What are pelvic floor disorders?
Female pelvic is an organ that involves with functions such as voiding, defecation, reproduction and sexual function. It consists of organs such as bladder, rectum, vagina, uterus, cervix and complex nervous system as well as vasculature and ligaments. In order to have intact function, the integrity of organs and proper innervations is essential. Pelvic floor disorders include a variety of problems and overall can affect up to one third of the women in their lifetime. Pelvic floor disorder symptoms include feeling of vaginal bulge and pressure, discomfort during intercourse, difficulty emptying the bladder, urinary and fecal incontinence, difficulty having bowel movement, sensation of incomplete bladder and bowel, urinary frequency and urgency, waking up at night to urinate, pain during intercourse, decreased sexual satisfaction, pelvic pain, blood in the urine, frequent urinary tract infections (UTIs), and vaginal dryness.
There is a wide variety of symptoms that are associated with disorders of pelvis in female patients. Through their extensive training, urogynecologist are at the position to consultant and manage these symptoms. (Author: Ali Azadi, November, 2017)
Pelvic Organ Prolapse & Treatments
What is pelvic organ prolapse?
Pelvic organ prolapse (POP) is a general term that is used when one or more of the pelvic organs drop or protrude through vaginal opening. It can involve any of the pelvic organs such as bladder, uterus and rectum. In most cases, there is more than one organ involved.
Prolapse is like a hernia where the organ falls through a weakness in the pelvic floor. It is very common and up to 20% of women may undergo surgery for prolapse in their lifetime.
While it can be asymptomatic in mild cases, patients usually have symptoms such as feeling a bulge in the vagina, protrusion of organ through vaginal opening, sensation or difficulty emptying the bladder and bowel, difficulty having intercourse, vaginal and back pain. Sometimes patients report that they have to push the bulge back in order to empty the bladder or bowel.
Pelvic organ prolapse can occur to anyone without risk factors but typically history of pregnancy, vaginal delivery, specially delivery of a large baby using instruments (forceps and vacuum), constipation, prior hysterectomy, soft tissue diseases are among the more common risk factors. (Author: Ali Azadi, November 2017)
What is cystocele?
Cystocele is bulging of the bladder to the vagina or when it protrudes out of the vaginal opening. It occurs when there is a weakness in the pelvic floor support. It has different stages depending on degree of prolapse. Stage 4 cystocele is when bladder completely protrudes out of vaginal opening. Most patients with mild degree of cystocele are asymptomatic or only feel pressure and fullness or discomfort during intercourse. When the bulge is noticeable, symptoms usually affect the quality of life and patients seek treatment. Bladder symptoms such as urinary urgency and frequency, waking up at night to urinate and sensation of incomplete bladder are among the bothersome symptoms. If Bladder doesn’t empty well due to the kink caused by cystocele, it can predispose patient to recurrent UTIs. (Author: Ali Azadi, November 2017)
What is the prolapse of uterus?
As the name implies, prolapse of the uterus happens when there is a drop of the uterus and cervix into the vagina. In mild cases, the cervix is displaced down in the vagina. In more severe cases, the cervix protrudes through the vaginal opening. Patients with uterovaginal prolapse often complain about vaginal bulge, feeling of fullness, discomfort during intercourse, vaginal bleeding from organ being in contact with outside, urinary symptoms such as urgency, frequency, waking up at night to urinate and difficulty emptying the bladder and bowel. Please notice that in most cases of advanced prolapse of uterus, there is drop of the bladder or rectum at the same time. Therefore, it is very important that if surgery is decided for management of prolapse, attention is made to the correction of cystocele and rectocele. Otherwise, despite having hysterectomy, symptoms of prolapse will not resolve. (Author: Ali Azadi, November 2017)
What is rectocele?
Typically, there is a support wall that separates the rectum and vagina (rectovaginal septum). If there is any weakness or damage of this structure, then rectum protrudes into the vagina. This vaginal bulge is called rectocele. Other than symptoms of vaginal pressure and fullness, many patients also complain about having difficulties with having bowel movement. Some patients even report that they have to manually push the bulge back, in order to facilitate bowel movements. Sometimes patients have to support the bottom of pelvis or even manually remove the stool from rectum. Occasionally, patients report the change in posture to facilitate the bowel movements. Difficulties with having bowel movement are associated symptoms of rectocele. Many patients also have constipation. Constipation and rectocele are typically associated. As patients with constipation have to strain more, it can make the rectocele worse by exerting more forces. At the mean time, when patient has rectocele, due to change in the normal pathway and angles, they have to strain more to have bowel movements. Constipation and prolapse, particularly rectocele are like “chicken and egg”. One can make the other one worse. Regardless, proper management of constipation is an important key factor to help with improvement of symptoms as well as to increase the success of rectocele repair surgery. (Author: Ali Azadi, November 2017)
What is enterocele?
When small bowel and intra-abdominal contents herniate through the vagina, we call it enterocele. Like other forms of prolapse, it is associated with a vaginal bulge with all the symptoms of pressure, fullness and difficulty with bowel movements and emptying the bladder.
Enterocele occurs mostly in patients who had prior hysterectomy but it can happen in patients with no prior history. Many times diagnosis can be difficult with examination and imaging might be needed. Proper diagnosis is essential in order to correct it during surgery. (Author: Ali Azadi, November 2017)
How is stage of prolapse determined? What is the stage of my prolapse?
The stage of prolapse is diagnosed clinically. It is determined during office examination as opposed to getting imaging or X-rays. The stages are ranked from 0 to 4. Stage 0 means that there is no prolapse while stage 4 means that the pelvic organs are completely come out of vagina and there is no support in pelvic floor anymore. Other stages are in between and increase in number as the bulge protrudes more. Typically, POP-Q system is the standard method used to map the different points of the pelvic support and is used for to determine the staging of the prolapse.
It is important to note that your doctor may not see the extent of the bulge that you might notice at home. Since the vaginal bulge gets bigger at the end of the day with physical activity and long time standing. Examination while standing and straining can be helpful when there is a discrepancy between your symptoms and your exam.
Advanced stages of prolapse (3 and 4 when vaginal bulge is noticed outside of the opening) can cause bothersome symptoms in most patients. Most of the time, treatment is indicated to help with symptoms, particularly with difficulty to void and having bowel movements. While some patients in stage 1 and 2 prolapse are symptomatic, many patients do not experience any symptoms. Many times, prolapse is diagnosed during a routine exam. It is important to know that it is your level of discomfort that dictates the need for treatment. (Author: Ali Azadi, November 2017)
What are the treatment options for pelvic organ prolapse?
Treatment options include observation, conservative treatment and surgical management. In cases that prolapse is not severe and patient is asymptomatic, observation and monitoring the symptoms would be an option. Even though worsening of the prolapse can be seen in some cases, for many patients the stage of prolapse does not change or has slow progression. Some patients prefer to correct the prolapse while they are still younger and healthier but in general, “no intervention” and “monitoring of changes” can be an acceptable option.
Pessary is a device that can be placed in the vagina in order to hold the bulge from coming out. The main advantage of pessary is that it allows the patient to avoid surgery. It can be considered as a short term or long term solution for some patients. Discomfort, vaginal discharge and interfering with intercourse are among some of the reasons that patients opt to have surgery as opposed to placement of a pessary. It is also worth mentioning that when there is severe vaginal atrophy or when pessary is neglected, it can cause vaginal ulcer and even erosion to the bladder or bowel. In general, pessaries are a relatively safe option for patients who like to defer surgery or are not a good candidate for surgical management.
Ultimately, surgical treatment can be considered for management of prolapse. Surgical correction can be done using various approaches. Minimally invasive approach is typically considered which allows rapid healing and return to normal activities. Vaginal, laparoscopic and robotic (da Vinci®) surgeries are minimally invasive approaches to correct the prolapse. Rarely, abdominal incision is needed for surgery. With the advancement of minimally invasive approach and its benefits, many patients prefer to proceed with surgery as oppose to using pessary. Natural tissue repair vs. use of biologic and synthetic mesh can be considered for surgery. There are benefits unique to each approach. There are factors that can make one option more preferable than the other approach for each individual patient. In general, as part of preoperative evaluation, we consider all the factors and review the risks and benefits and help the patient to make the best informed decision. (Author: Ali Azadi, November 2017)
What is a pessary?
Pessary is a device that can be placed in the vagina in order to hold the bulge from coming out. The main advantage of pessary is that it avoids the use of surgery to correct prolapse. It can be considered as a short-term or long-term solution for some patients. Discomfort, vaginal discharge and interfering with intercourse are among some of the reasons that patient opt to have surgery as opposed to placement of a pessary. It is also worth mentioning that when there is severe vaginal atrophy or if pessary is neglected, it can cause vaginal ulcer and even erosion to the bladder or bowel. In general, pessaries are a relatively safe option for patients who like to defer surgery or are not a good candidate for surgical management. (Author: Ali Azadi, November 2017)
Do I need to have surgery for prolapse?
