Case Study: Treating Vaginal Laxity and Sexual Dysfunction

By Dr Jorge Zafra and Dr Natasha Ranga / 17 Jan 2017

Dr Natasha Ranga details how she successfully managed a patient’s intimate vulvovaginal concerns with CO2 fractional laser

Globally, approximately 15% of the pre-menopausal population have vulvovaginal concerns,1 however the true figure may be underestimated as it is often being perceived as an embarrassing problem, so many patients may not seek help or treatment. Myself and Dr Jorge Zafra, who assisted me with this article, have personally noted an increase in popularity for vaginal treatments, however there is no one clear definition on what the procedure involves or its intended benefits.2

Managing concerns

The concerns that many patients present with include vaginal laxity, dryness, urinary stress incontinence, sexual discomfort, dyspareunia and psychosexual problems.2 Vaginal rejuvenation addresses all of the above concerns, and refers to restoring a woman’s intimate health to a pre-menopausal state and a pre-partum restoration. Sexuality plays an important part in a woman’s health, quality of life and general wellbeing. In my experience in general practice, these vaginal concerns are difficult to treat, and often women just put up with the concerns. Many women who have given birth vaginally, experience stretching of their vaginal tissue, while many post-menopausal women have vaginal atrophy changes. Both of these types of patients may have long-term physical and psychological consequences including loss of sensation, stress incontinence, vaginal laxity, and pain including dyspareunia or general intimate discomfort at anytime. Vaginal rejuvenation is the treatment of these concerns and lasers are at the forefront in the management.3

We have developed a protocol with a fractional CO2 laser that has a 360-degree probe that is inserted into the vaginal canal directing and concentrating the laser all around the canal to manage these concerns. The fractional CO2 laser directly remodels the vaginal mucosa via new collagen formation and elastic fibers on the skin.4 I used the Venus CO2 laser, which is what the protocol, the Venus-VT, is based on, however there are others available that may be considered for this treatment. One study has suggested that fractional C02 lasers can improve the vaginal canal tightness beyond the introitus without causing damage to the surrounding tissue.3 The protocol also includes treating the labia minora and majora as a non-surgical labiaplasty.

Case study introduction

In July 2016, 34-year-old Caucasian Patient A was treated for vaginal laxity and dryness. She had given birth to two children, the most recent being four years prior. In her consultation she said that she had had no previous non-surgical vaginal rejuvenation treatments. She also had no past medical history that would be significant to this procedure such as recent surgical labiaplasty, which is a clear contraindication. It should be noted that she had a Mirena coil in situ, previous surgical labiaplasty more than 10 years ago, no known drug allergies, no sexual health history, and cervical smears up to date with no abnormalities.

Treatment protocol: 

  • Cleanse the area with a mild antiseptic and allow to dry, so no residue is left to interfere with the fractional CO2 laser.
  • Fully insert the 360-degree laser head/vaginal probe and slowly withdraw it at 0.5cm intervals after each laser blast is delivered. Do not use any lubrication as this interferes with the laser treatment.
  • The laser is set to deliver the energy equally at 360 degrees in the vaginal canal; point energy is set to 19.0mj, power 19w and the duration 1.0ms.
  • There can be up to three passes of the laser treatment.
  • The laser setting and laser head is then altered for external treatment, targeting the labia minora and majora.
  • The external settings for the laser are; point energy 7.0mj, power 7w, duration 1.0ms.
  • Treatment delivery time is a short five minutes.


Questionnaires 

The International Consultation on Incontinence Questionnaire–Vaginal Symptom (ICIQ–VS)4 is a questionnaire developed to assess the impact of vaginal symptoms and associated sexual matters on quality of life and outcome of treatments. It focuses on 14 vaginal symptoms and 10 sexual matters; it takes up to five minutes to be completed, it scores a maximum of 53 in vaginal symptoms and 58 in sexual matters. The higher the scores, the more unsatisfied the patient. We suggest this is conducted prior to the initial consultation in the privacy of the patient’s home; some patients find it helpful to do in the company of their partner. The importance of the questionnaire is to measure both the severity and the perceived impact of symptoms, which enables the ability to monitor patients’ symptoms over time and to assess the effectiveness of treatment.8 The Female Sexual Function Index (FSFI),5 is a questionnaire that has been developed specifically for assessing sexual functioning (e.g. sexual arousal, orgasm, satisfaction, pain). The index has 18 items and has a maximum score of 36, which takes less than five minutes to complete. It is not a measure of sexual experience, knowledge, attitudes, or interpersonal functioning in women and was not designed for use as a diagnostic instrument and should not be used as a substitute for a complete sexual history in clinical evaluation.9 

Consultation

A joint discussion was undertaken with Patient A, which included a thorough medical, sexual, and gynaecological history and examination. The examination is very important and the use of dilators can be used to determine canal diameter, in this case this was not done as we did not have access to a dilator and instead used the patient’s answers to the questionnaires before and after. It is vital that the patient is provided with all necessary information regarding treatment including expectations, outcomes, and potential side effects prior to the treatment, and that they are given as much time as they need to ask questions. Included in our consent was a cooling-off period where at anytime Patient A could withdraw.

