Female Urology and Urinary Incontinence
Urinary incontinence, or UI, is a distressing and serious health problem. Its psychosocial and economic burden leads to significant quality of life issues. UI is more prevalent than hypertension, depression and diabetes, yet it is underreported. Fewer than half of all patients are willing to report their symptoms to their physicians. We are skilled at the diagnosis and treatment of these conditions. Female gender alone is a predisposing factor for UI, most affected by childbearing and number of pregnancies.
According to the International Continence Society, the three most common types of UI are:
- Stress urinary incontinence, or SUI: involuntary leakage with effort, exertion, sneezing or coughing.
- Urge urinary incontinence, or UUI: involuntary leakage accompanied by, or immediately preceded by, urgency.
- Mixed urinary incontinence, or MUI: involuntary leakage associated with urgency and exertion, effort, sneezing or coughing.
Stress urinary incontinence
Stress urinary incontinence results from bladder neck/urethral hypermobility and/or neuromuscular defects, i.e., intrinsic sphincter deficiency. This occurs when the intra-abdominal pressure exceeds urethral resistance.
Among women, these changes occur due to weak collagen, advanced age, pregnancy, obesity, advanced pelvic prolapse and chronic obstructive airway disease. Our fellowship-trained physicians can help you navigate the treatment options best suited for you.
Tomas Griebling, MD, is the only fellowship-trained female and voiding dysfunction urologist in Kansas and Missouri, offering the latest techniques in diagnosis and management of difficult female urologic problems.
Our facilities provide state-of-the-art videourodynamic equipment to provide specific information about the most complicated conditions in the bladder and urethra.
Dr. Griebling has specialized training in interpreting the results of such testing to ensure proper management of this condition.
The treatment options for stress urinary incontinence include:
- Conservative: voiding frequency, fluid modification, pelvic floor rehabilitation therapy
- Non-Surgical: intra-urethral plug, pessary
- Bulking injections are an endoscopic option for injection of synthetic material (Coaptite® or Macroplastique®) in the tissues at the bladder neck. This helps partially close the opening of the urethra and improve continence. This is performed through a cystoscope as an outpatient procedure.
- Minimally invasive mid-urethral slings were approved by the FDA in 2006 and have been a valuable addition to our treatment options. The appeal of this technology is the single incision, shorter hospital stay and reduced postoperative pain. Intermediate-term data reveals the outcome’s similar to the previously accepted mid-urethral sling options.
- The gold standard for stress urinary incontinence, introduced in the 1940s and popularized in the 1970s, is the pubovaginal sling, or PVS, which is placed at the bladder neck. This can utilize autologous (self tissue), cadaveric tissue or xenograft (animal-based tissue) for the graft material. This is associated with high success rates and high patient satisfaction. Our female urologists have the most experience with the placement of PVS in the region.
Urge urinary incontinence
Urge Urinary Incontinence is considered classically due to an overactive bladder muscle, or OAB, or an incompetent urethral sphincter. The underlying pathophysiology of OAB can relate to alterations in any of the reflex cycles in normal urination or structural changes in the smooth muscle, nerves or lining of the bladder. Treatment of OAB is based on diagnosis after excluding other pathologies, i.e., urinary tract infection, bladder stones or diabetes. Dr. Griebling provides the following treatment options:
- Conservative: lifestyle modification, bladder training, drug therapy (anticholinergic)
- Minimally invasive: Botulinum toxin, better known as Botox. These are intramuscular bladder injections performed through a cystoscope in an outpatient setting. Dr. Griebling has had success with Botox for patients crippled with incontinence and unresponsive to other treatments.
- Minimally invasive nerve stimulation: sacral nerve stimulation, or InterStim, increases voided urinary volumes (thereby reducing urinary frequency and nighttime urination), decreases urgency and reduces UUI episodes. Dr. Griebling is nationally recognized for his contributions in urinary incontinence and voiding dysfunction and has vast experience with sacral neuromodulation.
- Surgical: Bladder augmentation is a surgical therapy that uses a segment of intestine to increase the size and capacity of the bladder. This also helps to reduce the pressure of the wall of the bladder, which can help to protect kidney function. This procedure is used in select patients when other forms of therapy have not been successful, or in some patients with spinal cord injuries or a history of spina bifida.
Dr. Griebling has extensive experience with this form of surgical therapy.
Mixed urinary incontinence
Mixed urinary incontinence, or MUI, is often treated as part of the treatment of SUI and UUI. This approach should be individualized, depending on the severity of each component.
