12. Fractional CO2 Thermo-Ablative Vaginal Laser Therapy
Vaginal laser restores the vagina via superficial micro-trauma.
Useful in treatment of women with atrophic vaginitis—similar to oestrogen therapy.
Useful in patients who cannot tolerate oestrogen therapy (e.g. breast cancer patients).
Three doses delivered in office setting without need for anaesthetics, one month apart for 3 months in total—effect lasts up to 12 months on average.
Very early days in use in post-menopausal women with recurrent UTIs.
12.1 Introduction and Mechanism of Action
CO2 thermo-ablative lasers apply fractional micro-trauma to the lamina propria of the vaginal mucosa (the vaginal lining), causing immediate collagen fibre contractions, followed by inducing a repair and restoration of the vaginal architecture (initiation of new collagen and elastin synthesis), thus inducing a histologically confirmed restoration of the vagina.
Under the microscope, the thick squamous stratified epithelium is restored as well as the intracellular glycogen storage and synthesis of new components of the extra-cellular matrix. The limited penetration depth protects the underlying fibromuscular layers [1, 2].
Such lasers restore the vagina to a pre-menopausal state similar to topical oestrogen therapy and are currently in use in the treatment of atrophic vaginitis in post-menopausal women and are licensed for use in the UK .
The restoration of the vaginal “laxity” has also been used in treating women with stress urinary incontinence. Studies involving a series of patients show potential benefit in relieving mild urinary stress incontinence in women, however no high powered/high quality randomised control trial or comparison with placebo trials are available, meaning further trials are needed before any consensus can be reached in the use of vaginal lasers in stress incontinence .
Regarding UTIs, the restoration of the vaginal microenvironment replenishes the natural vaginal defences, in particular the acidic pH, which is likely a result of the increased presence of the commensal bacteria lactobacillus that synthesises lactic acid. Further, pH restoration is likely to also be aided by the repair of the vaginal architecture lost in menopause, restoring the normal moist conditions and vaginal secretions [5, 6].
The treatment is performed once a month for 3 months. Similar to a trans-vaginal ultrasound, a probe is inserted into the vaginal and the treatment applied. Apart from ample lubrication, no anaesthetic is needed and the whole treatment can be done in an outpatient setting. Prior to treatment, a vaginal swab, cervical smear and urine dipstick analysis is performed to exclude underlying active infection and exclude any evidence of cervical cancer.
12.2 Clinical Evidence
To date there has only been one prospective study  in the use of vaginal laser therapy in preventing UTIs, though with promising results. 12 post-menopausal UK women with recurrent UTIs received three courses of Vaginal CO2 Laser (Femtouch™) at monthly intervals. The authors reported after 6 months since commencing treatment, 11/12 (92%) of patients remained UTI free. 75% of patients remained UTI free by 12 months.
This was associated with a concurrent restoration of the acidic vaginal microenvironment, from an average of pH 7 pre-treatment, to pH 5.4 by the end of the three courses. By 12 months, the pH has worsened to 6 but was still better than pre-treatment.
Furthermore, there was concurrent improvement in the Vaginal Health Index Score, which assess elasticity, Fluid, pH, integrity and moisture of the vagina. Any score <15 is defined as atrophic.
The VHIS score improved from 11 pre-treatment to 20 at dose 3. The effect is maintained and slowly wears off over the year and by 12 months, the score is down to 15, which is still better than before treatment.
Its benefit (in particular in patients with a previous breast cancer history who cannot tolerate oestrogen) is promising whilst at the same time restores the patients sex life (if they want it!).
However, there is currently no long-term data available for this therapy and therefore its use in UTI prophylaxis is still very much in its infancy.