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Urogynecology
작성자 관리자 작성일 2019-12-31 조회수 2488

What is urogynecology?


The field of Urogynecology (a subspecialty within Obstetrics and Gynecology) is dedicated to the treatment of women with pelvic floor disorders such as urinary or fecal incontinence and prolapse (bulging or falling) of the vagina, bladder and/or the uterus.


Urinary incontinence (leakage of urine) is a very common condition affecting at least 10-20% of women under age 65 and up to 56% of women over the age of 65. While incontinence also affects men, it occurs much more commonly in women.


Prolapse simply means displacement from the normal position. When this word is used to describe the female organs, it usually means bulging, sagging or falling. It can occur quickly, but usually happens over the course of many years. On average, 11% of women will undergo surgery for this condition.


Prolapse and incontinence frequently occur together. Both conditions are believed to result from damage to the pelvic floor after delivering a baby. Other possible factors in the development of prolapse and incontinence are very heavy lifting on a daily basis (as some paramedics and factory workers might do) chronic coughing, severe constipation and obesity. More information is available in the FREQUENTLY ASKED QUESTIONS and Glossary sections of this website


Frequently asked Questions about URINARY INCONTINENCE:


What is Urogynecology? 
Urogynecology is a subspecialty within Obstetrics and Gynecology that focuses on disorders of the female pelvic floor such as pelvic organ prolapse (bulging out of the uterus and/or vagina), urinary incontinence, fecal incontinence and constipation. After completing a residency in Obstetrics and Gynecology, Urogynecologists complete fellowship training where they spend several years focusing only on these disorders. 


How common is urinary incontinence among women? 
Many women incorrectly assume that urine leakage is normal. While the problem of urine leakage is very common, it should never be considered normal. The most commonly quoted study estimates that 11 million American women currently suffer from leakage of urine. However, this estimate may be low. A study of 2800 postmenopausal women (average age 67) funded by the National Institute on Aging found that fifty-six percent of women experienced urinary incontinence at least weekly. 


What causes urinary incontinence? 
Urinary incontinence is a symptom, not a disease. This means that there are many possible causes of urinary incontinence. The key to treatment is identifying the specific type(s) of incontinence that a woman has through a careful medical interview and focused physical exam. It may also be necessary to perform a special test called urodynamics to diagnose the problem. Urodynamics are necessary if a woman is considering surgery to correct incontinence.
The two most common types of urinary incontinence are stress incontinence and urge incontinence.
Stress incontinence is urine leakage that happens during activity that causes pressure (or "stress") on the bladder such as laughing, lifting, coughing or sneezing.
Urge incontinence is urine leakage that occurs before a woman has a chance to get to the bathroom in response to an urge to urinate. Women with this type of leakage may also experience frequent urges to urinate and frequent nighttime waking to urinate. 


What treatment options are available? 
Stress incontinence can be effectively treated with pelvic floor exercises, devices that "block" the loss of urine, or surgery. There is also a new medication called Duloxetine that will soon be available for the treatment of stress incontinence. Urge incontinence is commonly treated with medications, biofeedback, or electrical stimulation to the nerves that control the bladder. There is even a new treatment for urge incontinence that involves placement of an electrical stimulator under the skin (similar to a pacemaker). The most important thing to remember is that there is a wide variety of non-surgical and surgical treatment options available for all kinds of urinary incontinence. For more specific information on the various treatment options for urinary incontinence and pelvic organ prolapse, click here NON-SURGICAL TREATMENT OPTIONS. 

I`ve heard that surgery doesn`t work for very long. Is that true? 
When it comes to treating stress incontinence, not all surgical procedures are created equal. Over the years, literally hundreds of variations of anti-incontinence surgery have been described in medical journals, and some of them don`t work very well. Fortunately, research studies have identified two basic kinds of surgical procedures that seem to be the "best": the retropubic urethropexy and the suburethral sling. There is no surgery for incontinence that has a 100% cure rate, but either the retropubic urethropexy or suburethral sling should permanently cure 75-95% of women with stress incontinence. A relatively new type of suburethral sling called "tension Free Vaginal Tape" (aka TVT) that became available in 1998 has rapidly replaced most other surgeries for stress incontinence. Nearly 1 million TVT slings have been placed worldwide, and many surgeons now consider the TVT-type sling to be the `gold-standard` treatment for the problem. The TVT procedure can be performed on an outpatient basis under local anesthesia. No surgery, however, should be taken lightly. Some potential complications of surgery for incontinence include difficulty emptying the bladder and development of urge incontinence. 


