Division of Uro-Gynecology & Pelvic Floor Reconstructive Surgery

Sam H. Hessami, M.D.
Director

Interstitial Cystitis (IC)

Interstitial Cystitis is a chronic inflammatory condition of the bladder. Its cause is unknown.  It is thought that unlike common cystitis (a urinary tract infection), IC is not caused by bacteria and does not respond to antibiotic therapy.  IC is most commonly found in women.

Symptoms include frequent day and/or night urination; the urgency to pass urine immediately; pain in the lower abdominal, urethral, or vaginal area; and some less common symptoms such as muscle and joint pain, migraines, allergic reactions, and gastrointestinal problems.  IC may be associated with other chronic diseases such as fibromyalgia, irritable bowel syndrome, and endometriosis.

A diagnosis of IC is made after ruling out other diseases by using a urine culture and cystoscopy, a test using a lighted scope to see inside the bladder.  Cystoscopy is performed under general anesthesia.  To diagnose IC, the bladder is distended with water during cystoscopy to check for pinpoint hemorrhages on the bladder wall that are the signs of IC.

There is currently no cure for IC. Palliative treatments include:

• Medications
• Instillations of medications directly into the bladder
• Dietary changes
• Stress management techniques, biofeedback, bladder-strengthening exercises
• Electrical nerve stimulation

Pelvic Floor Disorders and Treatment

Pelvic floor disorders involve a dropping down of the bladder, rectum, or uterus caused by weakness or injury to the ligaments, connective tissue, and muscles of the pelvis. Pelvic floor disorders become more common as women age.

The pelvic floor is a network of muscles, ligaments, and tissues that support the pelvic organs: the uterus, bladder, and rectum.  If the muscles become weak or the tissues are stretched or damaged, the pelvic organs may drop down and protrude into the wall of the vagina. If the condition is severe, tissues may protrude all the way through the vagina and outside the body.

Pelvic floor disorders usually result from a combination of factors, including pregnancy, vaginal delivery, obesity, chronic coughing, frequent straining during bowel movements, heavy lifting, hysterectomy, nerve disorders, injuries, and tumors.

Types of pelvic floor disorders:

All pelvic floor disorders are essentially hernias, in which tissue protrudes abnormally because another tissue is weakened.  Often, a woman has more than one type of pelvic floor disorder.  The most common symptom is a feeling of heaviness or pressure in the area of the vagina — a feeling that the uterus, bladder, or rectum is dropping out.  Symptoms tend to occur when a woman is upright and disappear when she is lying down.  Sexual intercourse may be painful.

• A rectocele develops when the rectum drops down and protrudes into the back wall of the vagina.  A rectocele can make having a bowel movement difficult and may cause a sensation of constipation.
• An enterocele develops when the small intestine and the lining of the abdominal cavity bulge downward between the uterus and the rectum or, if the uterus has been removed, between the bladder and rectum.  An enterocele may not cause symptoms, but some woman have a sense of fullness or feel pressure or pain in the pelvis.
• A cystocele develops when the bladder drops down and protrudes into the front wall of the vagina.  A cystourethrocele is similar but develops when the upper part of the urethra also drops down.  Either of these disorders may cause stress incontinence (passage of urine during coughing, laughing, or any other movement that increases pressure within the abdomen) or overflow incontinence (passage of urine when the bladder becomes too full).  After urination, the bladder may not feel completely empty.  Sometimes, a urinary tract infection develops.  Because the nerves to the bladder or urethra may be damaged, women who have these disorders may develop urge incontinence (an intense urge to urinate, resulting in passage of urine).
• In prolapse of the uterus, the uterus drops down into the vagina.  It usually results from weakening of the connective tissue and ligaments supporting the uterus.  Prolapse of the uterus may cause pain in the lower back or over the tailbone, although many women have no pain during walking.  A woman with total uterine prolapse may also have difficulty having a bowel movement.
• In prolapse of the vagina (also called vaginal vault prolapse), the upper part of the vagina drops down into the lower part, so that the vagina turns inside out.  Prolapse of the vagina occurs only in women who have had a hysterectomy.  Total prolapse of the vagina can cause pain while sitting or walking.  The condition may cause a compelling or frequent need to urinate.  Having a bowel movement may be difficult.

