Urogynecology/FPMRS

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CLS Health’s Female Pelvic Medicine and Reconstructive Surgery (FPMRS) clinic is a subspecialty within Obstetrics and Gynecology. Doctors called urogynecologists, or urogyns, receive special training to diagnose and treat women with pelvic floor disorders. Urogynecology is the study and treatment of pelvic floor disorders in women. The pelvic floor includes the muscles, ligaments, and connective tissues that support organs such as the bowel, bladder, uterus, vagina, and rectum.

Although your primary care physician, OB/GYN, or urologist may have knowledge about these problems, a urogyn offers additional expertise. Talk with your doctor about a referral to a urogyn if you have problems of prolapse, and/or troublesome urinary or fecal incontinence. Or, if you have problems with emptying the bladder or rectum, pelvic pain or bladder pain, fistulas.

Urogyns dedicate themselves to the study and treatment of PFDs in women. They are experts in all the various ways that PFDs can present. They also, if need be, offer special expertise in vaginal surgery.

Our female urologist treats women with pelvic floor disorders, such as recurrent bladder infections, urinary or fecal incontinence, and prolapse (bulging) of the vagina, bladder, and/or the uterus and rectum. We provide the most advanced care available to women with lower urinary tract and pelvic floor conditions. Additionally, we offer clinical trials for conditions such as urinary incontinence, fecal incontinence, overactive bladder, vaginal prolapse, and neurogenic bladder.

According to the American Urogynecologic Society, one-in-three women will experience a pelvic floor disorder in her life. Nearly all pelvic floor problems can be corrected through behavioral physical therapy, surgery, or medication.

             

             

Many patients benefit from minimally invasive surgical procedures performed by a bladder specialist. Minimally invasive surgery means less blood loss, faster recovery time, less pain medication, and less scarring. Some procedures can even be done on an outpatient basis.

We strive to treat Pelvic Floor conditions with compassionate and individualized care.The female pelvic and reconstructive surgery clinic at CLS Health offers the latest minimally invasive surgical and non-surgical treatments for women with:

The Female Pelvic and Reconstructive Surgery clinic is a part of CLS Health. CLS Health is a multi-specialty group with over ninety providers providing comprehensive inpatient and outpatient care in Baytown, Friendswood, Webster, Pasadena, League City, and surrounding areas. For more information, or to schedule an appointment with Dr. Danny Mounir, call 281-993-9817

Surgical and Nonsurgical Treatment Options:

Cystocele repair is a surgical procedure that is performed to repair the sinking of the vaginal wall or bulging of the bladder into the vagina.

The surgery may help to restore the normal position of your bladder and may reduce the pressure caused due to the bulging bladder onto your vagina. These surgeries are generally recommended in severe prolapse cases when physical therapy and medications do not resolve the condition. Surgery is generally done by taking a cut on the vagina or belly with basic three methods:

  • Anterior colporrhaphy: In this, the prolapsed bladder is repaired by making a cut on the vaginal surface and stitching the internal surface to strengthen the area.
  • Paravaginal repair: It repairs the prolapsed bladder by attaching it to the pelvic sidewalls.
  • Anterior colporrhaphy with graft: In this, a tissue graft is placed (if the tissue lining is very thin) along with stitches on the internal surface of the vagina.

Both non-surgical and surgical options are used to treat a rectocele. You should have a thorough physical exam and talk with your provider before deciding on the best treatment.
Non-Surgical Repairs
Most symptoms of a rectocele can be kept under control without surgery. Strategies include:

  • Avoid constipation by following a high-fiber diet (more than 25 grams of fiber per day) and drinking six to eight 10-ounce glasses of water per day.
  • Avoid straining during bowel movements and long periods of sitting on the toilet.
  • Use stool softeners if needed.
  • Follow exercises designed to strengthen and retrain the muscles of the pelvic floor.
  • Go to your provider to be fitted with a pessary, a device placed into the vagina to reduce the bulge.

Surgical Repairs
If non-surgical methods do not help control rectocele symptoms, surgery may be needed. Talking with a reconstructive surgeon who specializes in pelvic floor conditions can help women decide upon the best approach. In most cases, surgery is done under general anesthesia and takes about one hour.