How can I prevent this problem? 
We don`t fully understand all the factors that cause urinary incontinence, so it is difficult to recommend ways to prevent the problem. Pelvic muscle exercises (PME) - also known as Kegel exercises - are probably the best way to prevent stress incontinence. CLICK HERE for PME instructions. Another easy thing to try on your own is to avoid eating or drinking things known to irritate the bladder. For a copy of our "bladder diet," CLICK HERE. 


FAQ about PELVIC ORGAN PROLAPSE


What does "prolapse" mean? 
The word prolapse simply means displacement from the normal position. When this word is used to describe the female organs, it usually means bulging, sagging or falling. It can occur quickly, but usually happens over the course of many years. There are various types of prolapse, which can occur individually or together. Definitions and pictures of the various types of prolapse (cystocele, rectocele, uterine prolapse and enterocele) may be found by clicking on the GLOSSARY section. 


What symptoms are caused by my prolapse? 
The symptoms depend on which type of prolapse you have. Since prolapse usually occurs slowly over time, the symptoms can be hard to recognize. Most women don`t seek treatment until they actually feel something protruding outside of their vagina. The very first signs can be subtle - such as pain during intercourse or an inability to keep a tampon inside the vagina. As the prolapse gets worse, some women complain of a bulging or heavy sensation in the vagina that worsens by the end of the day or during bowel movements. Some women with severe prolapse even have to push stool out of the rectum by placing their fingers into the vagina during bowel movements. 


Why did this happen to me? Did I do something to cause this problem? 
The simple answer to this question is NO. There are many factors that seem to contribute to the development of prolapse, and almost none of them are things you can control. Genetics definitely plays a major role. Vaginal deliveries can predispose certain women to develop prolapse, but we haven`t learned how to identify these women BEFORE they have children. Other conditions that seem to go along with the development of prolapse are severe obesity, pelvic tumors and chronic constipation. Repetitive heavy lifting may contribute to prolapse as well. 


Do I need to have surgery for my prolapse? 
No, there are two other choices - to do nothing about it or wear a pessary. A pessary is worn in the vagina like a diaphragm. Pessaries come in many different shapes and sizes all designed to support the prolapsed pelvic organs. Many women are completely satisfied using a pessary for years - avoiding surgery all together. 


If I choose to use a pessary, won`t that give me an infection? 
The ideal way to use a pessary is to insert it each day as part of your morning routine, and take it out for cleaning each night. When this is not possible, women come to the office about four to six times a year for an exam and pessary cleaning. Even when a pessary is worn almost continuously, vaginal infections are rare. CLICK HERE for a picture of the various pessaries available. 


What will happen if I just ignore this problem? Will it get worse? 
Probably. It may not happen quickly, but if left untreated, pelvic organ prolapse usually gets worse. However, treatment of prolapse should be based on your symptoms. In rare cases, severe prolapse can cause urinary retention that progresses to kidney damage or infection, When this occurs, prolapse treatment is considered necessary. In most other cases, patients should be the ones to decide when to have their prolapse treated - based on the symptoms they are having. 


If I decide to have surgery, what can I expect during the recovery period? 
Depending on the extent of your surgery, the hospital stay usually lasts one to four days. Many women have difficulty urinating immediately after the surgery and have to go home with a catheter in place to drain the bladder. These catheters are usually only necessary for 3 - 7 days. Most patients require at least some prescription strength pain medicine for about one to two weeks after surgery. Following any of our surgeries to correct urinary incontinence or prolapse, we ask that patients take it easy for 12 weeks to allow proper healing. This means no lifting more than 8 pounds (the weight of a gallon of milk), no intercourse, and no exercise other than walking. CLICK HERE for more information about what to expect after surgery. 


If my surgery is successful, how long will it last? 
The goal of continence or pelvic reconstructive surgery is to recreate normal anatomy permanently. However, none of these procedures are successful 100% of the time. According to the medical literature, failures occur in approximately 5 - 15% of women who have prolapse surgery. In these cases, it is usually a partial failure requiring no treatment, pessary use, or surgery that is much less extensive than the original surgery. Patients who follow our recommended restrictions for 12 weeks after surgery give themselves the best chance for permanent success. 


I have prolapse, but I don`t leak urine. Do I still need bladder testing? 
Yes, if you are going to have surgery to correct the prolapse, bladder testing (called urodynamics) must be done first. That`s because the prolapsed portion of your vagina may be pushing on your urethra and preventing urine leakage. If that is the case, having the prolapse corrected can give you a new problem - urinary incontinence. The only way to tell whether a continence procedure is needed at the time of prolapse surgery is to perform urodynamics while holding the prolapse up in its normal position. 


