Stress Urinary Incontinence
Female stress urinary incontinence is a significant public health problem, with estimated prevalence rates ranging from 4–35 % of adult women. Brief involuntary urine happens when physical movement or activity — such as coughing, laughing, sneezing, running or heavy lifting — puts pressure (stress) on your bladder, causing you to leak urine.
It occurs when the muscles and other tissues that support the urethra (pelvic floor muscles) and the muscles that control the release of urine (urinary sphincter) weaken. The bladder expands as it fills with urine. Normally, valve-like muscles in the urethra — the short tube that carries urine out of your body — stay closed as the bladder expands, preventing urine leakage until you reach a bathroom. But when those muscles weaken, anything that exerts force on the abdominal and pelvic muscles — sneezing, bending over, lifting or laughing hard, for instance — can put pressure on your bladder and cause urine leakage. Your pelvic floor muscles and urinary sphincter may lose strength because of age, type of childbirth delivery, body weight and previous pelvic surgery.
The initial treatment option for SUI is pelvic floor muscle training (PFMT). It produces good results, but often fails to achieve consistent long-term improvement due to poor patient compliance and lack of support and guidance. Traditional surgical approaches such as open or laparoscopic colposuspension and anterior vaginal repair have been largely replaced with less-invasive midurethral sling suspension procedures and single incision polypropylene mesh mini-slings. While highly effective, they are associated with adverse events and complications such as bleeding, bladder perforation, urethral injury, infection, and groin pain.
Laser Therapy for Stress Urinary Incontinence (SUI) is of value in patients with mild and moderate Stress Urinary Incontinence and Mixed Urinary Incontinence (MUI). It is less invasive than traditional surgical methods for the treatment of incontinence. It has a much lower complication rate, and is well tolerated by patients. Recovery time is very short – the patient may return to her daily routine immediately, although it is recommended to respect standard precautions, such as avoiding efforts which may cause pressure to the bladder, and to avoid sexual activities for one week.
Preliminary clinical studies show that it is an efficient, easy-to-perform and safe procedure.
Vaginal relaxation is the loss of the optimum structural architecture of the vagina. This process is generally associated with natural aging and is specially affected by childbirth, whether vaginal or not. Multiple pregnancies further increase the alteration of these structures. During the vaginal relaxation process, the vaginal muscles become relaxed with diameters can greatly increase with a significant stretching of the vaginal walls. Under these circumstances the vagina is no longer functioning at its physiologically optimum state. Sexual gratification is directly related to the amount of frictional forces generated during intercourse. Friction is a function of the vaginal canal diameter, and when this virtual space is expanded it can lead to the reduction, delay or lack of orgasms. Thus, vaginal relaxation has a detrimental effect on sexual gratification because of the reduction of frictional forces leading to diminished sexual pleasure.
The most common current technique utilizes a surgical procedure that requires the cutting and rearrangement of vaginal and peripheral tissue in order to reduce the size of the canal. Operating on or near sensitive vaginal tissue is inherently risky and can cause scarring, nerve damage and decreased sensation. Furthermore, patients require an extended recovery period.
Laser Vaginal Tightening (LVT) treatments are much less invasive than traditional surgical methods for the treatment of vaginal relaxation syndrome. It has a much lower complication rate and is well tolerated by patients. Recovery time is very short – in two-to-three days the patient may resume normal sexual activity, and the treatment produces good results in a large percentage of treated patients.
The genitourinary syndrome of menopause (GSM) is the new definition for the variety of menopausal symptoms associated with physical changes of the vulva, vagina, and lower urinary tract, related with estrogen deficiency. Estrogen is a dominant regulator of vaginal physiology, including increased blood flow, improved epithelial thickness, reduced pH, and increased secretions.
GSM is chronic and is likely to worsen over time, affecting up to 50% of postmenopausal women (PMW). The symptoms related to GSM include genital symptoms of dryness, burning, irritation, but also sexual symptoms of lack of lubrication, discomfort or pain, and impaired function, as well as urinary symptoms of urgency, dysuria and recurrent urinary tract infections. All these symptoms may interfere with sexual function and quality of life.
Vulvovaginal atrophy is most commonly associated with the diminished estrogen levels that accompany menopause (spontaneous or induced) and aging. Estrogen plays an essential role in maintaining the elasticity and health of genital tissues. Declining levels increase tissue fragility and the risk for vaginal and urinary infections, irritation, dryness, urogenital pain, and the probability of vaginal tissue trauma.
Most of moisturizers and lubricants are available without prescription, at a nonnegligible cost, and may provide only a temporary relief. Conversely, hormone replacement therapy (HRT) can provide quick and long-term relief, while urinary symptoms often require additional, effective therapies. When HRT is considered solely for the treatment of vaginal atrophy, local vaginal estrogen administration is the treatment of choice. Although systemic risks have not been identified with local low-potency/low-dose estrogens, long-term efficacy and safety data are lacking. In addition, many women do not accept protracted HRT, or may present absolute contraindications, such as a personal history of estrogen-dependent tumors, particularly endometrial and breast cancer.
The use of a laser for the treatment of Genitourinary syndrome of menopause is a novel and non-invasive therapy based on photothermal effect of Er:YAG laser in non-ablative SMOOTH mode.
Laser energy from a Er:YAG 2940 nm laser is delivered to the desired locations of the vagina by using a special handpiece. When the laser is activated, it deposits thermal energy in the mucosa tissue, causing increase of glycogen content, collagen component and vascularization, associated with epithelial thickness, changes in lamina propria, increased angiogenesis, collagenesis, papillomatosis and cellularity of the extracellular matrix.
Laser Treatment of Vulvovaginal atrophy / Genitourinary syndrome of menopause is non- invasive and is well tolerated by patients. It offers short recovery time – in two-to-three days the patient may resume normal sexual activity, and the treatment produces good results in a large percentage of treated patients.
The Concept of Laser Treatment
Collagen is an important component of pelvic floor supportive structures—it makes up more than 80 % of protein content of the endopelvic fascia. Childbirth trauma can lead to destruction of collagen fibers in the pelvic floor, while aging slows down the synthesis of new collagen, both resulting in decreasing collagen content. Women with stress urinary incontinence have reduced collagen content in their anterior vaginal walls and pubocervical fasciae.
Using laser energy to achieve heat pulsing of collagen can improve collagen structure and initiate neo-collagenesis. As a result of the temperature increase, intermolecular cross-links that stabilize collagen triple-helix structure are broken, which leads to the shrinkage of collagen fibrils and improvement in tissue firmness. On this basis, laser-mediated heat pulsing of the endopelvic fascia and pelvic floor tissue could represent an effective non-surgical method for treating female urinary incontinence and other disorders resulting from diminished pelvic floor support.
With Fotona laser, precisely controlled laser energy pulses are delivered to the selected mucosa tissue in order to non-ablatively heat the collagen within the tissue. Collagen exposed to an appropriate temperature increase will experience a sudden contraction of its fibers, leading to the contraction and shrinkage of the irradiated bulk tissue. The thermal effect on collagen is not just momentary during exposure to the increased temperature, but continues throughout the processes of collagen remodeling and neo-collagenesis, resulting in the generation of new collagen and an overall improvement of the treated tissue’s tightness and elasticity.
The laser energy is also delivered in temporally optimally spaced, short laser pulses in order to prevent temperature build-up at the surface and to achieve homogeneous heating within a several-hundred-micron thick superficial layer of the mucosal tissue. The mucosal tissue is treated in a smooth, almost “feather-like” non-ablative manner, without any bleeding and with a precisely controlled temperature deposition that eliminates the risk of tissue necrosis.