Achieving a better quality of life

The INCONTILASE INTRA is a revolutionary new laser technique for the improvement of urinary continence in elderly patients and for the treatment of women suffering from the urinary component of the Genitourinary Syndrome of Menopause (GSM), including the management of Stress Urinary Incontinence (SUI). It consists of the application of Erbium laser in its non-ablative mode, using trains of long pulses called smooth mode. The goal is to generate a controlled warming process in the urethral mucosa and submucosa through the use of a small 8 French (3 mm in diameter) intraurethral canula, inserted therein.

We broke into the world with this idea ten years ago, promoting the futuristic idea that urinary incontinence could be treated without surgery through the use of a walk in/walk out procedure, the so called INCONTILASE, but this, is now no longer the future; it's a reality.

In the same manner as we did in the past, delivering heat inside the vagina for the treatment of SUI, today we have been working for almost the last four years on this new futuristic idea; a new development, the laser treatment of SUI and many other urinary conditions, working in the urethra itself.

I consider INCONTILASE INTRA as again being another truly futuristic concept, so that, for the most difficult cases of SUI (such as the Type III, Intrinsic Sphincteric Deficiency (ISD)), today we can now have a solution without surgery and/or without medication or fillers.

In addition, not only continence can be improved through the improvement of urethral trophism, but also all the symptoms and discomfort related to the aging process (dysuria, frequency and urinary urgency), this is the so called GSM.

It was exactly 41 years ago (early 1976) when Dr. Edward McGuire, an urologist at the University of Michigan, USA, first described the urethral sphincter component and its influence on the mechanism of urinary continence. McGuire described two components of this sphincteric mechanism:

1. The Muscular Mechanism, or Rhabdomyosphincter, which consists of striated muscle extending along 60-70% of the urethral length, being more noticeable in the middle third and whose contraction (involuntary) produces coaptation and increased urethral pressure, so that no urine leakage occurs during efforts.

2. The Mucosal or Intrinsic Mechanism, which extends along the entire length of the urethra and whose optimum performance is crucial for contributing to urethral coaptation and closure. It consists of mucosa (epithelium plus lamina propria) and a rich submucosal vascular plexus developed between a thin layer of smooth muscle and the mucosa. It gives an effective mucosal seal. All these elements of the Intrinsic Component will be affected to a greater or lesser extent by the lack of estrogens (which characterizes menopause and prolonged periods of lactation), and also affected by the natural process of aging. Due to the atrophy there is a 30% loss of effectiveness of the mechanism of urethral closure. During rest, the rhabdomyosphincter musculature provides additional tension to the walls of the urethra (to strengthen continence), which would be (by far) much more effective if there is a good trophism and vascularization. Although an adequate performance of the rhabdosphincter is important, the key factor that will determine continence is the trophism of the mucosa and submucosa vascular plexus.

Today we have sufficient evidence that the effectiveness of the intrinsic sphincter mechanism (functional sphincter) depends on the trophism of the mucosa and the state of the submucosal vascular plexus. Furthermore, the mucosa, submucosa and submucosal vascular plexus all depend on estrogenic activity. This explains the increased incidence and prevalence of urinary symptoms after menopause, and also the so called GSM, characterized by symptoms of vaginal atrophy (dryness, burning, itching, pain) and signs of urethral atrophy (urgency, frequency, dysuria and urinary incontinence).

According to recent studies published about the etiology of urinary incontinence and based on the not-so-recent statements by the International Continence Society, the current trend is to consider that, in the genesis of SUI, there is a combined degree of sphincter component (ISD) and a degree of the anatomical component (urethral hypermobility), rather than being pure forms (either 100% anatomical, or 100% sphincteric), which are the least common to find. This new trend (based on the latest findings), also explains why in many cases SUI and other urinary conditions are so recurrent and difficult to treat with the use of slings, laser treatments (with any wavelength) that focus only on correcting the anatomical component, and vaginal trophism with the use of a vaginal probe. The new approach of adding the urethral treatment deals with all the problems (vaginal trophism and urethral trophism).

Clearly, then, we can now improve both of the two components of continence, and we have failed to grasp the necessity for a therapeutic tool that would now allow us to improve not only elasticity, tension, trophism and vascularization of the vaginal, but also the trophism and vascularization of the urethral mucosa. Recognizing our incorrect isolation of the issues until now, and the essential need to combine our approach, is what we need to emphasize and understand.

After our initial findings, almost four years of experience using lasers in the urethra (being the creators of this technique), more than ten years experience using micro-ablative CO2 lasers vaginally (also being the pioneers of this technique), and having used Diode, Neodymium and even non-ablative Erbium lasers for years, we are firmly convinced that we must not only address the vagina, but we should definitely also focus on the urethral passage in postmenopausal women. In the same way that we improve trophism of the vaginal mucosa with lasers, there is no way to improve the trophism of the urethral mucosa without exercising a direct effect of the urethra.

We have had to wait 40 years since Edward McGuire defined the intrinsic mechanism of continence for us to, today, have the first therapeutic tool that allows us to address both components of continence safely and without complications, in a non-surgical, non-invasive, non-ablative, ambulatory, and above all, effective way. In our experience, we have not only succeeded with the good results obtained with the INCONTILASE technique, but we have also now been able to have better over-all results in those patients where the solely-vaginal technique previously yielded both satisfactory and unsatisfactory results. And what is even more encouraging is that we have managed to have much more long-lasting results over time thanks to a combination of INCONTILASE and INCONTILASE INTRA in the same treatment session.

Finally, I do wish to emphasize that, in all types of involuntary loss of urine (stress, urge or mixed), we now know that there will always be a greater or lesser extent (depending on the age of the patient and her risk factors) of deterioration or structural abnormality of the urethral mucosa and submucosa, with obvious effect on vascularization, and this would be crucial in the progression of symptoms and therapeutic failure of the conventional approach (both surgical and non-surgical).

We can, then, today treat all involuntary loss of urine associated with the natural aging process, combining both techniques, where the improvement achieved will logically depend on the predominant etiologic component and risk factors of the patient. We have even had very satisfactory results with the pure SUI Type III (ISD) without the anatomical component and with a urethral closure pressure VLPP of 25 cmH2O (urodynamic), which means a clinically urine-losing patient with minimal efforts. We can now understand, the impact on the improvement on the quality of life this result could have on this particular severe condition.

In light of these findings, all gynecologists must radically change the therapeutic approach we are now giving our patients, a fact that has been reflected in the high rates of incidence, prevalence and recidivism, moving towards a treatment that is etiological, comprehensive, pro-active and, above all, PREVENTATIVE. That is why I always say that the best treatment for urinary incontinence is not having urinary incontinence, and to avoid incontinence we should not only respect and preserve, but also stimulate cells and tissues, in order to maintain trophism and vascularization. This is a sine-qua-non requirement for our patients not developing over time GSM, and worse, some degree of stress urinary incontinence. We now can start to get everything right, for a better present and future.

References:

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(4)Espuña Pons, M. Incontinencia de orina en la mujer. MedClin (Barc) 2003;120: 464-472

(5)McGuire EJ, et al.Clinicalassesment of urethral sphincter function. J Urol 1993; 150 (5pt1): 1452-1454

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