Female Pelvic Medicine and Reconstructive Surgery Clinical Care

Stress incontinence is involuntary leakage when exerting effort, sneezing or coughing. In women, it can be treated in many ways, primarily with changes in behavior and exercises known as Kegel exercises. An inserted device, known as a pessary, can also be of benefit to some women.

Surgery, including urethral bulking agents (an injection) as well as slings made of a patient’s own tissue (fascia) or of polypropylene mesh can be effective as well. Men and some women with very severe incontinence may benefit from an artificial urinary sphincter which uses an inflatable balloon cuff to seal off the leaky urethra. 

Urge incontinence happens when the patient has accidents or leaks preceded by a strong urge to urinate without enough warning to get to the restroom, or in some cases, no warning at all. The first line in treatment is modifying what the patient drinks, particularly drinks containing caffeine, and when the patient drinks them.

There are some exercises that can also help postpone the urge to urinate. If these measures are not effective, then medications exist. If the medications do not help enough, or if they cause unacceptable side effects, then procedures exist to reduce the urge, such as injections of medication directly into the muscle of the bladder, electrical stimulation into nerves in the ankle that affect the nerves that connect to the bladder, or implantation of a stimulator that connects to the nerves as they leave the bladder and before they connect to the spine. The stimulator often involves two procedures: the first to place a wire designed to stimulate the sacral root nerve bundle to determine if this type of therapy will work for that particular individual, then a second procedure to connect this wire to the implantable generator if it does work as expected. The test period lasts from two to four weeks.

Mixed incontinence is a combination of stress and urge incontinence that is treated in the same way, often in stages, with the goal of treating the most troubling cause first. 

Often, patients cannot empty the bladder completely. If too much urine remains, it can leak out, effectively overflowing the capacity of the bladder and causing overflow incontinence. This has lots of causes, in women this can be caused by prior surgery in the pelvic area, such as a sling, or it can be caused by neurologic problems or dysfunctional voiding.

The treatments vary and can be as non-invasive as pelvic floor therapy, where a specialized physical therapist determines which muscle groups are not working properly and teaches the patient exercises that can help correct the dysfunction. Electrical stimulation such as sacral neuromodulation can also help for voiding dysfunction.

True incontinence is the rarest form of incontinence and is leakage without warning. The patient is unaware of any leakage until they notice wet pants. It can be caused by a birth condition such as an ectopic ureter, where the tube that connects the kidney to the bladder inserts in the wrong place, or it can be caused by a fistula. A fistula is an abnormal connection between the bladder and the vagina or the skin. In the case of the male urethra, this can be after surgery or radiation on the prostate. In the case of women, this can be after surgery or after a difficult childbirth. This condition in women is called vesicovaginal fistula and can heal on its own in some cases, but often requires surgery. This surgery can often be performed vaginally or laparoscopically with minimal incisions.

In some cases, the fistula is so severe or the tissue is of such poor quality that a repair is not likely to last, so urinary diversion is offered. This consists of bypassing the bladder by making a new bladder out of bowel. A popular type of diversion called the Indiana Pouch, which was created by faculty at IU School of Medicine in the 1970s, consists of a new bladder made from the patient’s right colon. It is emptied by placing a flexible catheter into the pouch through an opening near the belly button. The pouch has to be irrigated daily to clear the mucus naturally made by the colon so it does not cause infection or blockage.

Another less labor-intensive urinary diversion is called the ileal conduit, where a loop of small intestine is connected to the ureters (tubes that connect the kidneys to the bladder normally) and then brought out to the skin, near the belly button. This type of diversion drains constantly to a bag stuck to the side of the belly, so no catheters are needed and no irrigation is needed.

Pelvic organ prolapse happens when a portion of the vagina protrudes outside of the vagina, causing the woman to feel a bulge that can be uncomfortable. Pelvic prolapse is diagnosed with a pelvic exam and treatment includes pessary placement or surgery.

Surgical methods to treat pelvic organ prolapse range from tissue repair using stitches to a re-suspension of the whole pelvis, known as sacral colpopexy, which can be done laparoscopically with robotic assistance. Many of these repairs are done without mesh, using the patient’s own tissue from the leg.

Urethral stricture is scar tissue that forms in the urine tube and drains the bladder. This is most common in men, but can also be seen in women. It can be caused by an injury, surgery, prior procedures such as catheters or scopes placed in the urethra, or radiation. When the blockage becomes so severe the patient is having difficulty urinating, it can be stretched open with a small metal or plastic tube called a dilator. The scar tissue often comes back, and if it does, the next best step is often a surgical procedure called urethroplasty. Surgeons remove the scar tissue and bring the two healthy edges back together or place a graft taken from the mouth (“buccal mucosa”) or other parts of the body.

Many people with neurologic problems, such as multiple sclerosis, spinal cord injury, stroke, myelomeningocele, Parkinson’s Disease, and severe diabetes also develop bladder problems. These can include urinary frequency, urgency and incontinence as well as urinary retention. After a careful history and physical exam, a test called a urodynamic study is often helpful in determining what type of problem a patient has and what type of therapy is most likely to help. After the problem has been defined, intervention can range from pelvic floor therapy to surgery. Patients with a neurologic bladder problem may be at risk for dangerously high pressures in the bladder and so sometimes periodic blood testing, kidney ultrasound and urodynamic studies are needed.

Overactive bladder is a common term for a collection of symptoms, primarily urinary urgency, urinary frequency, small volume voids and getting up to urinate at night (“nocturia”). It is a clinical diagnosis and not based on urodynamic testing. It is necessary, however, to check how much urine is left in the bladder after urinating. This can often be done with a portable ultrasound device.

Treatment starts with behavior modification (for example, start looking for restrooms when entering a building) and exercises to help reduce the urgency. If these are unsuccessful, then medications to reduce the urgency may help. If the medications are not sufficient, then a procedure involving electrical stimulation of certain nerves associated with the bladder or injection of medicine directly into the muscle of the bladder wall can alleviate most overactive bladder symptoms. In many cases, an implantable peripheral nerve stimulator can provide relief for up to 5 years before the battery has to be replaced.

Vaginal mesh is used in many surgical procedures to repair other conditions, such as stress urinary incontinence or pelvic organ prolapse. Vaginal mesh that has not become exposed and is not causing symptoms does not need to be removed, but sometimes polypropylene mesh can become exposed, infected, enter the bladder or be a source of pelvic pain. In some cases, removal of the mesh and even part of the bladder or vagina is necessary.

The least invasive approach that removes only the mesh that must be removed is preferred. This is determined by history and a careful pelvic exam. Often, examination of the bladder with a camera called a cystoscope is needed. In some cases, computerized tomography (CT) scans or magnetic resonance imaging (MRI) studies are needed.