- UI occurs twice as often in women as in men.
- 1 in 4 women over the age of 40 will develop UI in their lifetime.
- Thirty percent of women will experience symptoms of UI immediately after child-birth. Most will see a resolution of symptoms 3 to 6 months after their delivery.
- There are several types of UI:
- Stress incontinence – Leakage happens with coughing, sneezing, exercising, laughing, lifting heavy things, and other movements that put pressure on the bladder. This is the most common type of incontinence in women. It is often caused by physical changes from pregnancy, childbirth, and menopause. It can be treated and sometimes cured.
- Urge incontinence – This is sometimes called “overactive bladder.” Leakage usually happens after a strong, sudden urge to urinate. This may occur when you don’t expect it, such as during sleep, after drinking water, or when you hear or touch running water.
- Functional incontinence – People with this type of incontinence may have problems thinking, moving, or speaking that keep them from reaching a toilet. For example, a person with Alzheimer’s disease may not plan a trip to the bathroom in time to urinate. A person in a wheelchair may be unable to get to a toilet in time.
- Overflow incontinence – Urine leakage happens because the bladder doesn’t empty completely. Overflow incontinence is less common in women.
- Mixed incontinence – This is 2 or more types of incontinence together (usually stress and urge incontinence).
- Transient incontinence – Urine leakage happens for a short time due to an illness (such as a bladder infection or pregnancy). The leaking stops when the illness is treated.
- Modest weight loss, approximately 8% of your body weight, can result in a 50-75% reduction in UI symptoms.
- Pelvic floor exercises, commonly called Kegel exercises if done properly can improve some symptoms of UI. However, using weighted Jade stones or Kung Fu vaginal exercises (non-medically suggested or supervised “therapies”) can result in over-stimulation of the pelvic muscles and result in voiding dysfunction or pelvic pain.
- Pelvic Floor Rehabilitation is a medically supervised program of muscle stimulation and pelvic floor exercises. This can be used to treat both stress and urge incontinence. It also has benefits for some women with fecal incontinence and chronic pelvic pain (CPP).
- Urge incontinence can be managed in several ways: behavioral modification, medication, pelvic floor rehabilitation, Botox injections and nerve stimulation.
- Surgery to treat stress incontinence typically involves placement of a sling which can be one of several types. This oftentimes can be performed as an outpatient surgical procedure.
- Women who have urinary incontinence may also have symptoms related to pelvic organ prolapse (POP). The treatment of these symptoms may require additional therapy or surgery.
- A Urogynecologist is a physician specially trained in treating Urinary Incontinence in women. These physicians will typically be board-certified in Female Pelvic Medicine and Reconstructive Surgery (FPMRS). Dr. Kevin O’Neil is board-certified in FPMRS and is a physician at MacArthur OB/GYN.
- You don’t have to live with urinary incontinence. The first step to getting better is to say something to your physician. The physicians at MacArthur OB/GYN want to help and we have the experience and tools available to work with you to improve your condition.
In the field of Obstetrics and Gynecology, there are currently 3 recognized, (board-certified), sub-specialties. These are: Maternal-Fetal Medicine, Reproductive Endocrinology and Infertility, and Gynecologic Oncology. This year however, the American Board of Obstetrics and Gynecology (ABOG), together with the American Board of Urology (ABU) are recognizing through a board certification process those physicians who devote the majority of their practice to the treatment of women with pelvic disorders.
In the past, physicians have divided the female pelvis loosely into three areas. The front part with the bladder was the urologist’s territory, the middle with the vagina and uterus was for the gynecologist and the back was for the gastroenterologists and colo-rectal surgeons. Sometimes you would have a gynecologist who also treated urinary incontinence, or a urologist who treated pelvic organ prolapse (ie, fallen bladder) and we would call these hybrid doctors “Urogynecologists”.
Fortunately, there has been recognition that there is quite a bit of inter-relation between all of these organ systems, plus the muscles that support them, the nerves and blood vessels that supply them and most importantly, the patient who is attached to all of these and is having an issue with one or more. For example, I see patient’s who have to strain or push down on the vagina to have a bowel movement because there is a weakness in the wall between the rectum and the vagina. Or a patient who has frequent bladder infections due to incomplete emptying caused a fallen bladder. Or, a patient who has bowel and bladder issues due to neurologic condition such as MS, or a stroke.
