Effects of non-ablative vaginal erbium:YAG laser treatment for interstitial cystitis/bladder pain syndrome: a case series (UNICORN-2 study)

Comorbid bladder pain syndrome and vulvodynia - a cross-sectional analysis of the UNICORN-4 study

BACKGROUND

Bladder Pain Syndrome/Interstitial Cystitis (BPS/IC) and vulvodynia often coexist, exacerbating patient symptoms and complicating the diagnosis and treatment. This study aimed to identify distinct subtypes within a BPS/IC and vulvodynia cohort and evaluate their symptom profiles, psychological characteristics, and sexual function indicators.

METHODS

A cross-sectional analysis was conducted on 150 female patients diagnosed with BPS/IC and vulvodynia. The patients completed validated questionnaires assessing bladder symptoms, psychological distress (PHQ-9 and GAD-7), and sexual function (FSFI and FSDS-R). Hierarchical and K-means clustering were used to identify patient subgroups.

RESULTS

Three distinct clusters were identified. Cluster 1 exhibited moderate bladder-specific symptoms and psychological distress. Cluster 2 had severe bladder symptoms and the highest psychological distress. Cluster 3, defined as the vulvodynia-predominant subtype, featured severe vulvodynia, significant psychological distress, and minimal bladder symptoms, aligning with a non-urologic pelvic pain phenotype. Sexual function was significantly impaired across all clusters, with Cluster 3 showing the most severe dysfunction.

CONCLUSIONS

This study highlights the heterogeneity within BPS/IC and vulvodynia populations. The identification of a vulvodynia-predominant subtype and non-urologic pelvic pain phenotype emphasizes the need for personalized treatment strategies addressing both physical and psychological factors, particularly sexual dysfunction and psychological distress.

Establishing Reference Values for Vaginal Vestibule Elastography in Healthy Postmenopausal Women

Objective This study aims to establish normative elastography values for the vaginal vestibule in healthy postmenopausal women and assess the variability of these values with age and measurement time during the day. Methods The study included 111 women aged 40-90, excluding those with medical histories or treatments affecting vaginal health. Elastography measurements were taken twice daily, between 9-10 AM and 3-4 PM, using real-time tissue elastography technology. Statistical analysis evaluated the effects of age, body mass index (BMI), and diurnal variation on vaginal vestibule elasticity. Results A significant positive correlation between age and elastography values was found (p=8.36×10⁻⁷), with elastography values increasing by approximately 0.0040 units per year. The mean elastography value was 28.32% (SD=5.87%) in the morning and 28.10% (SD=5.90%) in the afternoon, with a statistically significant difference (p=0.016). BMI showed a weak negative correlation with elastography values (r=-0.2021, p=0.0334). Conclusion Establishing reference values for vaginal vestibule elastography provides a foundation for improved diagnostic accuracy and early detection of gynecological conditions. The findings support the use of elastography as a non-invasive, reliable diagnostic tool in clinical practice. Future research should validate these results across different age groups and in women with specific gynecological conditions to further solidify the clinical applicability of vaginal vestibule elastography.

The Importance of Psychological Assessment in the Management of Bladder Pain Syndrome/Interstitial Cystitis and Vulvodynia: A Case Report

This case report emphasizes the crucial role of psychological assessment in the management of patients with bladder pain syndrome/interstitial cystitis (BPS/IC) and vulvodynia. A 48-year-old woman with a five-year history of refractory BPS/IC and vulvodynia presented with frequent urination, pelvic pain, and severe dyspareunia, which led to sexual aversion and divorce from her partner. Previous treatments, including lifestyle modifications, analgesics, anticholinergics, hydrodistension, intravesical dimethyl sulfoxide, and psychiatric interventions, had been ineffective. Psychological assessments using the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Toronto Alexithymia Scale-20 revealed severe symptoms of depression, anxiety, and alexithymia. Due to the patient's sexual aversion and the absence of a partner, a complete Female Sexual Function Index (FSFI) could not be administered. Instead, a partial FSFI and artificial intelligence-translated reference value of the Female Sexual Distress Scale-Revised were used to assess aspects relevant to the patient's condition. The patient underwent three monthly sessions of Fotona laser therapy, erbium, and neodymium laser at one-month intervals. Treatment outcomes were evaluated using the Numeric Rating Scale-11, Vulvodynia Total, Interstitial Cystitis Symptom Index, and psychological assessment tools. At the six-month follow-up, all physical and psychological symptoms showed significant improvement and complete remission was achieved at 12 months. Despite the overall positive treatment outcomes, the patient's sexual aversion persisted, and accurate measurement was not possible, highlighting the complexity of addressing sexual function in patients with BPS/IC and vulvodynia. This case report underscores the need for a holistic approach to managing these conditions, addressing both the physical and psychological aspects of the disease.

