Urogynecology

Urogynecology is a subspecialty of Obstetrics and Gynecology that deals with pelvic floor disorders.  Our practice offers the full scope of diagnostic techniques and treatment modalities to deal with these conditions.  We can provide the most comprehensive, state-of-the-art care for women with pelvic floor disorders.

These include:

• Urinary incontinence
• Overactive bladder
• Voiding dysfunction
• Pelvic organ prolapse
• Pelvic pain
• Sexual dysfunction

Urinary incontinence, the involuntary loss or urine, is a major health and quality of life concern.  It can adversely affect a woman’s daily activities, overall health and social interactions.  Urinary incontinence can have a significant negative impact on the family from an economic, emotional and interpersonal standpoint.  Approximately 40% of women in the community are affected but the exact prevalence are uncertain due to patient’s difficulty in addressing such a sensitive topic.

Those at highest risk for this disorder are:

• Older women with medical problems such as diabetes, emphysema and weight issues.
• Women with a previous history of multiple vaginal births, prolonged labors and difficult deliveries with complications.

There are many different types of incontinence and unfortunately no universal cure exists.  In this section, we will discuss the different types of urinary incontinence, the common diagnostic tests and procedures that help distinguish between the different types and lastly the current treatment options.

What Causes Incontinence?

The Continence Mechanism:  Normally, the bladder is well supported in the pelvis above the pelvic floor.  The vagina gives firm support to the bladder and urethra, so when pressure (from a cough, laugh or sneeze) reaches the pelvic floor, it is distributed equally around the bladder and urethra.  Pressure on the urethra helps close the urethra maintaining continence. 

Bladder Neck Mobility: If the urethra and bladder are not well supported, the bladder will rotate downward during straining.  When the pressure in the bladder exceeds that in the urethra, urine will leak out in spurts.  The major causes include damage to the pelvic floor muscles or nerves, lack of hormones and the effects of aging.

Sphincter Deficiency:  Under normal circumstances the urethral muscles form a tight seal preventing urine leakage.  Loss of an effective seal may occur as a result of prior surgery, radiation treatment or injury to the nerves of the pelvis.  This condition is suspected in women who have had prior bladder repairs, incontinence with normal daily activities such as walking or those who are unaware that they are having loss of urine.

Overactive Bladder Disorders:  Normally, the bladder remains relaxed and allows itself to fill until near capacity.  Under voluntary control, the urethra will relax as the bladder contracts, to accomplish urination. In overactive bladder disorders, some or all of that control is lost as the individual attempts to hold their urine.  Sometimes this condition can be attributed to neurologic problems, bladders stones, infection or even mental illness.  More commonly, the cause is unknown and women have frequent urination throughout the day and night. 

• What Causes Pelvic Prolapse?
• Evaluation
• Treatment Options

Pelvic organ prolapse refers to descent (or prolapse) of the vaginal walls and / or uterus below their normal position.  The degree to which the prolapse occurs is described as mild, moderate and severe.  In severe cases, the vaginal walls or cervix protrude beyond the vaginal opening and are visible or palpable outside the body.  Common terms for these conditions include cystocele, rectocele, pelvic relaxation and procidentia.

Many women with pelvic organ prolapse also report problems with bladder and bowel function.  Symptoms that are often associated with pelvic organ prolapse include urinary incontinence, difficult urination, discomfort with sexual intercourse, stool incontinence, difficult defecation, low back pain and low abdominal pain.

What Causes Pelvic Organ Prolapse

Although the pelvic organs are supported by the pelvic diaphragm, the presence of the vagina creates a natural weakness in its integrity.  Having multiple, large, prolonged births further weakens the tissue.  As the tissue weakens, it stretches and allows descent of the organs to or beyond the vaginal opening. 

Evaluation

History:  Questions are designed to cover several important areas of pelvic floor function such as : voiding, bowel function, what activities lead to loss of urine , pelvic pain, and sexual function.  Frequently a patient is asked to keep a voiding diary for 24 hours including times and amounts of voids.  Other medical condition will be reviewed in addition to prescription and over the counter medications, prior surgeries, previous deliveries and prior bladder infections. 

