Improving continence with laser treatments

After menopause a significant number of women face urinary complications and symptoms that negatively impact quality of life. Adrian Gaspar, M.D., obstetrics/gynecologist specialist and cosmetogynecologist in Argentina, recently discussed this topic at the American Society of Laser Medicine & Surgery annual meeting. Dermatology Times spoke with Dr. Gaspar about how the laser works and why it’s beneficial to women living with these urinary symptoms.

Q:  Why is it important to address the overall well-being of female patients?

A:  Based on my experience with conferences, this concept of the well-being of women and menopause is becoming more important. Many years ago this topic wasn’t even considered for meetings. But, now, we’re living longer and have different treatments to improve sexual performance in men as they age. So we, as gynecologists, need to be concerned about how our patients will handle the aging process. How can we help our patients have a normal sex life if they have severe symptoms or recurrent symptoms of dryness, burning sensations, itching or incontinence. This is very important because all of it is related to well-being.

Q:  What are the key points of your presentation?

A: Basically, the mechanism of continence has not been fully clarified yet. We know the urethral mucosa is essential to ensuring the urethra has a proper sealing capacity. After menopause, one in three women will have urinary symptoms. These are conditions related to a lack of estrogen. The majority of lasers that exist today target the vagina to improve vaginal dryness, and they work perfectly. But, the problem is that sometimes urinary symptoms can’t be completely solved through the use of vaginal lasers. We need to improve the urethra. About four years ago, I decided to start delivering energy inside the urethra with a special camera. We demonstrated, in two published studies in peer-reviewed journals, that urinary symptoms can be dramatically improved through the use of superficial warming processes on the urethra. So, we’re not treating incontinence. We’re improving continence. That’s totally different.

Remember that after menopause, according to the North American Menopause Society, 0.3 percent of patients will develop breast cancer. One percent of them will suffer a heart attack. But, 100 percent of patients will have genitourinary syndrome from menopause. Of that 100 percent, 50 percent will have symptoms in their lifetime, and one in three of that 50 percent will have urinary symptoms. They can be treated with estrogen and local creams and non-normal moisturizers. But, there are no complications with laser therapy because it’s light. It generates a warming process and generates vasodilation. After two session a year, you can have your patients free of urinary symptoms. It’s very important because it can be a walk-in walk-out procedure. It’s painless and only takes 12 minutes of your time. There are no contraindications that have been described because it’s just light. We haven’t had any complications. We are targeting the mechanism of continence by trying to make improvements the way estrogen does. When you use vaginal estrogen tablets, you are getting rid of vaginal dryness, itching, urgency, frequency, and incontinence. When you use lasers in the vagina and the urethra, you are improving the patients symptoms but without any hormones.

In the whole world, women have a valid concern about the use of hormones because of cancer. The longer we live now, the more patients will consult us for this condition. So, in the near future, I see us treating these symptoms with a combination of short-term estrogen to improve the water-retaining ability of the mucosa followed by lasers. Laser light loves water, so the more water there is in the mucosa, the longer lasting the effect of the laser.

We’re now working on a study with 80 patients to look at the combined treatment of estrogen and lasers. The outcomes, by far, are better than previous findings where we used only lasers. The urethral laser is like the vaginal laser. It’s a tool for the doctor to have in the wide array of possibilities to offer to the patient. It’s a new tool you can use to improve your patient’s quality of life.

Q:  What are the pros and cons of treating incontinence with lasers?

A: As for pros, you can have benefits without any complications. A con would be that sometimes you may not meet your patient’s expectations if you don’t clearly explain what you can correct with a laser and what you cannot correct. You will not cure a patient from prolapse or stress urinary incontinence. But, you will improve their quality of life by diminishing the severity of the condition. Laser light is a temporary effect. It could be a year or a year and a half - it depends on the patient. You need to explain. Tell her she’ll need extra sessions over time to maintain the effect the same way a dermatologist would use a laser on the face for rejuvenation. It’s the same with hormones. If you take them for months and, then, abandon them, the condition you’re treating will return.

Sometimes when you have severe atrophy, you need to prepare the mucosa for the laser or it won’t be well tolerated. It’s the same for the urethral or the vaginal laser. In younger patients - age 50 to 55 with perimenopause - you won’t have this problem. But, an elderly patient around 80 years old who is suffering from recurrent urinary tract infections will need to have the mucosa prepared first. Otherwise, she might have some bleeding and discomfort.

Q: For doctors who are new to this procedure, what mistakes might they make when implementing it?

A: Although this procedure is quite simple, you need to be familiar with urethral and vaginal probes because you’re introducing a probe camera into a small cavity. You need to be very careful. The procedure is ambulatory, but you must know about fluency and laser-tissue interactions. The lasers come with parameters in the software, but sometimes they need to be decreased or sometimes you need to make fewer passes because the patient isn’t tolerating the process according to her hormonal state.

Q: Have there been patients in your practice who responded well to treatment?

A:  I remember two cases. One woman, who is now 68-years-old, came to us for treatment after breast cancer. She was suffering from severe urinary symptoms and severe vaginal dryness. We gave her two sessions of combined vaginal and urethral lasers. She didn’t have intercourse, so her main complaint was itching and dysuria, frequency, and urinary urgency. She wouldn’t do any physical activity because she leaked urine. After two sessions, we improved her continence. She is now happy and has an extra session every six months. She goes into the office just to maintain the improvement she has achieved.

Another patient was 72 and was suffering from overactive bladder. She complained of urgency, incontinence, and frequency. She said that she needed to go to the restroom at least 15 times a day. After ruling out infections and taking an ultrasound of the bladder, the urethra, the abdomen, and the kidneys to rule out other possible problems, we decided to do laser treatment. She said that immediately after the first session, she had some minimal discomfort. But, after the second session, she said that she’d stopped taking the pills she used to control her bladder contractions. With this improvement with her continence, the problem had been solved. She’s happy now and can live a normal life according to the quality of life she used to have. She still leaks a minimal amount of urine, but she’s using the rest room no more than 5 to 6 times a day. This is very impressive for us.

Q: How large is the demand among patients for this type of procedure?

A:  I work in a huge urology clinic. We have at least 50 patients a day, and among them at least 3 or 4 patients would like to have one of these sessions. Even if they need surgery, we offer them the possibility of the non-surgical management of the condition. We can delay surgery. We can prepare the mucosa for surgery. Or, we can combine surgery with lasers to improve the urethra.

Until now, we have waited for our patients to exhibit symptoms before giving them any treatment. We’ve waited for bleeding, pain, and itching before prescribing estrogen. No gynecologist would wait until you had full osteoporosis before taking steps to try to improve your bone mass. And, now it’s that way with urinary symptoms. With this laser treatment, within one year, we can have patients totally free from suffering this part of the aging process.