• drnadiayousri

Vaginal Tightening?Which Treatment for Vaginal Laxity©

Updated: Oct 25

By Dr. Nadia Yousri, OB&GY Surgeon & Sexual Medicine & Regenerative Aesthetic Gynaecology Consultant™, FRCOG, MRCOG, PhD, MSc, DFSRH, Published 27/02/2021, copyrights reserved to www.drNYaesthetics.com©®




Vaginal laxity (loosening or loss of tonicity of vaginal wall & vaginal opening) is common presentation among women after childbirth and menopause with physical and psychological impact such as diminished or loss of sensation during intercourse that leads to unsatisfied sexual life, loss of confidence and low self-esteem affecting the intimate relationship.1-3

Vaginal Laxity is the main cause of sexual dissatisfaction. Vaginal laxity lacks standardized diagnosis and severity criteria. It is considered as a subjective complaint that reflects decreased sexual satisfaction due to vaginal loosening.

It has been estimated that up to 40% of women have complaints of sexual problems, including decreased libido, vaginal dryness, pain with intercourse, decreased genital sensation and difficulty or inability to achieve orgasm.4-6


Vaginal Laxity, How it Happens Following Childbirth?:

Vaginal laxity occurs during childbirth, when the vaginal tissue and lining is thinned out and stretched to accommodate the delivery of the baby.

Vaginal Laxity happens after several deliveries or big size baby, where the vaginal wall & its opening become unable to retract back to its initial shape or size due to overstretch & loss of the pelvic muscles’ tone that surround the vaginal opening -either due to mechanical overstretch or due to birth tears/injuries- resulting in looseness & weakness of vaginal tissues.

Vaginal laxity syndrome is the term describing a group of symptoms resulting from the disruption of the pelvic floor muscles & manifesting as loose vaginal opening, diminished sexual sensation, urine leakage & stool leakage (foecal urgency or incontinence) 7-9


Vulvovaginal Atrophy (VVA)/ Genitourinary Syndrome of Menopause (GSM), What is it?

Vaginal laxity at menopause is due to decline of Oestrogen hormone production that leads to loss of volume & strength of many feminine tissues that contain Oestrogen receptors that help to maintain the youthful shape & function. At menopause, atrophy (shrinkage) of tissues happens. There is a reduction in the plumpness (bulk/mass) of the pelvic floor muscles and in the vaginal and urinary areas due to diminishing of Oestrogen & its receptors mediating or responsible for both the wellbeing & function of the structures in the feminine area. Deficiency of Oestrogen hormone eventually leads to vaginal dryness and laxity.

Vaginal Laxity is a taboo! Women are reluctant to talk about it because they think it is embarrassing! Many women suffer in silence. They are convinced that the condition of vaginal laxity is part of the natural aging process & that is inevitable to happen and there is nothing would correct it but surgery. They struggle with a decrease in sexual satisfaction due to lack of enough physical friction during intercourse, (due to loose vaginal opening & the surrounding muscle tone) and diminished or loss of sensation and natural lubrication function. This elicits the symptoms of pain during intercourse (dyspareunia) or sensation of “cactus dryness” or irritation or burning sensation or uncommonly cracks in the vaginal wall with occurrence of spotting or bleeding following intimacy. The combination of all these symptoms come under the terminology or the diagnosis of Vulvo-Vaginal Atrophy (VVA) or Genitourinay Syndrome (GSM) is a combination of vulvo-vaginal laxity, vaginal atrophy, urinary incontinence, and orgasmic dysfunction). The GSM symptoms include genital symptoms (dryness, burning, itching, irritation, bleeding), sexual symptoms (dyspareunia and other sexual dysfunctions) and urinary symptoms (dysuria, frequency, urgency, recurrent urinary infections 10-12


Vaginal Laxitys: How to Treat- options

I) Surgical treatment

Vaginal Laxity can be treated by traditional surgical procedures called vaginoplasty (Anterior Coloporrahpy, Posterior Colpoperineorrahpy, Manchester-Fothergill repair, , perineoplasty and vaginal vault prolapse etc. Surgical option requires lengthy preparation, aenesthesia, stay in hospital and long time for recovery for weeks, not to mention the inherent risks of surgery & potential complications including scar tissue formation. 13-15


Female sexual dysfunction following vaginal surgery.

A significant percent of women report pain during intercourse. Some patients experience improved overall sexual function due to complete relief from coital incontinence.