How will my prolapse treatment affect my sex life? 
If you choose to use a pessary, your sex life shouldn`t change, except for the fact that the pessary usually needs to be removed prior to intercourse. If you have reconstructive surgery to correct prolapse, we recommend that you refrain from intercourse for three months after your operation to allow proper healing. After waiting three months, getting used to having intercourse will take some time, but most patients report an improved sex life afterwards.
When prolapse is severe, one surgical option is to completely close the vagina. This procedure (called colpocleisis or colpectomy) is less invasive than reconstructive surgery, which makes it especially useful for patients with severe medical conditions. Of course, intercourse is impossible after having this procedure, so it is only appropriate for patients who are ABSOLUTELY sure that they never want to be sexually active again. 


How did you ever get interested in this field? 
Treating prolapse and incontinence is challenging and very rewarding. Every patient has a unique set of symptoms, disorders and expectations, so we must individualize each treatment plan. Unlike most specialists, Urogynecologists have the opportunity to diagnose a condition; plan treatment based on the patient`s lifestyle and preferences; and follow up on the patient after treatment. It`s rewarding to see patients back after successful treatment, because they are usually very happy with their improved quality of life.
Also, we enjoy the challenge of improving patient care through medical research. Since our specialty is relatively new, there are many questions that still need to be answered through research studies. 


GENERAL TERMS


Pelvic floor muscles 
-A group of muscles in the pelvis that support and help to control the vagina, uterus, bladder urethra and rectum 
Bladder 
-A muscular organ which stores urine 
Ureters 
-A pair of tubes, each leading from one of the kidneys, to the bladder 
Urethra 
-A short narrow tube that carries urine from the bladder out of the body. 
Voiding 
-Passage of urine out of the body 
COMMON PELVIC FLOOR DISORDERS


Urinary incontinence 
-leakage of urine 
Stress incontinence 
-involuntary loss of urine during activities that put "stress" on the bladder such as laughing, coughing, sneezing, lifting, etc. 
Urge incontinence 
-An involuntary loss of urine preceded by a strong urge (also known as "overactive bladder") 
Dysuria 
-Painful urination 
Urgency 
-A powerful need to urinate immediately 
Frequency 
-The need to urinate more often than normal (more than every 2 hours or more than 7 times a day) 
Nocturia 
-Waking up frequently (more than once) during the night to urinate 
Cystocele 
-Prolapse or bulging of the bladder into the vagina 
Rectocele 
-Prolapse or bulging of the rectum into the vagina 
Enterocele 
-Prolapse or bulging of the small intestine into a space between the rectum and vagina 
Uterine prolapse 
-Prolapse or descent of the uterus into the vagina 
Fecal Incontinence 
-Accidental loss of solid stool, liquid stool, or gas 
Constipation 
-Variously defined as infrequent bowel movements (< 3 bowel movements per week), incomplete emptying of bowel contents, need to excessively strain to effect a bowel movement, passage of small, hard stools, or need to place your fingers in the vagina or the space between the vagina and anus to effect a bowel movement. 


History and Physical Exam


During your first visit to our office, your doctor will conduct an interview and consultation followed by a physical exam directed towards your condition (usually involving a pelvic exam). After gaining adequate insight about your concerns, your doctor may recommend specialized testing.


CYSTOSCOPY / URETHROSCOPY 
-A diagnostic procedure that allows us to look inside of your urethra and bladder using a small lighted scope. Special lenses and mirrors allow us to detect inflammation, stones or tumors of the bladder. 


ULTRASOUND 
-A procedure that uses sound waves to study the anal sphincter, bladder, urethra, kidneys, ureters or other pelvic organs. Tumors and other pelvic masses, including abscesses, can be identified using ultrasound techniques. 


URODYNAMIC TESTING 
-The name for a variety of tests that require a small catheter to be inserted into the bladder. The tests evaluate lower urinary tract function (bladder and urethra), including storing and emptying urine. These procedures are performed in the office. 


DYNAMIC FLOUROSCOPY OF THE PELVIC FLOOR 
-A procedure using X-rays and contrast material (dye that shows up on X-rays). The X-rays are used to project an image of the organs on a fluorescent screen. The contrast material, placed in the rectum, vagina and bladder, allows us to measure the extent of prolapse during defecation. This test is relatively quick and painless. 


