Frequently Asked Questions in Urogynecology
What is a Urogynecologist?
A urogynecologist and reconstructive pelvic surgeon is a doctor who has special training in caring for women with pelvic floor disorders.
Typically, a urogynecologist has completed a four-year residency in Obstetrics and Gynecology. This is followed by additional training in the evaluation and treatment of conditions that affect the support and function of the female pelvic organs and pelvic floor. The urogynecologists at OHSU are all board-certified and have completed two-to-three additional years of specialty training in managing pelvic floor dysfunction. Our doctors can offer both surgical and non-surgical treatment options to resolve your gynecologic problems.
What is the pelvic floor?
The pelvic floor refers to the muscles, ligaments, connective tissue and nerves that help support and control the functioning of your bladder, uterus, vagina and rectum.
Loss of support may lead to loss of bladder or bowel control, difficulty emptying your bladder or bowels and downward falling or bulging of your pelvic organs. Your pelvic floor can be affected by many things, but common causes of damage include childbirth, repeated heavy lifting, straining for bowel movements, some chronic diseases and surgery. Pelvic floor disorders often interrupt everyday activities such as exercise, shopping, travel and intimate relations.
What is urinary incontinence?
Urinary incontinence is the uncontrolled loss of urine that is bothersome enough to affect your quality of life.
Urinary leakage has many possible causes, but it most commonly falls into two main categories:
- Stress urinary incontinence (SUI) is the loss of urine as a result of physical activities that increase abdominal pressure. These activities include sneezing, coughing, laughing and straining when performing exercises like abdominal crunches or lifting objects. This increase in abdominal pressure leads to an increase in the pressure within the bladder, which behaves like a balloon filled with liquid. The rise in bladder pressure then forces the urethra open and urine loss occurs. Urine loss with stress incontinence often feels like a squirt, which can be small or large depending upon the amount of liquid in the bladder at the time and the holding strength of your urethral muscle. Common risk factors for stress incontinence include having had a vaginal delivery, previous pelvic surgery, radiation treatment to the pelvis, increased abdominal pressure due to respiratory conditions like chronic coughing, constipation, obesity and heavy lifting. In some cases there is also inherited weakness of the supportive connective tissue of the pelvis.
- Overactive bladder is urgency and frequency of urination either with or without actual urine leakage. Overactive bladder may awaken you from sleep more than once or twice a night. This condition may be due to actual spasms of the bladder muscle or increased sensitivity of the bladder. Urge incontinence is usually associated with a strong, almost overpowering sense of a need to urinate with concern that you will not be able to make it to the bathroom in time. These bladder spasms often happen when your bladder is not very full and can be triggered by hearing or feeling running water, cold air or even arriving at home and putting your key in the door. Occasionally it is caused simply by a particular amount of urine in the bladder. Overactive bladder typically leads to leakage of larger amounts of urine and is harder to control than stress incontinence. Typically, we don’t know what causes overactive bladder although there can be triggers (as noted above) or damage to the muscles or nerves that supply your bladder.
Are both types of urinary leakage treated the same?
No – that is why it is important to distinguish between the two main types of urinary leakage.
Both types can be helped if you strengthen your pelvic floor muscles by doing Kegel exercises. In addition, there are a variety of treatment options, including surgical procedures, available for each. However, if you have stress incontinence, it’s often managed by surgery, while medication is generally used for urge incontinence. Fortunately, there are now highly effective, minimally invasive outpatient procedures available for stress incontinence. If your overactive bladder condition has not responded to medications, there is a surgical procedure known as Interstim® available.
What about loss of support or prolapse of the pelvic organs?
As you age, it is quite common to experience relaxation of the support of your bladder, vagina, uterus or rectum, especially if you have had children by vaginal delivery.
This can be normal, but if it becomes bothersome it may cause a sense of pressure or bulging in your vaginal area. Sometimes you can even feel or see a bulge outside of your vagina.
- Loss of support for your bladder, known as a cystocele may contribute to urinary leakage, difficulty in starting your urine flow or even trouble emptying your bladder.
- A rectocele occurs when your rectum presses into the space of your vagina and can cause similar symptoms of difficulty starting or completing a bowel movement.
- Uterine prolapse, or vaginal prolapse if you have had a hysterectomy, can affect your bowel or bladder function or simply cause sensations of pressure.
If you have these conditions, you have a number of treatments to choose from, including surgical options.
I have loss of bowel control. Can you help this condition?
Urogynecologists are experts in treating many different causes of loss of stool control.
Commonly, you can manage this by paying attention to your diet, bowel habits and muscle strength. Although in some cases, your loss of control may be due to actual damage of your anal sphincter muscle that occurred at the time of a vaginal delivery. If you experienced a known tear to this muscle at childbirth, you may need surgery to repair the muscle.
