Pelvic Floor Disorders
Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS)
Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) is a chronic issue of bladder health. The patient suffering from IC/BPS experiences pain, pressure, or discomfort related to the genitourinary organs (bladder and urethra) in the absence of other conditions. A diagnosis of IC/BPS requires ruling out other potential causes of the discomfort or pain.
Common Symptoms
- Frequent urge to urinate to relieve pain
- Painful intercourse
- Pelvic floor spasms
- Urge to urinate that never goes away even after voiding
Treatment Options
Women with IC/BPS may benefit from a multimodal treatment approach. Our physicians develop an individualized treatment plan to treat the condition depending on the patient’s particular symptoms. We may create a plan that integrates multiple therapies to ensure speedy recovery with long-term outcomes, including:
- Bladder instillations
- Botox injections
- Medications
- Pelvic floor physical therapy
- Sacral neuromodulation
- Surgical therapies
Mesh Complications
Our team has extensive experience managing mesh complications that may arise from prior surgeries that utilized vaginal mesh. Some patients experience pelvic pain or pain during intercourse that occurs after pelvic surgery. Patients may also experience new urinary symptoms after the placement of mesh.
Complications That May Result After Surgery
- Infections
- Nearby organ perforation
- Pelvic organ relapse return after failing of mesh
- Urinary problems like worsening of incontinence
- Vaginal scarring
Common Symptoms
- Persistent pain in the pelvic region
- Vaginal bleeding that is not related to menstruation
- Pain during sexual intercourse
- Discomfort during urination and other related symptoms
- Abnormal discharge from vagina accompanied with pain indicating infection
Treatment Options
Your physician may prescribe medications to treat infection symptoms. However, the most effective mesh complication treatment is surgical removal and damaged tissue repair. At Mount Sinai, we tailor the treatment to meet the specific needs of each patient. Our experts are specialists in performing surgical mesh removal. Plus, we correct any subsequent urinary problems with non-mesh options.
Overactive Bladder, Urinary Incontinence, and Voiding Dysfunction
Overactive bladder is characterized by the sudden need to urinate. It primarily affects women and is a common medical problem. These sudden urges may lead to urinary incontinence, or the involuntary leakage of urine. Voiding dysfunction is a generalized term used to describe issues in the normal function of the bladder. There can be different non-neurogenic or neurogenic factors that can contribute to this condition. Various treatment options are available to treat these conditions.
Types of Incontinence
There are several different types of incontinence, which include the following:
- Gravitational incontinence (involuntary leakage with standing)
- Mixed urinary incontinence
- Overflow incontinence
- Stress urinary incontinence (SUI)
- Total incontinence
- Unaware incontinence
- Urgency urinary incontinence (often associated with an overactive bladder)
Overactive Bladder
Overactive bladder (OAB) is one of the most common pelvic floor disorders globally, affecting both women and men.
Common Symptoms
- Nocturia (nighttime) urination
- Urgency urinary incontinence
- Urinary frequency
- Urinary urgency
- Voiding dysfunction
Voiding Dysfunction
Voiding dysfunction is a condition in which the bladder cannot empty properly because of tight pelvic floor muscles.
Common Symptoms
- Frequent urination (urinating more than eight times per day)
- Inability to empty the bladder
- Urgency to urinate
Treatment Options
There are many options available to treat incontinence, overactive bladder, or voiding dysfunction, depending on the cause. Your physician may try behavioral training, lifestyle changes, pelvic floor exercises, and medicines. If the problem does not resolve, your doctor may recommend medical devices, injections, or surgery.
Behavioral Training
This generally includes bladder training and timed urination. Bladder training teaches individuals how to hold their urine for increasingly more extended periods to prevent emergencies and leaks.
Lifestyle Changes
Avoid drinking too much fluid, including alcohol and caffeine, which can increase urinary frequency and urgency. Losing weight also often helps stress incontinence by relieving pressure on bladder muscles. Identify and avoid foods that can irritate your bladder. If you smoke, try to quit. This may reduce coughing, which can trigger stress incontinence.
Exercises
Pelvic floor muscle exercises, also called Kegel exercises, can help strengthen bladder muscles and help improve any type of urinary incontinence, including overactive bladder. However, women who have difficulty emptying their bladder or have pelvic pain should avoid these exercises.
Medication
There are several medications available that can benefit individuals who experience overactive bladder symptoms. Your physician may recommend the medicine depending on your individual condition.
Medical Devices
Medical devices like pessaries, urethral inserts, and external urethral barriers help treat stress incontinence by keeping urine from leaking.
Injections
There are several injections available that can help treat incontinence, including but not limited to the following:
- Botulinum Toxin Type A (“Botox”): Individuals with urge incontinence (overactive bladder) can receive injections of the medication into the bladder muscle. It relaxes the bladder muscle and improves urinary urgency, frequency, and urgency incontinence.
- Urethral Bulking (Bulkamid, Coaptite, Collagen): This is a minimally invasive, non-mesh option for stress urinary incontinence. The doctor injects the bulking agent through a needle into the wall of the urethra. The bulking agent bulks up the urethral tissue and allows it to close up (“coapt”), preventing urine leakage. This improves leakage with coughing, laughing, exercise, and more.
