month follow-up, 80.0% of women reported to be at least improved. No adverse effects were observed.

CONCLUSIONS

Platelet-rich plasma injections were both effective and safe at least in the short term and could be offered as an alternative outpatient procedure for the treatment of SUI. However, these encouraging findings warrant further investigation with randomized controlled trials.

Safety of vaginal erbium laser: A review of 113,000 patients treated in the past 8 years

Background: Energy-based devices are becoming a popular option for minimally invasive vaginal procedures. The aim of this study was to obtain information on the frequency of occurrence of adverse effects (AEs) related to vaginal erbium laser (VEL™) treatment.Materials and methods: The global survey was conducted among practitioners using the non-ablative VEL™ (Fotona, Ljubljana, Slovenia). Users were invited to provide the number of patients treated with VEL™ and the number of observed laser-related AEs.Results: The survey was conducted from August 2018 to April 2019. Responses from 535 practitioners were collected, with a total of 113,174 patients treated in the period from 2012 to 2019. Out of 535 respondents, 160 (30%) shared detailed information about the indications they treated in a population of 62,727 patients, whereas 188 (35%) respondents provided information on the frequency of AEs observed in their treated population of 43,095 patients. All observed AEs were mild to moderate, transient and appeared with low frequencies.Conclusions: Minimally invasive thermal-only laser treatment using the non-ablative VEL™ procedures appears to be safe and the incidence of AEs is low.

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.

Characteristics of Non-Ablative Resurfacing of Soft Tissues by Repetitive Er:YAG Laser Pulse Irradiation

Background and Objectives

Recently, several minimally invasive gynecological, ENT and esthetic procedures have been introduced that are based on delivering “smooth” sequences of Er:YAG laser pulses to cutaneous or mucosal tissue at moderate cumulative fluences that are not only below the ablation threshold but typically also do not require local anesthesia.  To explain the observed clinical results using “smooth‐resurfacing,” it has been suggested that in addition to the direct heat injury to deeper‐lying connective tissues, there is an additional mechanism based on indirect triggering of tissue regeneration through short‐exposure, intense heat shocking of epithelia. The goal of this study is to improve understanding of the complex dynamics of the exposure of tissues to a series of short Er:YAG laser pulses, during which the thermal exposure times transition from extremely short to long durations.

Study Design/Materials and Methods

A physical model of laser‐tissue interaction was used to calculate the temperature evolution at the irradiated surface and deeper within the tissue, in combination with a chemical model of tissue response based on the recently introduced variable heat shock (VHS) model, which assumes that the tissue damage represents a combined effect of two limiting Arrhenius′ processes, defining cell viability at extremely long and short exposure times. Superficial tissue temperature evolution was measured during smooth‐resurfacing of cutaneous and mucosal tissue, and compared with the model. Two modalities of non‐ablative resurfacing were explored: a standard “sub‐resurfacing” modality with cumulative fluences near the ablation threshold, and the “smooth‐resurfacing” modality with fluences below the patient′s pain threshold. An exemplary skin tightening clinical situation was explored by measuring pain tolerance threshold fluences for treatments on abdominal skin with and without topical anesthesia. The obtained temperature data and pain thresholds were then used to study the influence of Er:YAG laser sequence parameters on the superficial (triggering) and deep (coagulative) tissue response.

Results

The simulations show that for the sub‐resurfacing modality, the parameter range where no excessive damage to the tissue will occur is very narrow. On the other hand, using pain tolerance as an indicator, the smooth‐resurfacing treatments can be performed more safely and without sacrificing the treatment efficacy. Two preferred smooth‐resurfacing treatment modalities were identified. One involves using optimally long pulse sequence durations (≈1–3 seconds) with an optimal number of pulses (N ≈ 10–30), resulting in a maximal short‐exposure superficial tissue response and moderate coagulation depths. And for deeper coagulation, without significant superficial heat shocking, very long pulse sequences (>5 seconds) with a large number of delivered pulses are to be used in combination with topical anesthesia.

Conclusions

A comparison of the simulations with the established smooth‐resurfacing clinical protocols in gynecology, ENT, and esthetics suggests that, through clinical experience, the clinical protocols have been optimized for the maximal superficial heat shock triggering effect. Further research is needed to gain a better understanding of the proposed role of heat shock triggering in the clinically observed regeneration of cutaneous, vaginal, and oral tissues following Er:YAG laser smooth‐resurfacing. Lasers Surg. Med. © 2021 The Authors. Lasers in Surgery and Medicine published by Wiley Periodicals LLC.