Since pelvic organ prolapse is not a life threatening situation, surgery is not always necessary and other options such as pessary can be considered. However, prolapse has negative impact on women’s quality of life. There are many studies that have shown high satisfaction rate after surgery. As part of the counseling, we will help you to assess the risks and benefits of each approach based on individualized characteristics, your values and your goals and expectations. The decision regarding having surgery or not is very individualized. Patients who are extensively counseled can always make better decisions that would fit their body and lifestyle. (Author: Ali Azadi, November 2017)
Do I need hysterectomy as part of my surgery for treatment of prolapse? Can I keep my uterus?
Even though many experts include hysterectomy as part of prolapse surgery, there are others that believe keeping uterus can be an option. This is a controversial topic and there are risks and benefits to each approach. Some believe that keeping the uterus will increase the risks of developing prolapse in the future, while others argue that hysterectomy make the surgery more invasive. The risks and benefits should be assessed individually and factors such as developing prolapse in the future, chances of developing malignancy, need for future pregnancy, patient’s age, and medical condition should be considered. But to make it simple, the answer is “yes”, uterine preservation is an option. (Author: Ali Azadi, November 2017)
What are different approaches for hysterectomy? Is one method better than others?
Hysterectomy means surgical removal of the uterus alone or with removal of cervix. It can be done through different approaches. Hysterectomy can be done through the vaginal approach (vaginal hysterectomy), laparoscopic approach (laparoscopic hysterectomy) or with the use of da Vinci ® robot (robotic hysterectomy). All these methods are minimally invasive with the advantage of rapid healing, minimal blood loss, and lower infection rates. Hysterectomy can also be performed by making an incision in the abdominal wall (abdominal hysterectomy). With the advancement of minimally invasive approaches, abdominal hysterectomy has become less common.
There are different reasons for hysterectomy which includes malignancy, benign fibroid tumors, heavy menstrual bleeding, pelvic pain and ultimately prolapsed uterus.
The best approach for each patient depends on the indication of hysterectomy, specific findings during examination, such as size of the uterus, size and shape of pelvis, degree of prolapse and many other patients’ specific characteristics.
Vaginal hysterectomy has the advantage of avoiding any incision in the abdomen; therefore, it has cosmetic benefits. On the other hand, laparoscopic and robotic approaches allow better visualization. This can be particularly helpful in identifying pathologies such as endometriosis. Easier access to ovaries can be considered as an advantage of laparoscopic or robotic approach.
The complication rates of hysterectomy such as injury to the bladder, ureters and bowels, blood loss and infection has been compared in the different approaches. All of these minimally invasive methods have the advantage of low complication risks.
It is needless to say that the experience of the surgeon performing any of the different methods of the hysterectomy is a key factor for success. (Author: Ali Azadi, November 2017)
What is the difference between supra-cervical hysterectomy and total hysterectomy?
When supra-cervical hysterectomy is performed, cervix will be preserved and only the uterus will be removed. In contrast, during total hysterectomy, the entire uterus and cervix will be removed. American College of Obstetricians and Gynecologists (ACOG) encourages physician to remove the cervix and uterus unless there is a clear benefit to keep the cervix. Some studies have shown less mesh erosion at the vaginal cuff if mesh is implanted after supra-cervical hysterectomies. Few studies show less sexual dysfunction with supra-cervical hysterectomy.
When a patient decides to keep her cervix, the potential risk of future cervical cancer should be considered. Therefore, in patients with history of cervical dysplasia (abnormal pap smear), there is a clear benefit of removal of the cervix at the time of hysterectomy. (Author: Ali Azadi, November 2017)
Do I need to take my ovaries removed at the time of prolapse surgery?
Depending on the surgical approach for correction of prolapse, sometimes it is possible to remove the ovaries and fallopian tubes. For many post-menopausal women, this is a unique opportunity to reduce the risk of ovarian cancer in the future. Removal of the ovaries and fallopian tubes is possible at the time of hysterectomy or at any laparoscopic surgery for correction of prolapse. Ovarian cancer is the leading cause of mortality among all the gynecological malignancies and unfortunately, there is no reliable screening test available. Therefore, ovarian cancer is often diagnosed at an advanced stage where treatment can be challenging. Removal of the ovaries and fallopian tubes during prolapse surgery allows women to significantly reduce their risk of malignancy without taking major risks. However, this decision depends on many factors. Ovaries produce hormones that are beneficial for women’s health, particularly for their cardiac and bone health. Most studies have shown that overall it is beneficial to keep ovaries prior to or shortly after menopause. However, this decision is individualized and depends on many factors such as family history of ovarian malignancies, genetic factors, history of ovarian cysts, endometriosis, and pelvic pain. (Author: Ali Azadi, November 2017)
What are the risks and benefits of pessary treatment?
The main advantage of pessary is that it allows patients to avoid surgery. Pessary can help with discomfort from prolapse and improve the symptoms without undergoing surgery. However, patients often need to wear it for rest of their lives.
Patients with pessary need to be observed with scheduled visits. In most cases, we recommend that pessary to be checked by specialist, at least every 3 months. There are many reported cases of vaginal ulcers and even fistulas when pessary is neglected. Some patients would like to try pessary prior to making the decision to have surgery. In general, pessary is desired mostly by elderly women, who opt not to have surgery or not considered to be a surgical candidate due to their poor medical condition. (Author: Ali Azadi, November 2017)
What happens if you don’t do anything for prolapse? Is observation an option?
Pelvic organ prolapse is not a life threatening situation. In some cases, there is medical necessity to manage the prolapse as the prolapse can affect emptying the bladder or kink the ureters. Sometimes prolapse can cause urinary retention by blocking the bladder exit. Otherwise, it is mostly the discomfort symptoms that would dictate the need for treatment. For this reason, many patients choose not to have any treatment and continue to observe. The argument about this decision is that in many cases, prolapse worsens with time and as the patients age, they may develop medical problems that can make surgery more complicated and challenging. Many women decide to have their prolapse fixed while they are younger and healthier. (Author: Ali Azadi, November 2017)
What is the best surgery for me?
Different approaches of surgery have been compared in different studies. Some surgical treatments have shown to have more anatomical success. Some surgeries are known to be less invasive. Minimally invasive approach is often considered the ideal method for most procedures. In order to choose the best treatment, there are different factors that have to be considered. These factor include patient’s age, level of physical activity, sexual activity, voiding function, bowel function, prior history of surgeries, immune status, medical condition and the overall health status of the patient.
Even though, we can compare one surgery to another in one aspect with certainty but the real question of which one is “the best” depends on various factors that can be different for each patient. Often times, the safety and invasiveness need to be compared to the success of surgery.
The best outcome will be achieved when the surgeon has competency in all the different surgical approaches and patient will be involved in the decision making process. (Author: Ali Azadi, November 2017)
What are the advantages of Robotic (da Vinci®) surgery?
The robotic surgery is a form of minimally invasive laparoscopic approach. The surgery is performed by making small incisions in the abdomen. With the advantage of state of the art technology, complex surgeries can be performed with less invasive approaches. The technical benefits of Robotic da Vinci® surgery are better visualization, use of multiple instrument at the same time, better dexterity, wider range of motions, and many other features that allows the surgeon to do fine and meticulous surgeries for complex cases. The benefit for patient could be rapid healing compared to procedures that require big incisions in the abdomen. Better visualization will help the surgeon to see the tissue planes better, which may decrease the chance of injury to organs as well as minimal blood loss. However, like any other technology, proper use of the robot is very important. While robotic approach performed by experienced surgeons can be beneficial for patients, lack of proper training and experience can be harmful. The learning curve to get familiar with the device can be long. (Author: Ali Azadi, November 2017)
What conditions can be treated with da Vinci® approach?
There is an increasing number of surgical procedures that can be performed with the use of da Vinci® robot. The field of urogynecology and pelvic floor surgery has particularly benefitted from this advanced technology. There are many complex surgeries that are routinely performed by the use of da Vinci® system which includes sacrocolpopexy for prolapsed organs, difficult hysterectomies, endometriosis and removal of abdominal mesh. The advanced technology allows these complex cases to be done using the least invasive method, which allows rapid healing, quick return to work and resuming routine activities for patients. (Author: Ali Azadi, November 2017)
What are the advantages of single site robotic (da Vinci®) surgery?
Recently, robotic surgery through one single incision has been introduced. Since the entire procedure is done through this single incision, which is usually in the naval area, it can be cosmetically beneficial for patients. The recovery and rapid healing will be the same compared to traditional multiport robotic procedures. (Author: Ali Azadi, November 2017)
What are the advantages of vaginal surgery?
Vaginal surgery can be performed for many gynecologic and pelvic floor disorders. It is minimally invasive and allows rapid healing. Avoidance of entry to the abdomen through incisions can be beneficial in patients who had prior abdominal surgeries where adhesions would be a concern. Retroperitoneal procedures such as anterior and posterior repair, sacrospinous ligament suspension and slings have the advantage of avoiding intra-abdominal scar tissue. Most patients can go home within 24 hours after surgery. (Author: Ali Azadi, November 2017)
Am I too old for surgery?
Patient’s general health status seems to be a more important factor than the age alone.
