Pelvic Health

What is Stress Urinary Incontinence? Stress Urinary Incontinence—the loss of urine control—is a common and often embarrassing problem. Some women may leak urine while coughing, sneezing or running. The effects of SUI can range from slightly bothersome to completely debilitating. For some women, SUI keeps them from enjoying activities with their family and friends for fear of public embarrassment.

What causes Stress Urinary Incontinence? SUI is twice as common in women as in men. Age, pregnancy, childbirth, and menopause are the primary causes. Other factors that may worsen SUI include obesity, smoking or illnesses that cause chronic coughing, excessive caffeine or alcohol use, or high impact activities or exercise for many years.

What are symptoms of Stress Urinary Incontinence? Patients with SUI may experience leakage of urine with coughing, sneezing, standing up, exercising, lifting heavy objects, laughing or sexual activity. Leakage may occur all the time or only occur when your bladder is full.

How is Stress Urinary Incontinence diagnosed? One of the fellowship-trained physicians will talk with you about your symptoms and perform a physical exam. A urine sample and blood test may be requested, and you may be asked to keep a bladder diary for several days to provide the doctor with as much information as possible to determine the cause of your SUI. Other special tests might include measuring the amount of urine left in the bladder with an ultrasound, testing bladder pressure, or looking into the bladder with a camera (cystoscopy).

How is Stress Urinary Incontinence treated? Treatment for Stress Urinary Incontinence depends on the severity of your problem and the root cause. We will take your history and do a thorough exam to recommend the approaches best suited to you. This may include a combination of treatments. Rest assured that we always try to suggest the least invasive treatments first.

The first type of therapy for SUI involves behavioral therapy and lifestyle changes. This can be as simple as watching fluid intake throughout the day and scheduling time to use the bathroom (timed voiding). It also may include smoking cessation, weight loss, and treating chronic cough or asthma. Exercises to help strengthen the muscles in your pelvis (Kegels) may also be suggested.

Another option for treatment of SUI is placement of an incontinence pessary. This is a ring placed in the vagina with a bump that sits on the urethra. The physician will place the pessary initially to make sure it fits and is comfortable. The pessary needs to be removed and cleaned regularly by the physician or a nurse. This is a good option if you do not want to undergo surgery.

Multiple surgical options are available for treatment of SUI.

• Sling—A piece of synthetic material, graft material, or a piece of the patient’s own tissue is used to create a hammock underneath the urethra to prevent leakage. This is the most common surgical procedure for SUI.
• Injectables—A material is injected around the urethra to “bulk up” the muscle and allow the urethra to close more easily. This may be done with a local anesthesia or light sedation. It is generally reserved for patients with mild SUI and may require more than one injection.

Can Stress Urinary Incontinence be prevented? While you can’t completely prevent SUI, there are some steps you can take to reduce your chances of being affected or decrease the severity of symptoms. Doing pelvic floor (Kegel) exercises can help strengthen your pelvic muscles. Staying at a healthy weight and smoking cessation can also help.

What is Pelvic Organ Prolapse? Pelvic Organ Prolapse (POP) occurs when one or more of your pelvic organs—uterus, vagina, bladder or bowel—shifts downward and bulges into or out of the vagina. Nearly a quarter of all women in the U.S. suffer from some form of Pelvic Organ Prolapse. There are several types of POP: anterior prolapse (cystocele), posterior prolapse (rectocele), uterine prolapse, and small bowel prolapse (enterocele).

What causes Pelvic Organ Prolapse? Aging, pregnancy and childbirth are the primary factors that lead to weakening of the vagina and its supports. Prolapse affects about one in three women who have had one or more children. It may occur during or shortly after a pregnancy or may take many years to develop. It’s important to point out that only about 11% will ever need surgery for prolapse in their lifetime. Menopause and conditions that cause excessive pressure on the pelvic floor—such as obesity, chronic cough or constipation—can cause further weakening.

What are symptoms of Pelvic Organ Prolapse? Although many women who have pelvic organ prolapse do not have symptoms, the most common is a feeling of pelvic pressure from the uterus or other organs pressing against the vaginal wall. Some women also experience other symptoms, including a feeling as if something is falling out of the vagina, a pulling or stretching in the groin or lower backache, painful intercourse, spotting or bleeding from the vagina, urinary problems (incontinence) or frequent or urgent need to urinate, and problems with bowel movements. Symptoms of POP typically worsen when you’re standing.