  • The most common surgical repair is a transvaginal rectocele repair, also called a posterior repair. The rectocele is reached through the vagina. It offers the chance to correct not only the rectocele but a thinned perineum and widened vaginal opening. It also has the advantage of not disturbing any tissue in the rectal area. This is the traditional approach to rectocele repair by urologists and gynecologists.
  • A rectocele can also be repaired by a colorectal surgeon through a transanal repair. The rectocele is reached through the anus. This method is preferred by many colorectal surgeons because it allows for correction of problems in the anal or rectal area, in addition to repairing the rectocele.

Other types of repairs or approaches may be used when additional procedures are required, such as for uterine or bladder prolapse (cystocele) or rectal prolapse through the anus.

A Enterocele Repair (small bowel prolapse) occurs when the tissues and muscles that hold the small bowel in place are stretched or weakened this is a vaginal hernia known as an Enterocele it is repaired by sewing the supportive layers together. This can cause the small bowel to move from its natural position and press against the wall of the vagina

Enteroceles Repair Procedures are usually repaired through the vagina unless there is another health problem that would require an abdominal incision.

Enterocele Repair is where the pubocervical and rectovaginal fascia (supportive layers) are sewn together, repairing the vaginal hernia known as an Enterocele. Most patients who have done an Enterocele repair also need a vaginal vault suspension. In many cases the Enterocele is further supported or repaired with the use of mesh. This can be part of the vault suspension or Rectocele repair.

For fistula repair, patients seek the expert advice from gynecologists, urogynecologists, or colorectal surgeons. Following the diagnosis of a fistula, the medical professional will decide the best plan of treatment based on its location, size, and condition. One treatment path may simply be controlling symptoms with a catheter. More severe fistula repair may require surgery.

Non-invasive Treatment

  • Fibrin glue. A specific medicinal adhesive used to seal fistulas.
  • Plug. This is usually a collagen matrix used to fill the fistula.
  • Catheters. Used to drain fistulas, catheters are usually employed on small fistulas to manage infection.

Surgical Treatment

  • Transabdominal surgery. The fistula is accessed through an abdominal wall incision.
  • Laparoscopic surgery. This is a minimally invasive surgery that involves a tiny incision and the use of cameras and small tools to repair the fistula.

Pharmaceutical Treatment

Antibiotics or other medication may also be used to treat any infection associated with the fistula. Yet there is no pharmaceutical solution to eradicate fistulas at this time.

While fistulas pose a serious threat to your body, high treatment success should encourage you or someone dealing with fistulas to seek immediate help.

A pessary is a prosthetic device that can be inserted into the vagina to support its internal structure. It’s often used in the case of urinary incontinence and a vaginal or pelvic organ prolapse. A prolapse occurs when the vagina or another organ in the pelvis slips out of its usual place. The support a pessary provides can help a woman avoid pelvic surgery.

Sacral nerve stimulation, also known as sacral neuromodulation is an option for the management of patients with overactive bladder.

Sacral nerve stimulation is considered in individuals who have found no relief through conservative therapy.

Sacral nerve stimulation uses mild electrical impulses to stimulate the sacral nerves, at the base of the spine, that control the bladder and pelvic muscles. Stimulation of these nerves may alleviate your symptoms of overactive bladder and help restore normal bladder function. In an overactive bladder the sacral nerves send several irrelevant signals to the bladder, resulting in a sudden urge to urinate. Sacral nerve stimulation interrupts these signals and provides symptomatic relief.

In this procedure, a small device known as a neurotransmitter is implanted under the skin of the upper buttock region and a mild electrical current is transmitted through lead wires to stimulate the sacral nerves. This helps regulate the functioning of the bladder and related muscles. Sacral nerve stimulation is not a cure for overactive bladder; however it may help reduce the frequency of voids or wetting episodes associated with overactive bladder.

Sacral neuromodulation is indicated in people with various bladder and urinary problems including urinary urgency, frequency of urination, urinary incontinence (leakage of urine) and non-obstructive urinary retention.

PTNS – Percutaneous Tibial Nerve Stimulation is indicated in Overactive Bladder (OAB) problems where symptoms of urinary urgency, urinary frequency and urge incontinence have been difficult to resolve by other treatments.

Percutaneous Tibial Nerve Stimulation (PTNS) is designed to stimulate indirectly the nerves responsible for bladder control.  This treatment acts on the tibial nerve as it passes around your ankle and targets the nerves in the spinal cord that control pelvic floor function called the sacral nerve plexus.

