Well-Woman Care
At Center for Pelvic Health and Wellness, we specialize in women’s health and offer gynecology and well-woman care (preventive care) for women of all ages, all stages of life. Our expert medical team is specialty trained in female pelvic health and wellness as well as gynecology and urology related conditions, treatments, and procedures. We are here to partner with you to help you live your best life.
Urinary Incontinence (Loss of Bladder Control)
Urinary Incontinence is the involuntary loss of urine and is a source of stress and embarrassment in a woman’s life. Incontinence is a very common condition effecting millions of women and men every year. In fact, more money is spent on adult diapers than on infant diapers every year. The treatments for incontinence vary depending on the cause.
Urge Incontinence is usually treated with bladder training and fluid management, pelvic physical therapy and muscle strengthening, medications that reduce bladder urgency, neuromodulation treatments such as posterior tibial nerve stimulation and InterStim to reduce urgency and leakage by stimulation nerves that influence the bladder, and Botox which reduces bladder contractions by directly injecting the bladder muscle with the neurotoxin Botulinum A.
Stress incontinence is the involuntary loss of urine with activity or cough and urge incontinence the loss of urine with the desire or urge to void. The evaluation of urinary leakage involves a pelvic exam, urine culture, urinary diary, and often bladder testing to document and clarify the type of leakage, so the correct treatments can be offered.
Stress Incontinence results from the loss of anatomical support of the urethra (the tube that carries urine out from the bladder) and the neck of bladder, weakening of the muscles surrounding the urethra, and loss of the cushion of tissue inside the urethra at the neck of the bladder.
Treatments are aimed at strengthening the muscles through pelvic floor exercises include Kegel exercises with a certified pelvic therapist, and now the Emsella® Chair which delivers high frequency electromagnetic stimulation of the pelvic floor resulting in stronger pelvic muscles. And, ThermiVa which increases the collagen matrix under the bladder neck and restores support to the urethra. This includes “bulking or plumping” the cushion inside the urethra to reduce the opening and escape of urine.
The most effective surgical treatment for stress incontinence is called a urethral sling. The urethral sling has evolved over 50 years to the current minimally invasive tension-free mesh sling. It is the most studied procedure for urinary incontinence ever and is highly effective and safe. The procedure is outpatient and takes about 30 minutes. Most women are able to go home in a few hours following surgery will the ability to void on their own.
The sling is made of a polypropylene mesh and is a permanent strip of material that sits under the urethra like a hammock. The tissues surrounding the sling grow into the fine pores of the mesh to keep it in place over about 6 weeks. Although most women feel little pain and recover quickly (within a few days to a week), strenuous exercise should be avoided for a minimum of 6 weeks and sometimes up to 12 weeks depending on healing and activities desired.
Is Mesh Safe?
In 2011 the FDA released a white paper about transvaginal placement of surgical mesh for pelvic organ prolapse. Slings were brought into the spotlight by the media and many lawsuits involving mesh. The FDA website restated the safety and effectiveness of slings based on many clinical trials.
The American Urogynecology Society Position Statement was released in 2014:
- Polypropylene is safe and effective as a surgical implant.
- The monofilament polypropylene mesh sling is the most extensively studied anti-incontinence procedure in history.
- Polypropylene mid-urethral slings are the standard of care for stress incontinence.
Pelvic Organ Prolapse (Relaxation of Vagina & Pelvic Organs)
Vaginal relaxation or pelvic organ prolapse are terms used to describe the relaxation, sagging, or protrusion of the vaginal opening and the walls of the vagina, sometimes including the uterus. This can result from pregnancy, childbirth including spontaneous as well as vacuum and forceps deliveries, heavy lifting, chronic cough, and obesity.
“My Bladder is Falling”
Anatomically the vaginal opening and vaginal walls contain fat and thin connective tissue that supports the surrounding structures.
The anterior or front wall of the vagina is directly under the bladder. Any relaxation or tearing in this tissue results in sagging of the anterior vaginal wall more commonly called a cystocele (what some women describe as a “fallen bladder”). Typical symptoms of this include vaginal pressure and bulging, difficulty emptying the bladder, and urgency of urination.