How is Pelvic Organ Prolapse diagnosed? The physician will begin by taking a thorough history and performing a physical exam of your pelvic organs. The exam helps us determine the type of prolapse and its severity. We will also ask you questions about your medical and family history, including details about your symptoms. Other special tests might include measuring the amount of urine left in the bladder with an ultrasound, testing bladder pressure, or looking into the bladder with a camera (cystoscopy).

How is Pelvic Organ Prolapse treated? Your doctor will make treatment recommendations based on the type of prolapse you have and its severity. This may involve one or a combination of treatment options, including physical therapy, non-surgical insertion of a pessary, or surgery to correct the area(s) of prolapse. Rest assured that we will always try to suggest the least invasive treatments first.

Non-surgical placement of a pessary into the vagina will help support the vaginal walls. The physician will place the pessary initially to make sure it fits and is comfortable. The pessary needs to be removed and cleaned regularly by the physician or a nurse. This is a good option for if you do not want to undergo surgery.
If you are looking for more permanent treatment, the prolapse can also be fixed surgically. Surgery can be performed through the vagina or the abdomen and may involve removal of the uterus, if still present.

Can Pelvic Organ Prolapse be prevented? Because vaginal and uterine prolapse have several different causes, there is no single way to prevent these problems. However, avoiding increased pressure inside your abdomen will diminish pressure on the pelvic floor. Steps you can take include: maintaining a healthy weight, avoiding constipation and chronic straining during bowel movements, alleviating chronic coughing, avoiding heavy lifting, smoking cessation, avoiding repetitive strenuous activities, and doing pelvic floor exercises (Kegels).

What is Interstitial Cystitis (IC)/Bladder Pain Syndrome (BPS)? IC or BPS is a chronic condition that causes bladder pressure, pelvic pain or bladder pain. The discomfort may range from mild to severe, or even debilitating. It can be made worse by filling the bladder and is often associated with urinary frequency.

IC most often affects women in their 30s and 40s, however, men may also be affected, often at an older age. When men have symptoms of IC/BPS, they often have inflammation of the prostate gland (prostatitis).

What causes Interstitial Cystitis (IC)/Bladder Pain Syndrome (BPS)?There is no known exact cause of IC/BPS, but there are likely multiple factors involved. Some possible causes include a break in the protective lining of the bladder, autoimmune reactions, infection, allergy or hereditary causes.

What are the symptoms of Interstitial Cystitis (IC)/Bladder Pain Syndrome (BPS)? Symptoms of IC/BPS can vary and fluctuate with time. Symptoms may be made worse by stress, menstruation, sexual activity or even exercise. The most common symptoms include:

·   Pain in the pelvis or vagina

·   Pain in the area between the vagina and anus (women) or scrotum and anus (men)

·   Urinary frequency—urinating small amounts during the day and night. Some patients may urinate up to 60 times a day.

·   Increased pain as the bladder fills that is relieved by emptying the bladder.

·   Pain during sexual intercourse or pain with ejaculation (men).

Symptoms are similar to those of a urinary tract infection (UTI), but most often, the urine is clear of bacteria. Patients who do get a UTI might have worsening symptoms.

How is Interstitial Cystitis (IC)/Bladder Pain Syndrome (BPS) diagnosed?IC/BPS is a clinical diagnosis of exclusion, meaning no other cause of the symptoms can be identified. One of the physicians will talk with you about your symptoms and perform a physical exam, including a pelvic exam or prostate exam. A urine sample will be requested, and you may be asked to keep a bladder diary for several days to provide the doctor with as much information as possible to determine the cause of your pain.

A cystoscopy (looking into the urethra and bladder with a camera) may be performed to look for any abnormal areas of the bladder (ulcers) and to determine how much urine your bladder can hold. If a suspicious area is found, a biopsy might be performed.

How is Interstitial Cystitis (IC)/Bladder Pain Syndrome (BPS) treated?Treatment of IC/BPS is often challenging, because there is no single treatment that eliminates the symptoms, and no one treatment works for everyone. You may need to try multiple options before you find a plan that works for you.

·   Physical therapy—Working with a pelvic floor physical therapist may help to relieve the pain and pressure associated with pelvic floor muscle tightening. Often they can give you exercises to do at home that help relax the pelvic floor muscles.