It is worthy to mention that the purpose of surgery is achieving anatomical tightening of the vaginal wall, but it does not lead to improvement in the function or the quality of the already atrophic vaginal tissues.16, 17 -By Dr. Nadia Yousri (FRCOG)


II) Non-Surgical Options: What are they?


1) Conservative


1.1. Pelvic Floor Exercises (Kegel’s)/physiotherapy

These aim to tighten the muscles surrounding the vaginal opening and improving the resting muscle bulk & tone. These exercises should be routinely done at least 3 times a day for 10-15 minutes daily & indefinitely.18, 19


1.2 Hormonal Replacement Therapy? How useful in VVA?

Use of Oestrogen Hormone Replacement (EHT) is meant to improve & reverse the atrophic changes happened in the vaginal wall. It improves the quality of vaginal tissues enhancing blood flow and thickening & abundance of the cellular element of the lining vaginal skin; an effect mediated by the Oestrogen receptors. Topical applications are usually advised to avoid or minimize the side effects. Forms like Creams, pessary, vaginal rings are usually prescribed to be applied for a two or three month-course that can be repeated every 3 months. [By Dr. Nadia Yousri (FRCOG)]

Vaginal Laxity is not expected to be improved by the ERT, but the lubricating function will be regained.20-22


What Are the New Trends in Non-Surgeical Treatment of Vaginal Laxity?

1.3 Non-Hormonal Non-Surgical “Aesthetic/Regenerative Gynaecology procedures

Nowadays most women are choosing the non-surgical “Aesthetic” better called “Regenerative Gynaecology”TM options such as use of Hyaluronic Acid Fillers or autologous cell grafting or autologous lipofilling, or Gold Thread Implantation radiofrequency and laser; all these aiming to tighten and rejuvenate vaginal tissues.23-28

Platelets’ Rich Plasma Injections (also known as O Shot): the use of autologous platelets’ sample after centrifuging the person’s blood sample and inject in certain points -by the experienced Gynaecologist Dr. Nadia Yousri- to stimulate tissue regeneration & vaginal rejuvenation. It has excellent results with the expert hand. Platelet-rich plasma (PRP) can be incorporated into genital rejuvenation.29-34

The use of PRP as a supplement of cell culture media has consistently shown to potentiate stem cell proliferation, migration, and differentiation. In addition, the clinical utility of PRP is supported by evidence that PRP contains high concentrations of growth factors (GFs) and proteins which contribute to the regenerative process. PRP based therapies are cost effective, also benefit from the accessibility and safety of using the patient's own GFs. In the last years, a great development has been witnessed on PRP based biomaterials, with both structural and functional purposes. By Dr. Nadia Yousri (FRCOG)

Genital rejuvenation involves the management of extrinsic (traumatic) and intrinsic (aging) changes of the vagina and scrotum. Lipofilling-with the additional injection of PRP (with or without hyaluronic acid)-has been used to successfully treat vaginal atrophy and vaginal laxity; the unexpected resolution of Lichen Sclerosis in one of the women prompts the consideration to initially use PRP for the treatment of this condition not only in women but also men.35-38


Vaginal Laxity & Laser treatment for vaginal tightening- By Dr. Nadia Yousri (FRCOG)

Laser has become increasingly popular for enhancing/gratification of sexual & orgasmic function along with the treatment of vaginal laxity by gently ablating the weakened tissue in the vaginal wall that improve vascularization & stimulates the natural body healing process promoting fibrin and collagen deposition. The new collagen and elastin formation improves lubrication and restores the strength and elasticity of the vaginal wall and the supporting connective tissue matrix.

The procedure is painless, takes few minutes, with 5-7 days downtime. It may take to 3 sessions to achieve the targeted success rate.

In a study -published in 2021 that included 84 pre-menopause women, with a mean age of 47.7 years who had CO2 Laser treatment for vaginal laxity with diminished sexual satisfaction, it was shown that CO2 laser treatment has both a statistically and clinically significant effect on participants' complaints and sex-life, which wanes by 6 months post-treatment. And that Laser therapy seems to be safe in the short term, with no serious adverse events reported in that current study.39-43


Radiofrequency for vaginal tightening- carried out by Dr. Nadia Yousri (FRCOG)

Radiofrequency is used to induce regeneration of the tissues through warming up the lining of the vagina and the vulva to induce collagen and elastin formation, improve blood flow and increase moisture in the vagina which makes the tissues tighten so the vaginal walls are stronger and plumper.