Revision surgery is a surgery to remove or repair transvaginal mesh implants. Because manufacturers designed the medical devices to be permanent, surgery to remove them is complex and often more painful than the initial mesh procedure.

Interstitial cystitis (IC) is a chronic bladder syndrome in which there is the presence of pelvic pain, bladder pain or pressure, and urinary frequency or urgency. The pain can range in severity from mild to severe.

The treatment of interstitial cystitis is complex and can involve many approaches.

Potential treatments include:

  • physical therapy or alternative therapies, such as guided imagery, massage, energy therapy, or acupuncture
  • bladder distention
  • bladder instillations with mixtures including DMSO, sodium hyaluronate, Heparin and others
  • surgery to repair Hunner’s lesions, such as laser surgery
  • neuromodulation, such as the use of electrical nerve stimulators
  • injections, such as Botox

Overactive bladder is a combination of symptoms that can cause you to need to urinate more frequently, have more urgency, experience incontinence (leakage) and a need to urinate at night. One or all of these symptoms can cause considerable stress and a negative impact on your quality of life.

Urinary stress incontinence occurs when an activity such as coughing, sneezing, or exercising causes a small amount of urine to leak from the urethra, which is the tube urine passes through. Stress incontinence (SI) is the most common type of incontinence suffered by women, especially older women. In addition, women who have given birth are more likely to have stress incontinence.

Urge incontinence is characterized by loss of urine that is associated with a sudden, strong desire to urinate that cannot be postponed. Other symptoms include a need to urinate frequently and waking often during the night to urinate. The condition is also known as overactive bladder.

Some people manage to avoid urine loss by urinating frequently, but find the continual need to have a bathroom available restrictive to their lifestyles.

Treatment for urge incontinence may include behavioral treatments such as pelvic muscle exercises, medication, electrical stimulation or Botox injections.

Urodynamics are a set of tests that measure lower urinary tract function. The aim of testing is to reproduce your child’s voiding patters to identify any underlying problem.“Uro” refers to urine and “dynamics” refers to a continuous activity. This means that “urodynamics” is a continuing test, not just a single picture like in a chest X-ray. Through this way of testing, the doctor is able to obtain a great deal of information about your child’s voiding patterns.

A cystoscopy is a procedure to look inside the bladder using a thin camera called a cystoscope.

A cystoscope is inserted into the urethra (the tube that carries pee out of the body) and passed into the bladder to allow a doctor or nurse to see inside.

Small surgical instruments can also be passed down the cystoscope to treat some bladder problems at the same time.

There are 2 types of cystoscopy:

  • flexible cystoscopy – a thin (about the width of a pencil), bendy cystoscope is used, and you stay awake while it’s carried out
  • rigid cystoscopy – a slightly wider cystoscope that does not bend is used, and you’re either put to sleep or the lower half of your body is numbed while it’s carried out

Flexible cystoscopies tend to be done if the reason for the procedure is just to look inside your bladder. A rigid cystoscopy may be done if you need treatment for a problem in your bladder.

Anyone can have either type of cystoscopy. Ask your doctor or nurse which type you’re going to have if you’re not sure.

A sacrocolpopexy is a surgical procedure used to treat pelvic organ prolapse. Pelvic organ prolapse is a condition that is caused by a weakening of the normal support of the pelvic floor, and is similar to a hernia in the vagina.

In a sacrocolpopexy procedure, the surgeon attaches surgical mesh from the vagina to the sacrum (tail bone), which is the bone at the base of the spine. If a patient still has her uterus, the surgeon may decide to remove it, with or without leaving the cervix in place. If the cervix is left in place, the mesh will be applied over the top of the cervix, as well as to the vaginal walls.

A sacrocolpopexy is usually performed laparoscopically (through small incisions, or cuts) in the following way:

  • General anesthesia is administered so that the patient is asleep during the procedure.
  • Four to five incisions are made on the abdomen.
  • The abdomen is inflated with carbon dioxide gas to create space to perform the surgery.
  • A laparoscope (a thin, telescope-type tube with a camera) and other instruments are passed through the incisions.
  • A piece of surgical mesh is attached to the front and back walls of the vagina and then to the sacrum to suspend the top of the vagina or the cervix back into its normal position.
  • In many cases, the surgeon will also remove the uterus, but may leave the cervix in place if it is still present. Some women also choose to have their Fallopian tubes and/or ovaries removed, depending upon age and family history.
  • If there is not enough support for the bladder or rectum, the surgeon may repair these areas, usually through the vagina.
  • If the patient has urinary incontinence, the surgeon may place a small piece of mesh underneath the urethra to give support when the patient coughs, laughs or sneezes.
  • At the end of the surgery, a small camera is used to examine the inside of the bladder to ensure there were no injuries during the surgery.

