WHAT IS A UROGYNECOLOGIST?
Are there differences between a urologist and gynecologist in this field? Yes.
A urologist trained in urogynecology is trained to take care of any problem that may arise in your urinary tract as well as urinary incontinence and pelvic organ prolapse. For example, if you have problems with kidney stones or develop a tumor in your kidney or bladder, a urologist can handle these problems for you. A gynecologist who finds these problems in your urinary tract will refer you to a urologist for further treatment as they are not trained to perform these types of procedures in their OB/GYN residency or Urogynecology Fellowship.
IS URINARY INCONTINENCE A NORMAL PART OF AGING?
Over 23 million Americans have a problem with bladder control and approximately 85% are women. Because women feel embarrassed about loss of urinary control, most do not seek professional help. A number of factors may contribute to incontinence such as childbirth, neurological diseases, pelvic surgery, estrogen deficiency, and radiation.
The staff at Capitol Urogynecology knows how embarrassing and devastating bladder problems can be to your quality of life. Although many bladder problems are not life threatening, conditions such as overactive bladder and urinary incontinence can interfere with your quality of life.
Urinary incontinence should not be viewed as an inevitable part of growing older and effective treatments are available.
Schedule your appointment with Dr. DuPont to learn more about what you can do. There are a wide range of options, and we can help you understand what may work best for you. We are dedicated to helping you return to a normal and active life.
WHAT ARE THE DIFFERENT TYPES OF URINARY INCONTINENCE?
Stress urinary incontinence is leakage that occurs with activities such as coughing, sneezing, laughing, lifting, sexual intercourse, and exercise.
Urge incontinence is leakage that occurs with a sudden urge to urinate that cannot be suppressed.
Mixed urinary incontinence is a combination of stress and urge incontinence.
Overflow incontinence is leakage associated with urine retention (the inability to empty one’s bladder).
WHAT CAN BE DONE FOR STRESS URINARY INCONTINENCE?
Kegel exercises require discipline and dedication to maintain any benefits. Exercises have to be done properly and regularly. Occasionally, the help of a physical therapist is enlisted to teach patients how to identify their pelvic floor muscles and contract them. Vaginal cones can also be helpful as a teaching aide. A physical therapist may also use E-stim techniques as an aide.
Pessaries with knobs need to be fitted and do not cure the condition. They work by putting pressure behind the bladder neck to increase resistance to leakage. They are made of silicone and have to be removed and cleaned on a regular basis. They are not always well tolerated due to pain, infection, or abnormal vaginal discharge. Additionally, they do not always work. For individuals who experience stress urinary incontinence on an intermittent basis during significant strenuous activity (e.g., playing tennis or jogging), a super-size tampon in the vagina may be effective in reducing or eliminating leakage during these activities.
Minimally invasive procedures that have a high success rate and a high patient satisfaction rate are available. These procedures are performed on an outpatient basis and consist of either intraurethral bulking agent injections or pubovaginal slings. Injections are not as durable and require booster injections. Dr. DuPont has performed over 1000 pubovaginal slings with a zero infection rate and a zero erosion rate.
IS LAPAROSCOPIC SURGERY OR ROBOTIC SURGERY BETTER THAN VAGINAL SURGERY FOR THE TREATMENT OF PROLAPSE?
There is no need to enter the abdominal cavity to repair most cases of pelvic organ prolapse. Typically, approaches that enter the abdominal cavity have higher associated risks, higher intraoperative surgical times, and, in some cases, more postoperative discomfort. Laparoscopic/robotic surgery is “minimal incision” but not necessarily “minimally invasive.”
WHAT IS THE G-SPOT SHOT ALL ABOUT?
A debate rages on about whether an actual G-spot exists. The evidence is mostly anecdotal reports or weak scientific reports. There is no evidence of an enhanced area of nerve endings in the vagina that would correspond to a G-spot. An Italian university correlated a thickened anterior vaginal wall with a higher orgasm rate.
Injections of the G-spot with a filler is used to enhance sexual arousal and orgasms.
WHAT IS PELVIC ORGAN PROLAPSE?