INTRAVENOUS PYELOGRAPHY (IVP) 
-An X-ray procedure that examines the kidneys and ureters. Contrast material (dye that shows up on the X-rays) is injected in an IV, and X-rays are used to track the dye as it goes from the kidneys through the ureters to the bladder and out of the body. 


ELECTRODIAGNOSTIC TESTING (EMG) OF THE PELVIC FLOOR 
-This testing evaluates nerve function of the pelvic floor. Small adhesive patches applied to various places on the body are used to determine the pelvic floor`s muscle response to a series of small electrical impulses. 


ANAL MANOMETRY 
-A test that uses a small catheter within the rectum to determine how well the anal sphincter works. 
In addition to these tests the Atlantic Health System Division of Urogynecology offers comprehensive, state of the art management of pelvic floor disorders including all surgical and non-surgical options for the treatment of urinary incontinence, pelvic organ prolapse, constipation, and fecal incontinence


SURGICAL TREATMENTS FOR STRESS INCONTINENCE


Burch retropubic urethropexy 
-Procedure done through an abdominal incision or through a laparoscope to resupport the bladder base by placing sutures in the vagina to attach it to a ligament on the pubic bone 


Suburethral sling 
-Placing a "strap" of material under the urethra to support it and prevent stress incontinence. The sling material can be synthetic or natural. The natural material can be taken from your own body or from cadavers. 


Periurethral injections 
-Injection of material next to the opening of the bladder in an effort to prevent stress incontinence. This procedure is performed in the office. 


Tension-free vaginal tape - type- sling 
-A special type of suburethral sling that requires a less invasive procedure, which allows it to be performed under local anesthesia on an outpatient basis. 


Suprapubic catheter 
-A catheter placed into the bladder through the abdomen - it is used to drain the bladder after surgery 


Neuromodulation 
-This is a new approach in the treatment of the overactive bladder, urinary retention and urinary frequency. Electrodes are surgically inserted into the nerves that control the bladder. For more information about this option, 


SURGICAL PROCEDURES TO CORRECT PROLAPSE


Anterior colporrhaphy 
-A vaginal procedure to reestablish the supports between the bladder and vagina to fix a cystocele. A synthetic mesh or organic graft material made be placed to reinforce this repair 


Paravaginal repair (vaginal or abdominal approach) 
-support the vaginal wall by attaching it to the pelvic sidewall to fix a cystocele. A synthetic mesh or organic graft material made be placed to reinforce this repair 


Posterior colporrhaphy 
-A vaginal procedure to reestablish the supports between the vagina and rectum to fix a rectocele. A synthetic mesh or organic graft material made be placed to reinforce this repair 


Transvaginal enterocele repair 
-Close the space between the vagina and rectum through a vaginal incision to prevent the small bowel from pushing the vagina out. This procedure will also resuspend the top of the vagina. 


Total abdominal hysterectomy (with or without bilateral salpingo/oophorectomy) 
-Remove the uterus (including the cervix), tubes and ovaries through an abdominal incision. 


Total Laparoscopic Hysterectomy 
-removal of the uterus (including the cervix) and possibly the tubes and ovaries through a laparoscopic approach 


Total vaginal hysterectomy (with or without bilateral salpingo/oophorectomy) 
-Remove the uterus (including the cervix), tubes and ovaries through a vaginal incision. 


Bilateral salpingo/oophorectomy 
-Removal of tubes and ovaries (performed eiter abdominally, vaginally or laparoscopically). 


Uterosacral ligament suspension 
-Suspend the top of the vagina to the uteroscral ligaments. this can be performed vaginally, abdominally or laparoscopically. 


Sacrospinous vaginal vault suspension 
-A vaginal procedure that attaches the top of the prolapsed vagina to a ligament in the pelvis 


Sacral colpopexy 
-A procedure (performed abdominally or laparoscopically) that attaches the top of the prolapsed vagina to the sacrum using either synthetic mesh or cadaveric material. 


Illiococcygeal fascial attachment 
-A vaginal procedure that attaches the top of the prolapsed vagina to pararectal supportive tissue. 


Supracervical hysterectomy 
-Removal of most of the uterus – leaving the cervix behind. This approach can be done abdominally or laparoscopically 


Total colpectomy 
-Complete closure of the vagina to correct prolapse. This procedure is only performed when the patient is ABSOLUTELY sure that she will never want to have intercourse again. 


