ABSTRACT
Background
Recurrent cystitis is a prevalent condition, especially among postmenopausal women, significantly impairing their quality of life. Antibiotic therapy has historically been the primary treatment; however, concerns over antimicrobial resistance have highlighted the need for alternative therapies. Vaginal laser therapy, a noninvasive approach, has shown promise in improving vaginal health and may help prevent recurrent cystitis. This study assessed the efficacy of vaginal laser therapy in reducing cystitis episodes and improving the vaginal environment among postmenopausal women with recurrent cystitis.
Methods
This retrospective study involved 51 postmenopausal women who received vaginal laser therapy between January 2023 and July 2024. Eligible patients underwent a pretreatment phase with estriol ovules, followed by vaginal laser therapy. The Vaginal Health Index (VHI), vaginal pH, and cystoscopic findings were evaluated before and after treatment and are presented as median (interquartile range). The cystitis‐free interval (CFI) was calculated to assess the duration between treatment and recurrence.
Results
The median number of cystitis episodes significantly decreased from 4 (3–6) in the 6 months before treatment to 0 (0–1) in the 6 months after treatment (p < 0.001 unless stated otherwise). The median CFI was 9.2 months. The VHI score significantly improved from 10 (9–13) to 18 (15–21), and vaginal pH significantly decreased from 8.0 to 5.5. Cystoscopic assessments indicated significant improvements in the atrophy of vaginal and periurethral tissues. Only grade 1 adverse events (7.8%) were observed, including vaginal pain and dyspareunia.
Conclusions
Vaginal laser therapy significantly reduced cystitis episodes and improved vaginal tissue health in postmenopausal women with recurrent cystitis. These findings suggest that this therapy may represent a promising alternative in selected patients. Further studies with larger sample sizes and prospective designs are required to confirm these results and investigate the long‐term benefits of vaginal laser therapy in managing recurrent cystitis.
Keywords: postmenopausal women, recurrent cystitis, vaginal health index, vaginal laser therapy, vaginal pH
1. Introduction
Cystitis is a common condition affecting women, such that approximately 60% experience at least one episode during their lifetime [1]. Furthermore, 20%–40% of affected individuals experience recurrence, and 25%–50% of those develop recurrent cystitis [2, 3]. Recurrent cystitis can lead to chronic symptoms, imposing both physical and psychological burdens on patients and significantly diminishing their quality of life (QOL). Clinically, recurrent cystitis is defined as three or more episodes of acute bacterial cystitis within 1 year requiring antibiotic treatment, or two or more episodes within 6 months that severely impact QOL [4, 5]. Historically, treatment has heavily relied on the use of antibiotics; however, the long‐term use of antibiotics has raised concerns about antimicrobial resistance.
In recent years, genitourinary syndrome of menopause (GSM), a concept introduced in 2014, has highlighted the multifaceted impact of menopause on the genital and urinary tracts, as well as sexual health [6, 7]. This concept has led to the development of more comprehensive treatment approaches. Among these, vaginal laser therapy (VLT) has emerged as a promising noninvasive treatment for pelvic floor disorders and vaginal atrophy. VLT is thought to stimulate vaginal tissue, promote collagen production, and support mucosal regeneration, thereby improving the vaginal microenvironment. Such improvement may lead to normalization of the vaginal microbiome and enhanced mucosal barrier function in the bladder and urethra, which could potentially prevent cystitis recurrence. However, the efficacy of VLT in preventing recurrent cystitis or extending the duration between episodes remains insufficiently documented.
In this paper, we report our initial experience with VLT as a treatment for recurrent cystitis in postmenopausal women. Specifically, we investigate its impact on the vaginal environment, focusing on improvements in tissue health and pH, as well as its potential to reduce the frequency of cystitis episodes. To our knowledge, this is the first study to explore the potential for VLT to address recurrent cystitis by targeting the underlying vaginal microenvironment.
2. Patients and Methods
2.1. Eligibility Criteria
This retrospective study was conducted at the Nihonbashi Pelvic Floor Clinic. We included consecutive female patients who presented with recurrent cystitis as their chief complaint and underwent VLT between January 2023 and July 2024. Recurrent cystitis was defined as three or more episodes of acute cystitis within 1 year requiring antibiotic treatment, or two or more episodes within 6 months that severely impact QOL. Cystitis was diagnosed based on the presence of pyuria (increased white blood cells in urine) accompanied by clinical symptoms, including dysuria, a sense of residual urine, urethral discomfort, hematuria, or suprapubic tenderness. Furthermore, recurrent cystitis episodes were confirmed by urinary culture showing bacterial presence at least once during the episode, corresponding to the onset of cystitis symptoms. Patients were considered eligible for VLT if they provided informed consent after receiving a detailed explanation of the procedure as a therapeutic option for recurrent cystitis. Screening tests for eligibility included the following criteria: postmenopausal status; vaginal pH ≥ 5.5; and negative test results for bladder cancer on cystoscopy, perineal abscess on perineal ultrasound, uterine disease on transvaginal ultrasound, and kidney disease on transabdominal ultrasound (Figure 1a).