Cardiovascular status and respiratory functions are particularly important. As prevalence of urinary incontinence and pelvic organ prolapse is more common in post-menopausal women and increases with age, most patients will undergo surgery at older age. Fortunately, the minimally invasive approaches allows for fast healing and an excellent outcome in elderly population. It is important to note that it is best to manage chronic diseases such as ischemia, COPD, asthma, and diabetes prior to surgery. We try to keep your primary care and your specialists involved closely. Multidisciplinary approach always works better. Our goal is to have the best outcome and communicate efficiently with all your other providers involved in your health. (Author: Ali Azadi, November 2017)
What Can I do to increase the success of my surgery?
To increase long term success of your surgery and avoid short term complications, adherence to post-operative instructions is the key. You will receive detailed post-operative instructions. In general, avoiding heavy physical activity and pelvic rest after surgery are very important. Since with minimally invasive approaches, the recovery is fast, patients forget to avoid heavy physical activities after surgery. There is no exact defined time to avoid heavy physical activity. In general, 6 weeks to 3 months after surgery is an important time as most healing and scar formation happens during this period. A good diet regimen and managing constipation can be important. Straining to have bowel movements associated with constipation can potentially damage the repair. (Author: Ali Azadi, November 2017)
Mesh & Management of Complications
What is Mesh?
In general, all the grafts that are used to reinforce tissue during surgery can be called “Mesh”. However, when we use the term “mesh”, mostly it means synthetic materials. These are products that are made of fibers into the shape of sheets and are implanted during surgeries such as hernia repairs, some cases of pelvic organ prolapse, and urinary incontinence.
There are different materials that have been used as mesh including polypropylene, marlex, marsilene, and teflone. Each has different biomechanical characteristics. Generally, polypropylene is considered the best available material. Current polypropylene fibers available are different from the earlier products as there are advancement in fiber size, weight, pore size and many other characteristics.
In general, the ideal mesh should have the following characteristics: be inert, not carcinogenic, not immunogenic, resistant to infection, and minimal shrinkage. Even though, there is no ideal mesh available, with the advancement in manufacturing the mesh material, there has been significant decrease in complications with the current products on the market. (Author: Ali Azadi, November 2017)
What is mesh erosion?
Mesh erosion is the most common complication noted when mesh is used in surgery. If the mesh fibers are exposed into the adjacent tissue, it is called erosion. Even though, there are scientific terms to differentiate a variety of situations, in general, when mesh is noticed, seen or palpated in areas that should not be seen, we call it mesh erosion.
Normally, mesh is implanted underneath the vaginal epithelium and underlying tissue in different pelvic floor planes. If somehow, mesh fibers are not covered well or protrude to the internal organs, mesh erosion takes place.
The most common type of erosion occurs when mesh is exposed in the vagina. Patients can notice it by palpation of the mesh fibers, constant vaginal discharge or bleeding, or discomfort during intercourse. Sometimes mesh is seen in the bladder or rectum.
The reported rate for mesh erosion varies. It can be as high as 10%. Mid-urethral slings and sacrocolpopexy meshes have much lower rate of erosion compared to vaginal mesh kits. In some series, mesh erosion is reported as less than 1%. It is known that high volume surgeons with experience in pelvic floor surgeries have lower rate of complications. (Author: Ali Azadi, November 2017)
What are the symptoms of mesh erosion to the vagina?
Mesh erosion to the vagina is the most common type of erosion. In this case, fibers of the mesh that are supposed to be covered by vaginal epithelium and underlying fibromuscular tissue, can be seen in the vagina.
Symptoms can include palpation of the fibers by patient, constant vaginal discharge, vaginal bleeding or spotting and pain during intercourse. Sometimes patient’s partner complains about noticing something sharp in the vagina. Many times it is described as being similar to sand paper. (Author: Ali Azadi, November 2017)
What are the symptoms of mesh erosion in the bladder or urethra?
Mesh erosion into the bladder is a rare complication with mesh surgery. The exposure of the mesh to the bladder or urethra can occur during surgery at the time of mesh placement or as a delayed presentation. Cystoscopy at the time of surgery is essential to ensure that mesh is not mistakenly placed in the bladder or urethra.
Patient may not notice discomfort with this complication. Instead, frequent urinary tract infections, blood in the urine or refractory overactive bladder can be noted when mesh is exposed in the bladder or urethra.
If you have prior mesh surgery and have any of these symptoms, it is essential to ensure that mesh is not exposed in the bladder or urethra. A simple office cystoscopy can be helpful in this case. (Author: Ali Azadi, November 2017)
How is mesh erosion to the vagina managed?
The management of mesh erosion depends on the patient’s symptoms, type of erosion and ultimately patient’s goals. Small erosions that are asymptomatic can be monitored without any need for intervention. Use of local estrogen in the form of vaginal cream or pill may allow vaginal epithelium to heal over the exposed area.
Sometimes, with smaller erosions, the fibers can be trimmed at office or in the operating room. Larger areas of mesh erosion may require removal of bigger portion of the mesh.
In general, the rule is to do as little as needed. In many situations removal of a small portion of mesh can manage the symptoms. Some cases which involve infection of the graft may require more aggressive management such as removal of the mesh. (Author: Ali Azadi, November 2017)
Can I have the entire mesh removed?
Removal of the entire mesh requires expertise in surgery since mesh can be deep in pelvis and adjacent to the nerves, vessels and internal organs such as bladder and bowel. The surgeon should be comfortable operating in critical areas and be familiar with pelvic anatomy. The risks and benefits regarding partial or entire removal of mesh should be carefully weighted with the risks involved. The risks include but are not limited to injury to bladder, bowel, large vessels, and nerves which may cause permanent damage.
The patient and the consultant should discuss the decision and plan carefully while considering the patient’s characteristics, symptoms, mesh type, patient’s goals and expectation and ultimately consequences of mesh removal should be considered. (Author: Ali Azadi, November 2017)
Who should remove my mesh?
Pelvic surgeons with experience in mesh removal are able to remove the mesh in deep layers of pelvis. Care must be taken to minimize injury to the bladder, rectum, colon, vessels and nerves. Depending on the kind of mesh used, these surgeries might need to be coordinated with other specialists. (Author: Ali Azadi, November 2017)
What should I do if my prolapse and incontinence recur after mesh is removed?
Recurring symptoms of prolapse and incontinence should always be considered if a patient decides to have mesh removal. However, recurrence of symptoms is not always the case. Sometimes, the scar tissue that forms can prevent the recurrence of the prolapse and incontinence. Not every patient who has surgery to remove the mesh will develop the initial symptoms.
If prolapse and incontinence recur, there are options available. If a patient decides to have surgical treatment, natural tissue repair using patient’s own tissue or biologic material can be used. Some patients may choose to have mesh used again after careful evaluation of the risks and benefits. (Author: Ali Azadi, November 2017)
Can prolapse and incontinence be fixed at the same time of mesh removal?
The answer is yes! Prolapse and incontinence can be repaired at the same time of mesh removal. It should be considered that there is a possibility that the patient may not develop prolapse or incontinence; therefore, there is a good chance that the repair may not be warranted. If a patient becomes symptomatic, additional repair might be necessary at a later time.
In cases that mesh is infected, natural tissue repair may be an option. It should be noted that it is not the best decision to insert another graft at the same time in an infected environment. It is better to allow the infection to resolve prior to implanting new materials. Besides, if the mesh is removed due to pain, performing another repair at the same time can be confusing. If pain does not resolve, it can be a confusing picture in the presence of the new repair.
Even though it is possible to remove the mesh and perform the repair surgery at the same time, it is better to consider all the circumstances and the decision should be individualized for each patient. (Author: Ali Azadi, November 2017)
What are the risks and benefits of using mesh in surgery?
Mesh has been used for hernia repair for decades. Use of mesh for pelvic organ prolapse and urinary incontinence has been done for many years. In general, the purpose of mesh is to increase the strength of repair, reinforcing the tissue and ultimately decrease the chance of failure. Even though these factors are beneficial to the patient, use of mesh is not without risks. Some of these risks include pain, infection and erosion to adjacent tissues. The bottom line is that there are some possible complications that can occur when mesh is used as compared to when the foreign body is avoided.
There are many studies that have shown mesh can increase the success of surgery in apical prolapse and anterior wall defects. This benefit is not shown in repair of posterior compartment and rectocele. In my opinion, patient selection is the key. While many patients can benefit from use of mesh in their surgery, not everybody is a candidate for it.
It is also important to note that the products used currently have improved significantly from the ones that were used. Even though, the search for the ideal material continues, research shows that the new products have many characteristics that allow improvement in surgical outcome without having significant risk.
Patients also need to know that not all the problems of mesh is related to the product. The way the product is used and the quality of surgery are very important. High volume surgeons with special training for the procedures have better outcome and fewer complications. Urogynecologist are considered experts due to extra years of training for pelvic surgery.
