Urogynecology or Female Urology is now officially known as ″The subspecialty of Female Pelvic Medicine and Reconstructive Surgery – FPMRS ″. Designations such as FPMRS obtained approval for board certification from the American Board of Medical Specialties in 2012, and in June 2013 practitioners began sitting for a mandatory board certification exam in the subspecialty for the first time. Dr Angelo Gousse is one of the first Board Sub -Certified in Female Pelvic Medicine and Reconstructive Surgery in South Florida.
The urologic conditions and treatment options for women vary significantly, because women have different anatomic and hormonal milieu than men. Over the past ten years there have been significant advances in FPMRS. These advances include understanding of female urologic disease processes and management options. Furthermore, several guidelines for management have been developed as a result of numerous evidence-based studies to guide the clinician.
Common Urologic conditions which fall within the domain of Female Urology include: recurrent UTIs, overactive bladder, pelvic organ prolapse, urinary incontinence, urethral syndrome, urinary fistula, interstitial cystitis (Bladder Pain Syndrome), urethral diverticula, female urethra stricture, female sexual dysfunction.
Chronic Urinary Tract Infections (UTIS)
Many women suffer from recurring urinary tract infections also known as chronic UTIs. Recurrent UTIs are defined as having at least two infections in six months or three infections in one year. This condition is typically caused by gram negative bacteria. Patients with febrile UTIs are considered cases of complicated UTIs and should undergo an upper urinary tract study to evaluate the kidneys and be prescribed a more aggressive course of antimicrobial agents.
Pelvic Organ Prolapse
Pelvic organ prolapse (POP) is a condition associated with laxity and defects of the muscles, ligaments and skin surrounding the vagina. These anatomical weaknesses cause pelvic organs such as the uterus, rectum, bladder, urethra, small bowel or vagina to prolapse out of their normal anatomic position. Some of the most common POP pathologies include: Cystocele (Bladder prolapse), rectocele (prolapse of the rectal wall/posterior compartment), enterocele (weakness of the cul de sac associated with bowel and peritoneal contents herniation), and vaginal prolapse.
Symptoms may include pelvic pressure and discomfort, sexual discomfort, and problems urinating or defecating.
Numerous transvaginal, abdominal, laparoscopic, or even robotic techniques have been developed to treat POP. Recent controversies and FDA warnings in the US have diminished the usage of synthetic mesh in the over the past 3 years. Usage of biologic allograft or native tissues has become more popular. Some patients prefer a non-surgical approach such as the usage of pessaries.
Urinary fistula is an abnormal opening within a urinary tract organ or an abnormal connection between a urinary tract organ and another organ. There are several types of urinary fistulas that are commonly encountered in Female Urology. They include: Vesicovaginal fistula, urethrovaginal, ureterovaginal fistula. The most common type of urinary fistula results from injury to the bladder during pelvic surgery, such as a hysterectomy or unattended vaginal deliveries (obstetric fistulas). It is important to note that abdominal hysterectomy is more commonly associated with vesico-vaginal fistula compared to vaginal hysterectomy. The treatment of urinary fistula is usually surgical. Transvaginal approaches can be as successful as abdominal approaches while offering the benefit of being less invasive and a quicker patient recovery.
Urinary incontinence, or the involuntary leakage of urine is one of the most common problems treated in female urology. It is important for the clinician to realize that there are several different types of urinary incontinence, each with a different cause and potential treatment options. These include stress incontinence, urge incontinence, overflow incontinence, mixed incontinence (simultaneous stress and urge incontinence), total incontinence and functional incontinence.
Improper diagnosis of the type of urinary incontinence is probably the most common reason for treatment failure. A detailed history and physical examination is of paramount importance in the proper diagnosis and sub typing of urinary incontinence. In select cases, urodynamic testing or cystoscopy may be useful. A neurologic history and physical examination should be obtained in order to rule out neurogenic bladder.
Patients with “pure” stress urinary incontinence report activity–related urinary leakage which interferes with their quality of life. Any increase in abdominal pressure such as coughing, sneezing, laughing, exercising, jumping, running, or event sexual activity may precipitate urinary leakage. Stress incontinence may or may not co-exist with pelvic organ prolapse. In most cases urethral hypermobility is noted with rotational descent of the urethra upon straining. The need for treatment is largely dictated by the degree that it affects the quality of life of the patient . Pad usage and pad weight are sometimes used to gauge disease severity
The current most popular surgical treatment to treat stress urinary incontinence is the sub-urethral sling. Transurethral bulking agent is another less successful and shorter duration treatment option. The suburethral sling can be performed using a synthetic mesh or biologic allograft, autologous rectus fascia. Abdominal procedures such as Burch urethropexy are effective but remain more invasive than the transvaginal sling procedures. Currently, there is no approved medication for stress urinary incontinence. There is no evidence that estrogen therapy is effective in the management of stress urinary incontinence.
Patients with urge urinary incontinence report involuntary urinary leakage with bladder spasm and strong urges to void. Urge incontinence is one of the symptoms associated with overactive bladderThe treatment algorithm of urge is very different from that of stress incontinence.
Behavioral therapy, fluid management, timed voiding, avoiding bladder irritants, pelvic floor exercises, Kegel exercises are useful in many cases. In more severe cases, anticholinergic medications can be used. Anticholinergics are plagued with adverse side effects such as dry mouth, constipation, cognitive side effects, and potential for urinary retention. In cases refractory to oral medications, intraderusor injection of onabotulinum toxin A (Botox) offers new hope to affected patients. The procedure is minimally invasive and can be performed in the office without general anaesthesiaThe usual dosage is 100 Units of Botox in patient with idiopathic urge incontinence refractory or intolerant to medications . This option is FDA approved in the USA.
Another option is Implant of sacral nerve stimulator. It is possible to stimulate the third (S3) sacral nerve via an implantable neuro-stimulator. Medtronic (Interstim) manufactures the most popular device. The procedure is performed under local anaesthesia with the patient awake.
Female urologic disorders affect a large portion of the population. Female Urology also known know as Female Pelvic Medicine is a broad field. The surgical techniques are varied and technically challenging. The treatment options are best dictated by an accurate diagnosis. The most successful female urologists must be astute diagnosticians.