·   Medications—Various medications may been used to treat IC/BPS, including non-steroidal anti-inflammatory meds (ibuprofen, Naprosyn), tricyclic antidepressants, antihistamines, and Elmiron, which is one of the only medications that is FDA approved to treat IC/BPS. For men with prostatitis symptoms, a course of antibiotics can be helpful if we suspect chronic infection of the prostate.

·   Bladder distention—This involves cystoscopy (looking into the bladder with a camera) and stretching the bladder with water. Some patients see temporary improvement in their symptoms, and this treatment may be repeated if the result is long lasting.

·   Bladder instillations—This involves placing a catheter in your bladder and instilling medication for approximately 15 to 30 minutes. The initial treatment is usually once a week for six to eight weeks, followed by treatments once or twice a month if your symptoms improve.

·   Nerve stimulation—This treatment can help with urgency and frequency by stimulating the nerves that supply the bladder. This can be achieved with weekly stimulation through the ankle, or with a permanent implant in the lower back, similar to a pacemaker.

·   Surgery—Surgery is used only rarely to treat IC/BPS, because removing the bladder or parts of the bladder often does not relieve the pain. In cases where other treatments have failed, surgery can be considered.

If you suffer from IC/BPS, you may require pain management beyond the scope of our practice. In this case, we will refer you to a pain management specialist who can work with you to develop a specific pain management treatment plan.

What is Neurogenic Bladder? Neurogenic Bladder (NGB) is the loss of normal bladder function, caused by damage to part of the nervous system. This can lead to bladder overactivity, when the bladder contracts frequently, or bladder underactivity, when the bladder does not contract enough to empty or does not contract at all. Some patients may also have injuries to the nerves supplying the sphincter muscle controlling urine flow, possibly leading to incontinence or inability to empty the bladder.

What causes Neurogenic Bladder? Any disease that affects the nervous system may lead to dysfunction of the bladder. This includes

conditions patients are born with, trauma, or long-term diseases that lead to nerve damage, including:

• Spina bifida (spine abnormality of newborns)
• Tumors of spinal cord or brain
• Spinal cord injuries
• Stroke or brain injuries
• Multiple sclerosis
• Parkinson’s disease
• Pelvic surgery or radiation
• Long-term diabetes

What are the symptoms of Neurogenic Bladder? Neurogenic Bladder may have a variety of symptoms. The inability to control urination is quite common. This may occur along with urinary urgency, with or without leakage and urinary frequency (daytime or nighttime). Often your bladder cannot hold as much urine as a normal bladder.

Some patients may not be able to urinate at all. Commonly after a traumatic injury or stroke, patients undergo a “shock” phase, which causes Urinary Retention. This is usually temporary, lasting six weeks to three months. Some patients have long term Urinary Retention because the sphincter muscle that normally keeps patients dry between urination is unable to relax when the bladder tries to empty.
The bladder normally stretches easily and stores urine at a low pressure. Some patients with NGB develop bladders that do not stretch well and cause pressure to the kidneys. This could lead to kidney damage long term if not treated. The increase in bladder pressure does not necessarily cause symptoms.

What are the risks of Neurogenic Bladder? Patients who have Neurogenic Bladder are at risk of developing various problems over time, including:

• Stones—These may develop in the kidney or the bladder.
• Urinary tract infections—Patients who do not empty the bladder well or manage their bladder with catheterization are at increased risk of infection in the urine.
• Reflux—Urine can back up into the kidneys if bladder pressures are too high. If a patient also has an infection, the infection may be transferred up to the kidneys causing a more serious infection called pyelonephritis.
• Kidney damage—If the bladder is not managed appropriately, recurrent infections or high pressures might cause kidney damage over time.

How is Neurogenic Bladder Diagnosed? Neurogenic Bladder is a clinical diagnosis, meaning patients with bladder symptoms or problems who also have a neurologic disease are considered to have NGB. When you have symptoms, one of the physicians will talk with you about your symptoms and perform a physical exam, including a pelvic exam or prostate exam. A urine sample is often requested to look for any signs of infection.

Baseline tests to look at the urinary tract and how the bladder functions are often performed, including:

• Renal and bladder ultrasound and abdominal x-rays that examine the anatomy of your urinary tract and look for stones.
• Imaging of the spine and/or brain may be performed as part of the work up of a your neurologic disease.
• Urodynamics (bladder pressure testing) are performed to establish a pattern of how your bladder behaves while it is filling and emptying.
• A cystoscopy (looking into the urethra and bladder with a camera) may be performed to look into your bladder and ensure there are no anatomical abnormalities.