Patients need to be aware of the potential risks involved and be warned about FDA notifications regarding mesh. Our goal is to help you understand your options. As it is the case for most treatments for pelvic floor disorders, surgery and use of mesh and the risks and benefits are individualized. We help you to make a good decision by explaining the benefits and understanding the risks. (Author: Ali Azadi, November 2017)
What are the potential complications of surgery with mesh?
Mesh erosion can occur to the adjacent organs. It occurs when mesh is felt in the vagina, or can be seen in the rectum or bladder. Sometimes patients feel pain during intercourse or have pelvic pain, which is mostly due to scar tissue and stricture from mesh. Other serious complications such as infection and rejection of mesh are rarely seen. Overall, reported complications from mesh can be as low as 1% in case series by experts. You can discuss the personal record history of complications with your physician.
National data registry is an effort by many organizations which allows patients to be aware of the complications for each doctor as this rate can be very different based on expertise, training and experience of the provider. (Author: Ali Azadi, November 2017)
Can I have natural tissue repair and biologic material used instead of having mesh?
It is possible to have pelvic surgery without the use of any graft. Biologic material can be used instead of the synthetic mesh. Examples of these grafts include cadaveric fascia, pig skin, etc. The main advantage of using these grafts is that it will incorporate to your body and will absorb (meaning that after some time, they cannot be found in the body), so they have the advantages of the mesh as they augment and reinforce the repair and they don’t have the disadvantage of synthetic mesh as they will be absorbed by your body. Even though they can be the best option for some patients (such as patients who previously had mesh and had complications from it), but the main disadvantage is that they may not last as long as synthetic mesh. Therefore, the decision to use biologic material should be individualized. (Author: Ali Azadi, November 2017)
What should I do if I have mesh complications?
The management of complications of mesh depends on various factors. Conservative treatments, partial removal of mesh, or complete removal of mesh can be considered. Sometimes pelvic pain and pain during intercourse can be managed conservatively by pain management and physical therapy. In cases that a tight band or bunched up mesh or nerve entrapment is the reason for pain, removal of the mesh or releasing the band can be considered.
In general, infected mesh needs to be removed as it can cause abscess. The infected mesh is a shelter for bacteria that cannot be easily treated with routine antibiotic therapy.
Management of mesh erosion can be different depending on each case. Small areas of erosion can be observed without any surgical intervention if the patient is asymptomatic. If patient has symptoms of bleeding and discharge, the small erosion can be trimmed at office or in the operating room. Larger areas of mesh erosion typically require removal of a bigger portion or the entire mesh.
In some cases, if the mesh sling is too tight which causes obstruction; it can be released without the need for extensive removal of the mesh.
Removal of the mesh requires experience and expertise in pelvic surgery due to close proximity of the mesh to vital organs such as bladder and bowel. Separating the mesh from adjacent tissues can be challenging as it feels like separating wet toilet paper from each other.
There will be less chance of damage and there will be higher chance of removal of mesh without having complications such as fistula if the surgeon is experienced with these types of surgeries. Some urogynecologists have the most experience and expertise in handling the mesh complications. (Author: Ali Azadi, November 2017)
I had prior mesh surgery and I have issues. What are my options? Does the mesh need to come out?
Unfortunately, some patients may experience problems after surgery with mesh. Depending on the symptoms, level of discomfort, patient’s age and findings during examination, management can be different.
Mesh erosions are the most common type of problems with these products. Small erosions can be managed conservatively in asymptomatic patients. Small erosions can be trimmed at the office or in the operating room. Larger areas of erosion usually require removal of a bigger portion of mesh or the entire mesh.
If mesh gets infected, typically removal is recommended. Antibiotic therapy is indicated but cannot solve the infection alone. The infected mesh can act as a shelter for bacteria and the antibiotic cannot reach the infection.
If mesh erodes to the adjacent organs such as urethra, bladder and bowel, surgical excision is typically indicated.
Pain after mesh can be managed differently depending on the presentation of symptoms and findings during examination. Conservative treatments with physical therapy and relaxation techniques are usually considered first line of treatment. If they fail, surgical excision can be considered. However, patient should be fully aware and be counseled extensively regarding risks, benefits and expectations from surgery. (Author: Ali Azadi, November 2017)
What should I do after mesh is removed? How am I going to deal with prolapse and incontinence?
Not everyone will have recurrence of the prolapse and incontinence after mesh is removed. Sometimes the scar tissue or the remaining portion of the mesh will do the work. However, if patient develops recurrence of the symptoms after mesh is removed, reconstructive surgery using natural/biologic tissue can be considered. We have experienced that patients who had problem with mesh in the past, are hesitant to have another surgery with the use of mesh. As it is the case for most situations, your best option depends on many factors. We will do our best to make sure you are informed and can make the best decision depending on your specific situation. (Author: Ali Azadi, November 2017)
Urinary Incontinence & Treatments:
What is urinary incontinence?
Urinary incontinence is a very common condition that can affect 1 in every 3-4 women in their lifetime. Urinary incontinence is involuntary loss of urine and it affects the quality of life. The affected women may wear pads and often time limit their activities due to the discomfort of urinary incontinence. Patients avoid engaging in physical activity and sexual relationship and often limit their presence in social events due to the fear of urinary incontinence. The consequences of urinary incontinence can be depression and interpersonal relationship difficulties as well as hygienic problems in the genital area.
Unfortunately, many women consider urinary incontinence to be a part of their normal life. Urinary incontinence can be common after pregnancy and childbirth. The first step is to realize that incontinence is not a part of normal life and help is available. Fortunately, there are many treatment options which are minimally invasive and non-invasive that can effectively solve the problem. (Author: Ali Azadi, November 2017)
What are the different types of urinary incontinence?
Involuntary leakage of urine can occur for many different reasons. For example, if the leakage of urine happens during physical activity, cough, sneeze or heavy lifting, it is called “stress urinary incontinence”.
Sometimes urinary leakage is involuntarily and is associated with strong urgency that is hard to defer. This kind of incontinence is called “urgency urinary incontinence”.
Stress and urgency urinary incontinence are the most common types of incontinence in women. However, there are other rare reasons that can cause urine leakage which should be considered.
In a patient who had prior pelvic surgery such as hysterectomy or TVT sling or history of mesh implant for treatment of prolapse, genitourinary fistula could be the cause of urinary incontinence. Depending on the location of the fistula, the presentation of incontinence would be different. For example, patients who develop vesicovaginal fistula after hysterectomy can have continuous leakage of urine from vagina.
History of gynecologic or pelvic cancer and radiation to pelvis can be a risk factor to develop fistula. Genitourinary malformations such as ectopic ureter can be the reason for urinary incontinence in rare cases.
In cases of neurogenic bladder, not only patient leaks with bladder contractions but also could have urinary incontinence from urine overflow.
In elderly patients with dementia, leakage from urine overflow is commonly seen.
Urethral diverticulum is also one of the reasons that patients may present with urinary incontinence. Urinary incontinence in the case of UTI can be seen in elderly women in the lack of typical symptoms.
In summary, urinary incontinence can be due to many different conditions. It is important that an accurate diagnosis is made since it can affect the treatment options. (Author: Ali Azadi, November 2017)
What is “stress urinary incontinence” and what are the treatment options?
“Stress urinary incontinence” is involuntary loss of urine that can happen with physical activity, lifting, bending over, cough, sneeze or intercourse. In general, any activity that increases the intra-abdominal pressure and causes pressure on bladder may cause leakage of urine. Patients can be affected with different severity. While it can happen to some women with extreme heavy physical activity such as running and lifting heavy weights at gym, for others with severe problem, urinary incontinence can occur with even mild activities such as walking, changing position from sitting to standing and even rolling over while asleep. Stress urinary incontinence is the most common type of urinary incontinence in women and it can affect 1 in every 4 women in their lifetime. It is mostly common in 4th and 5th decades of life and commonly can be seen after pregnancy and vaginal delivery. Instrumental delivery with vacuum or forceps in particular can increase the chance of stress urinary incontinence. Simply, if there is any change to the sphincter system at the urethra, the pressure increase in bladder can cause leakage of urine.
Stress urinary incontinence can be a frustrating situation for women. Many patients report that they limit their physical activity such as avoiding going to gym or running or even avoid sexual relationship due to the fear of urinary incontinence. Therefore, it can cause depression and anxiety.
In most cases, the first step for treatment is pelvic floor physical therapy and Kegel exercises. By strengthening the pelvic floor muscles, there will be an increase in resistance to the leakage of urine.
Some pessaries and tampons can also help by stabilizing the urethra. There are various surgical treatments that can significantly improve the condition. Procedures such as transurethral bulking injection which can be performed at the office as well as various surgical treatments such as slings, Burch colposuspension, and bladder neck suspensions are well studied and have shown safety with high success rates. (Author: Ali Azadi, November 2017)
What is “urgency urinary incontinence” and what are the treatment options?