Mathematical Approach to Synergistic Management of Bladder Pain Syndrome/Interstitial Cystitis and Vulvodynia: A Case Series Utilizing Principal Component Analysis, Cluster Analysis, and Combination Laser Therapy

This case series presents three patients with bladder pain syndrome/interstitial cystitis (BPS/IC) and vulvodynia, demonstrating the efficacy of an individualized treatment approach using cluster analysis and combination laser therapy. Principal component analysis (PCA) was used to visualize the dynamic nature of symptom clusters and guide treatment decisions. Case 1 was a 41-year-old woman initially classified as Cluster 1 (PCA coordinates: 1.65, 0.03) transitioned to Cluster 2 (-16.93, -21.75) after bladder hydrodistension. Subsequent Fotona laser (Ljubljana, Slovenia) treatment resulted in the complete resolution of symptoms. Case 2 was a 55-year-old woman, contraindicated for hormone therapy due to breast cancer history, presented as Cluster 2 (PCA coordinates: -24.16, 8.74). Fotona laser treatment shifted her to Cluster 1 (11.22, -20.22), followed by bladder hydrodistension for complete cure. Case 3 was a 49-year-old woman, initially in Cluster 0 (PCA coordinates: 1.892, 30.11), who underwent fulguration for Hunner's lesions. Posttreatment, she moved to Cluster 2 (-24.31, 1.767) and achieved full recovery after Fotona laser therapy. The dynamic nature of symptom clusters, visualized through PCA, guided treatment decisions. The PCA transformation, represented as y =WTz, where z is the standardized symptom vector and W is the principal component matrix, allows for the objective tracking of symptom changes. Combination Fotona laser therapy, including vaginal erbium YAG and neodymium YAG, has proven effective in managing vulvar pain, particularly when hormone therapy is contraindicated. This approach, addressing both urological and gynecological aspects, resulted in sustained symptom improvement for over 12 months in all cases. This case series highlights the synergistic relationship between BPS/IC and vulvodynia, demonstrating the efficacy of comprehensive, adaptive treatment strategies guided by mathematical analysis for complex pelvic pain syndromes.

Unsupervised Machine Learning Reveals a Vulvodynia-Predominant Subtype in Bladder Pain Syndrome/Interstitial Cystitis

Background Bladder pain syndrome/interstitial cystitis (BPS/IC) is a chronic condition characterized by pelvic pain and urinary symptoms. Despite its significant impact on patients' quality of life, the heterogeneity of BPS/IC symptoms and the presence of comorbidities such as vulvodynia may not be adequately captured by validated questionnaires. Identifying vulvodynia in BPS/IC patients is crucial for providing appropriate treatment options. This study aimed to identify subtypes of BPS/IC patients using unsupervised machine learning and to investigate the prevalence of vulvodynia in each subtype. Methods We conducted a prospective cross-sectional study of 123 BPS/IC patients and 64 age-matched controls. Hierarchical clustering was performed using data from validated questionnaires, including the Numerical Rating Scale-11, Interstitial Cystitis Symptom Index (ICSI), Interstitial Cystitis Problem Index (ICPI), Pelvic Pain and Urgency/Frequency scores, Overactive Bladder Questionnaire Short Form (OABq SF), Overactive Bladder Symptom Score (OABSS), and Pelvic Floor Distress Inventory-20. The optimal number of clusters was determined using the elbow method, and the characteristics of each cluster were analyzed. All participants underwent a vulvodynia swab test to assess vulvodynia symptoms. Results Unsupervised machine learning revealed three distinct clusters of BPS/IC patients. Clusters 0 and 2 differed significantly, with Cluster 2 characterized by significantly higher vulvodynia scores compared to other clusters (P < 0.001). In contrast, Cluster 2 had lower bladder pain scores (ICSI and ICPI) and overactive bladder symptom scores (OABq SF and OABSS) compared to other clusters. Clusters 0 and 1 were characterized by a predominance of bladder pain and urinary frequency symptoms, with Cluster 0 exhibiting more severe symptoms. Conclusions Our study identified distinct subtypes of BPS/IC patients using unsupervised machine learning, with Cluster 2 representing a vulvodynia-predominant subtype. This finding, along with the potential of targeted therapies such as non-ablative erbium YAG laser for vulvodynia, underscores the importance of assessing extravesical symptoms, particularly vulvodynia, for the diagnosis and treatment of BPS/IC. A tailored approach, including laser therapy for vulvodynia-predominant patients, may be necessary for optimal management of BPS/IC. The vulvodynia swab test plays a crucial role in assessing vulvodynia symptoms, underlining the limitations of validated questionnaires in capturing the full spectrum of BPS/IC symptoms. A comprehensive evaluation of patients, including the vulvodynia swab test, is essential for accurate subtyping and management of BPS/IC. Further research with larger sample sizes and investigation of the relationship between identified subtypes and other clinical data is warranted to advance our understanding and management of BPS/IC.