Pelvic organ prolapse can describe either the bladder (cystocele), rectum (rectocele), intestines (enterocele) or uterus sagging into the vaginal canal. Mild degrees (grade 1 or 2) typically do not require surgery as most individuals have no symptoms. Uterine prolapse can be quite impressive in its severest forms when the protrusion can extend several inches beyond the vaginal opening (complete procidentia). Some patients have expressed this predicament with humor (“I feel like I’m growing an udder!”). Uterovaginal prolapse can be complete or incomplete. In some cases, only the bladder is prolapsed or only the uterus, etc.
Vaginal rejuvenation is a term applied for the surgical treatment of mild prolapse, often performed to improve sexual function or body image. This is generally considered to be primarily a cosmetic procedure.
Transvaginal surgical repair of prolapse (via the natural orifice) remains the least invasive treatment approach for prolapse.
Pessary management avoids surgical treatment; however, it does not fix the problem and there is no guarantee that pessary management would provide a long lasting solution. In patients who are in generally good health, surgery is usually the best option.
WHAT ARE THE TREATMENT OPTIONS FOR COMPLETE UTERINE PROLAPSE (PROCIDENTIA)?
Pessary: doughnut, gellhorn, cube are the pessaries typically used to manage this type of prolapse. In the majority of cases, these are pessaries that cannot be self-managed and require periodic visits to the gynecologist or urogynecologist for cleaning maintenance.
Partial colpocleisis: partial closure of the vaginal canal without removal of the uterus. This procedure is the least invasive surgical option. Candidates for this procedure are patients who are older, no longer sexually active, without history of abnormal PAP smears, or poor candidates for formal, pelvic reconstructive surgery.
Pelvic reconstructive surgery: vaginal hysterectomy with or without ovary(s) removed plus any additional repair of cystocele or rectocele that may be required.
WHY IS MESH USED FOR REPAIR OF PELVIC ORGAN PROLAPSE?
Traditional repairs of genital prolapse that plicate ruptured tissue can have recurrence rates of about 50%.
In an effort to reduce these reoccurrence rates, biologic or synthetic (mesh) products have been used to reinforce these repairs. Synthetic meshes (e.g., polypropylene material) have been associated with recurrence rates of approximately 5% when performed by well-trained surgeons.
Surgical skill, experience, training and reputation are as important as the materials used to repair genital prolapse.
WHAT IS MESH EROSION?
Erosion rates with synthetic meshes are approximately 7%. They typically occur secondary to the mesh becoming infected. Small erosions into the vaginal wall are either managed with vaginal estrogen replacement to promote tissue healing and/or excision of the small area of exposed mesh (can often be done in the office or as a minor outpatient hospital procedure). The benefits of using synthetic mesh far outweigh the small risks of mesh erosion–especially when you take into account that the majority are minor and easily managed. General surgeons typically use synthetic meshes when performing inguinal (groin) hernia repairs for the same reason–to decrease recurrence rates. Rates of erosion are linked to surgeon’s skill, type of synthetic mesh selected, and patient’s tissue health.
WHAT IS INTERSTITIAL CYSTITIS?
Approximately 2.7 to 6.5% of American women age 18 or over have symptoms consistent with this debilitating condition. Patients often report that they have urinary frequency (10 times plus) or urgency due to pain, pressure or discomfort (not fear of leaking urine). The symptoms can periodically worsen (“flares”) leading sufferers to think that they have a urinary tract infection. When most of the urine cultures return negative, sufferers are left perplexed and frustrated. The delay in correct diagnosis can lead to many years of fruitless treatments for bacterial cystitis with antibiotic courses. Symptoms typically do not resolve with antibiotic courses or Lupron for endometriosis.
No one knows the precise etiology for IC. It is a diagnosis of exclusion. In spite of multiple theories that it is of bacterial origin, there has never been any definitive evidence of this that stands up in the literature. Long term antibiotic courses have not cured this condition.
What we know is that there is qualitative and/or quantitative damage to the glycoaminoglycan layer of the bladder lining. Thus, components of the urine penetrate this barrier and irritate the underlying bladder muscle and nerves causing symptoms. Treatment is aimed at alleviating symptoms as there is no cure at the present time.
New treatment involving liposomes (small fat-like bubbles that may coat or soothe the irritated bladder lining) are showing preliminary promise in treating IC and bladder spasms. These treatments are continuing to undergo clinical trials and are not as yet approved for marketing.
