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Treatments and Surgery for Bladder Conditions and Pelvic Disorders

For many medical conditions involving the bladder and pelvic floor, the first method of treatment may be in lifestyle changes and behavioral remedies, including weight loss, diet modification and physical therapies. Kegel exercises and bladder retraining are often effective techniques to strengthen pelvic muscles and regain control of the bladder. Biofeedback and electrical stimulation therapies may be introduced to monitor and improve the physical therapies before medications are prescribed. Doctors may suggest surgery if other noninvasive treatments have failed.

Patients should find out all their options for treating bladder conditions and pelvic disorders. Discuss the condition with a urogynecologist or urologist/gynecologist and inquire about the surgeon's experience. From the physician profile pages at the Bladder Health Program of South Florida website, there are links to each physician's private practice with more comprehensive explanations of specialized training.

Treatments

Surgeries:

Treatments

Kegel exercises are designed to make the pelvic floor muscles stronger. At the bottom of the pelvis, several layers of muscle stretch between the legs, attached to the front, back and sides of the pelvic bone. These are the muscles that hold up the bladder and help keep it from leaking. Building up pelvic muscles with Kegel exercises can help with bladder control. To perform Kegel exercises, women and men simply tighten and relax the pelvic floor muscles which control urine flow.

Bladder retraining is a way to help the bladder hold more urine. People with bladder pain often get in the habit of using the bathroom as soon as they feel pressure or urgency – before the bladder is really full. The body may get used to frequent voiding. Bladder retraining helps the bladder hold more urine before signaling the urge to urinate. Bladder training involves recording the time of each urination, and attempting to increase the time between each void. After several days, the urge to urinate may not return as frequently.

Biofeedback uses electronic measuring devices to help the patient become aware of the body's functioning and increase control over the important muscles. A vaginal or rectal probe relays information to a monitor to register when the bladder and urethral muscles contract. This procedure will indicate if the muscles are functioning properly. Biofeedback can supplement pelvic muscle exercises and electrical stimulation to relieve stress and urge incontinence.

Neuromodulation (Nerve Stimulation) For urge incontinence and overactive bladder conditions not responding to behavioral modifications, oral medications or pelvic floor exercises, stimulation of nerves to the bladder leaving the spine can be an effective form of pelvic floor rehabilitation in some patients. Neuromodulation delivers mild electrical pulses to the nerves that control bladder and pelvic floor function to improve symptoms of urgency, frequency, and incontinence, as well as bladder-voiding problems.

Percutaneous posterior tibial nerve stimulation (urgent PC) is low-voltage electrical neuromodulation from an electrode inserted just above the ankle to the lumbar-sacral nerves which control the bladder and pelvic floor muscles. Patients usually receive weekly 30-minute treatments for 10 to 12 weeks. This advanced treatment is less invasive than implanted sacral nerve stimulation.

Sacral nerve stimulation is conducted with an implant near the lower spine (tail bone). This procedure called InterStim® therapy is performed on an outpatient basis with a short recuperation time. At first, the doctor will use a battery-operated generator outside the body to deliver stimulation through a tiny wire implanted under the skin to see if the treatment relieves symptoms. If the temporary treatment works well, it may be possible to have a permanent generator about the size of a watch implanted that delivers stimulation to the sacral nerves in the back, much like a pacemaker.

A vaginal pessary is a medical-grade silicone ring that is inserted to help support the walls of the vagina, lifting the bladder and nearby urethra. Pessary placement is common for patients with pelvic prolapse disorders to control urinary incontinence. Similar to a contraceptive diaphragm, a pessary is fitted for each individual woman. Many women use a pessary only during exercise while others wear their pessary all day. Pessary users should see their doctor regularly to check for small scrapes in the vagina or vaginal and urinary tract infections that can result from using the device.

Surgeries

Surgery for Incontinence

According to the National Institutes for Health, there are more than 200 surgical techniques for urinary incontinence alone. Patients must carefully evaluate which, if any, surgical procedures are appropriate with an experienced urogynecologist or urologist/gynecologist. Specialists in the Bladder Health Program of South Florida at Memorial Hospital Miramar are skilled in a diverse range of innovative treatments and advanced technologies to diagnose and address incontinence and bladder conditions in women and men.

In some women, the bladder can move out of its normal position, especially following childbirth. Most stress or activity-related incontinence problems are caused by the bladder neck dropping toward the vagina. To correct this problem, the surgeon raises the bladder neck or urethra and supports it with a ribbon-like sling or web of strings, attached to a pelvic muscle or bone. The sling supports the urethra, much like a hammock to stop leakage. The three main types of surgery are retropubic (bladder neck) suspension and two types of sling procedures, retropubic and trans-obturator.

Retropubic (bladder neck) suspension uses surgical threads (sutures) to support the bladder neck. In this operation, the surgeon makes an incision in the abdomen a few inches below the navel and then stitches the threads directly to strong ligaments near the pubic bone or to the bone itself to support the urethral sphincter. This common procedure is often done under general anesthesia at the time of an open abdominal procedure such as a hysterectomy or hernia repair. It is also sometimes performed at the time of pelvic organ prolapse repair – which may cause the incontinence.

