Urogynecology

Chronic pelvic pain is one of many common pelvic floor disorders affecting people of all ages. Usually pain is considered “chronic” when it lasts longer than 6 months, and “pelvic” pain refers to the area below the belly button. Pain symptoms can be felt internally or externally and can be described as burning, sharp, achy, stabbing or cramping. The pain can happen anytime, including during intercourse, bowel movements, or when you urinate.

Pelvic pain can be caused by a number of conditions affecting the organs, tissues, or structures below the belly button. That would include structures like the uterus, the bladder, the small bowel, the rectum, the vagina, or the penis and testicles. Some of the common causes for chronic pelvic pain include endometriosis, uterine fibroids, pelvic floor trauma (including childbirth), aging, and sports injuries (even in childhood).

A urogynecologist will address pelvic pain specific to female anatomy and    physiological conditions unique to this population. 

Diagnosing Chronic Pelvic Pain

Your doctor will start with a complete history and pelvic exam. Imaging studies, muscle tests, nerve tests, or blood and urine tests could follow, depending on what they learn during examination.

Treatment for Chronic Pelvic Pain

There are a wide range of treatments available for chronic pelvic pain. Some of the more conservative approaches include behavioral modification and physical therapy. Other options could include topical, injectable, and oral medications. The most advanced treatments include surgery. You and your doctor should discuss the options that are appropriate for you, based on your unique medical history and what their examination and testing has revealed. The good news is that you don't have to suffer from pelvic pain - treatment is available!

Pelvic organ prolapse occurs when the abdominal organs lose their natural support and drop down within the abdominal cavity, creating increased burden on the pelvic floor. Because of this burden and anatomical change, some individuals will experience sexual dysfunction or bowel and bladder problems. This can be an uncomfortable, often embarrassing condition but you don’t have to live with it. It is a medical condition, not a normal part of aging, and treatment is available.

There are many ways to treat pelvic organ prolapse. One approach includes strengthening the pelvic muscles through exercises and physical therapy. Your doctor can support the pelvic muscles by inserting a device (pessary) that holds the prolapsed tissue in place. There are also surgical options using minimally invasive procedures. 

Pessary Fitting

For females, one option to treat prolapse is to use a device called a pessary. This device is inserted into the vagina to support the pelvic organs. For many women, pessaries are a simple, low risk treatment option. They allow you to be comfortable and active without surgery. About 85 percent of women can be fit successfully with a pessary regardless of age, medical history, or extent of prolapsed pelvic organs. It is important that the pessary fit your unique anatomy, and a urogynecologist has the necessary training to assist with that fitting process. 

Not all women are able to wear a pessary. Vaginal scarring, vaginal dryness, a surgically narrowed or shortened vagina, widened vaginal opening or very weak pelvic floor muscles are some reasons pessaries can fall out or be uncomfortable. Some of these problems can be treated to allow for pessary use. 

Pessaries also require ongoing care to avoid problems with vaginal discharge, odor, bleeding or ulceration. Many women can easily do this after receiving teaching from their health care provider. Neglecting appropriate care of a vaginal pessary can cause serious problems like erosion through the vaginal wall into the bladder or rectum. About 50 to 80 percent of women successfully fitted with a pessary use it on a long-term basis with proper care.

Consider wearing a pessary if you:

• Need help with urine leakage that occurs during exercise. 
• Have bothersome stress urinary incontinence (SUI) or pelvic organ prolapse (POP) symptoms and want a nonsurgical treatment. Some women want to delay surgery and others want to avoid it completely – a pessary can help in both cases.
• Have health problems that make the risks of surgery too great.
• Are able to manage removal, cleaning and reinsertion of the pessary on a regular basis. This can be done by you at home or through regular visits to your health care provider, but it’s very important to make sure it gets done.

For women who are unable or do not wish to use a pessary, sometimes surgical correction is an option. 

Prolapse surgery

If surgery is an option, the appropriate surgical procedure will depend on the type of prolapse, the patient’s personal health goals, and unique anatomy of the patient. Some procedures involve the use of mesh or the patient’s own tissue to rebuild support. For women who no longer desire sexual intercourse, surgically narrowing or closing the vagina is their preferred choice. Some women may need to consult a gastrointestinal or colorectal surgery specialist as well, to ensure that bowel function is as it should be. 

At the Pelvic Health Center, our team works using a collaborative approach among  specialist providers to ensure that you receive comprehensive treatment for all the symptoms you experience with pelvic organ prolapse.

Because of their specialized training in both urinary and gynecological systems, a urogynecologist is uniquely qualified to help find and treat the causes for urinary incontinence and dysfunction in a female patient. 

In order to determine the cause of the problem, the urogynecologist will take a careful medical history, perform a pelvic examination, and possibly recommend specific testing or imaging if necessary. Sometimes either a urodynamic study or cystoscopy may be appropriate to help you and your provider learn more. Your provider will determine which test is most appropriate based on what you say about your symptoms, your medical history and their examination.

Urodynamic study

Urodynamics is a test that is done in the clinic to help the provider see how your bladder functions - how the bladder stores urine, how the bladder empties urine and how the sphincter and the muscles of the bladder act. The information from this test will allow your provider to determine whether the problem is related to bladder or sphincter function, because these are treated very differently.

Patients should allow up to 90 minutes for this process, as each stage is carefully prepared and completed. Patients are asked to arrive with a full bladder and urinate into a container in the clinic. The volume of urine and rate at which the bladder empties are both carefully measured. Then a thin catheter (tube) is inserted into the bladder, and the bladder is filled with water. Further measurements are taken from the first urge to urinate until the patient feels they can't hold it anymore.

A good candidate for a urodynamics test is a patient who has urinary difficulty – incontinence, frequent urination, sudden strong urges to urinate, problems starting to urinate, painful urination, problems completely emptying the bladder and frequent urinary tract infections.

Cystoscopy 

A cystoscopy is a surgical procedure that allows a doctor to view the inside of the bladder and urethra using a thin, lighted tube called a cystoscope. The cystoscope has lenses like a telescope or microscope. Fluid is used to fill the bladder, and the doctor looks at an image of the inner wall of the bladder on a computer monitor to check for abnormal areas. Identifying abnormal tissue based on the appearance is an important part of diagnosing many serious conditions, and will allow you and your provider to determine the right treatment plan, based on your healthcare priorities and goals. 

Advanced Treatment Options

Many CHI Health physicians are actively involved in ongoing research to improve the lives of the patients in our care. One example is a current FDA trial for female Adjustable Continence Therapy to solve stress urinary incontinence. This outpatient procedure takes approximately 30 minutes with no overnight stay required. Placement and adjustment for this device involves the following process:

• Silicone balloons are placed on either side of the bladder neck to provide support to the bladder by restricting the flow of urine through two valves.
• Balloons are connected to a titanium filling port.
• During adjustment visits, the implanted balloons are tailored to each person's individual needs. At these visits a small needle is inserted into the port to add or remove fluids.
• Optimal results are generally achieved in 3-4 adjustment visits.
• This device does not need to be manipulated by the patient at any time.

Learn more about this trial.