Vaginal Laxity

Vaginal Laxity

Your first pregnancy, an exciting time of anticipation, sometimes a little apprehension but mostly a time of feverish planning for the arrival of your bundle of joy. Advice is abundant when planning your nursery, whether you should “go natural” or opt for a caesarean section or whether you should bottle feed or breastfeed.

Close girlfriends who have already been through the very personal and for many very spiritual experience of vaginal delivery may share their learnings of how “things down there” change post-delivery. Perhaps you may have attended antenatal classes where your midwife pre-educated you on potential pelvic floor issues you may experience post pregnancy or vaginal childbirth. Most women however go into motherhood unaware of what their pelvic floor is, let alone the problems such as vaginal laxity, loss of sensation during intercourse and even urinary incontinence, which are common conditions experienced by women post childbirth.

Vaginal laxity is the more common term for  a medical condition known as vaginal relaxation syndrome or VRS. VRS causes a number of symptoms such as weakening or relaxation of the vaginal muscles, loss of voluntary pelvic floor muscle control, decreased vaginal sensation, loss of urinary control which can in turn lead to what we term as sexual dysfunction. Sexual dysfunction is simply when the usually intimate, deeply personal and intensely pleasurable act of sex becomes uncomfortable or quite frankly very sore. Women tend to start avoiding having sex with their partners which can result in the couple feeling distanced from each other at a time when they need each other’s support the most. Some women become extremely anxious and tense during intercourse because of their fear of losing control of their bladder muscles and leaking urine. This together with the stress many sleep-deprived couples experience having a newborn in their home can cause feelings of resentment and depression.

Vaginal relaxation syndrome is extremely common. It is caused by vaginal childbirth or ageing. Vaginal childbirth is associated with 4 to 7 times more pelvic floor disorders than delivery by caesarian section. However, having a caesarian section does not guarantee that you will not suffer pelvic floor disorders in the future. The weight of carrying one or multiple babies to term can lead to over-stretching and damage to your muscles and tissue “down there.”

Figure 1

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Your gynaecologist or midwife may  recommend pelvic floor muscle exercises also known as “kegal” exercises. You may even be referred to a pelvic floor physiotherapist who will help you to isolate the correct muscles in your pelvic floor. Many women do not see results from “kegals” simply because women find it difficult to isolate and contract the correct muscles and don’t comply to the treatment regimen. Pelvic floor exercises only strengthen the muscles of the pelvic floor and have no effect on the soft and connective tissue.

There are gynaecologists’ or general practitioners who offer laser or radio frequency treatments. These treatments are usually considered to be non-surgical and can be performed in their treatment rooms without anaesthesia. A vaginal probe similar to a speculum is inserted inside the vagina. The laser uses high frequency light waves to burn targeted areas of the vaginal canal leaving areas of healthy tissue in between. The bodies process of healing causes the tissue to tighten. Radio frequency on the other hand uses radio waves to heat the tissue. You would require 3 treatments, 6-8 weeks apart and a yearly maintenance treatment thereafter to maintain the result. Maintaining the results can be costly as each treatment costs approximately R3000-R5000.

In July this year the Food and Drug Administration (FDA) issued a warning with regards the use of lasers and radiofrequency devices for vaginal tightening. The FDA is the body in the United States that regulates all food, medical devices and drugs being sold in the USA. They warned patients to be aware that the safety and effectiveness of energy-based devices to perform vaginal “rejuvenation” procedures had not yet been established and that these devices had not yet been cleared or approved for the treatment of vaginal symptoms related to urinary incontinence and sexual function. They advised patients that these devices could cause serious adverse events, including vaginal burns, scarring, pain during sexual intercourse, and recurring or chronic pain. In other words these devices could cause the patient’s sexual dysfunction symptoms to in fact worsen. They advised patients to discuss all available treatment options with their health care provider.

There are also surgical options available for those suffering from urinary incontinence however the American College of Obstetricians and Gynaecologists warns surgeons that these surgeries should be considered as a “last option” after all conservative treatments such as pelvic floor exercises have been exhausted.

The type of urinary incontinence most women suffer from as a result of childbirth and pregnancy is called stress urinary incontinence (SUI). A women with this type of incontinence will accidently leak urine when she sneezes, coughs, jumps, lifts something heavy and in any situation where the abdomen exerts downward pressure on the pelvic floor structures. When pelvic floor muscles and tissues have been damaged, the urethra (the tube that connects the bladder to the outside of your body) does not close off because the muscles and tissues that usually hold them firmly in place, have weakened and leads to the women leaking urine when coughing or sneezing.

Surgical options for stress urinary incontinence includes procedures that most women know as a “bladder lift” procedure. These procedures differ according to the type of “bladder lift” your gynaecologist or urologist has been trained to perform. These procedures may vary from those that are more invasive such as the “bladder colposuspension procedure” or the “fascial sling” procedure to the less invasive option that has become extremely popular in the last 20 years known as the “mid-urethral sling procedure”. The mid-urethral sling procedure involves a small incision inside the vagina as well as 2 small incisions either just above your pubic bone or in your inner thigh. A thin tape (usually 1cm wide) made from a plastic material called polypropylene is inserted and positioned just below the middle part of your urethra. This provides a scaffold for tissue to grow into and recreates the firm support needed to allow the urethra to close off during activities where downward abdominal pressure is exerted on the pelvic floor.

