Demands for cosmetic surgery in the female genital area are on the rise. Recently, supported by the media, aesthetic procedures have become an unavoidable topic. Motivations for cosmetic genital surgery are physical, psychological and sexual. Vaginal laxity remains usually underreported, although most women patients consider this condition bothersome with a significant impact on their relationships. The visual aspect and functionality of the introitus are marked most often as being responsible for sexual disorders and reduced quality of life. Surgeons in this specific field should follow crucial principles in ethics.

Noninvasive treatment has been recommended as the first line for urinary incontinence (UI) and genitourinary syndrome of menopause (GSM). However, surgical procedures are more likely to be implemented to cure vaginal relaxation syndrome (VRS) and UI but are associated with serious adverse effects. Less invasive operative mesh techniques are relatively effective, but not immune to complications such as bleeding, bladder perforation, urethral injury, infection, and retention requiring mesh resection. Additional financial costs and extended recovery time after mesh/sling surgery have induced a growing trend in non-invasive procedures. Contemporary scientific and technological breakthroughs have led to better clinical outcomes with minimally invasive procedures, shorter recovery times, and lower implicated costs. In that sense, recent evidence supports energy-based devices (EBD), mostly Er:YAG and CO2 laser and radiofrequency (RF) treatment, as an effective and compliant intervention for stress UI and lower stages vaginal and vulvar relaxation. 
Since 2015 clinical studies have shown the advantages of different energy-based devices (EBD) for the treatment of SUI/genitourinary syndrome of menopause (GSM). Most studies have referred to the use of nonablative Er:YAG SMOOTH® laser for the treatment of SUI and mixed urinary incontinence (MUI), and both Er:YAG and CO2 lasers in the treatment of GSM.
Head-to-head studies have shown that Er:YAG SMOOTH® improves urinary incontinence in women as effectively as the tension-free vaginal tape (TVT) and transobturator tape (TOT) procedures. 
Vaginal erbium laser (VEL) safely and effectively improve overactive bladder symptoms score (OABSS) compared to common pharmacotherapies, anticholinergics, and β3-adrenoceptor agonists.

There is no “perfect vagina” (vulva) as a standard. Diversity in appearance is physiological. Women and their partners should be counseled about that before any female genital cosmetic surgery procedure. Patients should understand the scheduled procedure's risks, benefits, and alternatives.

A key document is informed consent. The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances. The health provider's obligation is to correctly inform the patient of all possible benefits and risks, as female genital cosmetic surgery (FGCS) procedures are not exempt from secondary effects.

Irrelevant to women's desire for aesthetic perfection, medical professionals in the specific field of female genital cosmetic surgery should follow crucial principles in ethics. Their responsibility is proper counseling, based on evidence, and a professional approach with high-level skills and expertise in that area.

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Fistonic I, Fistonic N. Baseline ICIQ-UI score, body mass index, age, average birth weight, and perineometry duration as promising predictors of the short-term efficacy of Er:YAG laser treatment in stress urinary incontinent women: A prospective cohort study. Lasers Surg Med. 2018; 50:636–643

Continence 7S1 (2023) 101015
DOI: 10.1016/j.cont.2023.101015