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 therapy for genito-urinary disorders: A systematic review and statement from the Committee for Female Urology and Pelviperineology of the French Association of Urology]

INTRODUCTION

Vaginal LASER therapy is increasingly used in the field of urogynecology, but several points remain unclear. Our goal was to produce a systematic review of available evidence and provide a critical appraisal of available data.

METHODS

A systematic review until march 2020 was conducted using PubMed/MEDLINE, Cochrane and Embase databases. All studies about vaginal LASER use in the field of urogynecology were included.

RESULTS

Forty studies have been included (8 for genitourinary syndrome of menopause, 19 for stress urinary incontinence, 3 for overactive bladder, 7 for urogenital prolapse, 3 for other indications). Data were heterogeneous, and level of evidence was weak or very weak. Few studies were comparative, and only 3 were randomized). Mild improvement of symptoms and quality of life and limited satisfaction were seen for genitourinary syndrome, stress urinary incontinence, overactive bladder and prolapse. Few adverse events were reported. However, major methodological biases were noted regarding efficacy and safety evaluation. No long-term results were available.

CONCLUSIONS

While Vaginal LASER therapy seem to provide encouraging results, the level of evidence supporting its use was weak, especially regarding long-term outcomes. Studies of better quality are warranted before any recommendation can be made. Current use should be limited to clinical research.

A Systematic Review of Nonsurgical Vulvovaginal Restoration Devices: An Evidence-Based Examination of Safety and Efficacy

BACKGROUND

The efficacy and safety of vulvovaginal restoration devices were called into question in a U.S. Food and Drug Administration statement on July 30, 2018, claiming that women are being harmed by laser and other energy-based devices. The goal of this systematic literature review was to assess existing data, determine gaps in evidence, and propose opportunities for continued investigation pertaining to laser and energy-based vaginal restoration techniques.

METHODS

A review of literature using PubMed, Cochrane Library databases, Embase, MEDLINE, and the Cumulative Index to Nursing and Allied Health Literature was conducted on January 9, 2019, and articles up to this point were considered. For inclusion, studies had to be available or translated in English and relate to clinical medicine, direct patient care, and nonsurgical energy-based vulvovaginal procedures.

RESULTS

The authors found five level I studies, 19 level II studies, four level III studies, and 46 level IV studies that used 15 different devices. Various degrees of improvement of symptoms were reported in all studies. Adverse events/side effects were noted in two of the 13 radiofrequency device studies, 15 of the 23 erbium:yttrium-aluminum-garnet device studies, and 17 of the 37 carbon dioxide device studies. The majority of adverse events were considered mild.

CONCLUSIONS

The majority of studies resulted in mild to no adverse side effects. However, there is a large gap in level I evidence. As a result, the authors emphasize the necessity of supplemental data surrounding this subject and suggest that additional randomized sham-controlled studies be conducted to further investigate vulvovaginal restoration devices in an effort to address women's health issues.

Er:YAG laser in hysterectomized women with stress urinary incontinence: a VELA retrospective cohort, non-inferiority study

Objective: To test whether the erbium-doped yttrium aluminum garnet (Er:YAG) SMOOTH^® laser treatment efficacy on stress urinary incontinence (SUI) in hysterectomized patients is non-inferior to its efficacy in non-hysterectomized patients.Methods: In this real-world, retrospective cohort study performed in Turkey, Croatia and Italy, we enrolled a consecutive sample of 35 hysterectomized and 34 non-hysterectomized patients with SUI. We used the Er:YAG SMOOTH^® laser (Fotona, Slovenia) with a wave length of 2940 nm. The primary outcome was median reduction of SUI symptoms measured by the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short-Form (ICIQ-SF) with the non-inferiority margin defined as the minimum clinically important difference of ICIQ-SF (δ < 2.52 points).Results: In hysterectomized patients, the ICIQ-SF was reduced by 5 points (95% confidence interval 3-8; p < 0.001), a reduction of 45% (95% confidence interval 36-67%). After adjustment for baseline ICIQ-SF and five covariates, the reduction of symptoms in the hysterectomized group was not inferior to the reduction in the non-hysterectomized group.Conclusion: The Er:YAG SMOOTH^® laser treatment seems to improve the symptoms of SUI in hysterectomized women not clinically relevantly less than in non-hysterectomized women. It seems that the beneficial effect of Er:YAG SMOOTH^® laser treatment for SUI in hysterectomized women is time-limited.