Physical Exam:  The examination is targeted at those systems which help support vagina, cervix, uterus and bladder.  In particular, sensation of the surrounding external genitalia, the muscles of the pelvic floor, and the supports of the bladder, urethra and bladder neck will be evaluated regarding continence.  A rectal exam is performed to evaluate tone and for the absence of blood.  The amount of urine remaining inside the bladder can be measured with either a small catheter or bladder ultrasound.  With the patient in a standing position or bearing down, the physician tries to determine which organs in the pelvis have lost support and how severe that loss of support is. 

Urine culture:  A clean catch midstream urine culture is obtained to exclude infection as a cause of urinary incontinence.

Urodynamics:  Is an office based study using very small catheters, with pressure sensors, placed in the bladder, and either the vagina or rectum.  The goal is to observe the behavior of the bladder and urethra as the bladder is slowly filled.  If the bladder is overactive, the pressure will rise.  The patient will be instructed to tell the physician when she has a first sensation to void and when she can no longer tolerate bladder filling.  She will be instructed to cough and bear down to elicit any urine leakage. 

• Additionally, a device will pull the catheter slowly through the urethra to measure the pressure generated by the muscles in the urethra.  These studies help determine if the cause of incontinence is anatomic, a sphincter deficiency or an overactive bladder.  Finally, once the bladder is full, the patient is asked to empty her bladder while the volume and rate of flow are measured.  This helps determine if the bladder and urethra function normally, whether there is an obstruction, or if straining is required to pass urine.

 

Cystoscopy:  A small telescope is introduced into the urethra to evaluate the health and integrity of the urethra and bladder and look for the presence of a foreign body (stones, tumors or sutures from prior surgery), chronic infection or diverticulum.  The physician can observe the response of the urethra and bladder neck to coughing or straining. 

Treatment Options

Non-surgical treatments:

1. Medications:  may be helpful in overactive bladder with 50-60% improvement, but also help about 40% on individuals with stress incontinence.  Side effects are common. 
2. Physical Therapy: consists of pelvic muscle exercises such as Kegels, biofeedback, electrical stimulation and bladder training drills.  50% of those with stress incontinence and 40% of those with overactive bladder show improvement.
3. Behavior modification:  bladder training drills to lengthen time between voids
4. Continence Devices:  may be small disposable devices designed to fit in the urethra temporarily to hold the urine by blocking the urethra and removed for urination
5. Support Devices:  Pessaries are flexible devices that are custom fit to the vagina helping support the cervix and bladder neck (improvement 30-40% of the time).   Once inserted in the vagina, the pessary should be comfortable and stay in place with a variety of activities.  It should be removed and cleansed on a weekly to monthly basis
   

Surgical treatments:

1. Burch Procedure:  is an abdominal approach that elevates the bladder neck by lifting the surrounding vaginal tissue to the underside of the pubic bone.  (Successful 80-85% of the time for stress incontinence)
2. Sling procedure:  is a minimally invasive vaginal approach whereby a mesh is place under the urethra and acts as a bladder hammock giving dynamic support to the urethra ( successful 85-90% of the time)
3. Laparoscopic Vaginal Vault suspension:  with the use of mesh the fallen vagina is anchored to the sacrum
4. Periurethral injections:  is an office procedure whereby collagen/permanent material is injected near the urethra to help occlude the bladder neck.  (Most useful in sphincter deficiency without loss of support, successful 50-60% of the time)
5. Sacral Nerve Simulators:  Interstim is a surgical alternative to the treatment of overactive bladder not responding to medication.  It involves an implantable pacemaker that stimulates nerves in the sacral region thereby reducing the sensitivity of the bladder wall (60-80% success rate in properly selected patients, involves a test stimulation that lasts one week)
6. Vaginal hysterectomy:  is removal of the cervix and uterus through the vaginal opening.  Tubes and ovaries may or may no be removed concurrently.  This is usually combined with a bladder suspension if urinary incontinence exists

.