Often many of these tests are repeated on a regular basis depending on how your bladder is behaving or if treatments have changed.

How is Neurogenic Bladder Treated? The main goals of treatment of NGB are to prevent kidney damage and minimize bothersome bladder symptoms, such as urinary incontinence.
Patients who are unable to empty their bladder are often started on Clean Intermittent Catheterization (CIC). This is a method of emptying the bladder by placing a catheter into your bladder multiple times a day to empty the bladder and then remove the catheter after you are empty. Patients who are unable to do CIC on their own sometimes have the help of a caregiver. If a patient does not have access to a regular caregiver and is unable to do CIC, an indwelling catheter can be considered.

Patients who urinate on their own or perform CIC who experience inability to control their urine (Urinary Incontinence) are often initially managed with oral medications. If medications do not work, surgical options can be considered, including injection of medication into the bladder to help it relax, or surgery to make the bladder larger (bladder augmentation).

What is Fecal Incontinence? Fecal Incontinence is the inability to control bowel movements or unexpected leakage of stool from the rectum. This can occur while passing gas, or it can be complete loss of bowel control. Loss of bowel control is often quite embarrassing and may keep patients from doing many of their daily activities.

What causes Fecal Incontinence? Fecal Incontinence may be caused by a number of sources, including:

• Damage to the anal sphincter muscle, which usually occurs in women during childbirth—especially with an episiotomy or forceps delivery.
• Constipation or diarrhea.
• Nerve damage caused by childbirth, spinal cord injury, stroke, multiple sclerosis, or even long-term diabetes. Nerve damage may also occur during pelvic surgery.
• Radiation that has caused nerve damage or scarring in the rectum and does not allow the rectum to stretch.
• Inflammatory bowel disorders, such as Crohn’s or Ulcerative Colitis, which may cause scarring in the rectum that does not allow the rectum to stretch.
• Prolapse of the rectum through the anus or vaginal prolapse of the rectum in women may cause issues with bowel control.

What are the symptoms of Fecal Incontinence? Patients may only have episodes of incontinence with passing of gas or when they have diarrhea. The amount of leakage may be very small or might be significant. Patients may experience fecal urgency—the need to rush to the bathroom or inability to make it to the bathroom in time.

Fecal Incontinence may be associated with other common bowel symptoms, including constipation, diarrhea and/or gas or bloating.
How is Fecal Incontinence diagnosed? One of the physicians will talk with you about your symptoms and perform a physical exam, including a pelvic exam or prostate exam. Testing of the nerves around the anus during the exam is also performed.

Other tests may be ordered to evaluate the cause of incontinence. This could include an ultrasound, pressure tests, x-rays, MRI and/or using a camera to look into the rectum (similar to a colonoscopy). You may be asked to see a colorectal surgeon if further evaluation is needed.
How is Fecal Incontinence treated? There are various treatments for Fecal Incontinence depending on the cause. Often the first line treatment involves changes in diet and exercise. If diarrhea or constipation are not already being managed, medications may be given to help with these symptoms. Physical therapy to help control the muscles in the pelvis may also be recommended.

Nerve stimulation may be performed to help control the sensation and strengthen the sphincter muscles, similar to the treatment of Overactive Bladder.

If there is an anatomical problem, such as a damaged sphincter muscle or prolapse, surgery might be considered. For patients with severe incontinence who have failed other treatments, diversion of the stool through an opening in the abdomen (colostomy) may be considered.

What is a Urinary Tract Infection? Urinary Tract Infections (UTIs) can involve any part of your urinary system—kidneys, ureters, bladder and urethra. However, the most common infections involve the bladder and the urethra. Women have a higher risk of developing UTIs than men. An infection that is limited to your bladder can be painful or uncomfortable, but if a UTI spreads to your kidneys, serious consequences can occur.