Diagnosis of Pelvic Floor Disorders:

Pelvic floor disorders are usually diagnosed with a pelvic examination.  The doctor uses a speculum (an instrument that spreads the walls of the vagina apart) and may insert one finger in the vagina and one in the rectum to determine how severe a rectocele is.  A woman may be asked to bear down or to cough while standing.  Procedures to determine how well the bladder and rectum are functioning, such as urine tests, may be performed.  If a woman has a problem with the passage of urine or urinary incontinence, the doctor may use a flexible viewing tube to see inside the bladder (cystoscopy) or the urethra (urethroscopy).  The amount of urine that the bladder can hold without leakage, and the rate of urine flow may be measured.

Treatment of Pelvic Floor Disorders:

If the prolapse is mild, performing Kegel exercises can help by strengthening the pelvic floor muscles.  Kegel exercises target the muscles around the vagina, urethra, and rectum — the same muscles used to stop a stream of urine.  To perform Kegel exercises, squeeze your muscles tightly for about 10 seconds.  Then relax them for 10 seconds.  Repeat this 10 to 20 times in a row.  You should do Kegel exercises several times a day while you are sitting, standing, or lying down.

If the prolapse is severe, a small cube-shaped device called a pessary may be used to support the pelvic organs.  Other treatments include estrogen vaginal suppositories and creams or pelvic floor reconstructive surgery.

Pelvic Floor Reconstructive Surgery

Pelvic floor reconstructive surgery is used to treat prolapses of the uterus, rectum, bladder, and vagina. Hackensack University Medical Center offers minimal access prolapse surgery using a mesh to push back the prolapsed organ and hold it into place so that it no longer drops into the vagina.  These procedures are performed using general anesthesia, through several small incisions in the vagina and pubic hairline. Patients generally spend several days in the hospital afterward and recuperate within two weeks after surgery.

Urinary Incontinence

Urinary incontinence is uncontrollable, involuntary urination often due to injury or disease of the urinary tract.  It affects twice as many women as men.  Although the disorder can affect women of all ages, it is more common in the elderly because the efficiency of the sphincter muscle surrounding the urethra declines with age.  Urinary incontinence is uncomfortable and debilitating but very treatable.

There are several types of incontinence:

• Stress incontinence, which occurs when a person coughs, laughs, picks up something heavy, or exercises.  Stress incontinence is very common in women, particularly after childbirth, when the urethral sphincter muscles are stretched.
• Urge incontinence, an urgent desire to urinate, is accompanied by the inability to control the bladder.
• Total incontinence is the complete lack of bladder control because of the total absence of sphincter activity.
• Overflow incontinence, which occurs when the patient is unable to empty the bladder because of an obstruction.

Urinary incontinence can be treated with Kegel exercises, medications, or surgical procedures.  Some patients may be candidates for a same-day transvaginal, minimally invasive “bulking up” procedure of the urethra that does not require general anesthesia.  During the procedure,  an FDA-approved biomaterial is injected into the urethra via the vagina.  The biomaterial narrows the diameter of the urethra (the tube through which urine passes from the bladder out of the body during urination) and strengthens it so that urine cannot leak out.  This procedure is useful for young women who may want to bear more children or elderly women whose health cannot withstand surgery with general anesthesia.  Because the bulking up procedure requires only local anesthesia, it does not affect pulmonary or cardiac function.

For patients who are in general good health and can undergo surgery with general anesthesia or those who do not wish to bear any more children, a transvaginal “sling” procedure may be recommended.  During this procedure, a synthetic mesh is placed under the urethral sphincter to reinforce it and stop the leakage of urine.  Just three small incisions are made in the vagina and at the pubic hairline; patients generally spend one to three days in the hospital and recuperate within two weeks.