Figure 1.
Urethral orifice and vaginal grading, and treatment protocol for recurrent cystitis patients. (a) Treatment schedule for recurrent cystitis patients. After screening tests, patients were treated with vaginal laser ± vaginal estrogen. (b) Grading system for evaluating urethral orifice and vaginal conditions via visual examination. (c) Distribution of grades for urethral orifice and vaginal findings.
2.2. Treatment Protocol and Efficacy Assessment
Patients who provided informed consent for VLT underwent pretreatment evaluation using cystoscopy to observe the vaginal and urethral orifice regions. We hypothesized that periurethral and vaginal atrophy may contribute to recurrent cystitis. Before initiating treatment, the condition of the urethral orifice and vaginal findings were graded based on a predefined classification system, as outlined in Table 1. Representative imaging findings are shown in Figure 1b. Additionally, the Vaginal Health Index (VHI) was assessed before treatment, and its changes during the course of treatment were evaluated. Clinical signs of vulvovaginal atrophy were assessed through pelvic examination, using validated tools to quantify the severity of vaginal and vulvar atrophy. The VHI assigns a score of 1–5 to five parameters (elasticity, fluid secretion, vaginal pH, mucosal integrity, and moisture), and lower scores are associated with more severe vulvovaginal atrophy; a cutoff of 15 has been validated for diagnosis of vaginal atrophy [8]. A detailed evaluation of VHI methodology is provided in the Supporting Information.
Table 1.
Macroscopic findings of the vaginal and urethral orifice regions.
| Vaginal findings | Definition |
|---|---|
| Grade 1 | No redness and no exposure of the urethral mucosa |
| Grade 2 | Mild redness with very slight exposure of the urethral mucosa |
| Grade 3 | Moderate redness with partial exposure of the urethral mucosa |
| Grade 4 | Severe redness with up to half of the urethral mucosa exposed |
| Grade 5 | Severe redness with more than half of the urethral mucosa exposed |
| Urethral orifice findings | |
| Grade 1 | Distinct vaginal mucosal folds with thickness |
| Grade 2 | Reduced vaginal mucosal folds with slight thinning |
| Grade 3 | Progression of loss of vaginal mucosal folds with noticeable thinning |
| Grade 4 | Complete disappearance of vaginal mucosal folds with marked thinning |
| Grade 5 | Flattening of vaginal mucosa with extreme thinning, accompanied by redness or inflammation |
The laser treatment group of 51 patients first received a 1‐ to 2‐week pretreatment with 0.3 mg estriol ovules (three ovules per week) and then underwent three sessions of laser therapy over a 12‐week period. The rationale for the pretreatment is derived from the observation that the erbium laser shows high absorption in water, and the thermal‐only Er:YAG mucosal treatment method requires a highly moist environment. To improve hydroretention within the tissue, pretreatment was administered using a medicated vaginal suppository containing 0.3 mg estriol, applied three times per week for 1–2 weeks. During the second or third week, the first laser treatment was performed using a 2940 nm Er:YAG laser (TimeWalker, Fotona, Slovenia) with a special modality, SMOOTH mode, which delivers laser energy in a nonablative, thermal‐only technique based on the manufacturer's proprietary pulsing sequence. In total, three treatments were performed, spaced 4 weeks apart. The treatment protocol involved two steps: first, laser irradiation was applied to the entire vaginal canal, and second, to the introitus area. A special laser speculum was inserted into the patient's vagina to guide the laser beam delivery system, consisting of an Er:YAG handpiece with a 360° circular adapter. Several longitudinal passes were performed using step‐by‐step retraction of the handpiece, delivering a cumulative energy of 1000 to 1500 J to the entire vaginal canal. In the second step of the procedure, laser energy was delivered to the entrance of the vaginal canal, including the vestibule and introitus area. No anesthesia was used for the vaginal canal; however, 10% lidocaine ointment was applied to the vestibule and introitus area before treatment. Patients were instructed to avoid sexual intercourse and activities that could increase intra‐abdominal pressure during the initial postoperative period of 3 days after the intervention.
