Urogynecology

Diagnosis

It is critical that the correct diagnosis be made prior to instituting a treatment plan. Most often, the diagnosis can be made in the office and does not require complex or invasive testing. The diagnosis starts with a complete history and physical exam which can often determine the cause of urinary incontinence. Details regarding frequency and amount of urination as well as urinary leakage are reviewed. A past surgical and medical history as well as concurrent medications may provide additional information. Avoiding diary where the patient records how much she drinks, voids, and specifics regarding leakage episodes is helpful. 

The physical exam should include a mental status exam, general exam, and detail pelvic exam. The pelvic exam will often provide valuable information regarding the cause for urinary incontinence.  A urine sample to rule out infection and cancer is often obtained.  Office based testing can help to further determine and characterize urinary incontinence. This testing can include urodynamics (a filling test of the bladder using a catheter to assess normal and abnormal bladder sensation and function), cystoscopy (a lighted telescope inserted into the bladder thru the opening in order to visualize the bladder and assess for anatomic abnormalities including cancer), and radiologic tests (X-ray, ultrasound, or CT scan to assess for kidney stones and other anatomic abnormalities). 

Treatment

Treatment should specifically be customized for each patient on an individual basis based on their correct diagnosis, severity of condition, age, and ability to comply and treatment recommendations. Typically, treatment for overactive bladder is medical while treatment for stress incontinence is surgical. This may vary depending on severity of the condition and age of the patient as well as exam/test findings. Minimally invasive surgical techniques for patients with stress incontinence are generally performed as outpatient procedures. Patients receiving treatment for advanced prolapse may stay in the hospital overnight, if indicated.

Overactive bladder

Treatment of OAB is focused on reducing bladder spasms and increasing bladder capacity-thereby minimizing frequent urination and urinary leakage due to bladder spasms.  Typically, various treatments are recommended at the same time to achieve greater effect in a short time.  Patients who are refractory may benefit from addition of other treatment modalities including neuromodulation and/or Botox.

• Reduction of excess fluid intake and bladder irritants including caffeine and alcohol
• Pelvic floor exercises or Kegels exercises - contraction of the pelvic floor
• Bladder retraining - emptying the bladder at set intervals which increase weekly to allow the bladder to hold more urine over time
• Anticholinergic medication - primary medication type used for OAB-helps to prevent bladder spasms and increase bladder capacity-(Detrol, Ditropan, Oxytrol, Vesicare, Enablex, Sanctura)-side effects include dry mouth, constipation, and headache
• Pelvic floor physical therapy can help improve the muscles and nerves of the pelvis with techniques including biofeedback and electrical stimulation
• Neuromodulation techniques including peripheral acupuncture(SANS) and central implants(Interstim) modulate the nerves causing specificity to the bladder and is used in patients refractory to traditional noninvasive treatment options
• Botox injection into the bladder using cystoscopy, although not currently approved by the FDA and considered  investigational, has been used with good success in refractory cases. It is still currently under investigation

Stress Urinary Incontinence

Treatment of SUI is focused on improving bladder neck support and reducing urinary leakage. In cases of mild stress incontinence, pelvic floor sizes and physical therapy may result in significant improvement.  In cases of moderate to severe incontinence, surgery is the best option. Over the last decade, the surgery has evolved to become a very safe and effective outpatient procedure with success rates greater than 90% and complication rates less than 5%.

• Pelvic floor exercises or Kegels exercises - contraction of the pelvic floor. Pelvic floor physical therapy can help improve the muscles and nerves of the pelvis and improve baldder neck support with techniques including biofeedback and electrical stimulation
• Pessaries and other vaginal devices have been designed to specifically treat stress incontinence and those patients who are poor candidates for surgery or would like to pursue nonsurgical treatment options
• Surgery - Although over 100 different surgical procedures have evolved for the treatment of SUI - the most popular procedure currently performed is the suburethral sling which can be often be performed on an outpatient basis with IV sedation and local anesthesia. The procedure, often referred to as TVT(transvaginal tape) or TOT(transobturator tape)  depending on approach, is a vaginal technique which places a small  permanent mesh or tape underneath the urethra which acts as a hammock and prevents movement during activity. This support of the bladder neck results in surgical cure of the stress related incontinence.

Prevention

Given the increasing incidence of urinary incontinence in our aging population, greater attention is now being given in trying to prevent the condition. An easy intervention would be learning proper technique of pelvic floor exercises or Kegel's and performing them prior to the onset of urinary incontinence as a preventive measure. Most patients currently performing Kegel's as they perform the exercises incorrectly. All patients would benefit from confirmation of proper exercise technique by their physician or qualified pelvic floor physical therapist. Avoidance of chronic straining and weight loss can reduce the risk of stress urinary incontinence.  

In addition, patients with complaints of overactive bladder or urinary incontinence should be evaluated soon after the onset of the condition as patients with mild symptoms often have greater success with more conservative treatment options. Treatment of long-standing disease often involves more aggressive treatment with lower success rates. 

Method of delivery, vaginal versus cesarean section, and it's effects on urinary incontinence is currently controversial with conflicting data. It has been suggested that cesarean section protects the pelvic floor from long-term conditions including pelvic prolapse, urinary incontinence, and fecal incontinence but greater data needs to be analyzed prior to making clinical recommendations.