Minimally Invasive Surgery
There are surgical alternatives available to address different types of incontinence.
- Bladder Reconstruction: The surgeon harvests tissue from the intestine or stomach and uses it to create a larger bladder. The surgeon may also reposition the ureter and urethra when creating the larger bladder.
- Mid-Urethral Sling: The mid-urethral sling is the most common surgery to treat stress urinary incontinence. The surgeon utilizes a small strip of synthetic mesh that he places in an accessible manner underneath the urethra. This allows in-growth of tissue to help build up urethral support. Our surgeons have fellowship training and years of experience implanting synthetic mid-urethral slings and safely performing this procedure.
- Sacral Neuromodulation: This therapy helps to restore the function of the bladder and bowel. It can effectively treat various conditions, including urgency urinary incontinence, urinary frequency, bladder pain syndrome («interstitial cystitis»), fecal incontinence, and urinary retention. The surgeon implants a bladder pacemaker, which uses mild electrical stimulation of sacral nerves to regulate the behavior of the bladder and pelvic floor muscles. Mount Sinai was the first institution in Miami-Dade to offer an MRI-compatible, rechargeable device for sacral neuromodulation.
- Vaginal Sling: The surgeon introduces a strip of native tissue (“fascial sling”) to support the bladder neck or urethra like a hammock. The sling, which our surgeon secures inside the abdomen, helps treat stress incontinence by keeping the urethra closed during physical activity.
Pelvic Organ Prolapse and Vaginal Prolapse
Pelvic organ prolapse is a condition in which the muscles, ligaments, and skin surrounding a woman’s vagina weaken or break, causing pelvic organs such as the uterus, rectum, bladder, urethra, small bowel, or vagina to fall out of their normal position. This condition most commonly affects older women whose pelvic muscles and tissues are weakened or stretched from the effects of gravity, loss of estrogen, a strain of childbirth, or surgery.
Vaginal prolapse is a type of pelvic floor prolapse in which the soft tissue support of the vagina weakens, allowing surrounding pelvic organs to push into the vaginal wall.
Types of Vaginal Prolapse
There are several different types of vaginal prolapse, including the following:
- Cystocele (prolapsed bladder)
- Cystourethrocele (prolapsed bladder and urethra)
- Enterocele (herniated small bowel)
- Prolapsed uterus
- Rectocele (prolapsed rectum)
- Urethrocele (prolapsed urethra)
- Vaginal vault prolapse
Common Symptoms
- Pelvic pressure and discomfort
- Problems urinating or defecating
- Sexual discomfort
- Vaginal bulge
Treatment Options
The treatment depends on your doctor’s diagnosis of pelvic floor prolapse or vaginal prolapse type. Our physicians may try several non-surgical techniques to strengthen your vaginal muscles or use vaginal inserts to support the prolapsed organs. However, pelvic organ prolapse results from an anatomical defect that we can successfully treat with minimally invasive surgery in most patients.
Physical Therapy
This treatment includes electrical stimulation and pelvic floor exercises. During electrical stimulation, the doctor applies small electrical currents to specific muscles in your vagina or pelvic floor. The current causes your muscles to contract, which strengthens them.
Insertion of Medical Devices
Pessaries are rubber or silicone devices that come in a variety of shapes. Your physician can insert it into the vagina to support the vaginal wall and help restore urinary continence.
Minimally Invasive Surgery
Mount Sinai urologists commonly use abdominal or vaginal minimally invasive techniques to treat pelvic floor prolapse. Our physicians skillfully perform native tissue repairs for pelvic organ prolapse (which does not use surgical mesh) and robotic abdominal sacrocolpopexy, which uses FDA-approved surgical mesh.
Types of Surgical Interventions:
- Cystocele (bladder prolapse): The surgeon pushes the bladder back into place, repairs the connective tissue between the bladder and vagina to keep the bladder in its proper place, and removes extra tissue.
- Enterocele (herniated small bowel) and vaginal vault prolapse: The surgeon may perform a robotic sacrocolpopexy to secure the vaginal vault (the top of the vagina) to the sacrum (the base of the spine where it connects to the top of the pelvis). Alternatively, some patients may also benefit from native tissue repairs such as a sacrospinous ligament fixation. This is a vaginal procedure with no abdominal scars where the surgeon uses a suture to secure the vaginal apex to one of the toughest ligaments in the pelvis.
- Rectocele (rectum prolapse): The surgeon secures the tissue between the vagina and rectum to keep the rectum in its proper place and removes extra tissue.
- Tricompartmental Prolapse: Many women who have pelvic organ prolapse develop anatomic defects in several compartments. This requires the use of more than one compartment in the same surgery, often performing a hysterectomy.