Total colpocleisis 
-Closure of the vagina (similar to colpectomy) while leaving channels at the side for drainage from the uterus (which is not removed) 


Overlapping anal sphincteroplasty 
-Reattach divided muscle edges around anus to correct fecal incontinence 


NON-SURGICAL TREATMENT OPTIONS FOR PROLAPSE


Pelvic muscle exercises (PME) 
-Also known as Kegel`s exercises, they strengthen the support of the pelvic organs and are most commonly used to treat stress urinary incontinence. PME techniques are also useful in prolapse prevention. Once the symptoms of prolapse are severe, however, these exercises are of little benefit. 


Pessary 
-A device worn in the vagina like a diaphragm. Pessaries are used to support the vagina, bladder, rectum and uterus as necessary. They come in a variety of shapes and sizes, so a doctor or nurse must fit them. CLICK HERE for a picture of the various pessaries that are available. 


NON-SURGICAL TREATMENT OPTONS FOR URINARY INCONTINENCE


Pelvic Muscle Exercises (PME) 
-Also known as Kegel exercises, PME techniques are an effective treatment option for stress incontinence. Most women require guidance from a medical professional to learn how to contract the pelvic floor muscles correctly. 


Biofeedback 
-This term refers to a variety of techniques that teach patients bladder and pelvic muscle control by giving positive feedback when the patient performs the desired action. This feedback can be from an electronic device or directly from health professional. 


Bladder Training 
-This treatment for urge incontinence involves teaching a patient to urinate according to a timetable rather than an urge to do so. Gradually, the scheduled time between trips to the bathroom is increased as the patient`s bladder control improves. CLICK HERE for a copy of the instruction sheet we use to help with bladder training. 


The Bladder Diet 
-This is a list of dietary irritants to the bladder. Avoiding the items on this list can greatly improve such bladder symptoms as frequency and urgency. For a copy of the bladder diet CLICK HERE. 


Medications 
-There are a number of drugs that are used in the treatment of urge incontinence.
Four commonly prescribed drugs are Detrol, Ditropan XL, Oxytrol patch, and Sanctura 


Occlusive devices - Several types of pessaries are available that are designed specifically for the treatment of stress incontinence. These are especially useful for women who leak urine during specific activities such as exercise. There is also a new device that fits in the urethra and acts like a plug. This device is called FemSoftTM. 


Pelvic Floor Electrical Stimulation (PFES) - Vaginal or anal probes that deliver electrical current to the pelvic floor may be useful in the treatment of urge and mixed incontinence. 


History and Physical Exam


During your first visit to our office, your doctor will conduct an interview and consultation followed by a physical exam directed towards your condition (usually involving a pelvic exam). After gaining adequate insight about your concerns, your doctor may recommend specialized testing.


Each of the following tests is available through our office:


CYSTOSCOPY / URETHROSCOPY 
-A diagnostic procedure that allows us to look inside of your urethra and bladder using a small lighted scope. Special lenses and mirrors allow us to detect inflammation, stones or tumors of the bladder. 


ULTRASOUND 
-A procedure that uses sound waves to study the anal sphincter, bladder, urethra, kidneys, ureters or other pelvic organs. Tumors and other pelvic masses, including abscesses, can be identified using ultrasound techniques. 


URODYNAMIC TESTING 
-The name for a variety of tests that require a small catheter to be inserted into the bladder. The tests evaluate lower urinary tract function (bladder and urethra), including storing and emptying urine. These procedures are performed in the office. 


DYNAMIC FLOUROSCOPY OF THE PELVIC FLOOR 
-A procedure using X-rays and contrast material (dye that shows up on X-rays). The X-rays are used to project an image of the organs on a fluorescent screen. The contrast material, placed in the rectum, vagina and bladder, allows us to measure the extent of prolapse during defecation. This test is relatively quick and painless. 


INTRAVENOUS PYELOGRAPHY (IVP) 
-An X-ray procedure that examines the kidneys and ureters. Contrast material (dye that shows up on the X-rays) is injected in an IV, and X-rays are used to track the dye as it goes from the kidneys through the ureters to the bladder and out of the body. 


ELECTRODIAGNOSTIC TESTING (EMG) OF THE PELVIC FLOOR 
-This testing evaluates nerve function of the pelvic floor. Small adhesive patches applied to various places on the body are used to determine the pelvic floor`s muscle response to a series of small electrical impulses. 


ANAL MANOMETRY 
-A test that uses a small catheter within the rectum to determine how well the anal sphincter works. 
In addition to these tests the Atlantic Health System Division of Urogynecology offers comprehensive, state of the art management of pelvic floor disorders including all surgical and non-surgical options for the treatment of urinary incontinence, pelvic organ prolapse, constipation, and fecal incontinence

 

 

 

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