The treatment is painless and takes about 20 minutes and creates a gentle warming sensation. 44-53







Copyrights reserved® to Dr. Nadia Yousri TM, www.drNYaesthetics.com

Dr. Nadia YOUSRI, FRCOG, MRCOG, PhD, MSc & DFFP in OB&GY & Regenerative Sexual Aesthetics Consultant & Cosmetic Doctor


Links to the press:-

https://kuwait-press.com/8036/

https://new-bbc.com/7519

https://al3rabiya.com/7614

https://alkhaleej-news.net/7550/




References


1-Vaginal laxity: which measure of levator ani distensibility is most predictive?

Manzini C, Friedman T, Turel F, Dietz HP.Ultrasound Obstet Gynecol. 2020 May;55(5):683-687.


2-Vaginal laxity: what does this symptom mean?

Dietz HP, Stankiewicz M, Atan IK, Ferreira CW, Socha M. Int Urogynecol J. 2018 May;29(5):723-728. doi: 10.1007/s00192-017-3426-0


3-Self-Reported Vaginal Laxity-Prevalence, Impact, and Associated Symptoms in Women Attending a Urogynecology Clinic.

Campbell P, Krychman M, Gray T, Vickers H, Money-Taylor J, Li W, Radley S. J Sex Med. 2018 Nov;15(11):1515-1517.


4-Vaginal Laxity, Sexual Distress, and Sexual Dysfunction: A Cross-Sectional Study in a Plastic Surgery Practice.

Qureshi AA, Sharma K, Thornton M, Myckatyn TM, Tenenbaum MM. Aesthet Surg J. 2018 Jul 13;38(8):873-880.

5-Vaginal Laxity, Sexual Distress, and Sexual Dysfunction: A Cross-Sectional Study in a Plastic Surgery Practice.

Qureshi AA, Sharma K, Thornton M, Myckatyn TM, Tenenbaum MM. Aesthet Surg J. 2018 Jul 13;38(8):873-880.


6-Correlates of vaginal laxity symptoms in women attending a urogynecology clinic in Saudi Arabia. Talab S, Al-Badr A, AlKusayer GM, Dawood A, Bazi T. Int J Gynaecol Obstet. 2019 Jun;145(3):278-282.


7-Postpartum sexual function; the importance of the levator ani muscle.

Roos AM, Speksnijder L, Steensma AB. Int Urogynecol J. 2020 Nov;31(11):2261-2267


8-Pubovisceral muscle and anal sphincter defects in women with fecal or urinary incontinence after vaginal delivery. Murad-Regadas SM, Regadas FSP, Filho FSPR, Borges LB, da Silva Vilarinho A, Veras LB, Regadas CM, Regadas MM.Tech Coloproctol. 2019 Feb;23(2):117-128.


9-Pathophysiology of adult fecal incontinence. Rao SS. Gastroenterology. 2004 Jan;126(1 Suppl 1):S14-22. https://pubmed.ncbi.nlm.nih.gov/14978634/


10- Vaginal Health in Menopausal Women.

Alvisi S, Gava G, Orsili I, Giacomelli G, Baldassarre M, Seracchioli R, Meriggiola MC. Medicina (Kaunas), 2019 Sep 20;55(10):615


11- The effects of hypoestrogenism on the vaginal wall: interference with the normal sexual response.Lara LA, Useche B, Ferriani RA, Reis RM, de Sá MF, de Freitas MM, Rosa e Silva JC, Rosa e Silva AC. J Sex Med. 2009 Jan;6(1):30-9.


12-Addressing Vulvovaginal Atrophy (VVA)/Genitourinary Syndrome of Menopause (GSM) for Healthy Aging in Women. Nappi RE, Martini E, Cucinella L, Martella S, Tiranini L, Inzoli A, Brambilla E, Bosoni D, Cassani C, Gardella B. Front Endocrinol (Lausanne). 2019 Aug 21; 10:561.