Other new treatments include the use of Botox injections in the bladder muscle. Botox blocks the sensory neurotransmitter release going up the spinal cord. Use of Botox is also being looked at in a liposome bladder instillation-type formulation. This liquid form may reduce the incidence of urine retention but preserve its benefits.
WHAT IS NOCTURIA AND WHAT CAUSES IT?
The prevalence of nocturia increases with age. 50% of adults’ experience nocturia. About 25% void at least twice during the night and 25% also have enlarged prostates (BPH) or overactive bladder in conjunction with nocturia. Over production of urine at night is a major reason for nocturia in about 80% of patients and occurs either alone or in combination with other factors.
In patients 65 years or older, the rate of nocturnal polyuria (over production of urine at night) is as high as 93.9%. A voiding diary (records of fluid input and urine output volumes) is required to make the diagnosis of nocturnal polyuria.
HOW LONG DOES BOTOX WORK IN THE BLADDER?
otox was approved by the FDA in 1989. Use of Botox for urologic conditions is now approved for the treatment of urge incontinence. Use of Botox for overactive bladder has been ongoing for at least 10 years.
The main side effect is urine retention (inability to empty or completely empty the bladder). This can lead to the necessity to perform intermittent self-catheterization until the large residual volumes improve it occurs in a small number and is transient.
WHAT CAN I DO ABOUT FREQUENT UTI’S?
Frequent UTI’s are most commonly due to sexual intercourse. However, UTI’s can also
occur due to other co-morbidities such as kidney stones, anatomical abnormalities, catheterization, diabetes, and neurological conditions. In older women, bladder prolapse, incomplete bladder emptying and urinary incontinence is linked to UTI’s. If no correctable factors are identified, treatment options include antibiotic prophylaxis. Suppression antibiotic regimens can be used daily, every other day, or after intercourse to reduce infections. Additionally, natural products such as cranberry supplements, vitamin C, and D-Mannose may be useful. Topical vaginal estrogen has been shown to be effective in reducing UTI’s in postmenopausal patients by normalizing the vaginal pH improving blood flow, and restoring lactobacillus colonies.
WHY DO I LEAK DURING SEX (COITAL INCONTINENCE)?
Coital incontinence is a form of pelvic floor muscle dysfunction. It may occur in 20-35% of women and increases in incidence after menopause. It is very likely under reported due to the significant embarrassment most women experience with this condition.
Leakage occurring during sex is likely secondary to stress urinary incontinence. Both behavioral therapy (Kegels/pelvic floor muscle exercises) and surgical treatment (e.g., minimally invasive pubovaginalis slings) are used in the treatment of this problem. More than 80% of women with coital incontinence have stress urinary incontinence.
Leakage occurring with orgasm is likely secondary to bladder over activity (bladder muscle spasms). Medication for overactive bladder can be helpful as well as behavioral therapy. Orgasm can trigger urethral relaxation and bladder contraction, thus leading to incontinence. There is controversy regarding the existence of female ejaculation (fluid expressed from urethral Skene’s glands) and some women may confuse coital incontinence with female ejaculation.
IS THERE HOPE FOR CHRONIC PELVIC PAIN?
Pudendal neuropathy is one of the causes of pelvic pain and voiding complaints. The pudendal nerve is a mixed nerve and damage to the nerve can cause variable pain as well as bladder, bowel, and/or sexual dysfunction. Pain is usually bilateral and includes the suprapubic area, urethra, labia, perineum, rectum and occasionally the tail bone or inner thigh. There are 5 peripheral neuropathies that can be associated with pelvic pain: 1) pudendal neuropathy; 2) thoraolumbar junction syndrome; 3) middle cluneal neuropathy often associated with an episacroiliac lipoma; 4) abdominal cutaneous nerve entrapment; and 5) ilioinguinal and iliohypogastric neuropathies. The most common of these is pudendal neuropathy.
WHAT IS THE FUSS ABOUT MESH?
AUA (American Urological Association) Position Statement on the Use of Vaginal Mesh for the Repair of Pelvic Organ Prolapse.
Pelvic organ prolapse (POP) is a highly prevalent condition. Many effective treatments exist for this condition, including pelvic floor exercises, support devices such as pessaries, and surgery.