Surgery involves opening the tissue of the vagina to expose the underlying connective tissue and repairing the damage or tear in the tissue, trimming the excess vaginal tissue, and suturing the anterior wall tissue back together reducing the bulge and slightly narrowing the vagina. This is called an anterior repair or colporrhaphy.
The posterior or back wall of the vagina is directly above the rectum. Any relaxation or tearing in this tissue results in a bulge called a rectocele, and leads to difficulty completing a bowel movement, needing to support or splint the area to completely evacuate, and gaping/sagging of the vaginal opening. Surgery involves opening the tissue of the vagina from the perineum (space between the vagina and anus/rectal wall) and up along the back wall of the vagina, repairing the damage or tear in the connective tissue, trimming excess vaginal tissue, and suturing the posterior wall tissue back together, often including building up the perineum and reducing the size of the vaginal opening. This is called a posterior repair or colporrhaphy and perineorrhaphy.
What is Vaginal “rejuvenation/tightening” surgery?
Vaginal rejuvenation surgery is essentially another name for the above common procedures done for vaginal relaxation, cystocele, and rectocele. Most of the time, women seeking relief of the symptoms above qualify for anterior and posterior repairs and the surgery can be covered by insurance.
A traumatic childbirth can lead to tearing in any of the walls of the vagina and the vaginal opening. Depending on desire for future childbearing and delivery, repairs can be done vaginally to restore the vaginal anatomy and sexual wellness.
What if the uterus is falling?
The uterus can prolapse down the vaginal canal along with the anterior and posterior walls. The symptoms are similar to the above, vaginal pressure and bulging, as well as pelvic heaviness. Typically, if the uterus is involved in the prolapse, hysterectomy or removal of the uterus with or without the fallopian tubes and ovaries is done, followed by suspension of the vagina to ligaments in the pelvis to prevent further prolapse in the future. This can be done laparoscopically with the Da Vinci robot, vaginally, or through an open abdominal incision. An open incision is usually only done when a patient is combining her surgery with a tummy tuck or abdominoplasty. Coordination with plastic surgery is done in this case.
If the prolapsed uterus is moderate to severe, mesh is used to secure the vagina or small segment of the cervix left in place, to a strong ligament along the inner surface of the sacrum. This is called sacral colpopexy and is the gold standard surgery for advanced prolapse. Why mesh? The mesh used for this procedure has very low risk <3% of poking through the vaginal tissue and causing need for additional surgery and has not been called into question.
What is vaginal vault prolapse?
After hysterectomy, the vagina can be described as a tube. The very top of the tube can become detached and turn the vagina inside out. This is vault prolapse and causes symptoms of pressure and bulging. The surgical repair involves suspending the vagina to either ligaments in the pelvis or with mesh to the ligament along the sacrum. Typically, this is done laparoscopically with the Da Vinci robot.
What is a Hysterectomy?
A hysterectomy is defined as removal of the uterus, either through an abdominal incision, laparoscopic or robotic assisted laparoscopic, or vaginal routes.
Removal of the tubes and ovaries is often done if a woman is over the age of 50 years or in menopause.
Hysterectomies are a common gynecologic surgery that is done for many conditions:
- Abnormal bleeding
- Fibroids
- Prolapse
- Pain
The route of hysterectomy is individualized to each patient and their condition.
No matter which route is chosen, hormonal status and sexual function should be reviewed before any surgery. Most patients spend one night in the hospital and post operation restrictions include no lifting more than 15 pounds as well as pelvic rest for 8-12 weeks.
Recurrent UTIs (Bladder Infections)
Urinary tract infections (UTI) or bladder infections are a common occurrence. Typical signs and symptoms include urgency, urinary burning, and frequency, sometimes blood in the urine. A urine culture is important to make sure you are treated with the correct antibiotics. Greater than 4 UTIs in 12 months is considered recurrent UTIs.
The evaluation may include a pelvic exam, catheterized urine sample, cystoscopy (look into bladder with a camera), and kidney ultrasound.