What causes a Urinary Tract Infection? Urinary Tract Infections typically occur when bacteria enter the urinary tract through the urethra and begin to multiply in the bladder. The most common UTIs are cystitis (bladder) and urethritis (urethra).
• Cystitis is typically caused by Escherichia coli (E. coli), a type of bacteria that is commonly found in the gastrointestinal (GI) tract. Sexual intercourse can lead to cystitis. However, women who are not sexually active are also at risk because of the short distance from a woman’s urethra to the anus and from the urethral opening to the bladder. Women who have gone through menopause and women and men who do not empty the bladder completely are also at higher risk.

• Urethritis can occur when gastrointestinal bacteria spread from the anus to the urethra. It can also be caused by sexually transmitted infections, such as herpes, gonorrhea and chlamydia.

What are symptoms of a Urinary Tract Infection? You may or may not experience symptoms with a Urinary Tract Infection. If you do, they can include:

• A strong, persistent urge to urinate
• A burning sensation when urinating
• Passing frequent, small amounts of urine
• Urine that appears cloudy
• Urine that appears red, bright pink or cola-colored—a sign of blood in the urine
• Strong-smelling urine
• Pelvic pain, in women

UTIs may be overlooked or mistaken for other conditions in older adults. We can help.
How is a Urinary Tract Infection diagnosed? There are a number of tests and procedures that the physicians may use to diagnose Urinary Tract Infections, including:

• Urine sample—Your specimen will be analyzed to look for white blood cells, red blood cells or bacteria.
• Urine culture—This test uses your urine sample to grow bacteria in a lab. This tells the doctor what types of bacteria are causing your infection and which medications will be most effective.
• Ultrasound or a computerized tomography (CT) scan—If the doctor suspects that an abnormality in your urinary tract is causing frequent infections, these tests may also be used.
• Cystoscopy—If you have recurrent UTIs, your doctor may use a long, thin tube with a lens (cystoscope) inserted through the urethra to see inside your urethra and bladder.

How is a Urinary Tract Infection treated? UTIs are typically treated with antibiotics. The specific drugs that are prescribed for you and the length of time you need to take them will depend on your health condition and the type of bacteria found in your urine. Although the symptoms may clear up within a few days of treatment, it’s important that you continue the antibiotics for the full course prescribed by the physician to ensure that the infection is completely gone. The doctor may also prescribe a pain medication that numbs your bladder and urethra to relieve burning while urinating.

Can Urinary Tract Infections be prevented? Although there is no way to entirely prevent Urinary Tract Infections, there are steps you can take to reduce your risk. Drinking plenty of liquids—especially water—helps dilute your urine and ensures that you’ll urinate more frequently, allowing bacteria to be flushed out before infection can begin. Wiping from front to back helps prevent bacteria in the anal region from spreading to the vagina and urethra. Emptying your bladder soon after intercourse and drinking a full glass of water can also help flush out bacteria. Also, avoiding potentially irritating feminine products, such as deodorant sprays, douches and powders that can irritate the urethra will help.

What is Overactive Bladder? Overactive Bladder (OAB) impacts millions of men and women. In fact, 30% of all men and 40% of all women in the U.S. live with OAB symptoms, and those figures may be much higher because many others suffer in silence. OAB isn’t a disease; rather, it is a group of troubling urinary symptoms. The most prevalent symptom is a sudden, strong urge to urinate that you can’t control. Some people with OAB also have “urgency incontinence,” meaning urine leaks after they feel the sudden urge to go. This is different from incontinence that leads to leaking urine when you sneeze, cough or do other physical activity. With OAB, you may also experience frequent urination or waking at night to urinate.

What causes Overactive Bladder? As you grow older, the risk for OAB symptoms increases. For women who have gone through menopause and men who have had prostate problems, the risk for Overactive Bladder is higher. Often, the specific cause of an OAB is unknown.

However, there are several factors that can contribute to signs and symptoms of OAB, including:

• Neurological disorders, such as Parkinson’s disease, strokes, spinal cord injury and multiple sclerosis
• High urine production that can occur with high fluid intake, poor kidney function or diabetes
• Medications that cause a rapid increase in urine production or require that you take them with lots of fluids
• Factors that block bladder outflow, such as enlarged prostate, constipation or previous surgeries to treat other forms of incontinence
• Excess caffeine or alcohol consumption or other dietary triggers

What are symptoms of Overactive Bladder? OAB is itself a group of symptoms, not a disease. Signs of Overactive Bladder include feeling a sudden urge to urinate that’s difficult to control, urge incontinence or leaking urine immediately following an urgent need to urinate, or urinating frequently—usually eight or more times in 24 hours, and awakening two or more times during the night to urinate (Nocturia).

