Urogynecology

Overview

Urogynecology is a subspecialty of gynecology and obstetrics concerned with female pelvic medicine and reconstructive surgery. Urogynecologists are specialists who specialize in the diagnosis and treatment of pelvic floor diseases such as weak bladders and pelvic organ prolapse (your organs drop because the muscles are weak).

The bladder, reproductive system, and rectum are all housed on the pelvic floor. The field of urogynecology is relatively young. It did not exist prior to 2011. These health conditions were handled by a variety of professionals. For pelvic floor disorders, women frequently had to see many physicians.

In 2011, the American Board of Medical Specialties approved the certification making urogynecology its own field of study. This has made it easier for women to get the care they need without needing to see multiple doctors.

 

Pelvic Floor Disorders Symptoms

Pelvic floor disorders are among the most common conditions treated by urogynecologists. These medical conditions can be treated and often resolved. 

• Frequent urination
• Strong urge to urinate
• Burning while urinating
• Loss of bladder or bowel control
• Bladder pressure
• Feeling like the bladder hasn't fully emptied after urinating
• Heaviness or bulge in the vagina
• Frequent urinary tract infections (UTI)
• Trouble with bowel movements
• Pain during intercourse
• Chronic bladder or pelvic pain

 

Who Gets Pelvic Floor Disorders?

Pelvic floor disorders occur when your pelvic floor muscles tear or become weak. This happens for a range of reasons. The most common:

• Age
• Childbirth
• Repeated strenuous activity or lifting
• Pelvic surgery
• Chronic disease 
• Menopause
• Chronic constipation
• Some neurologic conditions 

 

What Does a Urogynecologist Do?

Urogynecologists deal with pelvic floor and bladder problems. Overactive bladders, weak pelvic muscles, reproductive difficulties, and bladder or rectal incontinence are all examples of this (the loss of control when going to the bathroom). Urogynecologists assess, diagnose, and treat patients.

Your treatment strategy will be determined by the nature of your difficulties and their underlying cause. Common treatments include:

Medications

Although not all incontinence issues call for medications, some do. Likewise, other pelvic floor conditions might benefit from treatment with medication. 

 

Injections

For bladder control issues and other incontinence issues, “bulking agents” can be used to help. Urogynecologists can do injection procedures with local anesthesia, outpatient, or in the office. 

 

Vaginal Pessary

Pessaries -- medical devices inserted into your vagina -- are used to support your organs if you have prolapse issues. Pessaries are soft and come in different shapes and sizes. Your doctor can fit you for one during an office visit. They can be removed for cleaning. 

 

Pelvic Floor Muscle Training

Kegel exercises can assist with conditions like prolapse. Kegel exercises include squeezing and releasing the pelvic floor muscles. These exercises can help with more severe prolapse symptoms, but they won't totally eliminate them.

 

Behavioral modification

Behavioral changes can help with a variety of bladder and bowel issues. Certain meals and beverages, in particular, might irritate your bladder. It is also simple to develop behaviors that might have a negative impact on how your bowel and bladder function in the long run. We will examine your daily behaviors to discover if there are any patterns that may be changed to enhance your condition.

 

Nerve Stimulation

The sacral nerves are found near the base of your spine. They transmit signals from your brain to some of the muscles involved in urination, such as the detrusor muscle. This muscle protects the bladder.

Your incontinence might be caused by your detrusor muscles contracting too frequently.

A gadget is placed near one of your sacral nerves, commonly in your buttocks. This device sends an electrical current into the sacral nerve.

This enhances signal transmission between your brain and your detrusor muscles. This will lessen your desire to urinate.

Sacral nerve stimulation can be unpleasant and painful. However, some patients experience significant relief in their symptoms.

 

Surgery

The urogynecologist could suggest surgery as well. These include:

1. Vaginal wall repair: 

The most frequent type of prolapse surgery is vaginal repair, which involves utilizing sutures or stitches to fix the prolapsed vaginal tissues. A colporrhaphy is a surgical procedure that employs a patient's own natural tissue to repair a prolapse. This operation makes no use of mesh. This procedure is often advised for women who suffer bladder (cystocele) or rectum (rectocele) prolapse, or a combination of the two. This operation can be combined with other surgeries for urinary incontinence and hysterectomy. 

 

2. Bladder installations: 

When diet change, stress management, and over-the-counter medicines are ineffective, bladder installations are recommended by the American Urological Association as a therapy option for IC/BPS. Bladder instillations, also known as bladder cocktails, are medication mixes that are injected directly into the bladder. The following are examples of instillations:

• Alkalinized Lidocaine and Heparin

Alkalinized Lidocaine and Heparin is a patented, proprietary compounded bladder instillation containing heparin and alkalinized lidocaine that has been pH-balanced. The ready-to-use, pre-filled sterile syringes contain the pre-mixed instillation, which may be delivered at a physician's office or recommended for the patient to use at home.

