Female Pelvic Medicine

Medications may be advised for interstitial cystitis, an inflammation of the bladder wall sometimes called painful bladder syndrome. Examples of treatments include heparinoid compounds (heparin) and DMSO (dimethyl sulfoxide), which relieve pain and inflammation.

A solution of the medication is directed into the bladder through a catheter, then held for an average of 10 to 15 minutes before the bladder is emptied. Treatment is given either every week or every other week for six to eight weeks and then repeated as needed. The patient usually feels improvement three to four weeks after the first six- or eight-week cycle.

Biofeedback is a practice designed to help patients better understand how their bodies normally behave. In the case of urge incontinence, biofeedback can help the patient recognize when the bladder is overactive and to contract the proper muscles to stop the urgency to urinate. A sensor is often used to monitor muscle activity in the vagina, rectum or on the pelvic floor.

PTNS is a non-invasive form of neuromodulation therapy (an alteration of nerve activity) that involves the stimulation of the posterior tibial nerve, which is near the ankle, on a weekly, outpatient basis.

In this procedure, an acupuncture needle/electrode is inserted near the nerve and a pad/electrode is adhered to the foot. The electrodes are then connected to a pulse generator, which delivers an electrical signal along the tibial nerve up to the sacral plexus in the pelvis, the group of nerves that controls bladder function.

For this treatment, the physician injects Botox directly into the bladder muscle during a cystoscopy (a procedure that enables the doctor to view the affected area through a tiny camera).

The drug partially paralyzes the bladder, relaxing it so it can store more urine, but leaving enough control to empty the bladder voluntarily. Botox treatment is not permanent – it typically lasts about nine months – and can cause side effects including urinary tract infections.

During this minimally invasive surgical procedure, a tiny pacemaker-like device is implanted through a small incision in the lower back and connected to a wire that is placed near the tailbone. This pacemaker calms the sacral nerves that control bladder function.

Because sacral nerve stimulation involves a permanent surgical implant, candidates must first undergo a trial known as the percutaneous nerve evaluation (PNE). In this procedure, a temporary electrode is inserted into to the pelvis area and connected to an external pulse generator, which produces a signal for three to five days. If the neuromodulation delivers positive results, the permanent pacemaker can be implanted.

The surgery:

The patient will be sedated for this procedure. The surgeon will insert an electrical pulse generator, like a pacemaker, under the skin in the upper, outer quadrant of the buttock. The generator is attached to a thin lead wire with a small electrode tip, which is anchored near the sacral nerve.

What to expect after surgery:

• Patients should be able to return home within an hour after the procedure.
• The pacemaker batteries may need to be replaced after three to five years.
• The success rate among patients with positive test results is up to 82%.

This procedure is relatively simple and can be done with minimal hospitalization and recovery time. The surgeon inserts a mesh tape under the urethra, like a hammock, to keep it in its normal position. The tape provides support for a sagging urethra so it remains closed (to prevent involuntary leakage).

The surgery:

The TVT procedure can be performed under local anesthesia and takes about 30 minutes. The surgeon makes tiny incisions in the abdomen and vaginal wall, through which the tape is inserted. No sutures are required to hold the tape in place.

What to expect after surgery:

• TVT surgery usually causes minimal pain and discomfort. Usually within hours of surgery, the patient will be asked to urinate to test how the bladder and urethra respond.
• It may be necessary to have a catheter – a thin, flexible tube – placed into the bladder to allow urine to drain during recovery.
• Although the patient may resume most normal activities within one to two weeks, driving is not advised for two weeks and sexual intercourse or strenuous activities are not advised for six weeks.

Injection therapy can be performed on both men and women. During the procedure, the physician injects collagen, body fat or synthetic compounds around the urethra, bulking up its wall so it can seal tightly and hold back urine. The procedure may also improve the function of the urethral sphincter – compressing the urethra near the bladder outlet.

The muscles of the pelvic floor and other supporting tissues hold the bladder, uterus and rectum in place. If these muscles and tissues weaken, the organs may shift out of their correct position, resulting in pelvic organ prolapse. The pessary will support and reduce stress on the bladder and other pelvic organs.

Kegels help to reinforce the muscles that control the flow of urine and can tighten the muscles of the pelvic floor. They may be prescribed for both men and women with incontinence or women with pelvic floor prolapse.

The exercise involves strongly contracting the pelvic muscles that hold back urine – many mothers may be familiar with the exercise from childbirth classes. These exercises should be performed as a regiment, meaning as many as 20 sets three times a day – but not during urination.

In this procedure, the physician inserts a mesh “kit” that pulls the vagina up to the sacrospinous ligament, which is located near the triangular bone just above the tailbone (sacrum).

The FDA has warned that transvaginal use of surgical mesh could introduce risks not present in traditional non-mesh or robotic mesh surgery, including: mesh erosion (exposure of the mesh in the vagina); mesh contracture (shrinkage); pelvic pain; pain with intercourse; bleeding and infection.

The surgery:

The patient will be given general or spinal anesthesia for this surgery. The surgeon will make incisions inside the vagina and then apply stitches to the tissue supporting the vagina, to strengthen it. The mesh is then placed underneath the vaginal skin and attached to the sacrospinous ligament. The incision is closed with stitches that will dissolve in one to two weeks.

The body’s own tissues will grow into the mesh within three to four weeks, enabling the mesh to reinforce the weakened vaginal tissue.

What to expect after surgery:

• The patient usually requires an overnight stay in the hospital before returning home.
• A catheter will be inserted into the bladder to drain urine and a material pack will be placed in the vagina to prevent bleeding. These will remain in place for one to two days.
• The patient will likely be prescribed antibiotics.

Prolapse occurs when the connective tissues or muscles within the body cavity are weak and unable to hold the vagina in place. The sacrocolpopexy can be performed on patients who have had a hysterectomy, or in conjunction with a robotic hysterectomy.

In the procedure, the surgeon connects the prolapsed vagina to the sacrum (the triangular bone just above the tailbone) using an artificial tissue material called a mesh. The Urology Group uses the da Vinci Surgical System for these procedures.

The surgery:

The da Vinci Surgical System combines computer and robotic technologies, making it possible to treat vaginal or uterine prolapse through a few small (1- to 2-cm), incisions, or operating ports.

The patient will be placed under anesthesia before surgery. The surgeon makes the incisions in the lower abdomen and then, using guiding robotic arms, inserts a soft synthetic mesh through the operating ports into the pelvic area. This mesh pulls the vagina up to the sacrum.

The body’s own tissues will grow into the mesh within three to four weeks, enabling the mesh to reinforce the weakened vaginal tissue.

What to expect after surgery:

• The patient usually requires an overnight stay before returning home.
• While sacrocolpopexy has traditionally been considered the “gold standard” for prolapse surgery, it requires abdominal surgery with post-operative recovery time of one to four weeks, depending on the patient.
• The patient may resume most normal activities within one to two weeks. However, driving is not advised for two weeks and sexual intercourse or strenuous activities are not advised for six weeks.
• Abdominal surgery also raises risks of intra-abdominal injuries, or bowel injury, but these are uncommon.

Benefits to the robotic method may include a shorter hospital stay, less pain, less risk of infection, less blood loss, fewer transfusions, less scarring, faster recovery and a quicker return to normal daily activities. None of these benefits can be guaranteed, however, as surgery is both patient- and procedure-specific.