Female Pelvic Medicine and Reconstructive Surgery

Gregory J. Bailey MD, FACOG, FPMRS
6440 W Newberry Rd, Suite 409
Gainesville, FL 32605
(352) 333-6161

What is an Overactive Bladder?

Overactive bladder is a condition that causes a sense of urgency or frequency. Often this requires trips to the bathroom. Common causes include urinary tract infections, interstitial cystitis and neurological disorders. There are treatment options available for most of these disorders.

How is Overactive Bladder Treated?

The key to treatment is to identify which disorder is present. There are certain tests that may be needed to help make the diagnosis. Tests may include urine cultures, cystoscopy, KCL bladder lavage, simple CMG or complex urodynamics. Treatments can include the bladder diet, medications, biofeedback, physical therapy and Neuromodulation.

What is Interstitial Cystitis?

Interstitial Cystitis (IC) is a chronic condition of the bladder often causing symptoms of frequency, urgency, painful urination, painful intercourse, and chronic pelvic pain tested positive for IC. A common theory of interstitial Cystitis is that it is a defect in the lining of the bladder (like an ulcer in the stomach). Treatments options include the bladder diet, medications, bladder lavage treatment and Neuromodulation.

How Common is Urinary Incontinence in Women?

Women often assume that urinary leakage in normal. It is a common disorder but should never be consider normal. A large study from the National Institute o Aging found that 56% of post menopausal women experience urinary incontinence at least weekly.

What Causes Urinary Incontinence?

Urinary incontinence is a symptom not a disease. These symptoms often arise because of childbirth injuries to the pelvic floor. There are many possible causes of urinary incontinence.

  • Stress Incontinence: is leakage when you lift, bend, laugh, cough or sneeze. This comes from the support of the bladder neck dropping/the weakening of the urethral sphincter muscle.
  • Urge Incontinence: occurs when the bladder develops unexpected muscle contractions. Leakage often occurs while rushing to the bathroom. Common triggers include hearing water run or walking into a cold room. Sufferers often experience frequent urges and frequent nighttime walking to urinate.
  • Overflow Incontinence: occurs when the bladder gets overfilled and overflows. This can occur with certain medical conditions that desensitize the bladder sensor. This may also occur when certain prolapses prevent complete emptying of the bladder.
  • Mixed Incontinence: is a combination of one or more of the above.

How is Urinary Incontinence Treated?

The key to treatment is to identify the specific type of incontinence. This can be done by performing a careful medical history and focused physical exam. Often specific diagnostic tests are used to help identify the disorders. Some of these tests include urinalysis, simple CMG, cystoscopy and complex urodynamics.

  • Stress Incontinence: can be treated with weight loss, Kegel exercises, estrogen creams, biofeedback physical therapy, certain pessaries (vaginal or urethral implants), trans-urethral bulking agents, or surgery.
  • Urge Incontinence: is commonly treated with medications, biofeedback or electrical stimulation to the nerves that supply the bladder (Neuromodulation).
  • Overflow Incontinence: may be treated with pelvic physical therapy, behavior modification, medications, or correction of a prolapse.

I've Heard That Surgical Correction Doesn't Last Very Long; is That True?

The surgical treatment for stress incontinence has evolved rapidly over the last 15 years. Hundreds of variation on surgical treatments have come and gone. There is no perfect treatment and no surgery that has a 100% success rate. Fortunately, research studies identified two basic types of surgical correction that seems to be the superior procedure: Retro pubic cystourethropexy and the sub urethral sling. Cure rates for these should approach 95%. The most common sub urethral slings (called TVT for Trans vaginal tape slings) involve placing a tension free tape under the urethra to support the urethra while coughing etc. This procedure has quickly become the gold standard of care. The TVT can be performed in an outpatient setting and sometimes under local anesthesia. Recently another sling has become popular; the TransObterator sling. The TO sling is also placed under the urethra but the approach is more lateral which makes injuring the bladder during placement less likely. When stress incontinence involves a weakened urethral sphincter muscle an alternative option is trans urethral bulking agents. This procedure can be done in the office through a cystoscope. A bulking agent is injected into the urethra to narrow the diameter of the urethra lumen. In the past, these materials would absorb over time and weren't popular. Permanent bulking agents have now been developed and offer more long-term promise. This procedure is well tolerated and takes approximately 20 minutes. It has a 60-70% success rate. It is a nice alternative for those patients who may be a poor surgical candidate.

How Can I Prevent This Problem?

Because a lot of these problems get worse with age, pelvic floor exercises are the best prevention to help delay these conditions. Pelvic muscle exercise including Kegel exercises may keep the pelvic floor muscles and urethral sphincter muscle in shape.

FREQUENTLY ASKED QUESTIONS ABOUT PELVIC ORGAN PROLAPSE...

Click Here for an animation of prolapse

What is Pelvic Organ Prolapse?

Prolapse simply means displacement from the normal position. When pelvic organ prolapse occurs, women experience bulging, sagging or falling from the vagina. This can occur quickly, but usually is gradual over time. There are different types of organ prolapse that can occur individually or together. The terms most often used are:

  • Cystocele: prolapse of the bladder through the top of the vaginal wall.
  • Rectocele: prolapse of the rectum through the top of the vagina wall.
  • Uterine Prolapse: When the uterus drops into or through the vagina.
  • Enterocele: Prolapse: of the small intestine through a space between the rectum and vagina.

What are the Symptoms of Prolapse?