Evaluating Non-ablative Erbium Yttrium Aluminium Garnet (YAG) Laser Treatment for Polypropylene Mesh-Induced Vaginal Erosion: A Case Series

Background Vaginal erosion caused by the polypropylene mesh is a serious side effect, and the development of effective treatment methods is required. This study explored the potential of non-ablative vaginal erbium yttrium aluminum garnet (YAG) laser treatment (VEL) as a novel treatment approach. Methods In this study, VEL was performed on nine women who experienced vaginal erosion after undergoing treatment for pelvic organ prolapse (POP) with polypropylene mesh. These patients visited our hospital between April and December 2020. Using the Renovalase (SP Dynamis Fotona d.o.o., Ljubljana, Slovenia), the laser was applied to the entire vagina, with intensive irradiation focused on the erosion areas. Detailed analyses of symptoms before and after treatment, as well as histopathological changes, were conducted one year post-treatment. Results Nine women were referred to our hospital due to vaginal erosion caused by polypropylene mesh. The participants' average age was 73.2 years (range: 69-81 years), with four patients having undergone transvaginal mesh (TVM) surgery and five undergoing laparoscopic sacrocolpopexy (LSC). The average time from mesh insertion to treatment initiation was 7.2 years (range: 3-15 years), with eight patients having previously attempted mesh removal. Post-treatment, significant improvements were observed in managing vaginal erosion and related bleeding, corroborated by histopathological analysis confirming cell regeneration and tissue repair. These improvements also resulted in significant improvements in bleeding management and quality of life (QoL). Conclusion VEL suggests the possibility of being an effective treatment method for vaginal erosion caused by a polypropylene mesh. However, further research is needed because of the small sample size and the limitations inherent in the retrospective case series design.

Not all lasers are the same: a scoping review evaluating laser therapy for vulvodynia

INTRODUCTION

Lasers are commonly used for treating various vaginal/vulvar conditions. To date, there is to our knowledge no available literature review on the effects of different types of lasers for the treatment of women with vulvodynia, a condition that causes chronic pain in the vulvar area.

OBJECTIVES

We sought to review the literature and summarize the existing published evidence regarding the effects of lasers for the treatment of women with vulvodynia.

METHODS

A scoping review with a systematic search was conducted that included studies investigating the use of laser treatment in women with vulvodynia. The National Heart, Lung, and Blood Institute Study Quality Assessment Tools were used for the quality assessment. The type of laser, effects on pain and function, and participants' perceived improvement as well as adverse events were analyzed.

RESULTS

Eight studies investigating laser therapy were included in the analysis: 1 randomized controlled trial, 5 before-after studies, 1 nonrandomized intervention study, and 1 case report. Several types of laser therapies were identified, ranging from mild noninvasive photobiomodulation to more invasive ablative procedures. Of the 6 studies that included pain outcomes, 3 studies showed statistically significant improvements from baseline to follow-up, and 3 demonstrated a reduction in pain from subjectively interpreted data. Similarly, each of the 2 studies investigating sexual function also reported an improvement (based only on subjective interpretation). Of the 2 studies with a comparison group, neither study was adequately powered to detect between-group differences. Furthermore, 57%-78% of participants reported improvement, with 1 study showing a greater statistically significant improvement in the low-level laser therapy patient group compared to the sham laser group. Outcomes and adverse events varied depending on the type of laser used.

CONCLUSIONS

Although these studies demonstrated some benefits of laser therapy for the treatment of vulvodynia, these findings should be interpreted with caution given the scarcity of the included studies that were robust and sufficiently powered. Future research should focus on conducting well-designed randomized controlled trials to evaluate the efficacy of different types of lasers in the treatment of vulvodynia.