Sling procedures are performed through a small vaginal incision. The traditional sling procedure uses a strip of synthetic mesh, animal tissue or the patient's own connective tissue called fascia to cradle the bladder neck in a tension-free manner at the level of the mid-urethra. The surgeon attaches both ends of the sling to the pubic bone or ties them in front of the abdomen just above the pubic bone.

Midurethral slings do not require any suturing for attachment and are performed in less-invasive procedures, usually on an outpatient basis. The two general types of midurethral slings are retropubic slings and transobturator slings. In retropubic slings, the surgeon makes small incisions behind the pubic bone or at the sides of the vaginal opening as well as a small incision in the vagina. The sling is suspended between the pubic bone and the bladder neck. A thin strip of synthetic transvaginal tape may be placed under the bladder. Transobturator slings are a more recent innovation, in which the sling is passed through the obturator foramen openings on either side of the pelvic bone avoiding the pelvic organs and reducing the risk of bladder and bowel injury.

Male slings can improve some types of urinary incontinence in men, especially after prostate surgery. In a sling procedure, the surgeon creates a hammock support below the urethra by placing a strip of biologic or synthetic material underneath the urethra and attaching the ends of the strip to the pelvic bone. Modern male slings using the transobturator do not require any bone attachment and keep constant compression below the urethra. The compression is strong enough to decrease leakage during activity while allowing for easy voiding without the need to press a mechanical pump.

Injections for stress incontinence using one of such materials as collagen carbon beads, or apatite paste, may be used to support (bulk up) the tissues near the urinary sphincter. The doctor injects the bulking agent into tissues around the bladder neck and urethra to make the tissues thicker and strengthen the urethra and reduce stress incontinence. The procedure takes about half an hour and the patient may go home soon afterward. Over time, the body may slowly eliminate or absorb certain bulking agents, so patients may need to repeat injections often.

Botox® for overactive bladder Botox (botulinum toxin A) is used to relax the muscles of the urinary bladder and reduce the urgent sensation to void. Under a local anesthetic, a physician threads a needle through a scope with a camera mounted on it. As it passes through the urethra, Botox is injected directly (intravesically) into the bladder muscle. The Botox procedure is done in the office and patients can usually return to work the same day. Treatments can be repeated every four to six months. Clinical trials on Botox as a treatment for overactive bladder are still being performed before it is expected to be approved by the Food and Drug Administration.

Artificial urinary sphincter is an implanted silicone device that keeps the urethra closed until the appropriate time to urinate. This inflatable device can help people who have incontinence due to weak sphincter muscles or because of nerve damage that interferes with sphincter muscle function. Considered the gold standard, It is especially effective in men who have developed moderate to severe urinary incontinence after prostate cancer treatment. Surgery to place the artificial sphincter typically requires general or spinal anesthesia. The device has three parts: a cuff that fits around the urethra, a small balloon reservoir placed in the abdomen, and a pump placed in the scrotum for men and underneath the skin in a woman's labia. Learn more about artificial urinary sphincter implants.

Extracorporeal shock wave lithotripsy uses high-energy shock (sound) waves to break up a kidney stone. Extracorporeal means outside the skin. Lithotripsy is a Greek word for stone crushing. The shock waves break a large stone into small stones that can pass through the urinary system. During the treatment a health technician will use ultrasound or X-ray images to direct the sound waves to the stone while a percutaneous urinary procedure drains small stones in the urine out of the urethra. The lithotripsy treatment should take about an hour. Learn more about what to expect.

Percutaneous urinary procedures help drain urine from the bladder or kidneys to flush out or remove kidney stones. Percutaneous means "through the skin." A percutaneous nephrostomy is the placement of a small, flexible rubber catheter through the skin into the kidney to drain urine. A suprapubic cystostomy passes through the skin of the lower abdominal wall into the bladder. Percutaneous nephrostolithotomy (or nephrolithotomy) is the passing of an endoscope through a small opening in the skin into the kidney to remove or break up the stone. This is sometimes known as tunnel surgery. The inpatient procedure usually requires a hospital stay of less than 24 hours.

Bladder instillation of medication (Intravesical instillation) During a bladder instillation, also called a bladder wash or bath, the bladder is filled via catheterization with a solution containing medicine. The solution is held for varying periods of time, averaging 10 to 15 minutes, before being emptied. Bladder instillations are treatments that are administered directly into the bladder via catheterization. Treatments are given every week or two for six to eight weeks and repeated as needed to treat interstitial cystitis and bladder cancers.

Bladder distention (hydrodistention) is a diagnostic cystoscopic procedure and treatment performed under general anesthesia that stretches the bladder capacity. Many people with interstitial cystitis (painful bladder syndrome) have noted an improvement in symptoms after a bladder distention has been done to diagnose the condition. In many cases, the procedure is used as both a diagnostic test and initial therapy. Researchers are not sure why distention helps, but some believe it may increase capacity and interfere with pain signals transmitted by nerves in the bladder.

