Non-ablative Erbium (YAG) and Neodymium (YAG) Laser Treatment for Anal Incontinence and Vaginal Atrophy: A Case Study

Abstract

In this case study, a 68-year-old woman with anal incontinence (AI) and vaginal atrophy (VVA), who did not respond to traditional treatments such as pelvic floor exercises or hormone therapy, underwent three sessions of laser treatment using RenovaLase (SP Dynamis; Fotona d.o.o., Ljubljana, Slovenia), which employs non-ablative Erbium:YAG and Neodymium:YAG lasers. Significant improvements were observed in the VVA symptoms, with AI being resolved. The Vaginal Health Index Score increased from 7 points at the initial assessment to 18 points at 12 months after treatment. Similarly, the Cleveland Clinic Florida Fecal Incontinence Score and St. Mark's Incontinence Score, initially at 4 points each, improved to 0 points, indicating resolution of incontinence symptoms. MRI results demonstrated vascular enhancement and growth in the anal sphincter, with the thickness of the internal anal sphincter slightly increasing from initial measurements to a maximum of 0.36 cm, and improvements in resting and squeeze pressures from 42 mmHg to 110 mmHg, respectively. These findings underscore the effectiveness of RenovaLase® laser treatment for VVA and AI symptoms, offering a novel option for pelvic floor health management in postmenopausal women, especially those resistant to the use of artificial devices for anal improvement. In the environment of hormonal decline after menopause, the atrophy of pelvic vessels leads to reduced blood flow. This situation, where a noticeable lack of blood flow occurs during pretreatment of the pelvic vessels, is addressed by laser treatment. This phenomenon has been named "re-canalization." This case suggests the potential of this therapy as an alternative for patients resistant to conventional methods involving the insertion of devices into the anus to improve fecal incontinence. Further research is needed to explore its potential benefits.

Keywords: anal incontinence; cleveland clinic florida fecal incontinence score; erbium:yag; neodymium:yag; st. mark's score; vaginal atrophy; vaginal health index score; vulvodynia swab test.

Figure 1. VEL+NdYAG+AEL treatment procedure

a. SP Dynamis; Copyright © 2013. Provided courtesy of Fotona d.o.o. (Ljubljana, Slovenia). This image in Figure 1a is provided free of charge by Fotona d.o.o. :. 1, Special glass speculum for laser; 2, PS03-GA angular adapter laser probe for the anterior wall of the vagina; 3, R11-GC circular adapter laser probe for the entire circumference of the vagina; 4, SmoothTouch LA Adapter probe for the entire circumference of the anus; 5, R33 NdYAG laser probe for vulvar irradiation. b. VEL step (glass speculum insertion). c. VEL step (laser irradiation of posterior vaginal wall by PS03-GA). d. VEL step (whole vaginal laser irradiation by R11-GC1). e. Nd:YAG laser (Fotona SP Dynamis, PIANO mode, spot size 9 mm, R33 non-contact handpiece, PIANO pulse mode (five seconds), fluence 90 J/cm²). f. AEL step (circumferential intra-rectal ErYAG irradiation with LA adapter). AEL: Erbium:YAG laser; VEL: Vaginal Erbium YAG; NdYAG: Neodymium YAG

Figure 2. The changes before and after laser treatment

a: VHIS (Vaginal Health Index Score, green closed circles) and vulvodynia swab test (green closed squares), b: CCFIS (Cleveland Clinic Florida Fecal Incontinence Score, blue closed circles), c: St. Mark’s score (green closed circles) and pad usage (red closed circles). Notations include T0 for initial consultation (pre-treatment), T18 (18 months after the third laser treatment, L3), and L1, L2, L3, and L4 indicating the first, second, third, and fourth laser treatments, respectively.

Figure 3. Anal ultrasound images

Using a 180-degree probe, each image showed the anterior (top) and posterior (bottom) aspects. Image a shows pre-treatment (T0), and image b shows post-treatment (T18). The yellow dotted lines indicate the internal anal sphincter as detected by ultrasound. Measurements of sphincter thickness at four equidistant points, using the perineum as the 12 o'clock reference and moving clockwise, are provided in centimeters (cm).

Figure 4. The anal sphincter muscles

The T2-weighted sagittal view MRI using a 1.5T MRI (Signa Creator, GE Healthcare, Chicago, USA). The images, with specified MRI parameters, show a comparison before (a: T0) and after (b: T18) treatment, with the urethra (U) and the anus (A) indicated by arrows. The yellow dotted lines identify the internal anal sphincter as seen on MRI, the green dotted lines represent the external anal sphincter, and the white lines outline the contour of the anus.

Figure 5. Changes in sagittal images before and after treatment

a: Illustration of organ names. b: before treatment (T0); c: after treatment (T18). The yellow circles indicate re-established blood flow within the blood vessels due to laser therapy. Credit: Illustration by the author (Nobuo Okui). RA: Rectus abdominis; Sy: Symphysis pubis; UB: Urinary bladder; B: Uterine corpus; C: Cervix of the uterus; A: Anus; S: Anal sphincter; R: Rectum; Sa: Sacrum

Figure 6. Restoration of blood flow in the urethra, vagina, and anus by ROI interest

1.5T MRI (Signa Creator, GE Healthcare, Chicago, USA). MRI was reconstructed into sagittal and axial 8-mm-thickness images after MIP treatment using 3D data acquisition of T2-weighted coronal images with fat suppression (TR 3500 ms; TE 100 ms; inversion time 150ms; flip angle 90°; FOV 42 × 48 cm; matrix 384 × 256). Each image depicts the upper (cranial) and lower (caudal) aspect. a: Before treatment (T0), b: After treatment (T18). U: Urethra, A: Anus. The yellow lines represent the ROI. ROI: Region of interest; MIP: Maximum intensity projection; FOV: Field of view; TR: Repetition time; TE: Echo time