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STRESS URINARY INCONTINENCE is defined as “The complaint of any involuntary loss of urine on effort or physical exertion (eg: sporting activities) or on sneezing or coughing”.

Standard definition by:

IUGA (International Urogynaecological Association)

ICS (International Continence Society)

PREVALENCE for urinary incontinence of any type in adult women – 5-72% (median 30%)

TREATMENT OPTIONS

  • Active pelvic floor rehabilitation exercises
  • Lifestyle changes
  • Pharmacological treatment
  • Surgery
  • Non-invasive modalities
    • Behavioural therapy
    • Pelvic floor muscle training
    • Platelet Rich Plasma
    • Energy based devices

ENERGY-BASED DEVICES IN SUI

MECHANISM OF ACTION

Heating the connective tissue of the vaginal wall to 40°C to 42°C.

  • Stimulation of (type 1) collagen remodelling and regeneration in the Extra matrix
  • Contracture of elastin fibres
  • Neo vascularisation leads to vaginal lubrication and an increase in small nerve fibre density in the papillary dermis
  • Growth factor infiltration
  • Increased glycogen concentration within the epithelium

PROCEDURE

  • OPD or Lunchtime procedure
  • 15 – 30 minutes
  • 2 – 3 sittings, 1 month apart
  • Touch-up sitting after 12 – 18 months

ADVANTAGES

  • Painless – no anaesthesia
  • No downtime
  • Practically no side effects
  • Restores vaginal milieu and flora, decreases recurrent vaginitis, recurrent UTI

ENERGY BASED DEVICES

  • Radio-frequency devices (RF)
  • Lasers
    • Micro-ablative fractional lasers like CO2 lasers
    • Non-ablative lasers like the Er YAG and diode
  • HIFU
  • HIFEM
  • Jett Plasma

RADIO FREQUENCY(RF)

This device emits focused electromagnetic waves that generate heat, reaching a thermal dose threshold causing collagen fibres to fold and become thicker and shorter. Collagen denaturation starts at 60°C, completing at 70-75°C. At 67°C, partial denaturation triggers a mild inflammatory response, activating collagen and elastin synthesis at 40-45°C, leading to skin tightening. Current mono-polar RF devices for vaginal treatment use mobile delivery, maintaining target surface temperature at or below 45°C.

CARBON DIOXIDE LASER

CO2 lasers emit light at a wavelength of 10,600nm which is greatly absorbed by tissue water. The subclinical thermal tissue effect from the laser beam induces dermal fibroblasts to initiate an inflammatory healing cascade, stimulating de novo collagen and elastin synthesis resulting in a thicker vaginal epithelium with a larger diameter, glycogen-rich epithelial cells.

Er YAG LASER

This near-infrared ablative laser emits light at a wavelength of 2,940nm and yields an absorption coefficient which is 16 times higher than a CO2 laser.

Penetration depth is 1-3 mm of tissue per J/cm2(20-30mm for CO2 laser). This has more precise skin ablation with very little thermal damage to surrounding tissues. Hence milder post-operative discomfort, oedema and erythema and overall faster healing time.

HIFEM

The high intensity focused electromagnetic therapy would be given by electromagnetic stimulation of the pelvic floor by a chair device. The electromagnetic field passes in a non-invasive manner through the neuromuscular tissue where the induced electric currents depolarise neuronal cells and initiate action potential.

The deep pelvic floor muscle contractions produced by this device are equivalent to 11,200 Kegel exercises over a 28-minute time interval. The treatment protocol will consist of 6 treatments scheduled twice a week.

HIFU

High-frequency focused ultrasound is a non-invasive technique that generates micro-thermal lesions by concentrating ultrasound beams at a target site without harming the epidermis or surrounding tissues. This process induces cellular damage and reduces volume, promoting the formation of new collagen and elastin in the extracellular matrix. Targeting the mid-section of the urethra, around 1.5-2 cm from the bladder neck, high-intensity ultrasound applicators aim to heat the endopelvic fascia and surrounding tissues, potentially leading to tissue stiffening and remodelling. The thermal treatment may tighten the tissue, creating a biological “hammock” by reshaping collagen and connective tissue and increasing hydrostatic pressure.

ADVERSE EFFECTS – Minimal
  • Discomfort during treatment.
  • Dysuria
  • Vaginal discharge/bleeding
  • Oedema
  • Itching
  • Mild burns

JETT PLASMA

This is a medical device based on the physical principle of DC performing membrane depolarisation, reversible electroporation, and heat generation, which activates the formation of new collagen connective tissue that breaks down and replaces the old tissue. The cells increase in volume, decreases the atrophy of vaginal mucosa and sub-mucous tissue and improves the tissue cohesion.

CONCLUSION

Over the past decade, significant technological advancements have emerged in the field of cosmetic gynaecology, focusing on reversing age-related tissue changes and restoring tissue function. These procedures address often unspoken issues in women’s health, hindered by a lack of awareness. Establishing standardised procedures is crucial for safe practice in this rapidly evolving field. Long-term studies are needed to validate the outcomes of novel approaches and ensure the effectiveness of treatments.

MBBS, MS, DGO, DNB, MRM PGD – HHM, FMAS, Masters in Cosmetic Gynaecology — Senior Consultant, Reproductive Medicine & Cosmetic Gynaecologist at Dr. KM Cherian Institute of Medical Sciences