I have tried Kegel exercises and these do not seem to solve my problem. Should I keep doing them?
Definitely – as long as you are doing them correctly.
We will check your muscle strength as part of your visit with us. Even though Kegel exercises may not resolve your pelvic floor condition, there is no question that you benefit from maintaining strong muscles. Your condition could even get worse if these muscles are not strong. Keeping strong muscles is an excellent way for you to participate in your treatment and to improve your treatment results. Whether you choose a non-surgical or surgical approach to your condition, Kegel exercises help.
What can I expect from a visit to the Pelvic Floor Health Service at OHSU?
Prior to your visit, we will request that you complete a patient questionnaire form to get a better sense of your pelvic complaints, how much they bother you, and how they are affecting your life and activities. We will also ask that you complete a 24-hour voiding diary that keeps track of your fluid intake and urinary output. This helps us better understand how your bladder functions on a typical day and is an important part of your evaluation. Once you arrive, we will review your health history and specific concerns and we will request a urine sample.
Your physical examination will be much like a typical gynecologic exam but with a more detailed focus on the support of your bladder, uterus, vagina and rectum. We also will test your Kegel muscle strength and evaluate your muscles and bladder for painful sites. If your pelvic organs are falling or bulging,we may examine you both lying down and standing as our loss of support may be more obvious when you are standing. Depending on your history and physical examination findings, we may also suggest testing. As specialists in the evaluation of pelvic floor disorders, there are several tests we perform in our office that may help more fully diagnose your condition.
Your specialist will then propose and explain a variety of therapies to cure or relieve symptoms of prolapse, urinary or bowel incontinence, or other pelvic floor dysfunction symptoms. He or she may advise conservative (non-surgical) or surgical therapy depending on your wishes, the seriousness of your condition and your general health.
Conservative options include medications, pelvic exercises, behavioral and/or dietary changes and vaginal devices (also called pessaries). Surgical procedures may also be discussed to treat incontinence and prolapse. There are a variety of different surgical procedures available and the suggestions for your surgery will be based on your specific condition and testing results. Your doctor will discuss all of the options that are available to treat your specific problem(s) before you are asked to make a treatment decision.
What is robotic minimally invasive surgery?
Our doctors use the latest technologies in minimally invasive surgeries including the daVinci Surgical Robot.
The surgical robot allows OHSU surgeons to perform most abdominal surgeries without making a large incision. We were the first academic pelvic surgery group in the Pacific Northwest to use the daVinci robot for repairing pelvic organ displacement (prolapse).
Laparoscopic surgery uses a lighted telescope, most commonly placed through a small incision at your belly button, to visualize the inside of your abdomen. Additional small incisions are made to place surgical instruments. Complex pelvic reconstructive surgery has traditionally been difficult to perform this way due to the nature of the instruments available to use. A laparoscopic robot uses surgical instruments that move exactly with the surgeon’s hand and a 3-D viewing system to allow us to perform these complex surgeries in a minimally invasive way. With this newer type of surgery, you usually have less discomfort, a shorter hospital stay, and faster recovery.
For more information, please see www.davincisurgery.com.
What is Interstim?
Interstim is an FDA-approved device. It is used to treat urge incontinence or overactive bladder that is not being adequately treated by the medications typically used in this condition. It can also be proposed if you are not able to tolerate these medications due to side effects. Interstim is a two-step outpatient surgical procedure that places a nerve stimulator at the level of the low back where the nerves that control your bladder function are located. This stimulator is attached to a small battery that allows you to set the level of nerve stimulation required to control your overactive bladder. The system functions much like a pacemaker for your bladder.
What are some of the pain conditions that can affect the bladder?
Unfortunately there are several pain conditions that can affect the function and sensation of your bladder and pelvic floor. One of the more well known is Interstitial Cystitis (IC), or Painful Bladder Syndrome (PBS).
This is a condition where your bladder is inflamed, but you do not have a urinary tract infection. IC causes you to urinate frequently due to pain within the bladder as it fills. We do not entirely understand what causes this condition, so treatment involves relieving your symptoms. Treatment often requires several different approaches including consultation with physical therapy and pain management specialists.
There are also some foods and drinks that can cause bladder discomfort. Sometimes the problem that is causing your pain is not within your bladder itself, but rather occurs outside of your bladder and affects its function. A common source of this type of pain occurs in the muscles of the pelvic floor such as the Kegel muscles. If you have muscle pain, it is best treated by a physical therapist who specializes in this type of therapy. Often the first step in obtaining relief, is identifying the source of your pain so that it can be appropriately treated.