What is a Urogynecologist?

A Urogynecologist is a physician that completed a full residency in Obstetrics and Gynecology and then spent 2–3 years specifically training in lower urinary tract and pelvic floor disorders. The full name of the specialty is Urogynecology and Pelvic Reconstructive Surgery. The anatomy and neurologic control of the pelvic organs and the pelvic floor in a woman is very complex, allowing for pregnancy and childbirth, sexual intercourse, and coordination of the musculature of the bladder, urethra, rectum and colon, and the pelvic floor to allow for urination and defecation. The pelvic floor also takes the brunt of the pressure of humans being upright bipeds. It is not surprising therefore that this complex system can sometimes not function normally and give rise to problems related to these systems. A Urogynecologist is uniquely qualified to evaluate, assess and offer therapy for these disorders, which may include coordination of care with other specialties such as Colorectal Surgery, Urology, Gastroenterology and Physical Therapy. Urogynecology is a relatively new subspecialty, with programs first becoming accredited 5–10 years ago, and it will be Board Certified within the next few years. Dr. Hall completed her fellowship training in Urogynecology and Pelvic Reconstructive Surgery in 1999, graduating from Harbor- UCLA under the tutelage of Dr. Narender Bhatia who was the first physician to have formal training in this fascinating specialty.

Why do some women have problems with urine leakage and prolapse?

Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) are extremely common. It is estimated that 11% of women will need surgery for SUI or POP in their lifetimes, and many more either use non-surgical methods or suffer in silence. We know that there is at least partially a genetic component, because certain families or ethnic groups have high incidence of prolapse and incontinence. Ask family members whether they have had problems with this since many people are reluctant to talk about it unless asked. Hernias may be an ancillary marker for poor connective tissue and risk of prolapse. Vaginal childbirth is a significant risk factor for pelvic floor problems. The more vaginal births, the larger the baby, the longer a woman pushes in the second stage of labor, the use of forceps or vacuum to deliver the baby, all increase the risk of future problems. Other conditions that chronically increase abdominal pressure like obesity, chronic cough, chronic constipation, and frequent heavy lifting also increase your risk.

Should I have a cesarean delivery?

Although pelvic floor problems are common, they certainly do not affect all women. Cesarean delivery before the onset of labor seems to be protective when compared to vaginal delivery, but pregnancy itself is a weak risk factor as well. We are not proposing that all women have a cesarean section. We are not at the point to be able to give a woman an estimate of her individual risk. The other thing to remember is that cesarean delivery, although very common, is still major surgery.  Although the risk of complications to mother or baby with cesarean delivery is low with the first and even second cesarean delivery, the risks (of excess bleeding, hysterectomy, fetal death) increase exponentially with the 3rd and higher order C-sections.

I want to have a vaginal delivery. Is there anything i can do to decrease the risk of future pelvic floor problems?

Yes! We know that doing pelvic muscle exercises increases the strength and weight of the pelvic floor muscles AND can improve SUI and POP if already present. The MOST critical time to be doing Kegel exercises is immediately after trauma, when rehabilitation is most effective. So after a vaginal delivery, I suggest to ALL women, do your Kegel exercises every time you feed the baby, whether you are breast or bottle feeding for at least three months. Also, if the first time you have noticed significant SUI is DURING your pregnancy, do not be alarmed. The hormone progesterone which is high late in pregnancy can decrease the urethral muscle tone and therefore can precipitate SUI. This often resolves after delivery. If on the other hand you begin leaking AFTER your delivery, this puts you at increased risk, but over time usually things will improve, especially if you are doing the exercises regularly.

How and when should I do Kegel’s exercises?

Only 50% of women can effectively contract their pelvic floor muscles. I use various ways to describe the contraction such as: “contract the muscles you would use to stop the urine stream or passage of gas” or “try to pull the vagina and rectum and coccyx inward” or "try to close the vaginal opening".

You can always put your fingers in the vagina and see if you feel a squeeze inside, or have your health care practitioner evaluate if you are doing the Kegel’s exercises properly. Do not regularly try to stop the urine stream as this can cause voiding problems over time. Since many women have trouble isolating these important muscles, specialized pelvic floor physical therapists can help, perhaps using modalities such as biofeedback or electrical stimulation.

Why does someone develop overactive bladder (OAB)?

Overactive Bladder is extremely common and causes symptoms of urinary frequency, urgency, and sometime leakage on the way to the bathroom. Only 10% of people with OAB have known neurologic disease and in the other 90%, we don’t know what causes it. It is more common than diabetes, is more frequent in women than men, and the incidence increases as we get older. It is NOT caused by holding your urine for long periods of time. The good news is that there are many behavioral and pharmacologic therapies that are quite effective in decreasing leakage and frequency. Restricting fluids and bladder irritants such as caffeine, artifical sweeteners and alcohol can help. Timed voiding to train the bladder to hold more and pelvic floor exercises that quiet bladder contractions may be effective. In addition, there are six medications specifically developed for overactive bladder symptoms. For refractory patients, BoTox injections into the bladder or Sacral Nerve Stimulation are also very effective.

Why do I get so many urinary tract infections?

It is shocking that most women DON'T get urinary tract infections (UTIs) all the time, but we don’t know why some women are prone and some are not. The urethra in a woman is only 3 cm long and it is adjacent to the vagina and rectum which naturally harbor many bacteria. It is rarely a question of hygiene, though it is always wise to wipe from front to back to minimize contamination. If a woman usually gets infections only after sexual activity, I recommend voiding after sexual activity to wash away any bacteria that can be “milked” into the urethra during sexual activity. There is a small percentage of women who get UTIs who have some underlying abnormality of the urinary tract but the vast majority have no abnormalities that can be found.

The two things that have been shown to decrease the infection rate in large studies are prophylactic antibiotics (taken either every day or with sexual activity) and vaginal estrogen in a post-menopausal woman. After menopause, the balance of bacteria in the vagina changes and estrogen restores the healthy balance. Vaginal estrogen preparations are MINIMALLY absorbed and have NEVER been shown to increase a woman’s risk of breast cancer or clotting disorders. Of course vaginal estrogens therefore do not have the benefits of systemic estrogen such as decreasing hot flashes, protecting against osteoporosis, improving the cholesterol balance in the blood, or other systemic effects.

Smaller studies have shown that Cranberry pills, Probiotics like Acidophilus, and Vitamin C may also decrease infections.