13-Safety, Efficiency, and Outcomes of Perineoplasty: Treatment of the Sensation of a Wide Vagina. Ulubay M, Keskin U, Fidan U, Ozturk M, Bodur S, Yılmaz A, Kinci MF, Yenen MC. Biomed Res Int. 2016;2016:2495105


14- British Society of Urogynaecology (BSUG); Autologous Facial Slings to Treat Stress Urinary Incontinence. Patient Information Leaflet. https://bsug.org.uk/budcms/includes/kcfinder/upload/files/Autologous%20fascial%20sling%20BSUG%20Mar%202018-2.pdf


15-Colpoperineoplasty in women with a sensation of a wide vagina.

Pardo JS, Solà VD, Ricci PA, Guiloff EF, Freundlich OK. Acta Obstet Gynecol Scand. 2006;85(9):1125-7.


16-Female sexual dysfunction following vaginal surgery: a review.

Tunuguntla HS, Gousse AE. J Urol. 2006 Feb;175(2):439-46


17-British Society of Urogynaecology (BSUG); Obesity: Effect on the Pelvic Floor, Risk for Surgery. Patient Information Leaflet. https://bsug.org.uk/budcms/includes/kcfinder/upload/files/info-leaflets/Obesity%20and%20the%20plevic%20floor%20BSUG%20July%202017.pdf


18-Postpartum pelvic floor muscle training and abdominal rehabilitation: Guidelines.Deffieux X, Vieillefosse S, Billecocq S, Battut A, Nizard J, Coulm B, Thubert T .J Gynecol Obstet Biol Reprod (Paris). 2015 Dec;44(10):1141-6. https://pubmed.ncbi.nlm.nih.gov/26530172/


19-Pubovisceral muscle and anal sphincter defects in women with fecal or urinary incontinence after vaginal delivery.

Murad-Regadas SM, Regadas FSP, Filho FSPR, Borges LB, da Silva Vilarinho A, Veras LB, Regadas CM, Regadas MM. Coloproctol. 2019 Feb;23(2):117-128.


20- Safety and efficacy of ospemifene for the treatment of dyspareunia associated with vulvar and vaginal atrophy due to menopause. Wurz GT, Kao CJ, DeGregorio MW. Clin Interv Aging. 2014 Nov 13; 9: 1939-50.


21- British Society of Urogynaecology (BSUG); BotulinumA Injections To Treat Overactive Bladder; Patient Information Leaflet: https://bsug.org.uk/budcms/includes/kcfinder/upload/files/Botox-BSUG-Dec-2019.pdf


22- British Society of Urogynaecology (BSUG); Urethral Debulking To Treat Stress Urinary Incontinence. Patient Information Leaflet. https://bsug.org.uk/budcms/includes/kcfinder/upload/files/Urethral%20bulking%20BSUG%20Mar%202018.pdf


23-Review of non-invasive vulvovaginal rejuvenation.

Photiou L, Lin MJ, Dubin DP, Lenskaya V, Khorasani H. J Eur Acad Dermatol Venereol. 2020 Apr;34(4):716-726.


24-Genital Rejuvenation: The Next Frontier in Medical and Cosmetic Dermatology. A Review. Cohen PR. Dermatol Online J. 2018 Sep 15;24(9):13030/qt27v774t5


25-First Use of Thermal Stabilized Hyaluronic Acid Injection in One-Year Follow-Up Patients with Genitourinary Syndrome. Garavaglia E, Sala C, Busato M, Bellia G, Tamburlin N, Massirone A .Med Devices (Auckl). 2020 Dec 4;13:399-410.


26-Gold Thread Implantation for Female Sexual Dysfunction and Vaginal Laxity: A Preliminary Investigation.Kim SM, Won YS, Kim SK. J Menopausal Med. 2020 Aug;26(2):130-134.


27-Platelet-Rich Plasma and Genital Rejuvenation.

Cohen PR, Riahi RR. Skinmed. 2019 Jul 1;17(4):272-274.


28- Novel technique of vulvo-vaginal rejuvenation by lipofilling and injection of combined platelet-rich-plasma and hyaluronic acid: a case-report.

Aguilar P, Hersant B, SidAhmed-Mezi M, Bosc R, Vidal L, Meningaud JP. Springerplus. 2016 Jul 26;5(1):1184.


29-Blood Plasma Derivatives for Tissue Engineering and Regenerative Medicine Therapies. Santos SCNDS, Sigurjonsson ÓE, Custódio CA, Mano JFCDL.Tissue Eng Part B Rev. 2018 Dec;24(6):454-462. https://pubmed.ncbi.nlm.nih.gov/29737237/


30-Platelets in wound healing and regenerative medicine.