The VLT protocol consisted of three sessions as a standard course; additional sessions were performed based on treatment efficacy and patient preference. Estriol treatment was not used when estrogen administration was contraindicated, such as cases involving a history of breast cancer. Depending on vaginal and periurethral tissue conditions, VHI, and patient‐reported symptoms, additional treatment sessions were considered. The minimally invasive nature of the procedure enabled VHI assessment at each treatment session. Cystoscopic examinations were conducted at the final treatment session if consent was obtained. Treatment‐associated adverse events (AEs) were evaluated and classified using the Clavien‐Dindo classification system.
2.3. Statistical Analysis
Statistical analyses were conducted as follows. Continuous parametric variables were summarized as medians with interquartile ranges (IQRs). The cystitis‐free interval (CFI) was defined as the time from initiation of VLT to occurrence of cystitis. Statistical comparisons between groups were performed using the χ 2 test for categorical variables and the paired t‐test for continuous variables, depending on data characteristics. p‐values < 0.05 were considered statistically significant. All statistical analyses were performed using Stata software (version 13.1; StataCorp LP, College Station, TX, USA), R software (R Foundation for Statistical Computing, Vienna, Austria), and GraphPad Prism (version 7.00; GraphPad Software Inc., San Diego, CA, USA).
3. Results
3.1. Patient Characteristics
In total, 51 patients were included in the study (Table 2). The median age was 63 years (IQR: 57–74), and all patients were postmenopausal. Three patients (5.9%) had a history of diabetes mellitus, and none were on sodium‐glucose cotransporter‐2 (SGLT2) inhibitors. Eight patients (15.7%) had previously undergone hysterectomy. During the study period, 44 patients (86.3%) received vaginal estrogen concomitantly with treatment. The median number of treatment sessions was four (IQR: 3–5). The median follow‐up period after treatment initiation was 8 months (IQR: 5–11). At the time of treatment initiation, cystoscopic findings revealed Grade 1 atrophy of vaginal tissue in 52.9% of cases and Grade 2 in 33.3%; corresponding values for periurethral tissue atrophy were 39.2% and 33.3%, respectively (Figure 1c). These findings suggest that patients with recurrent cystitis often have suboptimal urethral orifice and vaginal environments.
Table 2.
Patient characteristics.
| Variable | Value (n = 51) |
|---|---|
| Median age, years (IQR) | 63 (57–74) |
| Postmenopausal, n (%) | 51 (100) |
| Diabetes mellitus, n (%) | 3 (5.9) |
| Use of SGLT2 inhibitors, n (%) | 0 |
| Uterine prolapse grade, n (%) | |
| Grade 0 | 48 (94.1) |
| Grade 1 | 1 (2.0) |
| Grade 2 | 2 (3.9) |
| Post‐hysterectomy, n (%) | 8 (15.7) |
| ESBL detection, n (%) | 5 (9.8) |
| Concomitant use of female hormones, n (%) | 44 (86.3) |
| Median total laser treatments, n (IQR) | 4 (3–5) |
| Median follow‐up period, months (IQR) | 8 (5–1) |
Abbreviations: ESBL, extended‐spectrum beta‐lactamase; IQR, interquartile range; SGLT2, sodium‐glucose co‐transporter 2.
3.2. Efficacy of Laser Treatment
The duration from treatment initiation to cystitis recurrence (CFI) was analyzed using a Kaplan–Meier curve (Figure 2a), revealing a median CFI of 9.2 months. The number of cystitis cases decreased after treatment. The median (IQR) number of infections significantly decreased from 4 [3, 4, 5, 6] episodes in the 6 months before treatment to 0 (0–1) episodes in the 6 months after treatment (Figure 2b,c).
Figure 2.
Therapeutic effects in patients with recurrent cystitis. (a) Recurrence‐free interval after initiation of treatment. (b) Change in the number of cystitis episodes in each case from the 6 months before treatment to the 6 months after treatment. (c) Comparison of changes in the number of cystitis episodes before vs. after treatment.