“Urgency urinary incontinence” occurs when a patient notices a very strong urge to void but cannot wait and make it to the bathroom. Urinary incontinence with urgency is often associated with overactive bladder and urinary frequency. In a normal situation, we should notice the urinary urge gradually. First we notice that the bladder starts to get full and then gradually the urge gets stronger. So, in normal situation, we don’t have to go to bathroom the moment we feel the urge. For example, when we watch TV or we are outside shopping, this urge gradually increases and most people don’t have to interrupt their task to use the restroom. In a patient who has urgency urinary incontinence, the urge is sudden and very strong and patient cannot control it; therefore, urinary incontinence happens. It can be leakage of few drops or associated with completely emptying the bladder. Many times, patient notices that even though she has emptied her bladder, there are still dribbles afterward. In some other cases, urinary incontinence occurs without any warnings. Even though it is called urgency urinary incontinence, patient may not notice the urge and be unaware of the incontinence except noticing that there is moisture in the underwear or the pad gets wet. Urgency urinary incontinence is mostly associated with overactive bladder; therefore, in some patients, it can be managed with diet modifications or certain medications. There is also a role for improvement with physical therapy.
If the initial interventions do not work, advanced treatment such as bladder botox injection or sacral neuromodulation (InterStim®) therapy can be considered. Both methods are known to have high success rates and efficacy. Evaluation for the urgency urinary incontinence include a specialized pelvic exam for evaluation of the prolapsed bladder, a simple urine test to rule out urinary tract infections and in some cases, urodynamics and office cystoscopy.
In patients with a history of smoking or patients with history of bladder malignancies or mesh surgery, cystoscopy can be very valuable as it can detect bladder lesions and tumors. (Author: Ali Azadi, November 2017)
What are the non-surgical treatments for urinary incontinence?
The treatment for urinary incontinence can vary based on the reason and type of incontinence. Stress urinary incontinence can be improved with pelvic floor exercises. Many patients manage their symptoms by time voiding; for example, they empty the bladder prior to engaging in physical activity or intercourse. There are devices such as pessaries or tampons that can prevent the leakage by stabilizing and blocking the urethra. It is generally recommended to consider conservative treatments prior to surgical intervention.
On the other hand, urgency urinary incontinence can be improved by diet modification such as avoiding caffeine, carbonated beverages, and bladder irritants. Behavioral therapy and pelvic floor exercises are used to improve urinary incontinence.
If the urinary incontinence is due to overflow, timed catheterization can decrease the amount of incontinence. (Author: Ali Azadi, November 2017)
What is the role of pelvic floor physical therapy in the treatment of urinary incontinence?
Pelvic floor strengthening can be done by simple Kegel exercises. It can be performed by the patient at her home. However, we know that when patients are asked to do Kegel exercises, up to half of them use the wrong muscles and cannot do it correctly. Many use abdominal muscles during exercise. Pelvic floor physical therapists have special training to teach the patient to do these tasks correctly. It is similar to going to the gym with trainer and we all know that the results can be much better in that case.
During the initial evaluation and examination, we will assess your muscle strength and will monitor the improvements overtime. If performed correctly, pelvic floor physical therapy can be an integral part of treatment for urinary incontinence. (Author: Ali Azadi, November 2017)
What is the best surgery for treatment of stress urinary incontinence?
There are different surgical approaches to manage stress urinary incontinence. These surgical treatments are commonly invasive. There are procedures such as pubovaginal sling using fascia and Burch colposuspension that are more traditional. These are safe procedures that have been done for many years and are very well studied. The advantage of these surgeries is that there are no mesh material used. Burch colposuspension can be done in a minimally invasive fashion using laparoscopic approach. Basically, in this approach, the periurethral tissue is stabilized by being sutured to the patient’s ligaments.
The pattern of surgery for stress urinary incontinence has changed since mid 1990’s when mid-urethral slings were introduced. These are tapes made of polypropylene mesh that are surgically placed through small vaginal incisions to support the urethra. Due to being less invasive and excellent patient’s outcome, they have became very popular. There are thousands and thousands of patients undergoing mid-urethral slings for stress urinary incontinence each year. Even though in recent years, there has been a negative image of the mesh slings, mostly created by media as result of some law suits, in the eyes of medical societies and experts, these products are considered the standard of care for most women with stress urinary incontinence. Even though it is hard to call a procedure “standard of care,” slings have many advantages. They have shown excellent long term outcome, low complications, rapid return to work, and minimally invasive which makes them the first choice for many patients.
It is important to note that it is extremely critical to count factors such as experience and personal outcome of physician, correct patient selection and complete evaluation of incontinence into account when we want to consider surgical treatment.
There are various types of slings such as TVT, transobturator tapes and single incision slings. It is important to use the right product for each patient.
Transurethral bulking is also another method of treatment for stress urinary incontinence. This procedure can be done without any incision and even at the office under light anesthesia. The urethra will be injected with bulking materials to have better support. This can be done through a cystoscope without having any incisions.
We strongly believe that your surgeon should have competency in all the surgical approaches so ultimately the best procedure is chosen based on each patient’s desires and characteristics. (Author: Ali Azadi, November 2017)
Do I have to use mesh for surgical treatment of urinary incontinence?
Even though mid-urethral slings, as the most common surgical treatment, are made of mesh, there are a variety of surgical procedures that can effectively manage urinary incontinence without using mesh. Biologic materials such as fascia can be used instead of synthetic mesh. Burch colposuspension, which can be done laparoscopically or with the use of da Vinci® robot, is a very effective surgical method that can fix urinary incontinence. The periurethral vaginal tissue will be sutured to Cooper’s Ligaments and by stabilizing the urethra, incontinence will be improved. There are other surgical methods such as MMK and transurethral bulking that can be done to improve urinary incontinence without use of mesh.
While synthetic polypropylene mesh slings can be beneficial in improving urinary incontinence and often is considered as standard of care, it is important for patients to know that they have other options. Every person is different and the best procedure depends on many factors. For example, patients who previously had complications with mesh, may choose to have natural tissue repair. Urodynamic test findings in addition to many patient characteristics usually are considered in counseling a patient regarding the best treatment option specifically for her condition. (Author: Ali Azadi, November 2017)
Can I have all natural tissue repair for my for prolapse and incontinence surgery?
It is possible to use biologic grafts for reconstructive pelvic surgery for prolapse and incontinence. The main advantage of biologic material is that over time, they will incorporate to the patients’ own tissue. Therefore, some of the complications of synthetic mesh such as erosion and shrinkage is less common with biologic materials. Examples of biologic materials include patient’s own fascia (harvested from leg or abdominal wall), cadaveric fascia, animal tissue such as pig skin, and cow intestines.
The patient’s own tissue is harvested from other parts of body and will be re-implanted in pelvis. The advantage is that there is less chance of rejection by the body. Cadaveric and animal tissues are commercially available after extensive process of cell destruction and sterilization. The chance of acquiring infection is extremely low.
When a patient decides to have biologic grafts, the following factors should be considered. These products can result in reinforcing the tissue without having some of the complications of synthetic mesh but they may require more extensive surgery as harvesting processing may be involved. The clinical trials that have compared these products to synthetic mesh have shown lower long term efficacy.
While they are the best option for many patients, the risks and benefits should be individualized and factors such as long term success needs to be considered. (Author: Ali Azadi, November 2017)
What is Burch procedure? What are the risks and benefits of Burch procedure?
The Burch procedure or colposuspension has been done for many decades for management of stress urinary incontinence. This procedure has been very well studied and long term outcome is available, which indicates its high efficacy and safety.
Traditionally, it was done by making a small horizontal low abdominal incision and suturing the vaginal tissue surrounding urethra to the Cooper’s ligaments that is located in the inner side of pelvis.
By stabilizing the urethra, stress urinary incontinence will be improved. With the advancement of minimally invasive surgical procedures, Burch colposuspension is done through laparoscopic or da Vinci® approach. Therefore, the main advantage will be correcting the incontinence without the use of graft with making only small incision in the abdomen. Particularly, if a patient undergoes hysterectomy at the same time, these small incisions for hysterectomy can be used for Burch procedure.
Entry to the abdomen and possible injury to the intra-abdominal organs are among the risks of this procedure. Some studies comparing the slings to Burch procedure have shown slight lower chance of long term success with Burch. In some cases, Burch colposuspension should be offered to patients since the advantages can make it the best treatment for them.
Burch colposuspension requires high level of laparoscopic skills which may require extensive training. (Author: Ali Azadi, November 2017)
What is pubovaginal sling? What are the risks and benefits of pubovaginal slings?
Pubovaginal slings can effectively improve stress urinary incontinence. They are one of the oldest methods for treatment of bladder leakage. There are studies that have shown high success rates and low complications of these surgeries. They are different from mid-urethral slings in some aspects. The material used for these slings are mostly patient’s own fascia or other biologic materials; therefore, mesh is not typically used for these slings. They are surgically placed in bladder neck as opposed to mid-urethral portion. They work very well but can be more obstructive to bladder. Since these slings require incision in the abdomen, they are used less than mid-urethral slings.
Despite more invasive nature of these procedures, they can be an excellent option for many patients. In particular, the patients who had complications and mesh removal and dealing with incontinence may benefit from these slings. (Author: Ali Azadi, November 2017)
What is transurethral bulking injection? What are the risks and benefits of transurethral bulking injection?