 Sexuality plays an important part in a woman’s health, quality of life and general wellbeing 

The consultation is especially important in this type of procedure as it is such a personal treatment and the patient must feel completely comfortable with all of the treatment protocols. As there were no contraindications to treatment, Patient A was deemed suitable for C02 fractional laser. Patient A was given two questionnaires prior to the treatment; the ICIQ–VS4 and the FSFI,5 which were also conducted after the treatment and used as a comparison to determine the treatment’s effectiveness. The combination of the ICIQ-VS and FSFI questionnaire in the protocol is ideal for patient selection, evaluation of treatment outcome over time and recommendation of subsequent sessions or, if needed, gynaecology referral for further studies.

The questions are asked pre-treatment and then post-treatment at time intervals of seven days, one month, three months, six months and 12 months. The case study was at one month and seven days at the date of which this article was written.

For the pre-treatment questionnaires, her FSFI score was 24.9 and her ICIQ–VS4 score was 22. There are no scores that would be unacceptable to treatment as all patients would have been screened out with the initial history and any contraindications to the treatment highlighted. The results were analysed and her expectations discussed. She reported that her main concerns included laxity and occasional dryness and we were confident that the protocol would successfully treat these.

The exact details of the procedure were explained to Patient A and what she could expect to experience during the treatment was discussed. A consent form was signed and an information leaflet on post-procedure care was discussed with the patient and given to her for reference. Prior to treatment, patients are advised to avoid creams, lubricants and sexual intercourse for five to seven days. The key points discussed are outlined below:

  • When the laser head and surrounding vaginal probe is inserted for the internal treatment, there may be some discomfort, but it is generally described as smooth and comfortable.
  • For the external treatment, there may be some discomfort, but it is generally described as resembling a warm spoon against the skin.
  • The patient may experience some tingly sensations, especially during the outer treatment.
  • A ‘buzz’ or ‘sizzle’ sound may be heard the more external the treatment becomes.
  • There may be some soreness or irritation straight away and for 48 hours after.
  • It is not uncommon for there to be some spotting 24-48 hours after the procedure. 
  • There have been some patient reports of a ‘watery discharge’ occurring up to two to three days after the procedure, and they were advised to seek medical attention. In this one case, the patient was reviewed and examined for infection; swabs were sent and urine was checked and no infection was found. I advised her to allow time for it to resolve which it did within four weeks. This has occurred in one patient we have treated so it is now included in the aftercare advice.
  • Every patient is given a patient information leaflet on post treatment care and possible symptoms of concern.
It is vital that the patient is provided with all necessary information regarding treatment including expectations, outcomes, and potential side effects prior to the treatment 

Post-treatment care

Following treatment, Patient A was advised not to have intercourse for four days. She was also instructed to avoid creams, lubricants and feminine products for five days, avoid bathing or showering for four hours and to avoid swimming pools and hot tubs for 48 hours. This is important aftercare to increase collagen formation, allow the tissue to remodel and to prevent infection.

Results

The patient returned to clinic for a review at seven days, two weeks and at four weeks. At the four week review, Patient A was very pleased with the results, reporting an increase in vaginal tightness and sexual function and reduced vaginal laxity, which were reflected in her scores. Her FSFI score was 14.9 (previously 24.9) and her ICIQ Vaginal Symptoms Questionnaire 12 (previously 22).

Discussion

The treatment for this patient was viewed as successful as she had a marked reduction in the two questionnaires used. She also reported reduced vaginal laxity and improvement with stress incontinence during exercising. She will be reviewed at three, six and 12 months. During each review, the questionnaires will be repeated and the patient will report any changes. The results are expected to last 12 months after one treatment5 and this patient is eligible to have a second and third treatment at three-month intervals to improve the effects and to build upon the first treatment. Having a course of three treatments may help results last longer than 12 months, but there is no current evidence for this. She may not need second and third treatments, and the decision to go ahead will be based on her questionnaire scores and her reviews.

Conclusion

This case study highlights the effectiveness and safety of CO2 fractional laser treatment for vaginal laxity and dryness in pre-menopausal women. It is a simple and time efficient treatment. It is non-surgical with minimal downtime, is minimally invasive and no general anaesthesia is required. It is essentially an ambulatory treatment that can help the confidence and satisfaction of women. In this case, Patient A had a very good result with improved quality of life and sexual function. It must be noted that only adequately trained practitioners with laser safety training and expertise in this anatomical region, as well as in consulting and history taking, should be delivering this treatment to this sometimes-vulnerable group of patients. 


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