- Uterine prolapse: Many patients can benefit from this surgical procedure. It addresses this anatomical defect by securing the “apex” to ligaments in the pelvis. We can perform this procedure with or without a hysterectomy. Our surgical team has experience performing both abdominal and vaginal hysterectomy at the time of pelvic organ prolapse repair. Additionally, some women may elect a uterine sparing (“hysteropexy”) prolapse repair that can help correct uterine prolapse without the need for a hysterectomy.
Recurrent Urinary Tract Infections (UTIs)
Many women suffer from recurrent UTIs, defined as a bacterial infection that occurs two times within six months or three times within a year. UTIs account for more than seven million doctor’s office and emergency room visits in the United States each year. Fifty percent of women will experience a urinary tract infection in their lifetime, and once a woman contracts her first UTI, there is an 80% chance of her getting a second.
Types of UTIs
There are different types of UTIs depending on the affected urinary tract part. These include:
- Bladder (cystitis)
- Kidney UTI
- Urethra (urethritis)
Common Symptoms
- Cloudy urine
- Frequent or intense urges to urinate
- Pain or a burning sensation during urination
Risk Factors for UTIs
Several risk factors can cause UTIs, and women are more likely to be prone to symptomatic UTIs. For example, women who have gone through menopause are more likely to have UTIs when they lose the protective effect of estrogen on tissues that compose the vaginal lining. Medical conditions like diabetes, neurologic, and immune system disorders may also make some women prone to infections. The inability to empty one’s bladder, secondary to pelvic organ prolapse, is also a risk factor.
Treatment Options
Treatment for recurrent UTIs is highly variable from patient to patient. It depends on the part of the urinary tract that the infection affects.
Medications
One common treatment includes low-dose antibiotics taken daily for six months or longer with hopes to «break the cycle» of infections. Many women also benefit from using a topical vaginal estrogen to help prevent urinary tract colonization by bacteria and subsequent symptomatic UTIs.
Preventive Measures/ Behavioral Modifications
Physicians will also inform patients about general preventive measures and/or behavioral modifications. This may include incorporating researched compounds such as cranberry supplements, topical estrogens, or medications like Hiprex.
Urethral Diverticulum (UD) and Anterior Vaginal Wall Masses
Urethral diverticula refer to the condition in which a pouch or pocket forms along the patient’s urethra. These masses arise from periurethral glands. Because of their location, urine can fill them and cause infections.
Common Symptoms
These masses can be asymptomatic, but if they grow, symptoms can include the following:
- Blood in the urine
- Dribbling
- Nocturia
- Pain with sexual intercourse and urination
- Pelvic pain
- Recurrent urinary tract infections
- Symptoms related to the lower urinary tract same as overactive bladder
- Trouble in emptying your bladder
- Urinary blockage
Other Masses
Other vaginal wall masses (Skene’s gland cyst, Gartner duct cyst, and Urethral Caruncle) can arise from the vaginal wall. We have an experienced team to diagnose your particular condition and develop a personalized treatment plan to address the issue.
Treatment Options
The main option to treat UD is surgery. However, not all cases need surgical intervention. Some patients prefer not to undergo surgery until their symptoms get worse. In rare cases, UD may develop into cancer. If you don’t want to undertake surgical treatment, you must have follow-up appointments and counseling sessions with your physician.
Surgery
The surgical removal of the pocket or pouch is the key option for UD treatment. We have a team of highly qualified and experienced surgeons who perform the surgery. The UD pouch, in most cases, is attached to the opening of the urethra. It requires extreme care during surgery to prevent damage.
Our experts have extensive experience in performing UD surgery. They precisely target UD pockets while keeping the urethra safe using advanced technology, instruments, and their specialized skill set. Surgical options include:
- Creation of a permanent sac opening into the vagina
- Cutting into the neck of the sac
- Removal of sac
Urinary Fistula
A urinary fistula is an abnormal opening within a urinary tract organ or an abnormal connection between a urinary tract organ and another organ.
Types of Urinary Fistula
There are several types of urinary fistulas, including the following:
- Colovesical fistula: opening between the colon and bladder
- Enterovesical fistula: opening between the bowel and bladder
- Rectovaginal fistula: opening between the rectum and vagina
- Ureterovaginal fistula: opening between the ureter and vagina
- Vesicouterine fistula: opening between the uterus and bladder
- Vesicovaginal fistula: opening between the bladder and vagina
The most common fistula is between the urinary tract and the vagina. It usually results from injury to the bladder during pelvic surgery, such as a hysterectomy or a cesarean section for childbirth. Other causes of urinary fistula include pelvic cancer, radiation therapy, and inflammatory diseases.
Common Symptoms
- Abdominal pain
- Chronic urinary tract infections (UTIs)
- Constant urine leakage from the vagina
- Diarrhea
- Fever
- Irritation in the vulva (external female genital organ)
- Leakage of gas or feces into the vagina or fluid drainage from the vagina
- Nausea or vomiting
- Weight loss
Treatment Options
We have a professional team experienced in both vaginal and abdominal approaches to the reconstruction of urinary fistulas. With an early diagnosis, we can treat small fistulas through catheter drainage. However, most fistulas require surgical repair. If you have an infection associated with the fistula, your doctor may also prescribe antibiotics or other medications.