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According to a study funded by the National Institutes of Health, pelvic floor disorders affect nearly 25 percent of U.S. women. Pelvic floor disorders, such as incontinence and pelvic organ prolapse, occur when the pelvic muscles and connective tissue, which hold the bladder, uterus, bowel and rectum in place, are weakened or injured. Incontinence is trouble controlling urination or bowel movements, while prolapse is when organs such as the bladder or uterus drop lower than their normal position causing vaginal symptoms such as feeling a bulge or pressure.
When it comes to pelvic floor disorders, many women suffer in silence. Often, they are embarrassed to discuss their symptoms with a doctor or they assume it’s a natural part of aging. Patients may also have low expectations for treatment and limited knowledge that effective management options are available. All aspects of a woman’s life can be impacted by pelvic floor disorders, including emotional, social, physical, and sexual well-being, which in turn can negatively affect interpersonal relationships. Unfortunately, reliance on absorbency products continues to be a common management method for many women with incontinence.
Summit Medical Group offers a unique multidisciplinary team in one office, including urogynecologist, Jeffrey Segal, MD, FACOG and urologist, Rhonda Walsh, MD. Both doctors are fellowship trained and are board certified in Female Pelvic Medicine and Reconstructive Surgery. Together they have years of experience specializing in the treatment of stress incontinence (urine leakage when coughing or laughing), overactive bladder (having to go very frequently), pelvic organ prolapse, interstitial cystitis (painful bladder syndrome), and other complex urinary tract problems. They also work closely with Kevin Holzman, MD and Farshad Abir, MD in Summit Medical Group’s colorectal surgery division to address bowel dysfunction symptoms and fecal incontinence, which commonly overlap with urinary incontinence and prolapse. “As your physicians, we know how your quality of life can be affected by any one of these disorders and we want to do everything we can to help,” says Dr. Segal. “By creating awareness and properly diagnosing and treating these disorders, individuals can get back to the lives they once enjoyed.”
The following information features expertise from Dr. Jeffrey Segal, SMG Urogynecologist, and Rhonda Walsh, SMG Urologist.
Stress Urinary Incontinence: Stress urinary incontinence involves the involuntary leakage of urine associated with effort or exertion, such as sneezing, coughing, or exercising and is estimated to affect 4 to 35 percent of adult women. Vaginal delivery is a likely implicating factor due to direct damage to the pelvic muscles, connective tissues and nerves that occurs during childbirth. Other risk factors include obesity, smoking, and increased age. The spectrum of disease severity is wide, ranging from the occasional spurt of urine loss with physical exertion to continuous urinary leakage, which may be due to a faulty urethra.
Treatment options are also varied. Dr. Segal recommends initially managing patients conservatively with behavioral interventions, including pelvic floor muscle exercises and biofeedback for patients who may need help identifying the correct muscles to strengthen. Intravaginal devices that help support the bladder neck include over-the-counter bladder support devices or an incontinence dish that can be fitted in the office. The most effective treatment option, however, is surgery. Drs. Segal and Walsh perform minimally invasive outpatient surgeries that can be done in about 30 minutes under local anesthesia and have short recovery times. A mid-urethral sling is one such procedure that has been shown to have excellent long-term outcomes with an associated cure rate of about 85 percent. Another option for some patients, particularly for those with a poorly functioning urethra, is an office or outpatient procedure in which a bulking substance is injected through the urethra to better control urine flow through the bladder neck.
Overactive Bladder: This condition is also very common, affecting 16 percent of the population. It is defined by urinary urgency (a strong and sudden desire to urinate) and is often associated with urinary frequency (urinating more than eight times per day) with or without urge incontinence (urinary leakage before you can reach the bathroom). These symptoms tend to have a more severe impact on a woman’s quality of life compared to symptoms of stress urinary incontinence due to the unpredictable and uncontrollable nature of its symptoms. Conditions associated with overactive bladder include older age, neurologic diseases such as spinal cord injury or Parkinson’s disease, and pelvic organ prolapse, but most women with overactive bladder have no recognizable underlying disorder.
Compared to stress urinary incontinence, overactive bladder symptoms are more commonly and successfully treated using non-surgical approaches. Dr. Segal initially reviews a bladder diary with his patients, which tracks their daily fluid intake, urinary incontinence episodes, and activities during those episodes. Behavioral modification including fluid management, bladder retraining exercises and pelvic floor rehabilitation is often used in conjunction with medications called anticholinergics or mirabegron to successfully treat symptoms.
For patients who do not respond to or tolerate medications, there are three additional FDA approved treatment options. These include tibial nerve stimulation or Urgent PC, a non-surgical office-based treatment, that uses gentle electronic pulses to stimulate the nerves that control the bladder, Botox which is injected directly into the bladder in either the office or outpatient setting, and InterStim therapy that involves a test stimulation procedure allowing the patient to trial the therapy first, followed by implantation of the stimulator as an outpatient procedure.
Pelvic Organ Prolapse: Pelvic organ prolapse is the descent or bulging of segments of the vagina, typically involving either the uterus or the various pelvic organs behind the vaginal wall, including the bladder, rectum, and small bowel. Risk factors include vaginal childbirth, menopause, increasing age, connective tissue disorders and conditions that result in chronic increased intra-abdominal pressure, such as constipation. Symptoms may include a feeling of vaginal or pelvic pressure, the feeling of a mass or bulge in the vagina, difficulty or pain with sexual intercourse, incomplete bladder emptying or the feeling of stool getting trapped in the rectum upon defecation.
Like stress urinary incontinence, the definitive treatment for pelvic organ prolapse is largely surgical. According to Dr. Segal, it is important to tailor both conservative and surgical treatment modalities to meet each patient’s individual condition and expectations. Dr. Segal utilizes a vaginal approach for the majority of cases, which is the least invasive surgical approach. He stresses the importance of reconstructing a functional vagina of normal caliber and length, particularly for women who are sexually active. For patients who are medically fragile and no longer sexually active, there are other surgeries that can be done under sedation with local anesthesia. For patients who are not surgical candidates or for those who do not desire surgery, a pessary or vaginal insert, can be useful in relieving symptoms by re-supporting the structures that are prolapsed. Generally, patients are seen in the office every three months for removal and cleaning of the pessary.
Interstitial cystitis (IC). Also known as painful bladder syndrome, IC is characterized by urinary urgency and frequency and either sharp or dull pain in the bladder or other areas in the pelvis or lower abdomen. Patients usually report symptomatic flare-ups and remissions and often may have pain during or after sexual intercourse. Although the cause is unknown, it is thought to result in damage to the lining of the bladder. Early detection and treatment of IC reduces the number of advanced cases, leading to better outcomes. Dr. Segal recommends a multimodal approach in managing these patients, involving patient education, diet modification, pelvic floor rehabilitation, oral medications, and bladder instillations, to achieve a more effective clinical response.
Dr. Segal encourages patients who suffer from pelvic floor dysfunction to seek information and to discuss their symptoms with their physician. These conditions can have significant negative impact on multiple aspects of quality of life, and women should be aware that effective treatment modalities are available. Dr. Segal and Dr. Walsh will work with you to develop an individual treatment strategy that will achieve the best results.