Catheterization involves a thin tube a patient can learn to insert through the urethra into the bladder to drain urine. Catheters may be required once in a while, a few times a day, or all of the time. If the catheter is used all the time, it will drain urine from the bladder into a bag worn on the leg. Learn more about catheter use for women and catheter use for men. Patients with neurologic bladder disorders often benefit from long-term intermittent catheterization.

Surgery for Pelvic Organ Prolapse

Many different vaginal, abdominal, laparoscopic and robotic procedures are used to treat pelvic organ prolapse. If more than one pelvic prolapse condition exists, they may often be corrected during the same surgery. There is no consensus on the most effective operation and many considerations to discuss, involving long-term effects, risks of complications, use of biologic or synthetic mesh enhancements, sexual and reproductive implications, and other issues. Patients must carefully evaluate which, if any, surgical procedures are appropriate with an experienced urogynecologist or urologist/gynecologist.

Sacrocolpopexy is a procedure to surgically correct vaginal vault prolapse to hold the vagina in the correct anatomical position. Uterine prolapse may be treated by removing the uterus in a hysterectomy. Both procedures may be performed through abdominal or vaginal incisions. In younger patients and in cases of severe prolapse or failed previous vaginal repairs, a sacrocolpopexy is often preferable. In most situations, prolapse of the vaginal walls, urethra, bladder, or rectum can be surgically corrected at the same time.

Robotic laparoscopic surgeries

Robotic laparoscopic sacrocolpopexy and hysterectomy surgeries are minimally invasive alternatives to the traditional (open) gynecological surgeries. In pelvic laparoscopic surgery, the surgeon makes three to five small incisions in the lower abdomen and inserts a thin tube with a tiny video camera attached to one end. The camera sends a magnified image from inside the body to a monitor, giving the surgeon an optimal view of the pelvic organs. While viewing the monitor, the surgeon uses precision instruments to perform the required procedures.

Robotic surgery, using the da Vinci® Surgical System robot, allows an advanced, even less invasive and more accurate procedure, often offering a reduced risk for complications, a shorter hospitalization and faster recovery. However, this procedure may not be appropriate for every woman. There are numerous specialists in the Bladder Health Program of South Florida who are trained and experienced in robotic surgery to treat most pelvic prolapse disorders.

Pelvic Reconstructive Surgeries

Urethral dilation is an outpatient procedure for men or women to dilate, or widen, the urethra, if the flow of urine is obstructed or inhibited by a urethral stricture or narrowing. Under local anesthesia, a small instrument known as a filiform is passed through the urethra. The process is repeated with progressively larger plastic dilators until the passage may accommodate the stream. Urethral dilation is usually performed over several sessions.

Urethroplasty (open urethral reconstruction) is a surgical alternative to treat urethral strictures when dilation and other treatments have failed. There are two types of urethroplasty for men. The first, excision and anasmotomis (primary repair), involves complete excision of the narrowed diseased segment of the urethra and subsequent rejoining of the segments. The second method of urethroplasty grafts tissue from other parts of the body such as the inner lining of the mouth or penis foreskin to enlarge the narrow segment of the urethra. Patients should spend no more than a day or two in the hospital after surgery, but typically wear a catheter for two or three weeks.

Urinary diversion may be a consideration in a serious condition when the bladder must be removed or all bladder function is lost because of nerve damage, urethral damage or cancer. In this procedure, the surgeon creates a reservoir by removing a piece of the small intestine and directing the ureters to the reservoir. The surgeon also creates a continent stoma, an opening on the lower abdomen where the urine can be drained through a catheter or into a bag. A urinary diversion may mean a urostomy, which requires a pouch to be worn outside the body, or a continent diversion, which involves the creation of a pouch or bladder inside the body, usually using part of the digestive tract.

Vaginal wall repair (anterior vaginal wall repair) Advanced cystocele (bladder prolapse) may require surgery to move and keep the bladder in a normal position. The most common procedure for cystocele repair is for the surgeon to make an incision in the anterior (front) wall of the vagina and repair the area to tighten the layers of tissue that separate the organs, creating more support for the bladder. Surgeons may or may not choose to use a biologic or synthetic material (mesh augmentation) between the bladder and vagina. A catheter is often worn for a few days after surgery. The patient may stay in the hospital for two to four days and take four to six weeks to recover fully. Read a study comparing vaginal mesh augmentation with other pelvic prolapse surgeries.



Medical Disclaimer: The information provided in the Bladder Health Program of South Florida website should be used solely for educational purposes. It is not intended to replace the independent judgment of a healthcare provider. The appropriateness of a course of treatment for a patient may vary from the medical information provided herein due to individual conditions and/or complications. Always ask your physician about all treatment options, as well as the risks and benefits.

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