Treatment

It is not normal to live with uncomfortable symptoms of incontinence or pelvic organ prolapse. Effective help is available. The Center for Advanced Gynecologic Surgery and Pelvic Floor Medicine can direct a range of treatments.

The purpose of the information provided on this page is only to familiarize you with available treatment options. Please, contact you doctor for appropriate evaluation prior initiation of any therapies.

Prior to advising on any specific treatment options correct diagnosis must be established. It becomes possible after initial consultation and diagnostic testing if required.

Treatment may vary considerably depending on patient’s specific problems and ranges from simple conservative measures to very complex surgical procedures followed by comprehensive rehabilitation program.

Conservative Therapies for Patients with Urinary Symptoms

Dietary Modifications:

There is no "diet" cure for incontinence however, there are certain dietary irritants excluded from a diet may improve one symptoms significantly. For foods cause bladder irritants, please, refer to dietary irritants to urinary tract for more information. Patients with frequent urinary urgency at night suggested to reduce or depend on severity of symptoms totally eliminate consumption of Sodium Chloride (cooking salt). Sodium Chloride promotes water retention what in return converts in the urine at night producing frequency and urgency. Cooking salt can be substituted it by “Dash Salt” (sold in every supermarket), which contains Potassium Chloride a substance with salty taste but not retaining water. Please, pay attention to product label information because many would have significant amount of salt you may unintentionally consume. Of course curried, preserved, marinated, smoked and canned products may contain a lot of salt.

Regardless of the cause of your urinary problem, caffeine is sure to worsen it. The first step in your recovery should involve eliminating or reducing your caffeine intake. Caffeine is a regular part of the diet of most people in the world. It is found in many popular beverages and many over the counter cold medications. The caffeine content of many of these products can be found in the tables provided (Table1, Table2). Caffeine affects the bladder in two ways. First, it is a potent diuretic. It increases urine production and may readily overwhelm the bladder with urine. This clearly worsens incontinence. Secondly, caffeine irritates the bladder causing bladder spasms. Spasms are a major cause of urinary incontinence.

Fluids Management:

Many people drink either too much or to little of fluids. Either situation may produce urinary frequency and urgency. Drinking a lot of fluids will produce more urine hence more frequent urinations. With insufficient fluid intake urine is more concentrated and will produce irritation of the bladder. It also encourages the growth of bacteria. Remember it is always best to check with your professional if you have a strong odor of your urine to rule out infection.

Try to drink 5-7 glasses of fluids per day (7-9 during hot days if perspiring a lot) unless otherwise advised by a doctor. Patient with symptoms of fluid retention should avoid drinking after 6 p.m. If you become unusually thirsty after 6 p.m. drink just enough to quench your thirst.

Behavioral Modification Techniques:

• Bladder Retraining: Tools include voiding diaries, recognizing stimuli that initiate bladder contraction, relaxation techniques, urge suppression and prompted voiding. The main goal of bladder retraining is to achieve comfortable voiding intervals on average up to 3 hours. It is advisable to start by determining most comfortable voiding interval. Try to maintain voiding schedule in accordance with defined comfortable voiding interval during a day for one week. Next week add 15 minutes to you comfortable voiding interval and attempt voiding by clock regardless of a desire. Try to withhold voiding and control urine if feel urgency before anticipated/scheduled voiding time. Continue a regiment for entire week. Next week again extend voiding time for 15 minutes more. Continue increasing your comfortable voiding interval with 15 minutes increments each following week until achieve comfortable voiding intervals on average up to 3 hours or more if possible. This technique will allow resetting your threshold and increase comfortable voiding interval slowly with more chance for success. An entire bladder-retraining program may take several weeks before progress toward desirable results is achieved. It is helpful to have guidance and positive reinforcement.

A Bladder or Voiding Diary is a helpful tool and provide guidance in understanding the pattern to how often voiding occurs, how often there is an urge or strong desire to void, how often incontinence occurs, and other pertinent data related to urination. For a copy, click urinary diary.

• Scheduled/Timed Voiding: After desirable comfortable voiding interval is defined and achieved voiding should continue in accordance with established schedule around the clock during the day. This will allow bladder receptors to get use to certain amount of urine before they trigger involuntary contraction of the bladder muscle producing sense of urgency and possible urinary loss.