The surgery takes 2-3 hours to complete. When it is over, the patient will be taken to the Post-Anesthesia Care Unit (PACU) to wake up from anesthesia.

Vaginal prolapse can happen to any woman. It is a common condition that occurs in about one-third of women in the U.S. Most of those who experience it have had a vaginal birth.

As women age, the risk of a vaginal prolapse increases. It happens when the muscles supporting the pelvic organs weaken, causing the uterus, bladder or urethra to droop.

If kegel exercises, weight loss and other alternative treatments do not help, a vaginal prolapse procedure may be required. This surgery is also known as a pelvic organ prolapse surgery or a pelvic reconstructive surgery. Its primary purpose is to put the organs back in their places. The procedure ensures that the organs will remain in their correct position.

The surgery requires a piece of the patient’s tissue. In some cases, a donor’s tissue may be used or even an artificial material. It is done through the vagina, but can also be performed through small incisions in the abdomen.

A uterine prolapse (Utero-Vaginal) occurs when the ligaments of the uterus are stretched due to weakness in the pelvic floor resulting in the uterus slipping down into the vaginal passage. Cystocele and Rectocele can also lead to development of a uterine prolapse. With this type of pelvic organ prolapse, you will feel the uterus bulging into the vagina. Uterine prolapse is measured in stages ranging from stage 1 which is a minor prolapse, to stage 4 which is complete prolapse. It is very important to begin pelvic floor muscle training as soon as possible to regain the strength in your pelvic floor and lessen the symptoms of your prolapse.

A uterosacral ligament suspension is an operation designed to restore support to the uterus (womb) or vaginal vault (top of the vagina in a woman who has had a hysterectomy).

The uterosacral ligaments are strong supportive structures that attach the cervix (neck of the womb) to the sacrum (bottom of the spine). Weakness and stretching of these ligaments can contribute to pelvic organ prolapse. A uterosacral ligament suspension involves stitching the uterosacral ligaments to the apex or top of the vagina, thereby restoring normal support to the top of the vagina. This operation can be done vaginally, abdominally or laparoscopically (“keyhole”), and your surgeon will discuss these options with you. It is also sometimes done at the time of a hysterectomy in order to reduce the risk of prolapse in the future and can be combined with other procedures for prolapse or incontinence.

The sling surgical procedure is commonly recommended for the management of stress urinary incontinence, which is the most common type of urinary incontinence. Women often develop stress urinary incontinence from weak pelvic floor muscles (the hammock of muscles that support your bowel, uterus, and bladder), which places additional pressure on your bladder and urethra. With stress urinary incontinence, coughing, sneezing, exercising, or lifting heavy objects can lead to urine loss.

The sling consists of a mesh, either synthetic or created from your own body tissue, that serves as a hammock for your urethra or bladder and keeps your urethra closed to prevent urine leakage. The retropubic sling procedure refers to the surgical approach used to place your sling.

Transobturator Sling is a surgical procedure that uses a narrow strip of permanent mesh to correct stress urinary incontinence (SUI). This procedure is completed through the vagina and two groin incisions; it creates stabilization and support for the urethra, the tube carrying urine from the bladder to the outside of the body. Once placed, the sling lies under the urethra and acts as a hammock to provide the needed support to prevent urinary leakage during episodes of increased abdominal pressures, such as coughing, sneezing, or lifting.

A Burch urethropexy is a procedure to correct stress urinary incontinence (SUI). SUI is a type of urinary incontinence that is defined as involuntary leakage of urine related to an increase in intraabdominal pressure that occurs during sneezing, laughing, coughing or exercise. It is a very common condition that occurs in 1 in 3 women.

SUI occurs when the supports of the urethra are weakened allowing for hypermobility or instability of the urethral. The Burch urethropexy was original performed as an abdominal procedure. Sutures are placed in the retropubic space (space of Retzius) to suspend and stabilize the urethra.

The Burch urethropexy is an abdominal procedure performed to correct stress urinary incontinence. It involves placement of permanent sutures next to the urethra to suspend and support and correct hypermobility of the urethra that occurs due to weakness in the normal supports. A total of two stitches are placed on each side, one at the level of the bladder neck and the other at the level of the midurethra.

