Pelvic floor disorders

Urogynecology is a subspecialty within obstetrics and gynecology that focuses on disorders of the female pelvic floor such as pelvic organ prolapse (bulging out of the uterus and/or vagina), urinary incontinence, fecal incontinence and constipation. After completing a residency in obstetrics and gynecology, urogynecologists complete fellowship training where they spend several years focusing only on these disorders.

Many women incorrectly assume that urine leakage is normal. While the problem of urine leakage is very common, it should never be considered normal. The most commonly quoted study estimates that 11 million American women currently suffer from leakage of urine. However, this estimate may be low. A study of 2,800 postmenopausal women with an average age of 67 found that 56 percent of women experienced urinary incontinence at least weekly.

Urinary incontinence is a symptom, not a disease, with many possible causes. The key to treatment is identifying which type of urinary incontinence you have through a careful medical interview and physical exam. Sometimes doctors need to perform tests called urodynamics to diagnose the problem. Urodynamics are necessary if a woman is considering surgery to correct incontinence.

The two most common types of urinary incontinence are stress incontinence and urge incontinence. 

Stress incontinence is urine leakage that happens during an activity that causes pressure (or "stress") on the bladder such as laughing, lifting, coughing or sneezing.

Urge incontinence is urine leakage that occurs before a woman has a chance to urinate. Women with this type of leakage may also experience frequent urges to urinate and frequent nighttime waking to urinate.

Stress incontinence can be effectively treated with pelvic floor exercises, devices that "block" the loss of urine, or surgery. There is also a new medication called Duloxetine that will soon be available for the treatment of stress incontinence. Urge incontinence is commonly treated with medications, biofeedback, or electrical stimulation to the nerves that control the bladder. A new treatment for urge incontinence places an electrical stimulator, similar to a pacemaker, under the skin.  

There is no surgery for incontinence with a 100 percent success rate, but two procedures –  the retropubic urethropexy and the suburethral sling – work 75 to 95 percent of the time.

A suburethral sling called "Tension Free Vaginal Tape" (TVT) is considered by surgeons to be the best option for most women and can be positioned on an outpatient basis under local anesthesia.

Some potential complications of surgery for incontinence include difficulty emptying the bladder and the development of urge incontinence.

Most of the negative press about sub-urethral slings can be traced back to one or two poorly-designed products that are no longer on the market. The best synthetic slings are made of a loosely-woven polypropylene mesh designed especially for placement under the female urethra, providing the necessary support, while still allowing for excellent “tissue-in-growth.” In other words, your body will grow into the sling material within a few weeks after surgery. While problems with this approach can occur, they are very rare. It is recommended that you consult with your doctor for more information about the type of sling he or she will use.

We don't fully understand all the factors that cause urinary incontinence, so it is difficult to recommend ways to prevent the problem. Pelvic muscle exercises (PME) – also known as Kegel exercises – are probably the best way to prevent stress incontinence.  Also, avoid eating or drinking anything known to irritate the bladder.

Pelvic organ prolapse describes bulging, sagging or falling of female organs. Though it can occur quickly, it usually happens over the course of many years. There are various types of prolapse, and they may occur individually or together, including cystocele, rectocele, uterine prolapse and enterocele.

The symptoms you experience depend on which type of prolapse you have. The very first signs can be subtle - such as pain during intercourse or an inability to keep a tampon inside the vagina. As the prolapse gets worse, some women complain of a bulging or heavy sensation in the vagina that worsens by the end of the day or during bowel movements. Most women don't seek treatment until they actually feel something protruding outside of their vagina.

The simple answer to this question is no. There are many factors that seem to contribute to the development of prolapse, and almost none of them are things you can control. Genetics definitely plays a major role. Vaginal deliveries can predispose certain women to develop prolapse, but we haven't learned how to identify these women before they have children. Other conditions that may correlate with the development of prolapse are severe obesity, pelvic tumors and chronic constipation. Repetitive heavy lifting may contribute to prolapse as well.

No, there are two other choices ' do nothing, or wear a pessary. A pessary is worn in the vagina like a diaphragm. Pessaries come in many different shapes and sizes all designed to support the prolapsed pelvic organs. Many women are completely satisfied using a pessary for years - avoiding surgery all together.

The ideal way to use a pessary is to insert it each day as part of your morning routine, and take it out for cleaning each night. When this is not possible, women come to the office about four to six times a year for an exam and pessary cleaning. Even when a pessary is worn almost continuously, vaginal infections are rare.

If left untreated, pelvic organ prolapse usually gets worse. In most cases, patients determine when and whether to have prolapse treatment by considering their lifestyle and comfort needs.  In rare cases, severe prolapse can cause urinary retention that progresses to kidney damage or infection. When this occurs, prolapse treatment is necessary.

Depending on the extent of your surgery, the hospital stay usually lasts one to four days. Many women have difficulty urinating immediately after the surgery and have to go home with a catheter in place to drain the bladder. Catheters are usually only necessary for three to seven days. Most patients require at least some prescription strength pain medicine for one to two weeks after surgery. You should plan to take it easy ' no lifting more than eight pounds (a gallon of milk), no intercourse and no exercise other than walking ' for 12 weeks to allow proper healing.

The goal of continence or pelvic reconstructive surgery is to recreate normal anatomy permanently. However, none of these procedures are successful 100 percent of the time. According to the medical literature, failures occur in approximately five to 15 percent of women who have prolapse surgery. In these cases, it is usually a partial failure which may require pessary use, or surgery that is much less extensive than the original surgery. Patients who follow our recommended restrictions for 12 weeks after surgery give themselves the best chance for permanent success.

Not exactly. In 2008, the FDA did issue a warning about the use of vaginal mesh, claiming it can cause problems, such as “erosion” and pain. While this is true, we believe that the potential benefits need to be considered, as well. If your doctor is considering the use of synthetic mesh to reinforce your prolapse repair, he or she will inform you about both the risks and benefits. Ultimately, the choice will be yours to make.

The da Vinci Surgical System is a wonderful tool designed to make laparoscopic procedures easier to perform. It offers many patient benefits, including less blood loss, shorter operations, smaller incisions and minimal scarring compared to traditional laparoscopy. Your doctor will determine if robotic surgery is right for you.  

Yes. If you are going to have surgery to correct the prolapse, bladder testing (called urodynamics) must be done first. That's because the prolapsed portion of your vagina may be pushing on your urethra and preventing urine leakage. If that is the case, having the prolapse corrected can give you urinary incontinence. The only way to tell whether a continence procedure is needed at the time of prolapse surgery is to perform urodynamics while holding the prolapse up in its normal position.

If you choose to use a pessary, your sex life shouldn't change, except for the fact that the pessary usually needs to be removed prior to intercourse. If you have reconstructive surgery to correct prolapse, we recommend that you refrain from intercourse for three months after your operation to allow proper healing. After waiting three months, getting used to having intercourse will take some time, but most patients report an improved sex life afterwards.

When prolapse is severe, one surgical option is to completely close the vagina. This procedure (called colpocleisis or colpectomy) is less invasive than reconstructive surgery, which makes it especially useful for patients with severe medical conditions. Of course, intercourse is impossible after having this procedure, so it is only appropriate for patients who are absolutely sure that they never want to be sexually active again.

Treating prolapse and incontinence is both challenging and rewarding. Unlike most specialists, urogynecologists have the privilege to care for patients across the full continuum from diagnosis through treatment and follow-up. Every patient has a unique set of symptoms, disorders and expectations, requiring an individualized approach to care. What’s more, since our field is relatively new, there are many medical research opportunities available.