• Listed below are other behavioral techniques to control urinary urge:
- Do not rush to the bathroom. Try to be calm and maintain control. Rushing to the bathroom can intensify the urge for the bladder to contract.
- Do several quick contractions of the pelvic floor muscles. Use effort to keep from leaking. If possible, sit down for direct pressure on the pelvic floor.
- Relax. If you have practiced diaphragmatic breathing in the past, use that skill to relax. (Take slow, deep breaths through your nose, and then slowly breathe out through pursed lips.) Use distraction techniques to try and make the urinary urge go away.
- When you feel the urge subside, walk slowly and normally to the bathroom. You can repeat the above steps to gain control if the urge returns.
- You can slowly proceed to the toilet room to empty your bladder once the urge has subsided.

Supportive and Obstructive Devices:

Pessary:

A pessary is a device placed in the vagina to support the prolapse of pelvic organs and /or help with urinary incontinence. Most are made from silicone, and they come in various shapes and sizes. Your health care provider can prescribe and fit this device. It should be comfortable when properly placed inside the vagina. The health care provider should direct how often the pessary is to be removed and regularly cleaned. Some are removed once a day to twice a week, while others need to be removed and cleaned at least once every 2-3 months. In postmenopausal women Estrogen cream should be used to prevent pressure sores and infection in vagina.

Urethral Inserts and Patches:

Urethral inserts give women some personal control over incontinence. One type of insert is the urethral plug. The plug is available by prescription and works like a balloon that is inflated to prevent urine passage through the urethra.

Another type of plug seals the urethra, preventing urine from leaking out. When the woman needs to urinate, she removes the insert, and then replaces it again afterwards. It may be especially helpful to women who have incontinence mostly during exercises.

Recently, urinary patches have become available. They are small foam pads with gel adhesive that fit over the urethral opening and absorb minor leakage. Most are designed to seal the urethral opening. Easier to use than urethral plugs, patches are disposable, and replaced after each use. A small shield that fits over the urethral opening is another recent innovation. Generally, inserts are not recommended for women who need them all the time

Kegel’s Exercises:

Kegel’s exercises, or pelvic floor muscle exercises, were introduced by Dr. Arnold Kegel. Since he introduced these exercises, they have become one of the first options in the treatment of people with incontinence. The pelvic muscles can be exercised just like any other voluntary muscle in the body.

Pelvic floor exercises can strengthen the muscles of the pelvic floor, increasing the control of the loss of urine. They can improve the tone of the muscles supporting the pelvic organs. Kegel exercises can increase awareness, endurance, and control of the pelvic muscle, improving their sexual function.

The pelvis is the part of the body that includes the hipbones. The pelvic floor muscles stretch between the back, front, and sides of these bones, similar to a hammock. The vagina, urethra and rectum are passageways in these muscles. Support of these organs and their function such as urination and bowel elimination, as well as urinary and bowel continence largely depends on condition of these muscles.

The exercises are not hard to do. They do take time and effort to learn. They produce results when practiced regularly over time. Improvement can be seen within one month after starting the exercises. In two to four months, more noticeable benefits can occur. Tightening these muscles before sneezing, coughing, and lifting may reduce symptoms of urine leakage. Be patient and consistent and you will experience results. If you have recently had pelvic surgery, your doctor will advise you about when you can begin Kegel’s exercises.

Pelvic Physical Therapy:

• Vaginal Cones: For the pelvic floor, therapists frequently use vaginal cones as a convenient system of progressive pelvic floor weights. A set of five weights ranging from 20 g to 70 g is currently available in the United States Cone therapy can be initiated during a regular office visit. The lightest cone is inserted into the standing patient's vagina. Muscular contraction should be noted for proper cone placement. If the cone can be held within the vagina for 1 minute, the patient is advanced to the next heaviest cone. This process is repeated until the cone cannot be held for 1 minute. This cone will be used to initiate the progressive strengthening program. A typical program begins with the patient inserting the appropriate cone in the morning. The patient is instructed to be upright and go about her daily routine for 15 minutes, reinserting the weighted cone when she feels it is slipping out. The patient should have a conscious sensation of "holding" the cone. Cones, which are placed too far posteriorly in the vagina do not effectively work the muscles. This routine is repeated later in the day. When the patient can hold this cone for the full 15 minutes without it slipping, she is instructed to progress to the next heaviest cone.