Pelvic organ prolapse
Pelvic organ prolapse, or POP, is due to thinning or stretching of the collagen fibers in the connective tissue holding up the uterus, bladder, rectum and/or perineum. POP affects more than 30% of all women and 50% of women who have delivered a child. It is often described as “a woman’s hernia” and may worsen with age, requiring repair. This often presents as a bulge in the vagina, which may disappear while lying down. Other presentations may be difficulty emptying the bladder or bowels, pain or pressure in the vagina, recurrent urinary tract infections or limitations with sexual intercourse.
Dr. Griebling is the only fellowship-trained urologist in Kansas and Missouri with extensive knowledge in the diagnosis and treatment of POP. Diagnosis generally involves assessment with videourodynamics, a state-of-the-art test providing specific information about conditions of the bladder and urethra. This is especially beneficial in the management of urinary incontinence, which often goes hand-in-hand with prolapse.
Treatment options available for prolapse include:
Conservative-Pessary: a specialized device placed inside the vagina to help support the bladder and/or rectum and anatomically reduce the prolapse of the pelvic organs. This therapy may help reduce the symptoms of prolapse while avoiding the need for surgery.
- Vaginal: surgery through the vagina to repair one or more of the affected components of the prolapse (anterior or cystocele, apical and posterior or rectocele).
- Abdominal sacrocolpopexy: historically the gold standard for repair of apical prolapse, it is now reserved for complex cases that have failed to respond to multiple prior vaginal and/or robotic repairs.
- Robotic: state-of-the-art, minimally invasive surgery performed through 3-4.5 cm incisions using the da Vinci® Surgical System. This ideally provides greater precision and control. Patients experience less pain and blood loss, shorter hospital stays and shorter recovery times. This continues to maintain excellent clinical outcomes.
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We're here today to see a robotic sacrocolpopexy.
This is a robotic procedure planned for the treatment of apical prolapse in women who suffer from the feelings of pressure, pain, difficulty with urinating, having bowel movements due to the weakness in the pelvic floor.
This is associated with their history of pregnancies and childbirth in addition to the lack of estrogen associated with menopause.
This procedure will help in tacking the apex of the vagina to the sacral promontory to assist with adequate support, which will provide the patient relief of the symptoms that they present with.
The first part of the robotic sacrocolpopexy is the opening of the posterior peritoneum over the sacral promontory.
This can be tenuous as the middle sacral vessels run in the same space. In this portion, we're noting the dissected posterior peritoneum as flaps of the apex of the vagina.
We utilize one arm of a Y-shaped piece of polypropylene mesh to lay on the anterior vagina.
The mesh is attached to the apex of the vagina. We utilize six interrupted Gore-Tex sutures to hold the mesh in place on the anterior aspect of the vagina.
Now, we see the other arm of the Y attached to the posterior aspect of the vaginal apex.
Two Gore-Tex sutures are preplaced in the periosteum of the sacral promontory with care to avoid middle sacral vessels.
With support of the vaginal apex to confirm appropriate tension, the preplaced sacral sutures are used to tack the mesh down to the sacral promontory.
The posterior peritoneum is now pulled over the mesh tail and closed.
The mesh, as you see, has been fully retroperitonealized, bringing this procedure to a close.
The way the procedure is done, the patient is brought to the operating room.
They are actually awake.
Although, we do give sedation and local anesthetics, so they're very comfortable while we're doing the procedure.
What we do is we look for the specific landmarks.
So, we look for the tailbone, and then we identify the bones by feeling through the skin.
Once we've located the area where we believe the appropriate nerve root is, we actually take a small electrical conduction needle and place it through the skin that's been anesthetized and down into the opening in the bone, and that then sits down right alongside the nerve.
Once that's in place, we test it electrically and we take some X-ray pictures to make sure that we're in the right position.
Once we're sure that we're in the correct placement, we exchange this needle for an electrode that has four small contact points on it.
That actually again goes through the bone and sits down right alongside the nerve.
So, the nerve would be coming out kind of down in this area and that's what's going to give the electrical impulses to the nerve.
The patient wears this for one to two weeks.
It's connected to a little external wire that comes out of the skin, and the patient hooks it up to a small generator.
It looks sort of like a pager, and they keep a diary for us about their symptoms.
When they come back in one to two weeks, if it looks like they've had a good response and an improvement in their symptoms, then what we do is connect this lead to a small internal generator.
So, it's basically like a pacemaker battery, and that is put just under the skin kind of in the lower part of the back kind of above the hip.
It's very thin, and so for most patients they really don't even feel it unless they're pressing on it.
Then, this has a small set of computer chips in it that allows the patient to program the device and adjust it based on their symptoms.