How is Overactive Bladder diagnosed? One of the fellowship-trained physicians will talk with you about your symptoms and perform a physical exam. A urine sample and blood test may be requested, and you may be asked to keep a bladder diary for several days to provide the doctor with as much information as possible to determine the cause of your OAB. Other special tests might include measuring the amount of urine left in the bladder with an ultrasound, testing bladder pressure, or looking into the bladder with a camera (cystoscopy).

How is Overactive Bladder treated? OAB may require a combination of treatments, including specific behavioral interventions. We will take your history and do a thorough exam to recommend the treatments best suited to you. Rest assured that we always try to suggest the least invasive treatments first.

The first type of therapy for OAB involves behavioral therapy and lifestyle changes. This can be as simple as watching fluid intake throughout the day and scheduling time to use the bathroom (timed voiding), as well as making sure that the bladder is emptying by urinating again a few minutes after first emptying the bladder (double voiding). It also may include dietary changes to avoid foods and drinks that irritate the bladder, as well as weight loss. Exercises to help relax the muscles in the pelvis when the bladder is overactive may help. Working with a pelvic floor physical therapist may help with these exercises.

Multiple medications are available to help with OAB symptoms. The most common medications, anticholinergics, have been used for many years. Common side effects include dry mouth and constipation, which can cause worsening of bladder symptoms, so management of constipation before you start these medications is crucial.

A newer medication, Mirabegron, is now available for treatment of OAB. This medication doesn’t have the same side effects of dry mouth or constipation, but may cause a slight rise in blood pressure.

Injecting the bladder with onabotulinumtoxinA (Botox®) is a third line therapy, if medications and behavioral therapy fail. The medication helps by paralyzing the muscle of the bladder so that it doesn’t contract as often. The biggest side effects are Urinary Retention, Urinary Tract Infections, and blood in the urine. The effects of the medication last 6 to 9 months, on average.
Nerve stimulation is another third line option. The nerves of the bladder can be stimulated through the ankle (peripheral tibial nerve stimulation or PTNS), which requires weekly treatments for 12 weeks. If this option works well, continued monthly treatments are needed. A more permanent nerve stimulation called Sacral Nerve Stimulation is like a pacemaker for the bladder. A test is performed in the office to see if you are a good candidate before the stimulator is placed.

If all of these options are unsuccessful, surgery can be performed to make the bladder larger using a piece of intestine. In the most severe cases, the bladder can be removed and a new bladder can be surgically created using the intestines.

Can Overactive Bladder be prevented? While nothing can completely prevent OAB, there are some steps you can take to reduce your chances of being affected or the severity of symptoms. Managing chronic conditions like diabetes, staying at a healthy weight, watching fluid intake, and smoking cessation can also help.

What is a Fistula? A fistula is an abnormal connection between two organs that are not usually connected, such as the vagina and bladder, or between an organ and another structure, such as the skin. The types of fistula of the pelvis involve abnormal connections between the bladder, bowel and/or vagina.

·   Vesicovaginal fistula—a connection between the vagina and the bladder.

·   Enterovaginal fistula—a connection between the vagina and the small intestines.

·   Rectovaginal fistula—a connection between the vagina and the rectum.

·   Enterovesical fistula—a connection between the small intestine and the bladder.

·   Colovesical fistula—a connection between the large intestine (colon) and the bladder.

What causes a Fistula? Fistulas are usually caused by tissue damage. This damage leads to inflammation and eventually can form an abnormal tract between two organs or an organ and the skin.

There are a number of risk factors for developing Fistulae in the pelvis:

·   Prior surgery in the pelvis, vagina or rectum. The most common cause of a vesicovaginal fistula in the United States is prior hysterectomy.

·   Radiation for cancer in the pelvis (cervical, vaginal (vulvar), bladder, rectal or prostate cancer).

·   Inflammatory bowel conditions, including Crohn’s disease, ulcerative colitis, and diverticulitis.

·   Tear in the vaginal wall during childbirth or an infected episiotomy.

What are the symptoms of a Fistula? Fistulae are usually painless. Depending on the two areas that are connected, you may experience a variety of symptoms.

If the bladder is involved, you may experience:

·   Symptoms of a Urinary Tract Infection, such as burning with urination, urinary frequency, urgency, blood in urine.