Transurethral bulking agents are the least invasive surgical intervention for treatment of stress urinary incontinence. They can be done with the use of cystoscope without making any incision. Therefore, they can be done at the office and the recovery time is minimal.
This method may not be the best option for everyone. Compared to other treatment options, they may have lower efficacy. Overtime, the effect of these treatments decrease, and about half of the patients may require additional injections in the future.
If a patient is found to be a good candidate for this treatment, it can be considered as an option (almost an option between conservative treatment and surgical intervention). Urodynamic testing may show some of the characteristics of the patient’s urethral function that qualifies patient for this treatment.
Transurethral bulking injection could be considered as an excellent option for those who do not like to use mesh, or patients with prior complications from mesh, or elderly patients that require the least invasive treatment option.
With the use of cystoscope, through the urethra, bulking materials can be injected which will increase the resistance to the urethra.
There are different injection materials commercially available. Examples include Coaptite® (calcium based material) and Macroplastique®. (Author: Ali Azadi, November 2017)
I had prior surgery for incontinence and it did not work. What are my options now?
Going through surgery and still having urinary incontinence can be very disappointing. Sometimes the surgery works for a while and then incontinence starts again and sometimes the surgery does not do the job. Even though, satisfaction rate can be as high as more than 90%, there are some women that feel frustrated after surgery due to lack of reaching their expectations.
The good news is that there are still options available. The first step is to evaluate the reason for incontinence. If urinary incontinence is in the form of stress incontinence, another type of sling or bulking injection can be considered. However, in most cases, after sling, the urgency urinary incontinence can be the reason for leakage of urine. It is known that urgency urinary incontinence can develop after slings for stress incontinence. Sometimes, simple treatments such as medical therapy can control the symptoms. If not successful, advanced therapies such as nerve stimulation or botox can be helpful. It is important to ensure that urinary retention and overflow incontinence is not the reason for leakage of urine.
Often times, urodynamic testing can be valuable in determining the reason for incontinence in a patient who had prior surgery for incontinence.
It is worth mentioning that urgency urinary incontinence and worsening of overactive bladder can be seen in short-term during post-operative period. Most of the time, no intervention is necessary, as long as there is no obstruction from the procedure and urinary tract infection does not exist. Most patients will notice resolution of the symptoms in a few weeks. (Author: Ali Azadi, November 2017)
Recovery & Post Operative Restrictions
What is the downtime for prolapse and incontinence surgery?
Advancement in minimally invasive surgeries allows rapid healing and quick return to work. After extensive reconstructive pelvic surgery, patients typically do not need to stay at the hospital for more than one night. For majority of surgeries, patients will be able to be discharged and go home the day of surgery. Avoiding large abdominal incision allows the patients to resume normal activities quickly.
It is important for the patient to know that even though she feels that she is able to resume normal activities, she needs to avoid heavy physical activities for a few weeks after surgery to allow time for proper healing. It might not be possible to make an exact statement but it is generally recommended that patients avoid heavy lifting, strenuous exercises and intercourse for 4-6 weeks after the surgery. It is important to note that many activities such as driving and walking can be resumed a few days after surgery. Compliance with post-operative restrictions is very important in order to obtain long term success. (Author: Ali Azadi, November 2017)
What are my post-operative restrictions?
Post-op restrictions will be specifically discussed with you as they are different with each procedure and it may vary depending on your medical conditions.
In general, for most vaginal and laparoscopic or robotic surgeries, we recommend pelvic rest for 4-6 weeks. This includes avoiding intercourse or any type of vaginal insertion. Walking is encouraged, even on the day of surgery.
If you have incisions in the vagina or abdomen, we recommend avoiding bathtub or soaking in the water. Taking shower is Ok, even on the same day after your surgery.
We recommend avoiding heavy lifting and strenuous exercises for most major surgical procedures.
It is generally recommended to avoid working with machinery and driving for a week after surgery or during the time you are taking narcotics after surgery. Many patients return to their desk job within 4-5 days after surgery. For jobs that require physical activity, this time could be 1-3 months.
Your post-op instructions will be discussed with you specifically according to the type of surgery that you had as well as consideration of your general health, your age and level of physical activities. (Author: Ali Azadi, November 2017)
Do I need to restrict my activities after pelvic surgery?
Most patients can resume all activities with no restrictions within 3 months after surgery. We know that majority of the healing and scar formation will happen during the 2-3 months after the surgery. Heavy lifting which is a risk factor for developing prolapse can cause recurrence of prolapse. Regardless, it may not be possible for patients to change their lifestyle; therefore, when it comes to surgery option, future physical activities should be considered. Procedures with higher success rates might be the ideal option for younger patients with more physical activities. (Author: Ali Azadi, November 2017)
What kind of pain management will I have after prolapse and incontinence surgery?
Another advantage of minimally invasive approach for treatment of prolapse and incontinence is that there is minimal need for prolonged pain management. Even though, patients may require few days of narcotics, many patients report adequate pain management with the use of non-narcotic pain medications such as ibuprofen or acetaminophen. Pain management strategy after surgery is individualized. Some patients have painful conditions such as chronic pain syndrome including interstitial cystitis or fibromyalgia; therefore, these patients may require more aggressive pain management. While proper pain control is the goal, adjusting the dose is critical to avoid complications such as constipation which may delay recovery.
Post-operative pain management is a key element that needs to be discussed in advance. Our goal is to develop an individualized strategy while considering the type of surgery and patient’s characteristics which are key factors in pre-operative counseling. (Author: Ali Azadi, November 2017)
Overactive Bladder & Treatments
What is overactive bladder?
Overactive bladder (OAB) is a very common condition that affects millions of women. It can affect up to 1 in every 3 women. The symptoms include urinary urgency, frequency, or waking up at night that interferes with sleep. The urinary urgency and frequency can affect the patient’s quality of life and cause significant disruption of daily activities. Patients often have to interrupt their daily tasks to go to the bathroom. Many patients avoid social events and sexual activities due to the fear of urinating and need to use the restroom. These symptoms can cause frustration, anxiety and depression. (Author: Ali Azadi, November 2017)
What are the treatment options for overactive bladder?
Fortunately, there are many treatments available to manage symptoms of overactive bladder. Generally, conservative treatments are the first line options. Avoiding bladder irritant such as carbonated sodas and caffeine can improve symptoms. Many patients notice improvement of symptoms with bladder retraining.
If the patient remains symptomatic, medications can be prescribed. There are different medications available that can manage overactive bladder. If the patient does not want to take medication for long term, develops side effects, symptoms are not controlled, or there is a contraindication to the medications, advanced therapies such as bladder Botox® injection and InterStim® therapy can be considered.
Advanced therapies allow resolution of symptoms with higher efficacy. American Urology Association (AUA) has guidelines for management of overactive bladder. The ideal treatment for each patient depends on different factors. Complete evaluation and consideration of all the co-morbidities are essential in choosing the best treatment option available. (Author: Ali Azadi, November 2017)
What is the role of diet in managing overactive bladder symptoms?
Healthy diet is very important in managing overactive bladder. It is a key factor and often the first step in management of overactive bladder symptoms. Certain chemicals in foods and drinks can irritate the bladder mucosa, which is the inner layer of bladder. Urgency and frequency will be decreased when minimizing or eliminating the irritants from diet. Decreasing caffeine and alcohol intake and other bladder irritants can make a difference. Many patients report resolution of their symptoms with modifying their diet. (Author: Ali Azadi, November 2017)
I have tried medications for overactive bladder and continue to have symptoms. What are the advanced treatments for overactive bladder?
Even though medication therapy is often considered in the initial steps of management of overactive bladder, many patients are considered a good candidate for advanced treatments. Low efficacy, long term adherence, medication side effects and cost are among reasons that up to 50% of patients may search and choose an alternative treatment. Advanced therapies such as intravesical Botox® injection and InterStim® therapy are a good solution for the refractory cases of overactive bladder. (Author: Ali Azadi, November 2017)
What is Botox® for bladder?
Botox® injection to the bladder lining is known to be an effective method of treatment for overactive bladder and urinary incontinence. The procedure uses cystoscope and onabotulinum toxin A is injected to the bladder muscle with the use of a small lighted tube. The toxin is extracted from bacteria and is commercially available. Botox® will relax the muscles (similar to its effect for treatment of wrinkles), which eliminates bladder contractions and helps with urinary urgency, frequency and incontinence. The procedure is performed at the office and it takes less than an hour to complete. (Author: Ali Azadi, November 2017)
What are the advantages of Botox® for overactive bladder and incontinence?
Botox® injection for treatment of overactive bladder is very effective. There are many studies that have shown higher efficacy when compared to medications. Injection can be done in a fairly easy setting. Most patients receive it through an office procedure that takes only a few minutes. The procedure does not require heavy sedation or any incision; therefore, patients can resume their normal activities on the day of procedure. The injection typically works for 4-6 months. (Author: Ali Azadi, November 2017)
What are some of the contraindications for bladder Botox® injection?