So where does Female Pelvic Medicine and Reconstructive Surgery (FPM/RS) come in? For some physicians, they have completed a residency in either obgyn or urology and then had training in a fellowship, most commonly urogynecology. For others, like myself, I completed my obgyn residency back in 1997. The few urogynecology fellowships that were available were not, “approved” that is, recognized by the American Board of Medical Specialties. I spent as much of my residency as I could with the urologists at the hospital learning about treating incontinence and other urinary/bladder conditions in women, so off I went into private obgyn practice. I was very fortunate to spend the next 13 years working with Dr. J. David Wollenman who was a great friend and mentor to me until his passing in 2011. He and I both shared an interest in treating female incontinence, pelvic organ prolapse and other conditions like Interstitial Cystitis. And over the years, we were able to grow our practice and spend more time helping patients with those issues. In 2011, I was again blessed to merge my practice with MacArthur OB/GYN and work with an equally stellar group of physicians and nurses who have supported me and encouraged me to continue my focus on treating women with pelvic disorders.
In September of 2012, ABOG and AUA announced that the first subspecialty exam in FPM/RS would be offered in June of 2013. There would initially be two categories, FPM/RS and FPM/RS-Senior. The first category would be for those who entered their fellowship program within the last 3 years. The latter category would be for those who completed their fellowship, or on the basis of their clinical experience and dedication of the majority of their practice to the field of FPM/RS, i.e., what I have been able to do over the last 15 years.
People have asked me why I am taking the exam and what will it mean for my practice? I think that it is an opportunity for me to validate what I have trying to do for my patients over the years as well as a chance to measure myself against my peers in the same field. Everyone in medicine has a story about why they chose the specialty they are in. For me, part of it was my exposure to urogynecology cases in both my obgyn and urology rotations in medical school. I found the surgeries to be interesting and challenging, and I appreciated how grateful many of the patients were when they got a good result. This interest and appreciation continued for me during my residency and into private practice. Most people probably don’t think much about how multi-functional their pelvis, and the organs within it are. As I type this, I’m sitting on mine. It also functions as an area of storage and elimination of solid and liquid waste. It is intimately involved in sexual intimacy and reproduction. And it provides something to hold up our pants. No one gives any of this a second thought, until something doesn’t work the way it is supposed to. Unfortunately, as our population ages, the incidence of disorders affecting these normal bodily functions is increasing. So the creation of a sub-specialty called Female Pelvic Medicine and Reconstructive Surgery allows patients to seek out physicians with knowledge, training and interest in treating the many varied and interrelated conditions that may affect women and their bowel, bladder and reproductive organs. This can be done through various therapies such as behavior modification, biofeedback, physical therapy, medication, and surgery.
That was a quote from a sign I saw on vacation last summer. While we read it and laugh, we all know what it means. “How’s your bladder working?” is a common question that I ask patients in the office. The responses I get include, “fine, except when I ____”, or, I’m fine as long as I know where the bathrooms are. And while some patients may think this is normal, the fact is, it’s not.
The incidence of urinary incontinence does increase with age, but it isn’t something that you should, “learn to live with”. Once you’re potty trained, you should stay so. However, one survey found the overall incidence of urinary incontinence to be about 53% in women ages 20 to 80. Also, I heard once at a conference that we spend more money in this country on Depends® than we do on diapers. Not all leaking is the same. Loss of urine can be due to stress-incontinence, where the leakage occurs in response to an increase in abdominal pressure like coughing, sneezing or laughing. Urge incontinence is when the bladder empties without warning. Overflow incontinence is caused by a bladder not emptying completely and basically, “overflows”. Some woman have an almost constant leakage of urine which may be due to a problem with the urethra staying open all the time, like a drainpipe. Mixed incontinence is generally thought of as a combination of stress and urge incontinence.
And while there are many categories we can use to classify the type of incontinence, there are many reasons within each category as to why they occur. Taking a thorough history is an important part of the evaluation process, as is performing a pelvic exam and often times performing a urodynamic evaluation. Urodynamics is an office-based test whereby the physician can evaluate the function of the bladder, urethra and pelvic muscles to determine the cause(s) of the incontinence.
Once the cause(s) of the incontinence are determined, treatment options can be discussed. These can include one or more of the following: physical therapy, medication, behavioral modification or surgery.
The first step is to tell your doctor what is going on. If the treatment of incontinence isn’t their thing, they can send you to someone who can help. It saddens me to hear a patient say that they haven’t been able to do the things they love to do because they’re afraid of having an accident. You don’t have to “live with it”. I can think of many instances of patients who were embarrassed to talk about their problem, but after they did and we worked together to fix it, they were overjoyed and felt like they were able to reclaim their lives.