Etulain J. Platelets. 2018 Sep;29(6):556-568. https://pubmed.ncbi.nlm.nih.gov/29442539/


31-Platelet-Rich Plasma in Tissue Engineering: Hype and Hope.

Lang S, Loibl M, Herrmann M. Eur Surg Res. 2018;59(3-4):265-275.


32-Platelet-rich plasma (PRP) and Platelet-Rich Fibrin (PRF): surgical adjuvants, preparations for in situ regenerative medicine and tools for tissue engineering.

Bielecki T, Dohan Ehrenfest DM. Curr Pharm Biotechnol. 2012 Jun;13(7):1121-30.


33-Simultaneous concentration of platelets and marrow cells: a simple and useful technique to obtain source cells and growth factors for regenerative medicine.

Nishimoto S, Oyama T, Matsuda K. Wound Repair Regen. 2007 Jan-Feb;15(1):156-62.


34-Leukocyte- and platelet-rich Plasma (L-PRP)/fibrin (L-PRF) in medicine - past, present, future. Bielecki T, Dohan Ehrenfest DM. Curr Pharm Biotechnol. 2012 Jun;13(7):i-ii.


35-Rejuvenation Using Platelet-rich Plasma and Lipofilling for Vaginal Atrophy and Lichen Sclerosus.

Kim SH, Park ES, Kim TH . J Menopausal Med. 2017 Apr;23(1):63-68.


36-Platelet-rich plasma and hyaluronic acid - an efficient bio-stimulation method for face rejuvenation. Ulusal BG. J Cosmet Dermatol. 2017 Mar;16(1):112-119


37-Regenerative Medicine, Stem Cell Therapies, and Platelet-Rich Plasma: Where Is the Evidence? Goddard NV, Waterhouse N. Aesthet Surg J. 2020 Mar 23;40(4):460-465.


38-Fat, Stem Cells, and Platelet-Rich Plasma. James IB, Coleman SR, Rubin JP. Clin Plast Surg. 2016 Jul;43(3):473-88.


39-Laser therapy for the restoration of vaginal function.

Gambacciani M, Palacios S. Maturitas. 2017 May; 99: 10-15.


40-The Efficacy and Safety of CO2 Laser Treatment for Sexual Function and Vaginal Laxity Improvement in Pre-Menopausal Women.

Lauterbach R, Dabaja H, Matanes E, Gruenwald I, Lowenstein L. Lasers Surg Med. 2021 Feb;53(2):199-203


41-Patient reported vaginal laxity, sexual function and stress incontinence improvement following vaginal rejuvenation with fractional carbon dioxide laser.

Toplu G, Serin M, Unveren T, Altinel D. J Plast Surg Hand Surg. 2021 Feb;55(1):25-31


42- The energy-based devices for vaginal "rejuvenation," urinary incontinence, vaginal cosmetic procedures, and other vulvo-vaginal disorders: An international multidisciplinary expert panel opinion. Digesu GA, Tailor V, Preti M, Vieira-Baptista P, Tarcan T, Stockdale C, Mourad S. Neurourol Urodyn. 2019 Mar;38(3):1005-1008


43- The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology: An ICS/ISSVD best practice consensus document. Preti M, etal. Neurourol Urodyn. 2019 Mar;38(3):1009-1023.


44-Fractional CO2 laser treatment for vaginal laxity: A preclinical study.

Kwon TR, et al. Lasers Surg Med. 2018.


45-Laxity of the vaginal introitus after childbirth: nonsurgical outpatient procedure for vaginal tissue restoration and improved sexual satisfaction using low-energy radiofrequency thermal therapy. Sekiguchi Y, Utsugisawa Y, Azekosi Y, Kinjo M, Song M, Kubota Y, Kingsberg SA, Krychman ML .J Womens Health (Larchmt). 2013 Sep;22(9):775-81


46-Noninvasive Vaginal Rejuvenation: Radiofrequency Devices.

Hoss E, Kollipara R, Fabi SSk. inmed. 2019 Nov 1;17(6):396-398


47-Vaginal rejuvenation using energy-based devices.

Karcher C, Sadick N. Int J Womens Dermatol. 2016 Jun 21;2(3):85-88


48-Vaginal Rejuvenation: A Retrospective Review of Lasers and Radiofrequency Devices. Juhász MLW, Korta DZ, Mesinkovska NA. Dermatol Surg. 2020 Nov 3.