This procedure has proved to provide immediate relief for women suffering SUI and has been widely adopted worldwide. However all surgery comes with its set of surgical complications and according to a high level clinical paper published by Dr Blaivas, a New York urologist, and his colleagues in 2015, this complication rate can be as high as 15%. The tragedy is that a smaller percentage of these complications have been known to have life altering consequences for this small group of patients leading to a public outcry in counties such as the USA, the UK and Australia. The life altering complications that have been reported include the mesh over time cutting through surrounding structures such as the urethra or the rectum and pelvic or thigh pain that never resolves. The challenge with these types of complications is that it is difficult to remove the mesh years after implantation as it becomes so embedded in the tissue making it very difficult for a surgeon to find the mesh let alone remove it without damaging surrounding organs.

A new surgical option that is emerging for the treatment of SUI is what is called a peri-urethral injection or a bulking agent. This is where the surgeon injects an agent just below the tissue inside the urethra near to the bladder neck. The bladder neck is where the urethra enters the bladder. In the past these types of injections have been considered to be largely ineffective and were associated with complications as a result of the material injected finding its way to other areas of the body or hardening and causing pain during intercourse. Some of the materials that have been used for bulking in the past have even resulted in the body rejecting the material and the women end up passing the materials causing pain in the process. There is however a unique bulking agent that uses a material that is comprised of 97,5% water and 2,5% polyacrylamide. This homogenous gel allows the tissue to grow into the gel allowing the tissue to maintain its natural elastic properties. Studies where patients have been followed up for 7 years are showing extremely positive results with a very low

rate of complications that are easy to treat and which do not impact on patients quality of life in the long term.

A very exciting device has recently become available in South Africa that can be administered safely by the patient themselves in the privacy of their home. It is a high quality medical device that has been registered in the category of low risk medical devices in South Africa. The product is a CE approved medical device and is currently available in the UK and Europe. It is also a licenced Health Canada Medical Device. The company who developed this product are currently going through the process with the FDA in the USA to have this product approved for use as a medical device in the USA as well.

The product is called vSculpt®. It uses the treatment modalities of low-level light therapy (LLLT), gentle heat and sonic vibration to treat vaginal laxity, loss of vaginal sensation, stress urinary incontinence and even vaginal dryness. LLLT makes use of LED (light emitting diode) lights that emit energy at wavelengths of 662nm (visible red light) to 855nm (near infrared light) on the electromagnetic spectrum as seen in Figure 2.

Figure 2

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These wavelengths are far gentler than the radio waves used by radio frequency therapies making this type of treatment, known as photobiomodulation, safe to use without the supervision of a healthcare practitioner. The vSculpt® comes in two models, the vSculpt® and the vSculpt® PRO. The vSculpt® is available online while the vSculpt®PRO is available through approved healthcare practitioners in South Africa.

LLLT, gentle heat and vibration has been used for years in the field of sports injuries by physio therapists to heal muscle and soft or connective tissue damage. vSculpt® helps you to achieve the same healing effect inside your vagina.

The red and near infrared lights work on your cells which make up your various types of tissue in your pelvic floor. You may or may not have heard of microscopic organelles that exist in your cells called mitochondria. The mitochondria in your cells use ATP (Adenosine-triphosphate) molecules to produce energy within the cells. This energy is used to grow new collagen and elastin which are the proteins that gives your tissue and skin its youthful qualities.

Heat brings additional blood flow to your tissues bringing about natural healing. Heat also breaks down collagen and allows it to reconfigure as stronger more elastic tissue.

Vibration has also been used for years for the treatment of low bone density and obesity pretty much like the “wobble machines” you may have used at the gym? This vibration of the tissues makes use of our bodies natural reaction to mechanical stress, again increasing the body’s production of collagen and a glycoprotein called tenascin C which brings about natural tissue healing effects.

In a study published in the International Urogynaecology Journal in 2016, 38 patients who had suffered from moderate to severe stress incontinence experienced a 90% improvement in their symptoms after using the vSculpt® every second day for 10 minutes over a 6 week period. 48 patients who had suffered from various types of sexual dysfunction were asked to complete questionnaire’s that measured how vSculpt® had impacted their quality of life post treatment. 81% of the patients completing the Female Sexual Dysfunction Scale showed an improvement post treatment and 77% of patients completing the Female Sexual Function Index showed an improvement.

The beauty of this home use device is that once the patient owns the device, they have it for years. They can do the initial treatment and then pack the device away until our bodies natural ageing process prompts them to take it out the closet and repeat the treatment. This treatment is a deeply personal clinical treatment that can be administered by the patient themselves in the privacy of their own home. This is proving to be a very attractive option for women suffering from vaginal laxity, loss of sensation and stress urinary incontinence in South Africa. It is easy to use, safe and pleasurable. No problem with patient compliance with this device.

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