·   Passage of air while urinating.

·   Passage of stool contents in the urine.

If the vagina is involved, you may experience:

·   Continuous leakage of urine from the vagina (continuous incontinence).

·   Leakage of stool contents from the vagina.

·   Foul odor, discharge or gas from the vagina.

If the rectum is involved, you may experience:

·   Watery stools and/or urgency to pass bowel movements.

·   Continuous or frequent urine leakage from the rectum.

How is a Fistula diagnosed? One of the physicians will talk with you about your symptoms and perform a physical exam, including a pelvic exam or prostate exam. A urine sample is often requested to look for any signs of infection.

Imaging of the urinary tract, bladder or bowels might be necessary to identify the exact site of the abnormal connection. This may be performed with an x-ray of the bladder while filling your bladder with dye through a catheter (cystogram) and/or dye given orally or in the rectum.

If your symptoms involve a possible connection to the bladder, a cystoscopy (looking into the urethra and bladder with a camera) might be performed to find the fistula site.

How is a Fistula treated? Most fistulae are treated with surgery. The timing of surgery depends on a number of factors, including the cause and site of the fistula, as well as any other procedures that might need to be performed related to the cause.

Many fistulae to the vagina can be managed with surgery through the vagina, but some cases do require surgery through the abdomen. Fistulae involving the intestines may require the help of a general surgeon or colorectal surgeon to manage the bowel portion of the fistula.

What is Urinary Retention? Urinary Retention is the inability to empty the bladder. With chronic urinary retention, the patient may be able to urinate, but has trouble starting a stream or emptying their bladder completely.

What are the symptoms? The patient may urinate frequently; feel an urgent need to urinate but have little success; or feel they still have to go after they're finished urinating. With Acute Urinary Retention, it may be impossible to urinate at all, even with a full bladder. Acute Urinary Retention causes great discomfort, and even pain. Anyone can experience Urinary Retention, but it is most common in men in their 50s and 60s because of prostate enlargement.

What causes Urinary Retention? Urinary Retention can be caused by an obstruction in the urinary tract or by nerve problems that interfere with signals between the brain and the bladder. If the nerves aren't working properly, the brain may not get the message that the bladder is full. Even if the bladder is full, the bladder muscle that squeezes urine out may not get the signal that it is time to push, or the sphincter muscles may not get the signal that it is time to relax. A weak bladder muscle can also cause retention.

Chronic Urinary Retention, by comparison, might cause mild but constant discomfort. Patients have difficulty starting a stream of urine. Once started, the flow is weak. They may need to go frequently, and once they're finished, still feels the need to urinate. They may dribble between trips to the toilet because the bladder is constantly full, a condition called overflow incontinence.

How is Urinary Retention treated? Treatments to relieve prostate enlargement range from medication to surgery. With Acute Urinary Retention, treatment begins with the insertion of a catheter through the urethra to drain the bladder. This initial treatment relieves the immediate distress of a full bladder and prevents permanent bladder damage.

If you have retention after surgery, you will probably regain your ability to urinate after the effects of the anesthesia wear off. In such cases, you may need to have a catheter inserted once or twice with no other treatment required after you have shown you can urinate on your own. If you have Chronic Urinary Retention, or if acute retention appears to become chronic, further treatment will be necessary.

Bladder instillations are often used to treat patients with Interstitial Cystitis. Instillations help decrease bladder irritation, relieve pain, relax the bladder and pelvic muscles, and increase bladder capacity. For this procedure, your bladder is filled with a solution that you hold for varying periods of time—ranging from several seconds to 15 minutes—before the bladder is drained with a catheter. Depending on the severity of your condition, the instillations may need to be repeated several times to relieve your symptoms.

A bladder scan uses a portable ultrasound device that measures the amount of urine in your bladder. You will be asked to urinate, and then your doctor or nurse will use the bladder scan to determine the amount of urine left in your bladder. This helps us diagnose and detect chronic urinary retention.

A bladder stress test simulates the accidental release of urine that may occur when you cough, sneeze, laugh or exercise. While you’re lying down, a thin catheter is inserted into the bladder through the urethra, and fluid is inserted into the bladder through the catheter. (If your bladder is already full, the catheter may not be needed.)

