Urogynecology and Pelvic Floor Reconstruction

Advanced Specialty Care for Women

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Urogynecology and Pelvic Floor Reconstruction


Pelvic Organ Prolapse Review

The vagina and pelvic female organs and their surrounding structures (bladder, rectum, etc.) are attached to the pelvic bones by connective tissues such as muscle ligaments, tendons, and fascia. These tissues help form walls around the vagina and ensure the functions but also that normal urinary voiding and bowel movements can occur. As the pelvic muscles and other supporting structures become weak the connective tissues can fail, allowing pelvic structures like the bladder or rectum to bulge into the vaginal wall. Pelvic Organ prolapse can worsen over time.

This can cause the following symptoms:


A feeling of vaginal fullness, heaviness, or even pain

Pain or discomfort during intercourse

Loss of bladder control

Involuntary urination or inconsistent urinary stream

Difficulty with bowel movements

Recurrent urinary infections

This is a Normal Anatomy.


Common Causes:


Pelvic muscles, ligaments and connective tissues which have been weakened with age are the primary causes, but many other factors may play a role. These may include vaginal childbirth, previous vaginal surgeries, menopause, smoking, diabetes, obesity, a history of heavy lifting, chronic coughing, and chronic constipation. Sometimes pelvic organ prolapse can be caused simply by genetic factors.



What are the different types of pelvic organ prolapse?

When vaginal prolapse occurs, an organ has dropped (prolapsed) out of its normal position and can sometimes even protrude from the vagina. The definition of pelvic organ prolapse is different depending on what anatomic structure in the pelvic is pushing into the vagina, such as the bladder or rectum. When vaginal prolapse occurs, the upper part (apex) of the vagina has dropped to a lower position. It is possible for more than one organ to prolapse into the vagina at the same time. (See examples below).

The different types of pelvic organ prolapse

How is Pelvic Organ Prolapse Treated?

The best treatment for a specific type and severity of pelvic organ prolapse will vary from patient to patient. If your symptoms are mild, the doctor may recommend, Kegel exercises to strengthen the pelvic muscles, the use of a biofeedback, electrical stimulation device, or a pessary to relieve the symptoms. When the symptoms are severe enough to affect your quality of life, Dr. Gregerson may recommend surgery.

Urinary Urgency & Incontinence

Urinary incontinence is an inability to hold your urine until you get to a toilet. More than 13 million people in the United States–male and female, young and old–experience incontinence. Women experience incontinence two times more often than men do. Pregnancy and childbirth, menopause, and the structure of the female urinary tract (picture) account for this difference.


Older women, more often than younger women, experience incontinence. But incontinence is not inevitable with age. Incontinence is treatable and often curable at all ages. If you experience incontinence, you may feel embarrassed. It may help you to remember that loss of bladder control can be treated. You will need to overcome your embarrassment and see a doctor to learn if you need treatment for an underlying medical condition.


Incontinence in women usually occurs because of problems with muscles that help to hold or release urine. The body stores urine–water and wastes removed by the kidneys–in the bladder, a balloon-like organ. The bladder connects to the urethra, the tube through which urine leaves the body.


During urination, muscles in the wall of the bladder contract, forcing urine out of the bladder and into the urethra. At the same time, sphincter muscles surrounding the urethra relax, letting urine pass out of the body. Incontinence will occur if your bladder muscles suddenly contract or muscles surrounding the urethra suddenly relax.

What Are the Types of Incontinence?

Stress Incontinence


If coughing, laughing, sneezing, or other movements that put pressure on the bladder cause you to leak urine, you may have stress incontinence. Physical changes resulting from pregnancy, childbirth, and menopause are common events that cause stress incontinence. It is the most common form of incontinence in women and is treatable.


Pelvic floor muscles support your bladder. If these muscles weaken, your bladder can move downward, pushing slightly out of the bottom of the pelvic toward the vagina. This prevents muscles that ordinarily force the urethra shut from squeezing as tightly as they should. As a result, urine can leak into the urethra during moments of physical stress. Stress incontinence also occurs if the muscles that do the squeezing weaken.