 

• Dimethyl sulfoxide

The first and only FDA-approved bladder instillation for interstitial cystitis/bladder pain syndrome (IC/BPS) was dimethyl sulfoxide (DMSO, trade name RIMSO-50). It was approved in 1978, but the actual mechanism of action is still unknown, while it is considered to have numerous favorable effects:

• Reducing bladder irritation and pain (anti-inflammatory).
• Helping to relax the bladder and pelvic muscles (antispasmodic).
• Relieving pain by depleting the level of substance P levels from bladder nerves.
• Increasing bladder capacity by breaking down scar tissue by preventing the formation of collagen, a protein the body uses to create scar tissue.

Because of its ability to penetrate the bladder lining, several healthcare practitioners combine DMSO with other bladder-instilled drugs, such as heparin, steroids, bicarbonate, and analgesics, to improve absorption (pain medicines). However, as noted in the Fall 2009 Professional Perspectives, preferences for drugs used in bladder cocktails are changing in practice.

 

• Sodium Hyaluronate

Sodium hyaluronate solution (Cystistat and Hyacyst) is injected directly into the bladder to treat interstitial cystitis/bladder pain syndrome (IC/BPS). In the United States, neither of these medications is licensed for usage. They are, however, authorized for IC/BPS therapy in Europe and Canada. Clinical trials were conducted to determine the efficacy of sodium hyaluronate solution, commonly known as hyaluronic acid, in treating IC/BPS. Cystistat is so recommended in over 20 countries, including the United Kingdom, Canada, Austria, France, Germany, Greece, Ireland, Italy, the Netherlands, Portugal, Scandinavia, Spain, Switzerland, China, and others. Hyacyst is also accessible throughout Europe.

 

• PSD597 (Plethora Solutions)

This is the formulation of alkalinized lidocaine used in the clinical trial published earlier this year. It includes a delivery system and a proprietary formulation said to protect the active drug in the bladder and ensure that the drug remains in the optimal chemical form for transport across the bladder wall to its site of action.

 

• URG101 (Urigen)

This is a formulation of alkalinized lidocaine and heparin for instillation. Interim analysis of a phase 2 trial showed significant improvement in average daytime pain, daytime urgency, and symptom score.

 

• Uracyst (Stellar Pharmaceuticals):

This sterile sodium chondroitin sulfate solution (2.0%) formulation is authorized for sale in Canada and Europe. It is considered to repair the bladder's damaged glycosaminoglycan layer. In a six-week uncontrolled Canadian experiment, 53 patients with moderately severe IC got weekly instillations for six weeks, then monthly for 16 weeks for a total of ten treatments. Symptom and bother ratings were considerably decreased after 10 and 24 weeks.

 

• Misoprostol (Cytotec) for instillation:

This prostaglandin E1 analog is used orally to minimize the risk of stomach ulcers caused by NSAIDs. NSAIDs inhibit the NF-kappa B signaling pathway, preventing prostaglandin production. 

 

3. Bladder control surgery:

• Colposuspension: A lower stomach incision is required for colposuspension (abdomen). The surgeon will raise up the neck of your bladder and stitch it in place. In women with stress incontinence, this can help avoid involuntary leaks. Colposuspension is a long-term therapeutic option for stress incontinence. Following a colposuspension, the following complications may occur:

• difficulty emptying the bladder when going to the toilet.
• recurrent urinary tract infections (UTIs).
• discomfort during sex.

 

• Sling procedures: Making an incision in your lower tummy and vagina is required for sling treatments. To support the bladder, a sling of tissue is wrapped around its neck. It will also help to prevent unintentional leaks. The sling's tissue can be:

• taken from another part of your body (autologous sling)
• donated from another person (allograft sling)
• taken from an animal (xenograft sling), such as cow or pig tissue

An autologous sling is frequently used by the surgeon. This is created from a piece of the tissue that surrounds the abdominal muscles (rectus fascia). These slings are commonly used. This is due to greater understanding of their long-term safety and efficacy. One issue with using slings is having difficulties emptying the bladder when going to the toilet. Some women who have the surgery experience urge incontinence thereafter.

 

• Urethral bulking agents: A urethral bulking agent can be injected into the urethral walls. This expands the urethral walls and allows the urethra to seal with more power. This procedure is less invasive than previous surgical therapies for female stress incontinence. In most cases, no incisions are required. The compounds are injected into the urethra using a cystoscope. In general, this approach is less effective than other existing therapies. The efficacy of the bulking agents will also degrade over time. You may require more injections. You may get a minor burning sensation or blood when you pee after the injections. This normally only happens for a short time.

 

• Artificial urinary sphincter: The urinary sphincter muscle keeps urine from passing from the bladder into the urethra. To treat your incontinence, your doctor may recommend that you wear an artificial urinary sphincter. This is more commonly utilized as a therapy for males suffering from stress incontinence. It is rarely applied to women. Short-term bleeding is common during the process to install an artificial urinary sphincter. When you pee, it might also induce a burning feeling. It is fairly unusual for the gadget to quit operating in the long run. It may require further surgery to be removed.