The catheter is then removed, and you will be asked to cough. The doctor will look for any fluid loss and note the time interval between the “stress” (coughing) and the fluid loss. If the release of fluid is not detected during the bladder stress test, it may be repeated while you are standing. An absorbent pad may be worn to collect any urine released while you go about your daily activities.

OnabotulinumtoxinA has been used to treat patients with neurogenic bladder, and the U.S. Food and Drug Administration recently expanded the approved use of Botox® (onabotulinumtoxinA) to treat adults with Overactive Bladder (OAB) who cannot use or do not adequately respond to oral medications. When Botox® is injected into the bladder muscle, it causes the bladder to relax, increasing the bladder’s storage capacity and reducing episodes of urinary incontinence. The doctor will use cystoscopy to see inside your bladder while injecting the Botox®.

Patients who are unable to empty their bladder can learn to pass a catheter into the bladder as needed. Our nursing staff is trained to work with you to ensure that you can comfortably and safely insert and remove your catheter.

A colposcopy uses a light and a low-powered microscope to better view your cervix. This helps the physician find and, if necessary, biopsy abnormal areas in your cervix. For the test, you will lie on a table and place your feet in stirrups, just like you would for a pelvic exam. The doctor will then place an instrument (called a speculum) into your vagina to better see the cervix. Your cervix and vagina are gently swabbed with a vinegar or iodine solution to remove the mucus that covers the surface and highlight abnormal areas. The physician will place the colposcope at the opening of the vagina and examine the area. If any areas look abnormal, small samples of the tissue will be removed using small biopsy tools

Cystoscopy allows your doctor to look at areas of your bladder and urethra that usually do not show up well on x-rays by using a thin, lighted instrument called a cystoscope. The cystoscope is inserted into your urethra and slowly advanced into the bladder. Tiny surgical instruments can be inserted through the cystoscope, enabling your doctor to remove samples of tissue (biopsy) or urine. Small bladder stones and some small growths can be removed during cystoscopy, potentially eliminating the need for more extensive surgery.

Percutaneous Tibial Nerve Stimulation is a low-risk, non-surgical treatment for patients experiencing Overactive Bladder (OAB) and symptoms of urinary urgency, urinary frequency and/or urge incontinence. PTNS works by indirectly providing electrical stimulation to the nerves responsible for bladder and pelvic floor function. During PTNS treatment, your foot is comfortably elevated and supported, and a slim needle electrode is placed near the nerve at the tibial nerve (ankle). A device known as the Urgent PC Stimulator® is then connected to the electrode and sends mild electrical pulses to the tibial nerve. These impulses travel to the group of nerves at the base of the spine responsible for bladder function.

By stimulating these nerves through gentle electrical impulses (called neuromodulation), bladder activity can be changed. Because this change happens gradually, patients typically receive a series of 12 weekly, 30-minute treatments. After the 12 treatments, we will assess your response to the PTNS therapy and determine whether additional treatments will be needed occasionally to maintain the results.

A vaginal pessary is a removable device that is placed into your vagina to support areas of Pelvic Organ Prolapse. Pessaries may be made of rubber, plastic, or silicone-based material. Your doctor will help determine which type of pessary is best for you and will fit it to hold the pelvic organs in position without causing discomfort.

Nerve stimulation is a reversible treatment for patients experiencing Overactive Bladder (OAB), incomplete bladder emptying and fecal incontinence. Sacral Nerve Stimulation provides electrical stimulation to the nerves that control the bladder to help ease the symptoms of Overactive Bladder.

During a simple office procedure, a neurotransmitter device is implanted under the skin in the upper buttock area. This transmits mild electrical impulses through a lead wire close to your sacral nerve. These impulses influence the bladder sphincter and pelvic floor muscles providing bladder control. While SNS will not cure OAB, it can help reduce the number of voids and/or wetting episodes.

Urodynamic tests for urinary incontinence are measurements that help the physicians evaluate your bladder’s function and efficiency. For basic urodynamic testing performed in our office, you will be asked to arrive for testing with a full bladder. While you urinate into a container, the volume of urine and the rate at which your bladder empties will be measured. A thin catheter will then be inserted into your bladder through the urethra, and the volume of any urine remaining in your bladder—or post-void residual (PVR)—will be measured. Your bladder may also be filled with water through the catheter until you have the first urge to urinate. The amount of water in your bladder will be measured at that point. Then, more water may be added while you resist urinating until involuntary urination occurs.