49- Radiofrequency treatment of vaginal laxity after vaginal delivery: nonsurgical vaginal tightening.Millheiser LS, Pauls RN, Herbst SJ, Chen BH. J Sex Med. 2010 Sep;7(9):3088-95.


50-Laxity of the vaginal introitus after childbirth: nonsurgical outpatient procedure for vaginal tissue restoration and improved sexual satisfaction using low-energy radiofrequency thermal therapy.Sekiguchi Y, Utsugisawa Y, Azekosi Y, Kinjo M, Song M, Kubota Y, Kingsberg SA, Krychman ML. J Womens Health (Larchmt). 2013 Sep;22(9):775-81.


51- Evolution in the radiofrequency treatment of vaginal laxity and menopausal vulvo-vaginal atrophy and other genitourinary symptoms: first experiences with a novel dynamic quadripolar device. Vicariotto F, Raichi M.Minerva. Ginecol. 2016 Jun;68(3):225-36.


52- Safety and mechanism of action of non-invasive radiofrequency treatment for vaginal laxity: Histological study in the swine vaginal model. Kent DE, Bernardy J. J Cosmet Dermatol. 2020 Jun;19(6):1361-1366.


53-Dynamic quadripolar radiofrequency treatment of vaginal laxity/menopausal vulvo-vaginal atrophy: 12-month efficacy and safety. Vicariotto F, DE Seta F, Faoro V, Raichi M.Minerva. Ginecol. 2017 Aug;69(4):342-349.


54- Evaluation of the Safety and Efficacy of a Novel Radiofrequency Device for Vaginal Treatment. Caruth JC. Surg Technol Int. 2018 Jun 1; 32:145-149.


55-Evaluation of the safety and efficacy of a monopolar nonablative radiofrequency device for the improvement of vulvo-vaginal laxity and urinary incontinence. Lalji S, Lozanova P. J Cosmet Dermatol. 2017 Jun;16(2):230-234.

Published by Dr. Nadia Yousri, FRCOG, Aesthetic Regenerative Gynaecology Consultant©



External Links:


1-British Menopause Society update on HRT supply shortages. published: 23/08/2019.

https://thebms.org.uk/wp-content/uploads/2020/07/03-BMS-TfC-HRT-Practical-Prescribing-JULY2020-01E.pdf


2-Menopause Matters: https://www.menopausematters.co.uk/tree.php

3-British Society of Urogynaecology (BSUG); https://pcwhf.co.uk/resources/british-society-of-urogynaecology-patient-information-leaflets/


Copyrights reserved© to Dr. Nadia Yousri, www.drnyaesthetics.com-Published on 27/02/2021 © www.drnadiayousri.com®


Internal Links:

1-Urinary Incontinence, Non-Surgical Aesthetic Treatments

https://www.drnyaesthetics.com/post/urinary-incontinence-non-surgical-aesthetic-treatments


2-Gynaecology

https://www.drnyaesthetics.com/post/5faacaa77620370017d93ced/


3-Pain During Intercourse (Dyspareunia)-Non-Surgical Treatment

https://www.drnyaesthetics.com/post/5fab09b8770a8b001734ebaa/

4-Pregnancy Stretch Marks-The Tigress' Pattern!©

https://www.drnyaesthetics.com/post/5ce0df4ab8c6b601f51f838e/


5- Why Aesthetic Gynaecology procedures are best performed by a Gynaecologist©

https://www.drnyaesthetics.com/post/why-aesthetic-gynaecology-procedures-are-best-performed-by-a-gynaecologist


6-Non-Surgical Lip enhancement in both genders©

https://www.drnyaesthetics.com/post/609831e23f705e00157110f1/edit


7-Non- Hair loss treatment©

https://www.drnyaesthetics.com/post/60a4061ec32ed80015ac3466/editwww. https://www.drnyaesthetics.com/post/60a4061ec32ed80015ac3466/


8- Can erectile dysfunction really be cured with soundwaves https://www.dailymail.co.uk/health/article-8732429/Can-erectile-dysfunction-really-cured-soundwaves.html


ALL Copyrights Reserved & Published by Dr. Nadia Yousri, FRCOG, Aesthetic Regenerative Gynaecology Consultant© www.drnyasethetics.com©®


106 views0 comments