Welcome to plastic surgery talk with Dr. Steven Mulholland brought to you by SpaMedica.
Hello and welcome, Dr. Steven Mulholland in Toronto, Canada. Welcome to Plastic Surgery Talk, and our series of podcasts. Today’s podcast is on a very, very common clinical problem, stress urinary incontinence, or SUI. Some of the novel noninvasive treatments, nonsurgical treatments for the management of that SUI, specifically the Emsella. If you find these podcasts entertaining, educational, please share them on your social media channels with your friends and your connections, subscribe, and comment.
What is SUI? What is stress urinary incontinence? As it implies, it is a loss of urinary bladder control when you put a stress or pressure on the pelvic floor. It can happen where the patient that suffers from this condition tinkles a little bit, has a little leaking when she laughs or giggles or coughs or is straining to bend down and pick something up or exercise, and it is super embarrassing because a little bit of the urine then stains undergarments, and it can lead to malodorous and smells. It can be uncomfortable and is embarrassing. The typical treatment for SUI has also been quite invasive, generally improving, restoring tone to the bladder neck and urethral junction, which are invasive, have recovery risks, and typically were not appealing to patients.
We now have a whole category of noninvasive technologies that can give massive improvement of these annoying and embarrassing symptoms of stress urinary incontinence. What we’re going to talk about today are the radio frequency devices, specifically the Emsella.
What are the symptoms of stress urinary incontinence or SUI? It’s an involuntary unexpected and unwanted loss of control of the bladder, urethra, which is the urinary channel in a woman, loss of control at the bladder neck or at the exit part of the bladder through the urethra. Incontinence or a tinkle or a dribble of urine that stains the undergarment, leads to discomfort of having a wet undergarment, and can have a bad or malodorous smell. Very embarrassing for women socially. Also with intimacy, stress urinary incontinence, leaking of urine, smell of urine during intimacy can become very embarrassing. Stress urinary incontinence is much more common than has previously been reported or suspected. Upwards of 50% of women after menopause will experience symptoms of SUI, and 25-30% of women who have multiple [inaudible 00:03:07] children through a vaginal delivery can suffer some loss of tone or injury to the pelvic floor and stress urinary incontinence. Super common. We just need a treatment that is noninvasive and works.
What are the causes of SUI? We talked about it. Menopausal and loss of hormonal integrity, especially loss of estrogen, loss of muscle tone in the pelvic floor, loss of control in the bladder at the urethral junction, and with a little increased pelvic pressure, laughing, coughing, straining, working out, exercising, bending over, a little tinkle or a little stream of urinary incontinence, which leave the symptoms of discomfort, of staining, and odor. So the causes are menopausal changes in the pelvic floor, postpartum traumatic changes to the pelvic floor through vaginal birth, and then one of the more common causes of stress urinary incontinence is hereditary predisposition that’s manifested by a loss of pelvic floor tone resulting from pelvic surgery or uterine delivery. These are the most common causes for stress urinary incontinence.
What are the treatments for SUI? Typically it has been an invasive surgery performed by uro-gynecologists or urologists where there is support and more control and an angle placed between the bladder and the urethra. These bladder support procedures that they are called, suspension techniques, meshes to improve the angle between the bladder neck and the urethral, are invasive. They have invasive risks. There is risk of long term failure of the technique, of inserted foreign body and mesh, and typically have not been favored by women with modest degrees of SUI, and then they live with the silent misery of their SUI without an option. The last few years we’ve had an explosion in technologies that improve the symptoms of SUI. These are principally the noninvasive women’s health technologies, either intervaginal or external techniques that improve the strength of the pelvic floor and strengthen the pelvic floor, improve the continency or the maintenance of continence between the bladder and the urethra.
One of the most revolutionary technologies for the treatment of SUI is called Emsella. What is Emsella? Emsella stands for EM, and sella, S-U-E-L-L-A. M stands for electro magnetic, so it is an electromagnetic spectrum of energy, like radio frequency meets microwave. Sella is Latin for chair. So it’s an EM chair or an incontinence chair. We have other electromagnetic technologies or radio frequency energy devices that also improve incontinence, vaginal lapsing, the signs and symptoms of vaginal atrophic changes, of dryness, discharge, and inflammation, that can also occur with menopause of Tamoxifen, the sudden onset of menopause by taking an anti-cancer, post-breast cancer treatment that cuts off the estrogen.
We know the causes of SUI. The treatments have typically been invasive. Now we’ve got non-invasive options, and we can divine them into vaginal or intervaginal treatments and non-intervaginal external treatments. The internal treatments, great technologies like the Femme 360, the Votiva, the ThermiVa, the TempSure NV with the intervaginal applicator. These are devices where the applicator is inserted into the vaginal canal. The radio frequency energy gradually and non-ablatively, non-invasively heats up the mucosa and the pelvic floor to about 40-42 degrees, which is sustained for about 30 minutes. A treatment is done once a month for three months, and you can significantly improve symptoms of SUI or stress urinary incontinence about 80-90% reduction in that little annoying embarrassing tinkle of urine by restoring the tone of the pelvic floor and the strength and the angle that the urethral bladder junction.