• Biofeedback Therapy: Biofeedback is the process of reinforcing something that is happening in the body. Receiving feedback helps to increase awareness of muscle response. It can be used as a learning technique to measure the strength and duration of pelvic floor muscle contractions, as well as muscle relaxation during rest. Biofeedback reinforces the proper performance of pelvic floor muscle exercises.

Biofeedback is initiated after recommendation from your physician. Biofeedback uses specialized equipment and it is painless. In the health care settings, the equipment is operated by a health care provider or clinician with special training.

Sensors detect the contraction of muscle tissue. These sensors can be placed on the skin by adhesive, or an internal sensor can be placed in the vaginal or rectal space. The method usually depends on the equipment available. The data that the sensors collect are converted into sound or images. By hearing or seeing a result of your muscle contraction, you can modify and try to optimize your responses of the muscles in the pelvic floor.

The results will guide a program of pelvic floor muscle exercises you can do at home between clinic visits. Usually 2 to 8 clinic visits are needed in order to see successful results. Sometimes, portable biofeedback monitors are prescribed to assist persons with practicing pelvic muscle exercises at home.

• Electrical Stimulation: Electrical stimulation, also called pelvic muscle stimulation, is a treatment used to aid in the reeducation of pelvic muscles after injury, disuse or prolonged muscle spasm. The application of electrical stimulation to the pelvic muscles has been has been shown to improve bladder and bowel evacuatory problems as well as urinary and flatus/gas or fecal incontinence.

The muscles and nerves of the bladder can be activated by external sources. An internal electrode is placed either vaginally or rectally and attached to a battery operated hand-held machine. The machine has preset readings, which deliver a comfortable, timed stimulation to the area causing either the muscles to contract or relax. Individual treatment may vary from several weeks to long-term usage. They can be used to help you identify the muscles, create a stronger awareness of your muscle contraction and provide a timed exercise session.

Medications:

• Hormone Replacement Therapy: Estrogens is a hormones taken up by receptors in the tissue of the vagina and urethra. It facilitates healthy integrity in these tissues. After menopause, the ovaries may not produce a therapeutic level of estrogen. This can result in thin, dry tissue in the walls of the vagina and urethra and subsequently contribute to urinary incontinence. If you have questions about estrogen and incontinence, your physician can discuss with you the benefits and risks of estrogen replacement therapy.

• Antispasmodics: In the medical treatment of urge incontinence medications that help to relax the detrusor muscle around the bladder are sometimes effective. Some of these medicines are:
     - Oxybutinin Chloride or Ditropan (anticholinergic also)
     - Dicyclomine HCL or Bentyl
     - Flavoxate or Urispas (anticholinergics also)
     - Tolterodine or Detrol (anticholinergics also)

• Anticholinergics are a group of medicines that also relax smooth muscle. They can have the following side effects: dry mouth, impaired idea, constipation, tachycardia, postural hypotension, increased intraocular (eye) pressure (contraindicated for patients with closed-angle glaucoma).
- Propantheline or Pro-Banthine
- Methantheline

• Tricyclic Antidepressant: Imipramine (also has anticholinergic effects) may cause drop in blood pressure when standing up suddenly. Imipramine relaxes the detrusor muscle around the bladder and tightens the urethral sphincter. It is often used to treat stress and mixed urinary incontinence.

The best success rate for treatment of stress urinary Incontinence is obtained with surgical approach.

Conservative Therapies for Patients with Bowel Symptoms

Individualized approach in treatment of patients with dysfunctions should be applied depending on their specific problems. Definitive diagnosis should be established prior to initiation of any treatment. Most of the time it requires comprehensive diagnostic testing.

Therapy measures usually include dietary modifications, physical therapy, medications if needed and surgery as indicated.

Surgical Treatment

Surgical treatment of pelvic relaxations with associated urinary and/or bowel symptoms are multifaceted and especially very complex if patient has failed previous operations. In this case it is advisable to seek a help of a physician formally trained in Urogynecologic and Pelvic Reconstructive surgery. Right procedure addressing all pelvic relaxation defects at the same time will provide the best success and longevity of operation. If quality of patient’s tissues will be found to be inadequate to provide adequate long-term support, reinforcement with synthetic materials or allograft should be strongly considered to prevent recurrence. Training to perform these operations are obtained through fellowship programs usually offered in university setting.