Laser Treatment for Patients With Vulvodynia and Interstitial Cystitis/Bladder Pain Syndrome: A Case Series (The UNICORN-3 Study)

Introduction Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic pain disorder characterized by urgency, frequency of urination, and pelvic pain. Women with IC/BPS often experience sexual dysfunction, vulvodynia, and vaginal health issues. Combined erbium and neodymium yttrium aluminum garnet (YAG) laser treatments targeting the vagina and vulva have shown promise in improving symptoms. Our study aims to investigate the effectiveness of these combined laser treatments in women with IC/BPS and vulvodynia. Methods Women diagnosed with vulvodynia and IC/BPS underwent combined laser treatment using vaginal erbium:YAG laser (VEL) and neodymium:YAG laser (Nd:YAG). Various parameters were evaluated, including the vulvodynia test, numeric rating scale (NRS-11) for pain, interstitial cystitis symptom index and problem index (ICSI and ICPI), pelvic pain and urgency/frequency symptom score (PUF), and mean urination volume/daily urination frequency in a three-day urination diary. Treatment was administered three times, with intervals of one month between each session, and follow-up evaluations were conducted at six and 12 months. All statistical analyses were designed and programmed by the AI chatbot GPT-4 (chatGPT-4). Results Fifteen female patients diagnosed with vulvodynia and IC/BPS were treated with three sessions of VEL + Nd:YAG. Significant improvements were observed in the vulvodynia test, NRS-11 scores, PUF, ICSI scores, ICPI scores, mean urination volume, and daily urination frequency at six and 12 months (p<0.01). Short-term improvements in IC/BPS pain scores correlated with improvements in the vulvodynia test (p=0.007), suggesting a synergistic effect. However, no significant correlations were found at 12 months. Conclusion Combined laser treatments targeting the vagina and vulva showed significant therapeutic effects in women with IC/BPS and vulvodynia. The addition of Nd:YAG to the VEL treatment enhanced outcomes. Short-term improvements in IC/BPS pain scores correlated with improvements in the vulvodynia test, indicating a synergistic effect. Long-term improvements in both vulvodynia and IC/BPS symptoms may occur independently. These findings highlight the importance of comprehensive approaches for treating coexisting vulvodynia and IC/BPS.

Long-Term Improvement in Urinary Incontinence in an Elite Female Athlete Through the Laser Treatment: A Case Report

Stress urinary incontinence (SUI) is increasing in elite female athletes (EFAs), affecting competition results and quality of life. Pelvic floor muscle training (PFMT) is the first-line treatment for SUI, and surgery is generally performed when PFMT is insufficient. However, in EFA, there are few cases in which surgery is performed and fewer reports. Therefore, there is no known general treatment strategy for EFA with SUI. In our study, a 23-year-old track-and-field medalist with severe SUI was successfully treated with a vaginal and urethral erbium-doped yttrium aluminum garnet laser (VEL + UEL). After 12 treatments over one year, urinary incontinence decreased from 300 mL or more in the 400 m track run before treatment to 0 mL. She did not experience any more problems during running or competition. There was no recurrence of SUI for three years, and the urethral pressure profile examination confirmed improvement. MRIs showed that the left puborectalis muscle was absent from the first visit. The urethra was oval with an anteroposterior outer diameter of 10 mm and a transverse outer diameter of 13 mm before treatment. However, after three years of treatment, both anteroposterior and transverse diameters became circular, measuring 11 mm. Vaginal wall thickness increased from 8 to 12 mm at the center of the height of the urethra, making it possible to support the urethra, and pretreated adipose tissue space between the urethra and vagina disappeared. It was noted that the uneven and fragile urethra/vagina, the presence of adipose tissue space, and the absence of the left puborectalis muscle may have been the cause of the SUI. One year of VEL + UEL treatment resulted in long-term improvement of SUI; MRI showed changes in the urethra and vagina.