Stress incontinence can worsen during the week before your menstrual period. At that time, lowered estrogen levels might lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause.


Urge Incontinence


If you lose urine for no apparent reason while suddenly feeling the need or urge to urinate, you may have urge incontinence. The most common cause of urge incontinence is inappropriate bladder contractions.


Medical professionals describe such a bladder as “unstable,” “spastic,” or “overactive.” Your doctor might call your condition “reflex incontinence” if it results from overactive nerves controlling the bladder.


Urge incontinence can mean that your bladder empties during sleep, after drinking a small amount of water, or when you touch water or hear it running (as when someone else is taking a shower or washing dishes).


Involuntary actions of bladder muscles can occur because of damage to the nerves of the bladder, to the nervous system (spinal cord and brain), or to muscles themselves. Multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, stroke, brain tumors, and even injury that occurs during surgery – all can harm bladder nerves or muscles.

Overflow Incontinence


If your bladder is always full so that it continually leaks urine, you have overflow incontinence. Weak bladder muscles or a blocked urethra can cause this type of incontinence. Nerve damage from diabetes or other diseases can lead to weak bladder muscles; tumors and urinary stones can block the urethra. Overflow incontinence is rare in women.

Other Types of Incontinence


Stress and urge incontinence often occur together in women. Combinations of incontinence–and this combination in particular–are sometimes referred to as “mixed incontinence.”


“Transient incontinence” is a temporary version of incontinence. It can be triggered by medications, urinary tract infections, mental impairment, restricted mobility, and stool impaction (severe constipation), which can push against the urinary tract and obstruct outflow.

How Are Urgency & Incontinence Evaluated?


The first step toward relief is to see Dr. Gregerson. He is well acquainted with incontinence and will learn the type you have.


To diagnose the problem, he will first ask about symptoms and medical history. He will give you a questionnaire. Your pattern of voiding and urine leakage may suggest the type of incontinence. Other obvious factors that can help define the problem include straining and discomfort, use of drugs, recent surgery, and illness. If your medical history does not define the problem, it will at least suggest which tests are needed.


Dr. Gregerson will physically examine you for signs of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and poor reflexes or sensations, which may be evidence of a nerve-related cause.


Dr. Gregerson will measure your bladder capacity and residual urine for evidence of poorly functioning bladder muscles. To do this, you will drink plenty of fluids and urinate into a measuring pan, after which the doctor will measure any urine remaining in the bladder. Your doctor may also recommend:


Stress test–You relax, and then cough vigorously as the doctor watches for loss of urine.


Urinalysis–Urine is tested for evidence of infection, urinary stones, or other contributing causes.


Blood tests–Blood is taken, sent to a laboratory, and examined for substances related to causes of incontinence.


Ultrasound–Sound waves are used to “see” the kidneys, ureters, bladder, and urethra.


Cystoscopy–A thin tube with a tiny camera is inserted in the urethra and used to see the urethra and bladder.


Urodynamic Testing


How Is Incontinence Treated?


For most causes of urinary incontinence, the following are commonly used as a conservative starting point in treatment.


Kegel Exercises

Electrical Stimulation

Biofeedback

Bladder Training & Timed Voiding

Kegels Exercises


You can use a type of exercise called “Kegels” to strengthen the pelvic floor muscles that control urination. When doing Kegels, you tighten, hold, and then relax the muscles that you use to start and stop the flow of urination. A special form of training called biofeedback can help you locate the right muscles to squeeze. It helps to start with just a few Kegel exercises at a time, and gradually work your way up to three sets of 10. Another method for strengthening pelvic floor muscles is electrical stimulation, which sends a small electrical pulse to the area via electrodes placed in the vagina or rectum. While this sounds unpleasant, there is no pain associated with this therapy.


Another technique that can strengthen the pelvic and bladder muscles is the use of weighted cones. The tampon-shaped cone is inserted into the vagina and held there by contracting your pelvic muscles. As your muscles strengthen, the weight of the cone is gradually increased. This helps improve your ability to hold urine until you get to a bathroom. While pelvic exercises often help, the mainstay of OAB treatment is the use of medications called anticholinergics.