UTI Prevention Tips
- Avoid wearing thongs when possible
- Change pads frequently
- Increase water intake
- Urinate at least every 3 hours
- Urinate before and after intimacy
- Use baby wipes or pour water over the area as you void (urinate) after intimacy
- Take an antiseptic (Prosed, Urelle, or Uribel) or antibiotics (if prescribed by your doctor) after intimacy
- Take probiotics daily (pill forms—Align, Culturelle, or Trader Joes Acidophilus Super Complex (least expensive) and/or yogurt with live cultures) for bacterial balance in intestines & vagina
- Take D-Mannose supplement 400-500 mg in morning and at night for prevention of bladder infections (this coats the bladder). ClearMax is available at Center for Pelvic Health and Wellness for your convenience
- Use a dab of estrogen cream at urethral/vaginal opening 3 times per week for tissue health (if advised by your doctor)
Recurrent Vaginal Infections (Yeast and Bacterial Vaginosis)
A vaginal infection is considered recurrent when you have had four or more infections in one year.
Vaginal Yeast Infections
A vaginal yeast infection is a fungal infection that can cause intense itching, irritation of the vulva and vagina as well as vaginal discharge. Candida is a type of yeast that normally lives on the skin and inside of the body without causing any problems. However, Candida can multiply and cause an infection if the environment inside of the body and vagina changes. Antibiotics are a common cause of yeast infections because antibiotics can get rid of the good bacteria while they are also killing the bad bacteria.
Symptoms of Vaginal Infections
- Vaginal itching or soreness
- Pain during sexual intercourse
- Pain or discomfort when urinating
- Abnormal vaginal discharge
- A strong fish-like odor, especially after sex (bacterial vaginosis only)
Although most vaginal infections mild, some women can develop severe infections involving redness, swelling, and cracks in the wall of the vagina.
Who gets Vaginal Infections?
Vaginal infections are common. Women who are more likely to get vaginal infections include those who:
- Are pregnant
- Use hormonal contraceptives (for example, birth control pills)
- Have diabetes
- Have a weakened immune system (for example, due to HIV infection or medicines that weaken the immune system, such as steroids and chemotherapy)
- Are taking or have recently taken antibiotics
It is very important to see your doctor right away in order to make sure that you are diagnosed correctly so that you can start a treatment plan that will work for your condition. Your doctor will often take a sample of your vaginal discharge and send it to the laboratory to confirm the diagnosis.
Overactive Bladder (Urinary Frequency)
Overactive Bladder is a condition that is characterized by urinary urgency (strong desire to urinate), frequency (urinating more than 8 times in 24 hours), and/or urge incontinence (leakage of urine associated with urgency).
Overactive bladder may lead to embarrassment from unexpected urinary leakage limiting one’s work and social life. The good news is there is help. After a brief evaluation to determine the cause of overactive bladder, you can receive treatments that may greatly reduce or eliminate the symptoms of overactive bladder and help you manage their effect on your daily life.
A basic evaluation will establish the cause of the overactive bladder and to rule out any underlying medical conditions. The typical evaluation includes a full medical history; physical examination with particular focus on your abdomen and genitals (the location of the bladder and associated organs); urine sample to test for infection as well as traces of blood or other abnormalities; and specialized tests to assess bladder function (urodynamics) and/or look inside your bladder (cystoscopy).
What Treatments are Available for Overactive Bladder:
- Behavioral interventions such as reduction of fluids or timing of fluids, timed voiding, pelvic muscle retraining, and absorbent pads.
- Medications that relax the bladder including tolterodine (Detrol), fesoteridine (Toviaz), oxybutynin (Ditropan), an oxybutynin skin patch (Oxytrol), trospium (Sanctura), solifenacin (Vesicare), darifenacin (Enablex), and Mirabegron (Myrbetriq).
- PTNS (posterior tibial nerve stimulation) adjusts signals of the overactive bladder nerves through an acupuncture technique in the ankle. Twelve weekly, 30 minute sessions are needed to determine if you respond, and then ongoing periodic treatments are used for a lasting effect.
- InterStim (sacral nerve stimulation) helps to adjust the signals of the overactive bladder nerves to allow more normal urinary urge and voiding. An office test can determine if you would be a good candidate for the permanent small implant that goes under the skin in the gluteal region.