Broaden Horizons: The Advancement of Interstitial Cystitis/Bladder Pain Syndrome

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a debilitating disease that induces mental stress, lower urinary symptoms, and pelvic pain, therefore resulting in a decline in quality of life. The present diagnoses and treatments still lead to unsatisfactory outcomes, and novel diagnostic and therapeutic modalities are needed. Although our understanding of the etiology and pathophysiology of IC/BPS is growing, the altered permeability of the impaired urothelium, the sensitized nerves on the bladder wall, and the chronic or intermittent sensory pain with inaccurate location, as well as pathologic angiogenesis, fibrosis, and Hunner lesions, all act as barriers to better diagnoses and treatments. This study aimed to summarize the comprehensive information on IC/BPS research, thereby promoting the progress of IC/BPS in the aspects of diagnosis, treatment, and prognosis. According to diverse international guidelines, the etiology of IC/BPS is associated with multiple factors, while the presence of Hunner lesions could largely distinguish the pathology, diagnosis, and treatment of non-Hunner lesions in IC/BPS patients. On the basis of the diagnosis of exclusion, the diverse present diagnostic and therapeutic procedures are undergoing a transition from a single approach to multimodal strategies targeting different potential phenotypes recommended by different guidelines. Investigations into the mechanisms involved in urinary symptoms, pain sensation, and bladder fibrosis indicate the pathophysiology of IC/BPS for further potential strategies, both in diagnosis and treatment. An overview of IC/BPS in terms of epidemiology, etiology, pathology, diagnosis, treatment, and fundamental research is provided with the latest evidence. On the basis of shared decision-making, a multimodal strategy of diagnosis and treatment targeting potential phenotypes for individual patients with IC/BPS would be of great benefit for the entire process of management. The complexity and emerging evidence on IC/BPS elicit more relevant studies and research and could optimize the management of IC/BPS patients.

Is Erbium/Neodymium Laser Combination Therapy an Effective Treatment Option for Interstitial Cystitis/Bladder Pain Syndrome With Vulvodynia?

Interstitial cystitis/bladder pain syndrome (IC/BPS) is often associated with vulvodynia and poor vaginal health. IC/BPS causes pelvic and bladder pain and urinary symptoms, which considerably reduce the quality of life. To date, this condition has no definitive cure. Local estrogen therapy (LET) has been proposed as a treatment for vulvodynia and poor vaginal health to improve the symptoms of IC/BPS. However, chronic LET could be contraindicated or not desired in some patients. The present study reports the case of a 55-year-old postmenopausal woman with IC/BPS who was successfully treated with combined vaginal erbium (VEL)/neodymium (Nd:YAG) laser (VEL+Nd:YAG) therapy. The patient presented with a five-year history of pelvic pain and urinary frequency. Direct approaches for the bladder (such as hydrodistension, anticholinergic drugs, and transurethral Hunner lesion ablation/cauterization) were conducted with inconsistent results. Immediately prior to the patient's presentation, LET was administered for 12 weeks; however, this therapy resulted in mild improvement and poor patient satisfaction. After presentation, VEL+Nd:YAG therapy was conducted once a month for three months. The patient reported considerable decrease in pain during urination. The improved symptoms were maintained for six months after the last therapy session. These results suggest that VEL+Nd:YAG therapy is an effective method for improving symptoms in patients with IC/BPS.

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

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

Examining vaginal and vulvar health and sexual dysfunction in patients with interstitial cystitis (UNICORN-1 study)

INTRODUCTION AND HYPOTHESIS

The Vaginal Health Index Score (VHIS) and vulvodynia swab tests are used to assess vaginal health and vulvodynia. However, few studies have used these tests in patients with interstitial cystitis/bladder pain syndrome (IC/BPS). IC/BPS is a chronic, debilitating disorder, characterised by urinary frequency, urinary urgency and pelvic pain. It adversely affects organs adjacent to the urinary system, leading to complications of sexual dysfunction. This study was aimed at understanding sexual dysfunction in patients with IC/BPS, as well as deterioration of vaginal health and vulvodynia.

METHODS

This study compared the vaginal health of IC/BPS patients with that of asymptomatic control individuals. The Pain Urgency Frequency (PUF) score, Female Sexual Function Index (FSFI), VHIS, and vulvodynia swab tests, were used as tools. The PUF and FSFI are questionnaire-based surveys of bladder symptoms and sexual function respectively. VHIS evaluation and vulvodynia swab tests are performed by physicians. The PUF was used to assess baseline IC/BPS symptoms to validate the patient population, and FSFI, vulvodynia swab tests and VHIS were used to determine between-group differences.

RESULTS

Thirty-seven patients were recruited in each group. The IC/BPS group had a higher PUF score (18.19±3.51 vs 3.56±2.35; p<0.05), worse total FSFI (15.72±4.46 vs 26.3±4.93; p<0.05), and worse vulvodynia swab test and total VHIS (11.59±2.87 vs 22.05±3.05; p<0.05) scores than those of the control group.

CONCLUSIONS

Asian women with IC/BPS experienced greater sexual dysfunction, worsened vaginal health and increased vulvodynia compared with control individuals. Information on vaginal and vulva health is very useful in evaluating IC/BPS patients.