Symptoms depend on the type of prolapse you have. Most women don't seek treatment until they actually feel something bulging out of the vagina. Early symptoms can include pain with intercourse, difficulty keeping a tampon in, lower back pain after standing, urinary incontinence or constipation. As the condition grows women may begin to feel increased pressure in the vagina that worsens during the day. Symptoms can grow to the point where it is difficult to empty the bladder completely. Initiating bowel movements may require pushing the stool out by putting a finger in the vagina. Eventually a bulge will appear coming out of the vagina which can grow to baseball size or larger.

Why Me? What Did I Do To Cause This?

There are many factors that seem to contribute to the development of prolapse. Vaginal deliveries play a major role and genetic predisposition is a key factor. We are unable to determine which patient is predisposed at this time. Other conditions may play a role including obesity, pelvic tumors, chronic constipation, and lack of estrogen.

Do I Need To Have Surgery For My Prolapse?

There are three options to deal with prolapse. It is rarely a life threatening condition. Doing nothing is one option. The other two options are to wear a pessary or to have a surgical correction. Pessaries are worn in the vagina like a diaphragm. They come in a variety of sizes and shapes and can be worn for many years with minimal maintenance. Surgical corrections have improved greatly over the years and success rates are over 95% after 5 years.

If I Do Nothing Will It Get Worse?

It may not happen quickly but, if left untreated, over time the condition often worsens. In rare instances, prolapse can cause urinary retention that may lead to kidney infection or damage. In these cases, treatment is necessary. Otherwise, the decision to treat the prolapse should be based on your symptoms.

How Do I Use A Pessary And How Do I Keep From Getting An Infection?

An ideal way to use a pessary is to insert it daily, then take it out and clean it nightly. If doing this daily isn't possible, it can be worn continuously then removed and cleaned in our office every 6-8 weeks. A lubricant should be used regularly to keep it from irritating the vaginal walls.

If I Choose Surgery, What Will The Recovery Be Like?

Depending on the extent of your surgery, the hospital stay will usually last from 1-4 days. Immediately after surgery, packing is often placed in the vagina, which will be removed about 6-8 hours later. Upon removal, some of the immediate pelvic pressure and discomfort will be relieved. A urinary catheter is usually kept in over night. Often the swelling in the vagina area will make it difficult to urinate the following day. Bladder training will be continued until you are voiding freely. This may involve going home with a catheter and having a visiting nurse come and work with you there. Most patients will require some prescription strength medicine for a week or two after surgery. When grafts or slings are used, we ask that you avoid heavy lifting or straining for 12 weeks. (Lift nothing heavier than a gallon of milk; stay on stool softeners to avoid constipation.) This will allow proper healing and scaring in of the tissues. This is important in the success of these procedures. Intercourse, weight bearing exercises and straining can usually resume after 12 weeks

What is The Success Rate? Will it Last Forever?

Our goal is to have your pelvic reconstructive surgery recreate the normal pelvic anatomy and have it last forever. Unfortunately, not all procedures are successful 100% of the time. However, with the use of grafts and slings, the success rate should approach 95% after 5 years. If failure occurs, it is often only a partial failure requiring no treatment, pessary use or a less extensive surgical repair.

If I'm Not Leaking Urine With My Prolapse, Do I Still Need Bladder Testing?

Yes. If you are having any type of prolapse surgery, bladder testing should be done beforehand. If a repair is done without considering the bladder, new problems of urinary incontinence can develop.

How Will This Affect My Sex Life?

We hope that the repair will actually improve or enhance your sex life. Often rebuilding the vagina can tighten the vaginal walls and create more sensation for both partners. However, there are times when a pelvic floor repair may cause scarring that can lead to painful intercourse. This usually responds to lubrication, estrogen cream and pelvic floor physical therapy. Ability to achieve orgasm should not change.

FREQUENTLY ASKED QUESTIONS ABOUT ANAL INCONTINENCE...

What is Anal Incontinence?

Anal incontinence is the involuntary leakage of gas, liquid stool or solid stool.

What Causes Anal Incontinence?

Like other pelvic floor disorders, anal incontinence usually occurs because of childbirth injuries. Even normal easy vaginal deliveries can result in direct injury to the anal sphincter muscle or to the innervations of the rectum and sphincter. About 15% of the time, anal incontinence occurs because of a direct injury to the anal sphincter. This may or may not be because of a direct injury to the anal sphincter. This may or may not be recognized during childbirth. After childbirth you can often compensate for this problem. However, as you age, the weakness in these muscles may become more apparent. There are other conditions that can lead to this disorder. Some of the more common include; Hemorrhoids or Hemorrhoid Surgery, Inflammatory Bowel Disease, Radiation Enteritis, Multiple Sclerosis, Parkinson's Disease, Spinal Cord Injuries, Stroke, Dementia, Diabetic Neuropathy, Rectal Prolapse and Descending Perineum Syndrome.

What Can Be Done To Treat Anal Incontinence?

There are different approaches to treating anal incontinence and it often depends on which condition is causing it. A complete history and physical will help identify potential problems. Anal manometry, Trans anal ultrasound and prudential nerve motor latency studies are diagnostic tests that may be helpful in the evaluation. Treatment options include dietary changes, weight loss, bowel management, biofeedback physical therapy, anal sphincter repair, rectocele repair, and sacral nerve Neuromodulation.

Women's Pelvic Health, 6440 W Newberry Rd, Suite 409, Gainesville FL, 32605 (352) 333-6161