To investigate factors contributing to treatment efficacy, we analyzed changes in the vaginal environment. Among 49 patients with sufficient data (excluding two cases), the median (IQR) VHI score significantly improved from 10 [9, 10, 11, 12, 13] at baseline to 18 [14, 15, 16, 17, 18, 19, 20] at the end of treatment (p < 0.001 unless stated otherwise; Figure 3a,b). Significant improvements were observed across all individual VHI components (Supporting Information S1: Figure 1). Additionally, the median (IQR) vaginal pH significantly decreased from 8.0 (7.0–8.5) to 5.5 (4.5–6.5). Vaginal and periurethral tissue conditions were also assessed via cystoscopy before and after treatment. Baseline assessments were performed for all patients, whereas posttreatment evaluations were conducted in 40 patients, excluding 11 cases where consent was not obtained. As shown in Supporting Infromation S1: Table 1, the grades of both vaginal and periurethral atrophy significantly improved after treatment. Representative findings are presented in Figure 3c, demonstrating improvements in periurethral atrophy and the disappearance of purulent vaginal discharge.
Figure 3.
Mechanism by which vaginal laser treatment improves recurrent cystitis. (a) Difference in Vaginal Health Index before vs. after treatment. (b) Difference in vaginal pH before vs. after treatment. (c) Representative case showing changes in urethral orifice and vaginal conditions before vs. after treatment. (d) Changes in the vaginal environment induced by menopause significantly affect the vaginal condition and microbiota, which, in turn, play a critical role in the development of recurrent cystitis.
Although administration of vaginal estrogen can aid the treatment of chronic cystitis [9, 10], seven patients in this study did not receive concomitant estriol suppositories as hormone therapy. Even in this subgroup, cystitis frequency and vaginal pH both significantly decreased after treatment; the VHI score also improved (Supporting Information S1: Figure 2).
3.3. AEs
AEs observed during the treatment period were classified according to the Clavien–Dindo grading system. AEs of any grade occurred in four patients (7.8%), all of which were classified as Grade 1. The specific AEs included vaginal pain in three patients (5.9%) and dyspareunia in one patient (2.0%; Table 3). All AEs were noted at the time of the first outpatient visit following the initial laser treatment session.
Table 3.
Adverse events during therapy.
| No. of patients | 51 |
|---|---|
| Any AE, n (%) | |
| Yes | 4 (7.8) |
| No | 47 (92.2) |
| Highest AE grading, n (%) | |
| I | 4 (7.8) |
| II–V | 0 |
| Specification of adverse events, n (%) | |
| Pain | 3 (5.9) |
| Dyspareunia | 1 (2.0) |
Abbreviation: AE, adverse event.
4. Discussion
This study represents the first reported evidence of VLT as a treatment for recurrent cystitis, demonstrating a reduction in the frequency of cystitis episodes. Urinary tract infections are a major health concern worldwide, with treatment costs in the United States alone reaching $1.6 billion [11]. This condition is particularly troublesome for women, especially postmenopausal women who experience recurrent episodes that significantly affect their QOL [12]. Conventional treatment has centered on antibiotics, but patients experiencing recurrent cystitis often face challenges, including repeated flare‐ups over short periods. In such cases, reliance on antibiotics alone is insufficient. A more comprehensive approach that addresses the vaginal environment is essential for effective management. This study focused on improving vaginal health through both local estrogen therapy and VLT, with the goal of enhancing treatment outcomes by combining these approaches.
Vaginal bacterial colonies may be involved in the development of cystitis [13], with the vagina potentially acting as a bacterial reservoir. Pabich et al. [21] highlighted that women with cystitis have higher levels of vaginal Escherichia coli and enterococci relative to those without cystitis, and that a higher abundance of lactobacilli is associated with a lower frequency of vaginal colonization by E. coli. Furthermore, vaginal lactobacilli are more prevalent in women receiving hormone replacement therapy. These findings suggest that hormonal changes during menopause substantially affect the vaginal microbiota, which in turn plays a critical role in the development of cystitis [14, 15]. Treatment approaches aimed at improving vaginal health—such as local estrogen therapy, Lactobacillus supplementation, and VLT—are strategies that may help prevent recurrent cystitis.
