Vaginal estrogen compared to CO₂ LASER to prevent recurrent UTI in menopausal women:a pilot RCT

Topical vaginal estrogen is effective in preventing urinary tract infection for menopausal women with recurrent urinary tract infections (rUTI). CO2 LASER has been studied as a treatment for vaginal atrophy. Some clinical studies have shown CO2 LASER to have a similar effect on the vagina, improving pH, lubrication, and sexual function. We hypothesize that CO2 LASER treatment of the vagina is non-inferior to topical vaginal estrogen for prevention of UTI in menopausal women.

Methods: A pilot, randomized controlled trial was performed at 2 tertiary care academic institutions, evaluating prophylactic treatment of menopausal women with rUTI. Inclusion criteria included no current vaginal estrogen treatment, menopausal state, and 2 culture proven UTIs in 6 months, or 3 UTIs in 12 months. Primary outcome was recurrence of UTI, with secondary outcomes evaluating vaginal symptoms with DIVA, and urinary incontinence with MESA questionnaires. Adverse events were also reported.

Results: Twelve patients were enrolled, 7 using vaginal estrogen (E2) and 5 undergoing LASER treatments. Baseline characteristics between LASER and E2 groups were similar. Participants were, on average, 68 years old, White, non-diabetic and had 4 UTIs in the last year. E2 patients had baseline vaginal pH 7.2 and LASER patients had pH 6.3 (p=0.332). 5/7 E2 patients experienced another UTI while 2/5 LASER patients had another UTI by month 4 after initiation of treatment (p=0.035). DIVA and MESA scores did not differ at 4 months between groups. MESA urge questions showed greatest change -2.6 for E2 and -1.6 for LASER (p=0.643). Vaginal pH for E2 was 5.8 and 6.4 for LASER at 4 months. The most common adverse event was noted to be abnormal bleeding which was mild and self-limited in the LASER group. Vaginal itching, burning and irritation was also noted in the LASER group. 2 severe adverse events were noted in the E2 group, urosepsis and diverticulits. Neither was felt to be related to the estrogen treatment.

Conclusions: In this small pilot randomized controlled trial, LASER vaginal treatment appeared to be non-inferior to E2 in prevention of rUTI. However, there was a high rate of recurrent UTI in both groups, which was unexpected for the E2 group. Small sample size limits the ability to make firm conclusions. Larger comparative studies are warranted before LASER should be considered for rUTI prophylaxis. While clinical efficacy is uncertain, LASER treatment does appear safe with mild adverse events.