- BOTOX (botulinum toxin A) in small doses directly injected into the bladder muscle, relaxes bladder muscle spasm. Side effects include difficulty in urination (retention).
Painful Bladder Syndrome (Interstitial Cystitis)
®Women get bladder infections more often than men do because a woman’s urethra is a lot closer to her anus, which harbors bacteria. Bladder infections are caused by bacteria, generally a bacteria called E.Coli. This is why it’s critical to wipe from “front to back” after you go to the bathroom—otherwise you risk wiping bacteria such as E.Coli into the entrance of your urethra. It’s also important to urinate after sexual play and intercourse.
During different stages in your life such as pregnancy and menopause, the bacteria balance can change which can lead to a higher chance of bladder infections.
Symptoms of bladder and urinary tract infections include:
- Peeing more often
- Peeing only small amounts at a time
- Pain in your abdomen, lower back, or pelvis area
- Cloudy or bloody urine
- Fever
An untreated bladder infection can lead to a kidney infection and sepsis. It’s important to call your doctor if you have symptoms of a bladder infections.
Sometimes women experience symptoms of a bladder infection yet there is no bacteria in their urine. This is called cystitis or painful bladder syndrome. There are many therapies that we can prescribe for you based on your symptoms and findings of your physical exam. Physical therapy, pain relievers, prescription medicine, nerve stimulation, Botox® injections, and surgery.
Pelvic Floor Dysfunction (Levator Myalgia and Hypertonic Pelvic Floor)
The pelvic floor supports the bladder, vagina, urethra, uterus, and rectum. The pelvic floor is just like any other muscle in the body and can spasm and create sharp or dull pain. For some women, the pelvic floor muscle can become too tense and are unable to relax.
After a diagnosis by your doctor an appropriate treatment plan can begin.
Treatments for Pelvic Floor Dysfunction May Include:
- Pelvic floor physical therapy
- Biofeedback
- Muscle relaxants
- Botox injections
Pelvic Muscle and Core Weakness
Pelvic muscles can become weak, torn, overstretched, or spasm just like any other muscle of the body. However, unlike other muscles weakness or disorders in the pelvic floor muscles can lead to leaking urine or bowel, pain with urination, painful intercourse, and general discomfort.
What Causes Pelvic Floor Dysfunction?
- Childbirth, particularly an assisted birth or the birth of a large baby where an episiotomy was needed
- Trauma or injury to the pelvic area
- Obesity
- Previous pelvic surgeries
Treatments for Pelvic Muscle and Core Weakness
- Medication
- Pelvic floor physical therapy
- Emsella®, a non-invasive, non-surgical pelvic floor strengthening and tightening treatment
- Surgery
Bowel Incontinence (Loss of Bowel Control)
Incontinence of stool or anal incontinence is most often due to a tear in the anal sphincter or circular muscle that keeps stool and gas from escaping. Traumatic childbirth and or anal surgery are causes of this. Immediate repair is preferred; however, many women have undiagnosed tears in the anal sphincter at the time of childbirth and may present much later in life with inability to control gas and stool. Loss of stool can also happen if the muscle is weakened and stools are loose or urgent. Surgery on the anal sphincter such as hemorrhoid or anal fissure surgery can also lead to stool leakage. Post evacuation smudging is common if stools are loose or incomplete evacuation occurs.
The evaluation for this issue involves a pelvic exam and usually an ultrasound of the anal sphincter. Sometimes a test called defecography is also done to further evaluate the function of liquid (contrast) in the rectum and the defecation process.
Treatment options include:
- Bowel regimen: includes bulking the stool with insoluble fiber (food and supplements)
- Pelvic Floor Physical Therapy: promotes the strengthening of muscles of the pelvic floor which surround the anal opening. Biofeedback and vaginal weights can be also be used.
- Interstim Sacral Nerve Neuromodulation: reduces stool loss by increasing pelvic floor tone and reducing fecal urgency through sensory nerves.
- Anal Sphincter Repair: Outpatient repair of torn or interrupted anal sphincter. Best results for reduction of leakage of stool is achieved if repair done as soon as injury occurs, but improvement can be 50-85% even if done more than 20 years later.