Procedures for Treatment of Stress Urinary Incontinence:

• Marshal –Marchetti-Krantz Procedure: Abdominal retropubic procedure introduced in 1949 where paraurethral vaginal tissues are attached to posterior (inner) side of pubic bone in the midline to support hypermobile urethra.

• Burch Colposuspention: Abdominal or laparoscopic retropubic procedure where paraurethral vaginal tissues are attached to ligamentous tissue (Cooper’s ligaments) on the top of pubic bone and lateral (on the sides) to the midline to support hypermobile urethra.

• Needle Procedures: Number of conceptually similar procedures where paraurethral vaginal tissues are suspended to anterior abdominal wall. These operations have fell out of favor due to lack of long-term results.

• Sling procedures: Number of conceptually similar procedures where either patient own tissue, synthetic mesh, cadaveric or porcine materials are brought from underneath and on the sides of the urethra to the anterior abdominal wall where it fixed to provide a support for urethra in treatment on stress urinary incontinence. Recently minimally invasive surgeries have been introduced with very high success rate and longevity of results.

Procedures for Treatment of Pelvic Organs Prolapse:

• Anterior colporrhaphy: Vaginal operation to restore the integrity of the tissues between the bladder and vagina in the midline and reestablish support for the bladder to repair a cystocele. Also known as “anterior repair”.

• Paravaginal defects repair: This is a procedure, which performed via vaginal, abdominal or laparoscopic approach where anterior vaginal wall is attached of the to the pelvic sidewalls to repair a displacement cystocele.

• Posterior colporrhaphy: A vaginal operation to repair and reinforce posterior vaginal wall and prevent bulging of the rectum into vaginal space to correct a rectocele. Also known as “posterior repair”.

• Halban's culdeplasty: Closure of cul-de-sac (the space between the vagina and rectum) via abdominal or vaginal routs to prevent and/or correct an enterocele (the small bowel protrusion) into vagina by placing sutures in longitudinal fashion.

• Moschowitz culdeplasty: Closure of cul-de-sac (the space between the vagina and rectum) via abdominal or vaginal routs to prevent and/or correct an enterocele (the small bowel protrusion) into vagina by placing sutures in circular fashion.

• McCall's culdeplasty: Closure of the cul-de-sac (the space between the vagina and rectum) via abdominal or vaginal routs to prevent and/or correct an enterocele (the small bowel protrusion) into vagina by bringing utero-sacral ligaments (attachments of the uterus and vagina to pelvic bones) to the midline. This will also suspend the top of the vagina.

• Utero-sacral ligament suspension: Suspension of the top of the vagina to the utero-sacral ligaments. This can be performed vaginally, abdominally or laparoscopically.

• Sacro-spinous vaginal vault suspension: A vaginal operation when the top of the prolapsed vagina is attached to the sacro-spinous ligament in the pelvis. Most of the time performed on the right side (due to the fact that rectum covers sacro-spinous ligament on the left side). Vagina always somewhat deviated to the side where it is attached and posterior to the rectum.

• Sacral Colpopexy: A procedure (performed abdominally or laparoscopically) that attaches the top of the prolapsed vagina to the sacrum using either synthetic mesh, cadaveric or porcine materials.

• Illiococcygeal fascial attachment: A vaginal operation when the top of the prolapsed vagina is attached to the fascial tissue covering pelvic floor muscles.

• Total colpectomy and colpocliesis: A vaginal operation leading to closure of the vagina to repair the prolapse. The results of closure of the vagina are permanent, irreversible and sexual function is not possible.

• Partial colpocliesis: A vaginal operation leading to complete approximation of anterior and posterior vaginal wall (similar to colpectomy) to achieve almost complete closure of vagina while leaving channels at the side for drainage from the uterus (which is not removed). This procedure will not allow evaluating cervix or the uterus. The results of partial closure of the vagina are also permanent, irreversible and sexual function is not possible.

• Total abdominal hysterectomy (with or without bilateral salpingo / oophorectomy): Procedure directed on removal of the uterus (body and cervix), tubes and ovaries through an abdominal incision.

• Total vaginal hysterectomy (with or without bilateral salpingo / oophorectomy): Procedure directed on removal of the uterus (body and cervix), tubes and ovaries through a vaginal incision.