Botox® injection is an excellent treatment for overactive bladder, but not every patient is a candidate for it. The bladder muscle receptors will be blocked by this treatment which can cause a small percentage of patients to develop incomplete bladder emptying or urinary retention after Botox® injection. Normally this side effect will be resolved in 4-6 months, but there might be a need for self-catheterization during this period. If a patient does not want to take that risk or is not able to do self-catheterization, the alternative treatments should be considered. Due to difficulty with emptying the bladder, the risk of urinary tract infection may be increased. Patients with chronic UTIs, may not be the best candidates for Botox®. Certain neurological diseases such as guillain barre and myasthenia gravis are considered a contraindication to Botox® injection. (Author: Ali Azadi, November 2017)
What is the nerve stimulation for bladder (InterStim® therapy)?
Sacral neuromodulation (InterStim® therapy) is an advanced novel treatment for management of many pelvic floor disorders such as urinary urgency, frequency, nocturia, urinary incontinence, incomplete bladder emptying (retention) and fecal incontinence. This therapy was introduced about 20 years ago and has evolved. It is basically like a “pacemaker” for bladder and bowel. It works by stimulating the pelvic nerves (third sacral nerve root). The electrical stimulation will be transferred to brain and through a complex mechanism the function of pelvic nerves will be improved. The pacemaker is implanted in an outpatient procedure. (Author: Ali Azadi, November 2017)
What are the advantages of sacral neuromodulation (InterStim® therapy)?
Sacral neuromodulation (InterStim® therapy) works similar to a pacemaker. Therefore, it improves the function of the bladder and bowel through modulating the nerves. InterStim® therapy is in contrast to other treatments that suppresses the function of organs. For example, medical therapy and Botox® treatments control the bladder symptoms such as urgency and frequency by suppressing the activity of the bladder muscles and decrease the sensation. Even though, the symptoms will be controlled, difficulty in emptying the bladder may be encountered.
Some of the side effects of traditional treatments will not be seen with InterStim® therapy. This can be advantageous for patients with overactive bladder who also has constipation and memory loss.
Medical treatment typically has some suppressing effects on other organs and as a result will cause worsening of constipation and memory loss. With InterStim® therapy, there is no chemical used; therefore, the patients do not experience the side effects or interaction with other medications seen with other therapies
Prior to the implantation, there will be a test to ensure the patient will respond to the treatment. Physicians and patients find this aspect very helpful. As opposed to most medical treatments and surgical treatments, patient has the luxury to experience the treatment prior to making any decisions. Since the battery life is long (3-8 years in most patients), long term effect is another benefit of sacral neuromodulation. (Author: Ali Azadi, November 2017)
What is involved with InterStim® therapy?
After a complete evaluation by your physician and failed conservative treatments, you may be considered to be a candidate for InterStim® therapy. We will discuss the treatment, the risks and benefits in depth with you. If you decide to proceed with the InterStim® therapy, we will test your nerves to make sure that your body will respond to the treatment prior to the implant.
There are 2 ways to be tested for this therapy: office test or test in the operating room. The office test is commonly known as PNE (percutaneous nerve stimulation) which is done at the office. After injection of local anesthetic, a small lead which is the size of a guitar string will be located next to S3 nerve root via insertion through sacrum. Then it will be connected to a temporary pacemaker that the patient carries externally for 3-5 days. During this time, patient will have an opportunity to evaluate her response to treatment. She will be asked to document the frequency of urination and note the number of episodes of incontinence. By comparing the log before and after treatment, we will have a tool to evaluate the response to treatment. The goal for success is more than 50% improvement but ultimately, the patient’s experience allows her to evaluate the effects of the treatment. This procedure is well tolerated at office and patient can return to normal activity the day of the test.
The operating room test (stage 1) has the same test concept but it is different as it is typically performed in the operating room. The actual lead will be implanted under the guidance of an X-ray. With this method, there is more accuracy in placement of the lead and it can be ensured that the desired part of the nerve is stimulated. Additionally, it has the advantage of longer evaluation time. The test can be prolonged for 2 weeks. This is beneficial for incomplete bladder emptying and fecal incontinence which may require longer evaluation period.
If you respond positively to the test and wish to have the treatment, then the actual pacemaker will be implanted underneath the skin over the buttock area. The incision is very small, only 3-4 cm, and patient can leave the hospital shortly after surgery. (Author: Ali Azadi, November 2017)
Who would be a good candidate for InterStim® therapy?
InterStim® therapy is approved by FDA for refractory overactive bladder, urgency urinary incontinence, non-obstructive incomplete bladder emptying and fecal incontinence.
Patients with refractory overactive bladder and symptoms of urinary urgency, frequency and urgency urinary incontinence, who have tried conservative treatments and medical therapy are good candidates for InterStim® therapy. If medical therapy, due to side effects, is contraindicated, InterStim® therapy could be considered. Many times, overactive bladder is associated with co-morbidities such as constipation and difficulty emptying the bladder. In these cases, InterStim® therapy has obvious advantages. If a patient suffers from incomplete bladder emptying (urinary retention) without having any obstruction, InterStim® therapy would be an excellent choice.
A complete evaluation of urinary system would be helpful to identify the best candidates. This therapy can be life changing for candidates with incomplete bladder emptying since the alternative InterStim® therapy is self-catheterization.
Ultimately, InterStim® therapy has revolutionized the treatment of fecal incontinence. While the alternative treatments can be painful and have low success rates with many complications, InterStim® therapy has offered a minimally invasive and effective treatment option. Patients with fecal incontinence, who have been treated with InterStim® therapy, are often amazed with the change in their quality of life. A comprehensive evaluation of fecal incontinence such as a rectovaginal exam and some tests such as manometry, ultrasound and colonoscopy can be used to identify if the patient is a good candidate for treatment. Prior to InterStim® therapy, it is essential to have conservative therapy and diet modification.
Besides the approved indications by FDA, there are other conditions that this treatment can be used successfully. Constipation has been an indication for this treatment outside of the US. It has also been used for indications such as sexual dysfunction and pelvic pain syndromes. (Author: Ali Azadi, November 2017)
What are some of contraindications to InterStim® therapy?
MRI of abdomen and pelvis is contraindicated in patients with InterStim® implant. This is mainly due to the heat effects from magnetic radiation in the presence of the metal implant. However, it is important to know that patients can safely have MRI of brain and other parts of the body. They can also safely have CT scan for the abdomen and pelvis if imaging is indicated.
Implantation of the pacemaker requires some type of anesthesia (local or general). It is essential to ensure that the patient will be evaluated for safety of these interventions.
InterStim® cannot be implanted in an area of the body with an active skin infection or cellulitis. Patients with are a risk of infection, proper broad spectrum antibiotics is required to minimize the risk.
The treatment manual provided by Medtronic is a good source of information for all the consideration of this treatment. (Author: Ali Azadi, November 2017)
Am I a candidate for Botox® or InterStim®? Which one is better for me?
Both bladder Botox® and InterStim® therapy are excellent treatment options. Each of these treatment options have advantages and disadvantages. In order to obtain the best treatment results, proper patient selection is the key. Patient characteristics such as age, severity of symptoms, level of physical activity, prior treatments, other medical conditions and co-morbidities should be considered. Tests such as urodynamics and cystoscopy will provide additional information about the bladder that makes one treatment superior to the other. (Author: Ali Azadi, November 2017)
Interstitial Cystitis (IC):
What is interstitial cystitis (IC)?
Interstitial cystitis, commonly known as IC is a frustrating condition of the bladder that can affect women. It is diagnosed when the patient has chronic urinary urgency and frequency, as well as bladder/pelvic pain without having UTI. It is a mysterious disease as it can have different presentation and it can affect patients in different severity. We also use the term “Painful Bladder Syndrome” which implies the variation in the symptoms.
This condition is very common among middle aged women. In fact, as the severity of disease can have a wide variation, many patients with this condition have missed diagnosis. Since the symptoms can be similar to UTI, the patient usually has multiple urine tests and many urgent care visits before they are officially diagnosed with interstitial cystitis. Some patients present with symptoms of urgency and frequency while in others pain is the prominent symptom.
There are different theories regarding the pathophysiology of interstitial cystitis. There is evidence that it can be linked to irritation of the bladder lining by allergens and environmental factors. (Author: Ali Azadi, November 2017)
How should I manage my interstitial cystitis (IC)?
There are many treatment options available that can manage symptoms and discomfort of interstitial cystitis. The challenge for many patients is to have their diagnosis confirmed. There is frustration due to frequent urine tests to check for UTI and investigate hematuria (blood in urine) since it can be one of the presentations of the IC.
American Urology Association (AUA) has guidelines and recommendations regarding different steps to manage interstitial cystitis.
The initial steps of treatment include diet modification and avoiding bladder irritants. A variety of medical therapies, pain control techniques and managements such as physical therapy are available to decrease the pain. Instillation of the medications to the bladder in order to locally control the disease can also be considered. Ultimately, if the symptoms cannot be controlled with initial management, advanced techniques such as bladder Botox® and InterStim® therapy can be considered.
