No. 358-Intravaginal Laser for Genitourinary Syndrome of Menopause and Stress Urinary Incontinence

ObjectiveThis technical bulletin reviews the evidence relating to risks and benefits of using intravaginal laser technology in the management of genitourinary syndrome of menopause and stress urinary incontinence.Intended UsersGynaecologists, urogynaecologists, urologists, and other health care professionals who assess, counsel, and provide care for women with genitourinary syndrome of menopause and stress urinary incontinence.Target PopulationAdult women with genitourinary syndrome of menopause and stress urinary incontinence seeking complementary or alternative treatment options to topical estrogen, non-hormonal vaginal moisturizers, physiotherapy, intravaginal devices, and surgery.OptionsThe discussion relates to intravaginal laser treatments for genitourinary syndrome of menopause compared with topical estrogen and that for stress urinary incontinence.OutcomesThe outcomes of interest are objective and subjective rates of response to treatment, histologic outcomes, and procedural complications.EvidencePubMed, Medline, the Cochrane Database, and EMBASE were searched using the key words “genitourinary syndrome of menopause,” “vaginal laser,” “topical estrogen,” and “urogenital atrophy.” Results were restricted to English and human research. Articles were included until the end of September 2016. Clinical practice guidelines and guidelines of specialty societies were reviewed. Included studies were observational or prospective cohort when available. Only publications with study groups larger than or equal to 20 individuals were included, and non-peer-reviewed papers were excluded.Validation MethodsThe content and recommendations were drafted and agreed upon by the principal authors. The Board of the SOGC approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework.Benefits, Harms, and/or CostsIt is expected that this technical bulletin will benefit patients with genitourinary syndrome of menopause by ensuring treating physicians are aware of all treatment options including the potential benefit and associated risk with intravaginal laser therapy. This should guide patient informed consent before such procedures are undertaken. There are no direct harms or costs identified with the implementation of this guideline.SponsorsThe SOGC.Summary Statements1.Histologic evaluation has shown a similar short-term improvement in vaginal epithelial maturation in post-procedural vaginal wall biopsies with the use of intravaginal laser as that seen with local estrogen (Moderate).2.Short-term observational studies of small patient number with the use of intravaginal laser have demonstrated reductions in symptoms (including dryness, burning, itching, dysuria, and dyspareunia) and improvements in sexual satisfaction indices (Low).3.Short-term observational studies of small patient number with the use of intravaginal laser have demonstrated improvements in symptoms of stress urinary incontinence (Low).Recommendations1.In patients declining or with apparent contraindication to local estrogen, intravaginal laser therapy may be considered for short-term relief of symptoms associated with genitourinary syndrome of menopause (Conditional, Low).2.There is insufficient evidence to offer intravaginal laser therapy as an equivalent modality to local estrogen for the treatment of genitourinary syndrome of menopause (including vulvovaginal atrophy, lower urinary tract symptoms, and sexual dysfunction) (Strong, Very Low).3.There is insufficient evidence to offer intravaginal laser therapy as an effective modality for the treatment of stress urinary incontinence over alternate managements such as pelvic floor physiotherapy, incontinence pessaries, or surgery (strong, very low).4.Long-term use of intravaginal laser therapy for the management of genitourinary syndrome of menopause or stress urinary incontinence remains experimental and should remain within the protocols of well-executed clinical trials in attempts to establish its safety and efficacy (Strong, Very Low).5.Intravaginal laser therapy should not be offered to patients to prevent recurrent urinary tract infections as no literature exists to support such use (Strong, Very Low).