Those are the intervaginal technologies. The only disadvantage, they are noninvasive, there’s no risk, there’s no discomfort, but you have to get unclothed. You have to have a probe inserted gently and atraumatically in the vaginal space, generally performed by my medical aestheticians, so our female members of our medical med spa team, and the treatment takes about 30 minutes.
The Emsella, totally different. It’s a non-intervaginal technology. The patient literally comes in in comfort exercise clothes, like jogging pants or Lululemon yoga pants, and after being assessed for candidacy, that is making sure there’s no cervical cancer, there’s no pathology in the endovaginal canal, they’re medically well, they don’t have a Pacemaker, they sit down on this chair, the EM-electromagnetic, Sella, chair, the electromagnetic chair, and pulses of electromagnetic energy go up into the pelvic floor and cause the pelvic floor to contract. Not just like any old contraction like you do during a Kegel exercise where you strain and you hold your pelvic floor tone. There are about 20,000 super maximal contractions that happen in 30 minutes, which would take you a decade of Kegel exercises to get what you get in 30 minutes of one hair session. We do a series of treatments, generally once a week if the patient can make it once a week, or once every couple of weeks for a series of four to six treatments to achieve 80% or better reduction in average symptom complex SUI.
How does the Emsella work then? As we outlined, it is emitter of electromagnetic energy. Emanating from the center of the chair, there’s a little disk that the patient doesn’t see under the chair. Under the chair, there’s a large capacitor generator complex hooked up to the electromagnetic machine. What comes up from the chair in the central circular plate, which is about the size of the buttocks, is electromagnetic energy that flows right up into the pelvic floor. You have to position the patient in the middle of the chair so that that perineum, the area between the vaginal opening and the anal canal, the pelvic floor is right against the center of the disk, and electromagnetic energy flows in a pulse form noninvasively up through the clothing into the perineal form and induces contraction.
Not just contractions like that, but super maximal contractions, literally thousands of contractions every few minutes. We tight rate up the energy of that electromagnetic field until it’s tolerable, not painful, but patients really feel that contraction occurring. Of course if you do it over several sessions you’re going to get a hypertrophy or an amplification of the size and the strength of the pelvic floor muscles. Upwards of 20-30% improvement in the size, the muscle fibrous size and number of pelvic floor muscle that overcomes the atrophy that’s been created by the menopause, the trauma, the delivery, that led to the weakening of the pelvic floor. It’s a series of treatments. We do electromagnetic bodybuilding if you will of the pelvic floor, with the patient fully clothed sitting in the middle of this Emsella or this chair.
What is the protocol? How does it work? Well, generally it’s going to be four to six treatments depending on the severity of the symptoms. Generally once every week or two the patients visit the clinic. They have their Emsella treatment. Each treatment lasts about 30 minutes, and it’s very tolerable. It’s not necessarily a pleasant feeling, but it’s not unpleasant. It’s the sensation of contraction of your pelvic floor muscles, which is very tolerable compared to pain of other certain things we do like injectable fillers, Botox, laser hair removal, those are far more painful than the Emsella. I would call it noninvasive, uncomfortable but tolerable, 30-minute biostimulation through an EM, electromagnetic field, of the pelvic floor. We do a series of sessions, and we assess the efficacy at the end of those sessions. Some patients responds in as few as two to three sessions once every week or two, and some take four to six sessions, but generally about 80-90% reduction of all symptoms can occur with a simple noninvasive outpatient treatment, sitting in a chair, the incontinence chair called Emsella.
Who is an Emsella candidate? Who’s an SUI patient that would be a candidate for this? First of all, of course they need to have the symptoms of stress urinary incontinence. SUI can’t be incontinence of a neurogenic bladder or some other traumatic injury or legion. It has to be SUI from postmenopausal hormonal changes or SUI from post breast cancer Tamoxifen or SUI resulting from multiple [inaudible 00:12:30] childbirth or trauma to the vaginal floor through episiotomy or just transvaginal delivery birth trauma. Those are the best candidates. The indications and the cause. Of course contraindications would be any radio frequency sensitive Pacemaker such as a cardiac pacemaker, a bladder pacemaker, a neurogenic intercranial pacemaker, pregnancy. A patient can’t be pregnant and sit on this electromagnetic energy chair. Patients with cancer in the areas of treatment, if they have vulvar cancer or cervical cancer or cutaneous legions in the perineum, active open sores that are undiagnosed, systemic medical diseases such as MS ALS, rheumatoid arthritis, lupus, that is not treated or under control. These are the rare but relative and absolute contraindications for patients that shouldn’t be doing the Emsella SUI treatment.
After your series of Emsella treatments, the stress urinary incontinence chair, we can expect really good outcomes, 80% plus improvement. In many patients, their SUI is gone how long will it last? Let’s say you stop sitting on the chair. You top your super maximal contractions, that 20,000 contractions in 30 minutes. Will it come back? The answer is yes. Unfortunately, the biological up regulatory hypertrophic effect on your muscle of your pelvic floor will wither away and waste, just like imagine you go to a gym, and you work out and you get buffed and tones, and then you just say ugh. You don’t work out for two years. That muscle tone will subside. The muscle fibers return to their original size and shape, and you may lose control of that bladder neck again.