Vesicovaginal fistula repair is surgery to close or remove a fistula between your bladder and vagina. A fistula is an abnormal tissue connection or hole. When you have a fistula, urine exits your body through your vagina, and you cannot control the flow of urine.

A bladder biopsy is a diagnostic surgical procedure in which a doctor removes cells or tissue from your bladder to be tested in a laboratory. This typically involves inserting a tube with a camera and a needle into the urethra, which is the opening in your body through which urine is expelled.

Your doctor will likely recommend a bladder biopsy if they suspect your symptoms might be caused by The symptoms of bladder cancer include:

  • blood in the urine
  • frequent urination
  • painful urination
  • lower back pain

These symptoms can be caused by other things, such as an infection. A biopsy is done if your doctor strongly suspects cancer or finds cancer through other, less invasive, tests. You’ll have tests of your urine and some imaging tests, such as an X-ray or CT scan, before the procedure. These tests will help your doctor determine if there are cancer cells in your urine or a growth on your bladder. The scans cannot tell if the growth is cancerous. That can only be determined when your biopsy sample is reviewed in a laboratory.

The paravaginal defect repair restores the natural support of the vaginal fornices by reapproximating them to the arcus tendineus fascia pelvis overlying the levator and obturator internus muscles. Pelvic surgeons employing this surgical technique distinguish between cystcoele caused by attenuation or tearing of the pubocervical fascia (the midline defect) and cystcoele caused by detachment of the pubocervical fascia from its sidewall support (the paravaginal defect).

The paravaginal defect repair can be undertaken either through an abdominal or vaginal approach. Both procedures have been used to treat cystcoele and stress urinary incontinence with success rates that range from 66 to 97 percent. The postoperative morbidity associated with paravaginal repair, including urinary retention, detrusor instability , and recurrent pelvic prolapse, is reduced when compared to the traditional anterior colporrhaphy and retropubic incontinence procedures.

Urethral bulking injections are a treatment for SUI. Injections may also be used for women that still leak after surgery. With a this camera (called a cystoscope) inserted into the urethra, the doctor uses a thin needle to inject the bulking agent around the walls of the urethra. This helps to hold in urine when you are doing activities like coughing, sneezing, or exercising.

A hysterectomy is surgery to remove your uterus (partial hysterectomy) or your uterus plus your cervix (total hysterectomy).

If you need a hysterectomy, your doctor might recommend robot-assisted (robotic) surgery. During robotic surgery, your doctor performs the hysterectomy with instruments that are passed through small abdominal cuts (incisions). The magnified, 3D view makes possible great precision, flexibility and control.

When you have a minimally invasive hysterectomy, you’re likely to have less pain and lose less blood than is typical with open abdominal surgery. You’ll probably be able to resume normal daily activities more quickly than you could after open surgery.

Descending perineum syndrome is characterized by the bulging and excessive descent of the perineum during defecation, often with a weak pelvic floor, and can be demonstrated with either physical examination or defecography. Typically, patients present with a long history of chronic straining and a sensation of incomplete evacuation followed by a sensation of obstruction. Over time, complaints of mucoid discharge, bleeding, and perineal irritation may occur due to the prolapse of the anterior rectal wall. It is best described as a vicious cycle of straining and constipation, which leads to more straining and exacerbation of the anatomical abnormality and descent of the perineum.

Perineorrhaphy, also known as Perineoplasty, is the most common type of vaginal surgery performed. The term refers to surgeries that correct conditions involving the perineal body: namely, the span of tissue between the vaginal opening and the anus. These conditions can include vaginal opening looseness or tightness, incontinence, a damaged or scarred perineum, vaginal warts, decreased sexual sensation or pain with penetration, to name a few.

Vaginal reconstruction or vaginal rejuvenation surgery are the terms used for a wide range of procedures whose objectives are to repair or reconstruct the vagina. Vaginal surgery of this kind aims to reduce pain and improve the appearance, size, function and possibly the sensitivity of the vagina.

Several procedures may be included under this umbrella term including:

  • Vaginoplasty (tightening of the vagina)
  • Labiaplasty (reshaping of the labia)
  • Vulvaplasty (reshaping of the vulva)

Reduction of pain is not the only positive result of vaginal surgery, many women discover a renewed self-confidence post-procedure.

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