I’m often asked by my patients whether they can eat certain foods, drink alcohol, be around people who smoke or smoke themselves, etc. Whenever I’m asked these questions, I apply what I call the “Two-year old rule.” I ask the patient to imagine that their baby is already born and is two years old, sitting in a high chair. Then I ask the question, “would you give the food, drink or cigarette to your two year old?” Usually the answer is a chuckle and “no”. Then I explain that a woman who is pregnant should assume that anything she puts into her body would probably make it to her baby.
When talking about foods, two important questions to ask are; is it healthy for the woman and her baby and, is there any chance of it making them sick? Take ‘junk food’ for example. While tasty, there is generally a lot of sugar and/or fat with little in the way of nutritional value (i.e. protein, vitamins, minerals, etc.). I get the part about it being tasty, but why waste a meal on something that is only going to grow your hips and not your baby? Another food category is uncooked or raw foods such as raw seafood or meat. Eating these can increase your risk for food-borne illness. Besides making you very sick, even worse than bad morning-sickness sick; the bacteria can make your baby sick as well. So save the sushi for after you deliver, and wash your hands really well when cooking with raw meat.
Next is alcohol. We don’t know of a “safe” amount of alcohol that a pregnant woman can ingest and not harm her baby. We know that ingesting an ounce of alcohol a day (1 glass of wine, 1 beer, or 1 shot) significantly increases a women’s risk of her baby having Fetal Alcohol Syndrome. There is also some newer research that suggests this risk is present at even lower amounts of alcohol consumption. So again, if you wouldn’t give a shot, beer or glass of wine to a 2 year old (and you shouldn’t) then don’t give them to your baby when you’re pregnant.
Then there is caffeine. Found in all sorts of yummy things: coffee, tea, soda and … CHOCOLATE! According to the March of Dimes, pregnant women should limit their caffeine intake to less than 200mg a day, which is about 1 twelve-ounce cup of coffee. Milk chocolate has around 7mg of caffeine per ounce, and dark chocolate about 20mg per ounce but they also come with a lot of sugar (remember those hips).
Finally, there is smoking. Short answer: DON’T. I know that it is hard to quit (nicotine is more physically addictive than cocaine), but do it for yourself and your baby. Again, the two-year old analogy: would you leave a two year old next to the tail pipe of a running car? Basically it’s the same stuff as cigarette smoke. Smoking increases your risks of preterm delivery, low birth-weight baby, and a baby with increased chances of having SIDS (Sudden Infant Death Syndrome), asthma, learning disabilities and other issues. I’ll stop my rant about smoking for now, but here is a website with some helpful quit-smoking advice: women.smokefree.gov.
So while you are pregnant, just think ahead to when your little one is two, sitting in a high chair, covered in strained peas and carrots… I mean, sitting there like an angel daintily eating cheerios with their fingers, and be glad that you made those healthy choices during your pregnancy.
As a physician, I believe that I wear many hats. Among them are: healer, teacher and student. Since joining MacArthur OB/GYN in 2011, I found that one way to combine these hats into one was by becoming a clinical investigator on the research studies that our office participates in. The impetus for MacArthur OB/GYN to join in these studies came from my partner, Dr. Jeff Livingston, who has a passion for educating patients.
So how does being a clinical investigator in a research study help my patients? For one thing, it offers patients the chance to receive a new treatment or therapy that may help their condition. The study may also involve following patients for an extended period of time and this outcome data may result new knowledge that results in large-scale changes to doctors’ clinical practice. Also, we are able to attract patients who may have been outside our practice; and helping more people in the community is definitely a good thing.
So what clinical studies are we participating in at this time? We are participating in 5 clinical studies, and they are:
- A study of a medication to treat Interstitial Cystitis/Bladder Pain Syndrome
- A Post-market study looking at the long-term outcomes of two types of sling procedures for urinary incontinence
- A study of a medication to treat endometriosis
- A study of a medication to treat uterine fibroids
- A study of a medication to treat yeast infections.
Each study has specific inclusion and exclusion criteria. In addition, patients generally receive the study medications for free and are compensated for their time. In order to participate, a patient may be identified by one of our doctors as being potentially eligible, or a patient can contact our office and express an interest in participating; in which case they would be scheduled to see one of the doctors who is either the Principle Investigator or Sub-investigator for the particular study.
Hopefully reading this will encourage you if you have one of these conditions (IC/Bladder Pain, Urinary Incontinence, Endometriosis, Fibroids, or Chronic Yeast Infections) to contact Veronica Almanza at 214-223-5479. She can explain the study to you in more detail and arrange a visit with one of our physicians. We are here to help.