Bladder Training with Timed Voiding


This treatment is used for urge and overflow incontinence. The patient keeps a voiding diary of all episodes of urination and leaking, and the physician analyzes the chart and identifies the pattern of urination. The patient uses this timetable to plan when to empty the bladder to avoid accidental leakage. In bladder training, biofeedback and Kegel exercises help the patient resist the sensation of urgency, postpone urination, and urinate according to the timetable.


Timed voiding is another way of saying bladder training. This technique helps change the way you use the bathroom. Instead of going whenever you feel the urge, you urinate at set times of the day, called scheduled voiding. You learn to control the urge to go by waiting – for a few minutes at first, then gradually increasing to an hour or more between bathroom visits.


Treatment for Overactive Bladder:


Additional treatments are necessary when faced with overactive bladder. With OAB an inappropriate signal from our nervous system causing the muscles in the bladder wall to contract and release urine at the wrong time. Medications called anticholinergics can combat this problem by blocking the nerve signals and reducing bladder muscle contractions. They relax the smooth muscle of the bladder, reducing detrusor muscle contraction and subsequent urgency, frequency and urge incontinence (wetting accidents).

Treatment of Stress Urinary Incontinence:


Stress Urinary Incontinence occurs when the position of the urethra is not maintained when pressure is applied to activities such as coughing, sneezing, laughing or lifting. The above treatments may not sufficiently address this form of urinary leakage. Treatment addresses supporting the urethra either mechanically by a vaginal device known as a pessary or by vaginal reconstructive surgery.


Pessaries


A pessary is a stiff ring that is inserted by a doctor or nurse into the vagina, where it presses against the wall of the vagina and the nearby urethra. The pressure helps re-position the urethra, leading to less stress leakage. If you use a pessary, you should watch for possible vaginal and urinary tract infections and see your doctor regularly.


Surgery

When a pessary fails, or when a patient cannot tolerate it due to a variety of personal and physiological factors, surgical intervention may be necessary. Dr. Gregerson has over 20 years of surgical experience treating complex urogynecological problems surgically. He evaluates your pelvic using a system known as the “POP-Q” to accurately measure the extent of your problem and then customizes the surgical treatment to your specific needs.


Other Treatments


Many women manage urinary incontinence with pads that catch slight leakage during activities such as exercising. Also, you often can reduce incontinence by restricting certain liquids, such as coffee, tea, and alcohol. If your urine loss is mostly during exercise the FemSoft urethral insert is a “plug” that is single-use, inserted prior to exercise and disposed of after that. They cost about seven dollars per device.


Finally, many women who could be treated resort instead to wearing absorbent undergarments, or diapers–especially elderly women in nursing homes. This is unfortunate because diapering can lead to diminished self-esteem, as well as skin irritation and sores. If you are an elderly woman, you and your family should discuss with your doctor the possible effectiveness of treatments such as timed voiding, pelvic muscle exercises, and electrical stimulation before resorting to absorbent pads or undergarments.


Points to Remember:


Urinary incontinence is common in women.

All types of urinary incontinence can be treated.

Incontinence can be treated at all ages.

You need not be embarrassed by incontinence.


Stress Urinary Incontinence with Uterus (Fig. 3)

The image to far left shows normal anatomy with urine in the bladder. The urethra is suspended from the pubic symphysis by the intact pubo-urethral ligaments. The center image depicts the urethra under the influence of pressure such as laughing, coughing and sneezing or lifting. The position the urethra is maintained by the intact pubo-urethral ligaments and no stress urinary incontinence or leakage occurs. The image on the far right depicts the urethra under the influence of pressure such as laughing, coughing and sneezing or lifting. The position the urethra is not maintained as the pubo-urethral ligaments are not intact and stress urinary incontinence or leakage occurs when pressure is applied from laughing, coughing and sneezing or lifting releasing small amounts of urine to leak.



Original Image above (Fig. 3) Courtesy of BARD Medical. Images Modified for Education Purposed by DK Veronikis, M.D.

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