Noninvasive approach favoured for SUI management
The noninvasive approach appears to be more favourable than surgery for the management of stress urinary incontinence (SUI), according to an expert who presented at the Royal College of Obstetricians & Gynaecologists World Congress 2018 held in Singapore.
Despite numerous (approximately 400) surgical alternatives introduced over the years – from Kelly’s plication in the 1900s to mini-slings in 2000s – none of these managed to satisfactorily treat SUI, said Dr Navneet Magon, a urogynaecologist from New Delhi, India.
Furthermore, while the FDA-approved transobturator tape, a variant of surgically-introduced mid-urethral mesh slings, remains the current gold standard for SUI treatment, meshes have apparently created a ‘mess’ despite minimal complication and high success rates. [N Am J Med Sci 2012;4:226-230]
The complications and increasing failure rates associated with surgery led clinicians to seek other options, he added.
From scalpel to wands
With these concerns surrounding surgical approaches, energy-based devices such as lasers and radiofrequency (RF) are now being driven towards the forefront of SUI management, said Magon. However, he cautioned on the use of RF as there is not enough data supporting its use or safety.
Laser therapy directs a photothermal effect on the vaginal mucosa and connective tissue to alter its composition and architecture to subsequently improve morphology and function. The thermal action triggers mucosal shrinkage without tissue destruction. [Lasers Surg Med 2017;49:137-159; Int Urogynecol J 2017;28:1445-1451; Int Urogynecol J 2017;28:1443-1444]
“[Laser therapy] may be a useful minimally invasive approach for SUI … Tissues are tightened … to provide a base on which the urethra can relax, and the laxity [is achieved] to some extent,” explained Magon. The mechanical pull of deeper tissue layers following shrinkage further promotes elasticity, thickness, and strength of the vaginal wall, he added.
However, multiple ablative procedures may lead to vaginal fibrosis and consequently generate sexual or quality of life (QoL) issues which is a very important consideration, said Magon.
Clearing the misconception
QoL issues such as SUI are often treated as least priority, and most women forego treatment as they deem incontinence as a normal part of ageing, Magon underscored. However, he reiterated that it is not normal to leak as one ages. “[This is] why we are not able to [provide] treatment for women who need it,” he said, adding that should patients consider treatment, they lean towards noninvasive options.
Overall, clinicians should offer treatment alternatives supported by evidence demonstrating their therapeutic advantages, said Magon. “[We] need to be cautious that something being shown as the panacea for everything may not actually be the panacea.”
“[Patients with SUI should receive] the best and safest treatment possible [that] they don’t have to think twice before [laughing or sneezing] in public,” concluded Magon, who mentioned new SUI treatment alternatives such as stem cell therapy, magnetic stimulation therapy, and the use of fats and fillers. However, he cautioned against usage in routine clinical practice as these are currently investigational.