About a year ago, I was in private practice by myself, covering both my practice and that of my partner, Dr. Wollenman, who was ill and recently passed away this July. I was visited by a representative from Intuitive Surgical who asked if I had any interest in learning about robotic surgery. My first reaction was no, because I didn’t see the benefit. Dr. Wollenman and I had been operating together for years, performing most of our hysterectomies vaginally and what could be less invasive than that? Also, to use the robot required a learning curve and time commitment.
As I listened to the rep speak about the technology, and the statistics that over 60% of hysterectomies in this county are performed abdominally (only 10% of mine were abdominal). I thought perhaps the technology would be helpful for ‘other’ doctors who couldn’t operate vaginally. But then the rep discussed other procedures such as myomectomy, endometriosis surgery and vaginal prolapse surgery being done robotically and I started to feel intrigued.
Myomectomy is the removal of uterine tumors called fibroids. It is usually done through an open incision because the uterus is very difficult to suture using traditional laparoscopic techniques. As I watched a video of a laparoscopic myomectomy using the daVinci robot, I was impressed. The surgeon was using the instruments just as if he had shrunk his hands to fit inside of the patient. Cutting, cauterizing and suturing with grace and precision. And the picture was incredible. I was used to performing a myomectomy through an open incision, balancing the size of the incision versus the size of the fibroids and the size of the patient, trying to make it ‘just big enough’, struggling with the lights in the OR to position them so when I moved my head I wasn’t blocking my own view. Here on the video, the picture was beautiful, in 10 times magnified high definition. The rep pointed out to me that in real life it was even better, because the surgeon had a 3D, 10x, high definition picture. My interest grew.
I went home that night, got on YouTube and spent the evening watching videos of various robotic surgical procedures, including surgery for endometriosis and vaginal prolapse, two areas of particular interest to me.
Endometriosis is a benign condition, but can cause significant pain. Often, during surgery for this we find that the endometriosis has implanted over the patients ureters, bladder and rectum. These are particularly sensitive and difficult areas to excise the endometriosis using traditional laparoscopic techniques. But I was seeing the surgeon using the daVinci with precision and dexterity unavailable with traditional laparoscopic instruments (or ‘straight sticks’ as they are nicknamed).
For years, I have been interested in the treatment of vaginal prolapse and urinary incontinence in women. I’ve been to many meetings and conferences to learn the latest surgical techniques. Almost all of what I’ve learned is variations on how to approach the problems vaginally. However, the operation that is considered the ‘gold standard’ to treat vaginal prolapse is called an abdominal sacrocolpopexy. The traditional approach involves making an abdominal incision and fixing a piece of mesh to the tissue in front of the sacrum and the to the vaginal tissues to support it. However, I had gotten away from this, as had many Obgyns, because of the prolonged hospitalization and recovery due to the abdominal incision. Watching videos of laparoscopic sacrocolpopexys with the daVinci robot was very exciting. Patients with complete vaginal prolapse were able to get very good results without the need for large abdominal incisions.
So after seeing the videos and researching the subject some more, I began to think that the daVinci might be a better mousetrap. I made arrangements and traveled to York Hospital in York, PA; which is considered a robotic surgery ‘epicenter’ and observed cases. I was even more amazed and impressed, watching the surgery in person, at the visualization and dexterity afforded the surgeon by the daVinci. I came back to Texas excited and energized to begin training. I made the arrangements and had my training completed in January of 2011. In February of this year, Dr. Sakovich performed the first robotic hysterectomy at Baylor Irving and I performed the second. Needless to say, it was a very exciting time at the hospital as we got the robotic surgery program going amidst our annual DFW ice storm.
Since then, I’ve performed numerous surgeries including hysterectomy, endometriosis surgery, sacrocolpopexy and myomectomy using the daVinci robot. Again each time, I am thrilled and amazed with the visualization I have and the dexterity of the instruments. But one of the things I’ve been most impressed with is how quickly patients are able to recover from surgery. Most of my patients, including those having hysterectomy, are able to go home from surgery the same day and are ready to resume most activities within about 2 weeks. This is an improvement even over my patients who’ve had vaginal hysterectomies.
I would have to say that I’ve become a convert to the advantages of robotic surgery. I’ve also seen some glimpses of the future where we will be able to reduce the number and size of the laparoscopic incisions down to 1 or 2. I truly believe that the robotic surgery technology has allowed me to provide better care for my patients. I feel blessed to have had the opportunity to use the technology and to have joined the group of doctors here at MacArthur OB/GYN who have supported and encouraged my efforts.