 

• Tape procedures: Vaginal mesh surgery involves inserting a strip of synthetic mesh behind the urethra to stabilize it. The urethra is the tube that drains urine from your body. Tape surgery is another name for vaginal mesh surgery for stress incontinence. The mesh remains in the body forever. In circumstances where it is clinically appropriate and safe, the HSE has halted the use of transvaginal mesh implants for the therapy of stress urine incontinence or pelvic organ prolapse. The Chief Medical Officer suggested that the suspension be maintained until the HSE has completed implementing new recommendations.

 

What Urogynecology Can Treat?

You're not alone if you've ever asked, "Is this normal?" No symptom or worry is off-limits in the practice, and no patient is too young or too elderly. Even when addressing sensitive themes or symptoms, an all-female team of doctors will put you at ease.

Dealing with a pelvic floor dysfunction or other urogynecology disorders can be humiliating. Some of the ailments can be addressed as follows:

    1. Urinary incontinence, urinary retention, and other voiding problems:

Disorders resulting in the involuntary leakage of urine include functional, stress, urge and overflow incontinence, and overactive bladder syndrome (OAB).

    2. Pelvic organ prolapses:

Types of pelvic organ prolapse affect different parts of the vagina and may include cystocele, urethrocele, rectocele and uterine prolapse.

    3. Fecal incontinence:

A lack of control over defecation, leading to involuntary loss of bowel contents.

    4. Diverticula and vaginal agenesis:

Diverticula may be a congenital area of weakness in the bladder wall through which some of the bladder lining protrudes. Vaginal atresia is a congenital abnormality characterized by a deformed, nonfunctional, or absent vagina.

    5. Overflow incontinence:

Urinary incontinence that occurs when the bladder is so full that it continually leaks urine.

    6. Urethral diverticulum:

A short section of the urethra that bulges outward, creating a small pocket in which urine can collect.

    7. Urethral sphincter insufficiency:

A condition in which insufficient bladder sphincter support causes urine leakage when the abdominal muscles tighten during a physical movement or activity, such as coughing, laughing, and sneezing.

    8. Uterine prolapse:

Occurs when the uterus drops down into the vagina, and in severe cases, outside the vagina.

    9. Vaginal vault prolapse:

A condition characterized by part of the vaginal canal protruding from the opening of the vagina; usually occurs when the pelvic floor collapses as a result of childbirth.

    10. Overactive bladder syndromes:

A urological condition characterized by a frequent, urgent need to urinate.

    11. Voiding and defecatory dysfunction:

Urinary or defecatory dysfunction, such as incontinence, constipation, tenesmus, splinting, and fecal incontinence.

    12. Fistulas:

An abnormal passage or hole that has formed between two organs or an internal organ and the skin.

    13. Cystocele, enterocele, rectocele:

Various types of pelvic organ prolapse.

    14. Detrusor overactivity (urgency incontinence/overactive bladder):

A condition in which the bladder muscle (the detrusor) contracts unexpectedly during bladder filling.

    15. Rectovaginal fistulas:

Fistula is a medical condition in which there is an abnormal connection between the rectum and the vagina.

    16. Stress urinary incontinence:

Also known as SUI, an unintentional loss of urine prompted by a physical movement or activity, such as coughing, sneezing, running or heavy lifting, which puts pressure on the bladder.

    17. Uterine fibroids and endometriosis:

Uterine fibroids are noncancerous growths of the uterus that often appear during childbearing years. Endometriosis is a condition resulting from endometrial tissue adhering outside the uterus, causing pelvic pain.

    18. Vaginal agenesis and stenosis:

Vaginal agenesis is a congenital abnormality characterized by a deformed, nonfunctional, or absent vagina. Stenosis is the constriction or blockage of the vagina.

    19. Vesicovaginal and urethrovaginal fistulas:

Types of abnormal connection between the bladder or urethra and the vagina.

 

Conclusion

Urogynecology is a subspecialty of urology and gynecology that focuses on female pelvic floor problems.

Prolapse and incontinence are common together, and both can be caused by pelvic floor damage after delivery. Heavy lifting, coughing for an extended period of time, severe constipation, and obesity are also risk factors.

Because a high percentage of women may be impacted by different problems connected to pelvic floor issues or have other health concerns, physicians collaborate with other experts to develop complete treatment programs that treat each woman individually based on her requirements.

Urogynecologists are specially trained to treat pelvic floor diseases such as:

• Cystocele/Rectocele/Enterocele
• Uterine Prolapse/Vaginal Prolapse
• Stress Incontinence
• Urge Incontinence
• Mixed Incontinence
• Overflow Incontinence
• Fecal Incontinence
• Postpartum Pelvic Floor Dysfunction
• Recurrent Urinary Tract Infections
• Genitourinary and Rectovaginal Fistula
• Urethral Diverticulum
• Vaginal Cysts
• Constipation
• Painful Bladder Conditions/Interstitial Cystitis
• Sexual Dysfunction