You may have a return of stress urinary incontinence, so we do recommend patients come in every 304 months for a single Emsella chair treatment. If you have severe symptoms or you’ve had 85% reduction, we may recommend coming every month or six weeks, but on average, four visits a year of a single treatment protocol should maintain the pelvic floor hypertrophy or increase in muscle fiber, tone, and dynamic control of that incontinent bladder neck junction that you can maintain the benefits of SUI improvement with very few ongoing maintenance treatments, generally 3-4 times a year.
What’s the average price for Emsella SUI treatment? That depends on the clinic and the location, the physician, and where in North America you might be, but if you look across North America, the series of Emsella treatments, the cost is usually between $2-4,000. On average, let’s say $3,000 for the program, which compared to the cost of private surgery for mesh or bladder neck suspension, a fraction of the cost. It’s noninvasive. There are no scars. There’s no real risk other than it’s not as successful as you want it to be, and there’s the ongoing negligible costs of several hundred dollars for a maintenance program for each session to maintain a 90% plus improvement. Around $2,000 is the average selling price for the series of treatments. Between $2-4000 would be the range. In general you can expect a high degree of success and satisfaction, and a relatively affordable and non-arduous 3-4 times a year single treatment maintenance program.
How to choose the right center for your SUI? You want to make sure that you’re going to a center like SpaMedica that is committed to technology to help with your problem. Emsella is the most attractive of the energy based technologies for SUI because you don’t have to get unclothed. You don’t have to have an intervaginal radio frequency energy device treat you. You can walk in and walk out, so it’s your usually entry level let’s try and see if this works. However, if you have significant SUI, if you have a lot of flow during the increased pelvic pressure, if you’ve done the Emsella and you don’t fully respond and you want a better improvement, you’ll want a center again like SpaMedica where I’ve invested in other technologies that can pick up where the Emsella may have left off.
So intervaginal devices, there can be intervaginal ablative devices, where we do resurfacing to heat the muscularis mucosa layer of the pelvic floor and the mucosa. Those are the fractional carbon dioxide intervaginal devices. We have a Mona Lisa Touch. We have an intervaginal CO2 from Cineron called the Core Intima. We have intervaginal radio frequency ablation, fractora, and so if we fail to gain the kind of control you want with the Emsella, we can do intervaginal ablative treatments. Now that’s more commonly used when the cause of the SUI is from menopause. The estrogen, you get vaginal atrophy, pain, discharge, inflammation, discomfort during intercourse, and often managing the mucosa with fractional CO2 combined with the Emsella is an ideal program.
We also have intervaginal radio frequency devices. Let’s say you don’t have postmenopausal signs and symptoms of vaginal atrophy, and you don’t have post Tamoxifen, post breast cancer signs of vaginal atrophy. You don’t need ablation of the mucosa, of your vaginal vault, because you don’t have dryness or inflammation or discharge, but you do have some vaginal laxity from significant trauma during childbirth or during pelvic surgery. An episiotomy gone bad where you just have vaginal laxity symptom, and or stress urinary incontinence. Then you may need a supplemental intervaginal treatment in addition to the Emsella. The Femme 360 is a wonderful technology with a very comfortable probe that’s inserted in the vaginal canal, and with temperature monitoring will heat up the vaginal canal and the overlying and surrounding muscle tissue, the pelvic floor, to 42 degrees comfortably for about 30 minutes. That more focused radio frequency energy can be more effective in refractory Emsella cases.
We also have another technology, the Votiva, that also sends intervaginal radio frequency probe, and it has temperature control so you know the temperature at all times, temperature feedback control, and is again very good for vaginal laxity syndromes, where you feel that lack of competency, that lack of fullness and satisfaction during intimacy and intercourse you might have had before babies and before the vaginal canal was either traumatized during delivery or there’s a surgical episiotomy that divided the post tier vaginal wall or lateral vaginal wall, and you lost some of that tone. The intervaginal technology can improve that more so than the Emsella, and you get the additional benefit of improving the pelvic floor with regards to the bladder, the urethral neck stress urinary incontinence. The Votiva, very good for that. The Femme 360, very good intervaginal radio frequency device.
We also have the ThermiVa, which can be an adequate device for this. Between the fractional ablative CO2s and ablative RFs and the intro nonablative RFs, we have lots of technology that can serve to improve upon a partial response to the Emsella or to offer better result that the Emsella fails. You want to pick a center for your SUI that has multiple technologies to give you more options, give you the best possible reduction in that annoying, that embarrassing, and sometimes socially disabling stress urinary incontinence.
Thank you for joining me again. Dr. Steven Mulholland here on Plastic Surgery Talk in Toronto Canada. For our latest installment of our podcast series, SUI, stress urinary incontinence treated specifically with the high tech and new Emsella or incontinence chair, electromagnetic chair. If you found this entertaining, educational, and informative, please share it with your friends and contacts and your social media channels, subscribe, and comment. See you next time.