First, local estrogen therapy has shown a preventive effect on recurrent cystitis, with improvements in vaginal microbiota and pH, as demonstrated in randomized controlled trials [9, 10]. In addition to estrogen therapy, the use of lactobacilli has also been explored [16, 17]. Uehara et al. found that vaginal suppositories containing Lactobacillus crispatus reduced the frequency of urinary tract infections in women with recurrent cystitis [16]. Similarly, Sadahira et al. [17] reported a significant reduction in cystitis episodes after use of Lactobacillus suppositories. These findings support the hypothesis that better vaginal health can reduce the incidence of recurrent cystitis. Although the effectiveness of VLT for recurrent cystitis has not previously been demonstrated, CO2 laser therapy has shown promise in improving the vaginal mucosa in patients with GSM [18, 19]. Studies have revealed improvements in symptom scores for issues such as pain, dryness, and dysuria after laser therapy [18]. Additionally, histological examinations of vaginal tissue after laser treatment have shown increased epithelial thickness and improved connective tissue structure [19]. More recently, the second‐generation Er:YAG laser has been introduced as a noninvasive alternative treatment for GSM, particularly among patients who cannot use estrogen due to a history of breast cancer [20, 22]. Er:YAG laser therapy is considered more effective and longer‐lasting than topical estrogen therapy [23]. Its mechanism of action appears to involve collagen production in the vaginal mucosa, which may contribute to improvements in the vagina and surrounding mucosal structures, including the urethra [24].
Building on this background, we investigated the efficacy of VLT for recurrent cystitis. Our findings suggest that VLT can substantially reduce the frequency of cystitis episodes and extend the duration of freedom from cystitis‐related symptoms. No clinically significant AEs were observed, and the treatment was administered safely. The improvements in vaginal tissue health, pH, and VHI observed in our patients indicate that VLT can positively influence the vaginal microenvironment. To improve tissue hydroretention, we used estriol suppositories in combination with VLT. However, in some cases where patients could not receive estrogen therapy due to contraindications such as a history of breast cancer, VLT alone was effective in preventing recurrent cystitis. These results emphasize the potential for VLT to constitute an effective treatment for recurrent cystitis, offering a promising alternative for patients who do not respond well to conventional antibiotic treatments.
This study had some limitations. First, it was a retrospective analysis based on initial clinical experience with a relatively small sample size. Second, some patients (n = 13) did not attend follow‐up visits after 6 months; the majority of these patients did not experience recurrence of cystitis‐related symptoms and therefore did not seek further medical care. Exclusion of these cases did not alter the overall trends of our results, reinforcing the therapeutic benefit of VLT. Third, although the median follow‐up period was 8 months—providing valuable preliminary insight into the short‐ to midterm efficacy of VLT—longer follow‐up is necessary to evaluate the durability and long‐term effectiveness of the treatment. A follow‐up study assessing outcomes beyond 12 months is currently planned. Finally, we did not include a direct comparison between the effects of vaginal estrogen and VLT. In future studies, a larger sample size will enable comparison of the therapeutic effects and safety profiles of vaginal estrogen and VLT in recurrent cystitis, as well as investigation of their potential additive or synergistic effects.
In conclusion, menopause substantially affects the vaginal condition and microbiota, which in turn plays a critical role in the development of recurrent cystitis (Figure 3d). Our findings provide strong preliminary evidence supporting the potential efficacy of VLT for the recurrent cystitis. Future studies with larger sample sizes and prospective designs are needed to confirm these results and explore the underlying mechanisms of action. Our ultimate goal is to establish VLT as a reliable and effective treatment option, offering long‐term relief for patients with recurrent cystitis.
Disclosure
Approval of the research protocol by an Institutional Reviewer Board: The Nihonbashi Pelvic Floor Clinic Research Ethics Committee approved the study protocol (2025‐02). Informed consent: Written consent was waived because the data were anonymized (opt‐out approach). Registry and the Registration; No. of the Study/Trial: Not applicable. Animal studies: Not applicable.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Supporting Figure 1: Treatment effects on recurrent cystitis (vaginal health index). Supporting Figure 2: Therapeutic effects in cases treated with vaginal laser treatment without vaginal estrogen. Supporting Table 1: Macroscopic changes before and after vaginal lesion treatment.
Acknowledgments
The authors gratefully acknowledge the expert English language editing provided by Textcheck Inc.
Abe H., Urabe F., Nakazono M., Kawaharada A., and Kimura T., “Vaginal Laser Therapy as a Potential Treatment Option for Postmenopausal Women With Recurrent Cystitis: Initial Experience From a Single Institution,” Lasers in Surgery and Medicine 57 (2025): 700‐707. 10.1002/lsm.70061.
Hirokazu Abe and Fumihiko Urabe contributed equally to this study.
Data Availability Statement
The data supporting the findings of this study are available upon reasonable request from the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supporting Figure 1: Treatment effects on recurrent cystitis (vaginal health index). Supporting Figure 2: Therapeutic effects in cases treated with vaginal laser treatment without vaginal estrogen. Supporting Table 1: Macroscopic changes before and after vaginal lesion treatment.
Data Availability Statement
The data supporting the findings of this study are available upon reasonable request from the corresponding author.