• Bilateral salpingo/Oophorectomy: Procedure directed on removal of tubes and ovaries (performed either abdominally, vaginally or laparoscopically).

• Overlapping anal sphincteroplasty: Reattach divided muscle edges around anus to correct fecal incontinence.

Preoperative Preparation

Preoperative work up:

• Labs: During final preop consultation with a doctor you will receive preprinted preop orders sheet where all required tests would be indicated. It may include appropriate blood work, EKG and X-Ray as needed. Occasionally, patients with severe medical problems may be required to obtain a Medical Clearance from their Primary Care Physician or Cardiologist. Patient with severe pulmonary problems may require a consultation with Pulmonologist (lungs specialist) and pulmonary function tests as needed.

• Admitting to the hospital: Within three days prior to surgery patients have to register in the admitting department of the hospital where surgery would be conducted. There they would have a medical record number assigned and referred to laboratory for tests indicated in preop order sheet.

• “Bowel Prep”: Patient undergoing bowel surgery will require to perform a “bowel prep” to allow their bowel to be absolutely free of fecal matter and prevent contamination of surgical field as well as delay a fecal stream postoperatively.

• Preop Medications:

- Patients taking “blood thinners” including Aspirin and/or Anti-inflammatory or pain medications must discuss this with a physician and may need to stop their medications at least seven days prior to their surgery. Be aware that many “over-the-counter” medications may contain Aspirin-like compounds. Please, discuss it with your pharmacist or physician to avoid bleeding complications during surgery.

- Please, bring a list of your medications, including vitamins and herbs that you are currently using to the hospital.

- You are advised to take only anti-hypertensive medications on the day of surgery as it is prescribed.

- If you are taking any diabetic medications, please, do not take them on the day of surgery unless instructed otherwise by your physician.

- If you taking any breathing treatments (inhailers) please, bring them to the hospital on the day of surgery.

Hospital Care:

Patients are asked to arrive to the hospital on day of surgery at least 1½ hours prior to scheduled operation unless advised otherwise. After surgery patients transferred to recovery room where they remained for about 1-1½ hours until completely recover from anesthesia. Then they transferred to assigned room on the medical-surgical floor. Usually it takes about three days to recover and gain enough energy to released to home given no complications occurred. Criteria for discharge are as follow:

• Patient is able to ambulate without assistance, given she was able to do it prior to surgery.

• Post-operative pain is well controlled by oral medications without a need or intravenous meds.

• Patient is able to eat and drink without nausea and vomiting.

• Patient is able to pass flatus.

• Many patients after reconstructive surgery for prolapse or urinary incontinence with require bladder catheterization and may leave a hospital with a catheter in place. This is not a complication bur rather a routine recovery process. It happens due to urethral edema (swelling) and changes in voiding mechanism. Patients will be given a trial of voiding on second postoperative day. Nurses will work with patients to educate them how to manage their catheter so, it would not be any concerns how to do it at home if needed. Patients who’s would be able to regain their voiding function will have their catheters removed prior to their discharge from the hospital.

• If needed patients with fragile health and severe medical problems may need to be transferred to rehabilitation hospital or nursing home for further recovery. Visiting nurses, physical and occupational therapists are available on out-patient bases as required by patient’s condition to facilitate their recovery.

• Before leaving a hospital patients will receive preprinted “Discharge Instructions”, “Bladder Catheter Instructions” and “Dietary Instructions” as needed.

• Discharge medications will be called in to the pharmacy of your choice.

Post-operative Care:

First follow up visit with your doctor will be about two weeks after surgery or sooner if indicated, then as frequently as needed. Patients should adhere to postoperative “Discharge Instructions”, which describe all-important aspects of recovery process to assure success of operation and they are:

• Nutrition
• Hygiene
• Activities
• Bladder Drill
• Exercises
• Vaginal Discharge
• Sexual activity
• Bowel habits
• Medications
• Follow-up Care

You may call your doctor with any problems and you will be seen on emergency basis as needed. With questions call after 5 pm, with emergency any time it occurs.

Patients who would leave a hospital with suprapubic bladder catheter in place will be expected to call a doctor every three days to report their progress with voiding. Patients after bowel surgery will need to stay on “Low Residue Low Fiber Diet” for three weeks after surgery and then switching to “Fiber Rich Diet”.