The best management for interstitial cystitis is to develop a system and use all the available sources as needed. (Author: Ali Azadi, November 2017)
Pain with Intercourse:
I have pain with intercourse. What could be wrong?
Pain with intercourse (dyspareunia) can be due to various reasons. Based on the reason for pain, the management will be different. In many cases, the pain with intercourse is caused by pelvic floor muscle spasm (Levator Myalgia). In this case, relaxation techniques and pelvic floor physical therapy can be helpful.
In patients with prior pelvic surgery, especially when mesh is used, scar tissue can be the cause of pain. Depending on the results of examination, treatment will be different.
There are a variety of gynecological reasons such as endometriosis that can cause pelvic pain and dyspareunia. Interstitial cystitis can also be a reason for pain, particularly when there is association with bladder symptoms.
Vaginal dryness due to menopause or decrease in hormone levels can cause discomfort during intercourse. Various treatment options are available to improve this condition.
In summary, finding the reason for pelvic pain and dyspareunia is the most important step which can be challenging. A detailed pelvic examination and assistance of imaging such as pelvic ultrasound or CT scan, as well as diagnostic tests such as cystoscopy can be helpful to find the etiology of pelvic pain. (Author: Ali Azadi, November 2017)
What are the treatment options for pain during intercourse?
Pelvic floor physical therapy can relax the pelvic muscles and often is considered as the initial step. The result is always better with a motivated patient and a skilled physical therapist. If the pain is due to mesh, there might be improvement with excision or releasing the scar tissue. If the pain is due to nerve entrapment, which typically is known by having special pattern, it might get better by surgical intervention and releasing the entrapped nerve. In case the pain is due to endometriosis, medical therapy and surgical excision can be considered. (Author: Ali Azadi, November 2017)
Can my decreased libido be associated with prolapse, incontinence or overactive bladder?
A variety of pelvic floor disorders can cause discomfort in the pelvis and as a result, they can affect sexual desire indirectly. Changes in anatomy and discomfort from urinary symptoms can affect the desire for intimacy. There are many studies that have shown improvement in sexual function after treatments to resolve pelvic organ prolapse and urinary incontinence. Some of the treatments include local application of hormones, laser therapy, or surgical options. (Author: Ali Azadi, November 2017)
Fecal Incontinence & Constipation:
What is fecal incontinence?
Fecal incontinence is the involuntary leakage of stool. It is very common but unfortunately, is ignored in many cases. Patients may hide it since they feel embarrassed to discuss this condition. It can cause significant negative impact on patient’s social life. Unfortunately, even mild disease can cause significant discomfort, as patients tend to avoid social events and personal relationships due to fear of fecal incontinence.
Fecal incontinence can be caused by different etiologies. Anal sphincter damage after vaginal delivery can be a reason to have fecal incontinence. Nerve damage after traumatic delivery or with aging can cause fecal incontinence. If you are suffering from fecal incontinence, please discuss it with us, as there are many options available. There is no reason to suffer! (Author: Ali Azadi, November 2017)
What are the diagnostic tests for evaluation of fecal incontinence?
It is important to consider the reasons that may result in fecal incontinence. GI diseases such as ulcerative colitis and Crohn’s disease can be investigated by colonoscopy. Fistulas are rare causes of incontinence but it is important to keep them in the differential diagnosis list. Anal sphincter function and anatomy can be evaluated by office tests such as manometry and ultrasound. There are also imaging such as defecogram or MRI that can evaluate the function and anatomy of colon. (Author: Ali Azadi, November 2017)
What are the treatment options for fecal incontinence?
There are novel treatments available that have changed the management of fecal incontinence over the past decade. The initial step is to identify the reason for incontinence. Increasing fiber intake and modifying diet in order to have formed stool texture is very important. Regardless of the etiology of the fecal incontinence, there will be less leakage with formed stool. Avoiding bowel irritants such as caffeine can be helpful. If there is damage or disruption of the anal sphincter, surgical correction (sphincteroplasty) can be helpful.
In case of rectal prolapse, a surgery to stabilize the rectum (Rectopexy) is required to help with the incontinence. Bulking injection to the rectum is a novel treatment for fecal incontinence in selected patients.
Ultimately, Sacral Neuromodulation (InterStim® therapy) has changed the management of fecal incontinence by offering a minimally invasive method to improve the function of pelvic nerves and muscle tone. The ability to do the test at office provides a great advantage with this treatment. (Author: Ali Azadi, November 2017)
What can I do to manage constipation?
Constipation is a very common condition in the United States and is associated with many pelvic floor disorders. Optimal management of constipation is a key factor and increases success of other therapies in pelvic floor disorders. Unfortunately, American fast food diet is a risk factor for constipation. Adequate hydration and increase intake of vegetables and fibers are the most important interventions to manage constipation. Adding fiber bars that are commercially available provides a good source of fiber.
There are a variety of stool softeners available over the counter that can increase the frequency of bowel movement and will soften the stool. (Author: Ali Azadi, November 2017)
How can I increase my fiber intake?
Grains, vegetables and cereals in diet will increase fiber intake. As the amount of fiber varies in each product, it is important to be aware of the grams of fiber in each product. (Author: Ali Azadi, November 2017)
See the chart listing high fiber foods on the link below.
What is the role of laser treatment for pelvic floor disorders?
Laser treatment to the vulva and vagina has been available as an alternative treatment to help with vaginal atrophy and urinary incontinence. Even though, there is no long-term data available, short-term data support their efficacy and safety. It can be an alternative treatment to the use of local hormone. Typically, the treatment is offered in a few short office sessions. Treatment works by allowing the collagen and soft tissue to remodel. In addition to cosmetic results, some studies show improvement in urinary symptoms and urinary incontinence. (Author: Ali Azadi, November 2017)
I get frequent UTIs. How can I prevent them?
Frequent urinary tract infection is frustrating and can cause discomfort for the patient. It is more common after menopause due to the decrease in the hormone levels. Due to the thinning of tissue and decreased resistance to the bacteria, infection can easily reach the bladder. These bacteria usually originate from anus area.
Use of local estrogen is commonly recommended for post-menopausal women who suffer from recurrent UTIs. It is important to know that systemic hormones such as pills and patches do not have the same efficacy as local estrogen.
Adequate hydration may help as it will increase the frequency of urination. We always recommend patients to have good perineal hygiene. Always try to clean after urination and bowel movements with a moist tissue from front to back (from urethra to anus), as the opposite will transfer bacteria to the opening of the urethra.
Cranberry products as well as some medications may change the chemical characteristic of urine or block the receptors that are known to decrease chances of developing UTI. For patients who suffer from recurrent UTIs, a work up of genitourinary system could be helpful to rule out reversible causes such as stones, mesh erosion, foreign body and anatomical abnormalities that predispose a patient to UTI.
It is important to make sure that bladder adequately empties. Urinary retention or inability to empty the bladder is a reversible cause of UTI. If urine stays in the bladder, the bacteria will have a chance to grow! Prophylactic antibiotics at low dose for prolonged time might be necessary to decrease the chances of UTI. Overall, it is very frustrating to deal with recurrent UTIs and it is important to know that a combination of interventions are necessary, as each attack the problem from a different angle. (Author: Ali Azadi, November 2017)
When my urine is tested, it shows blood. What should I do?
American Urology Association (AUA) has guidelines for evaluation of blood in the urine. Full evaluation of urinary tract (kidneys, ureters, bladder and urethra) is necessary to rule out malignancies. The full evaluation usually includes imaging of GU system with a special CT scan, cystoscopy and urine cytology. There are many benign conditions such as UTI and interstitial cystitis that can cause blood in the urine. The evaluation should be individualized for each patient. (Author: Ali Azadi, November 2017)
What can I do for vaginal dryness?
Vaginal dryness is associated with low levels of hormones that is due to menopause. There are different products such as vaginal creams, vaginal tablets and rings that can be used locally to help with vaginal atrophy and dryness. It is important to note that systemic hormone replacement such as oral pills or patches do not have the same effect on vaginal tissue.
For patients who do not wish to use hormones, other methods such as laser therapy and radiofrequency treatment can improve vaginal tissue. The best method for each patient and risks and benefits should be discussed considering the goals, symptoms and all the co-morbidities. (Author: Ali Azadi, November 2017)
What is urethral diverticulum? What is the treatment of urethral diverticulum?
Urethral diverticulum is an outpouch of the urethra that presents itself as a vaginal cyst. It can cause vaginal pain, discomfort with urination and urinary incontinence. It can also present with recurrent UTIs. Diagnosis of urethral diverticulum requires a careful examination and keeping the diagnosis in mind when a vaginal cyst is encountered. Cystourethroscopy and MRI of the pelvis can confirm the diagnosis.
The treatment is surgical excision. Surgical expertise is needed for excision of urethral diverticulum in order to preserve the urethra as much as possible. The goal of surgery is to remove the diverticulum with minimal damage to the urethra and peri-urethral tissue that are responsible for continence. (Author: Ali Azadi, November 2017)
How maternal pelvic floor trauma occurs during delivery?
See the link below for information on this topic.