Reno, Sparks Top Urogynecology Practice
The field of Urogynecology (a subspecialty within Obstetrics and Gynecology) is dedicated to the treatment of women with pelvic floor disorders and support problems, such as vaginal, bladder, rectal and uterine prolapse, which can lead to voiding dysfunction, discomfort and/or pain.
Urogynecology also addresses women with urinary incontinence and other bladder problems. Our office provides state-of-the-art testing and treatment for these issues. Paula Naughton, RN, is our nurse specialist who works closely with our urogynecology patients. She performs urodynamic testing, pelvic floor evaluations, biofeedback Kegel exercises, and pretibial nerve stimulation (PTNS). She is also a valuable resource to our patients providing education, support and follow-up throughout the pre and post-operative process.
The following are some commonly treated problems in the field of Urogynecology:
Pelvic Support Problems (Cystocele, Rectocele, Enterocele, and Uterine Prolapse)
Urinary Tract Infections
There are non-surgical treatment options for urogynecological problems that deserve mention here.
Paula's Programs (Urodynamic Testing, Pelvic Floor Assessment, Biofeedback with Electrical Stimulation, and Percutaneous Nerve Stimulation (PTNS))
Other treatment options
Dilators are used to open the vagina and allow for intercourse without pain. These may be recommended for patients experiencing pain with intercourse for all different reasons. Our office has some dilators to purchase discreetly if you are having issues in this area. Ask one of our doctors for more information. The cost depends on the product but ranges from $20 to $40.
Pelvic Support Problems
Urinary incontinence is the involuntary loss of urine. There are many different types of urinary incontinence but the most common types we treat in women are:
Stress urinary incontinence is loss of urine with activity or strain such as, coughing, sneezing, jumping, laughing, etc. This problem often starts after having children. Patients may complain of no longer being able to run secondary to embarrassing leaking of urine.
Detrusor instability or over active bladder is loss of urine usually associated with frequency and/or urge with inability to control it. Sometimes, patients with this problem will get up to empty their bladder several times during the night. For example, a person affected by this may not be able to get to the bathroom in time or may lose urine with the sound of running water or when they place their hands in water.
Mixed incontinence is urinary loss that occurs as a result of both stress urinary incontinence and overactive bladder.
It is important to determine the type of urinary incontinence that a patient has because optimum treatment is different for each. The workup for urinary incontinence usually involves a detailed history and physical, urodynamics (study of the bladder), bladder diary, urine analysis, and sometimes, a pelvic floor evaluation. Your doctor will review the results of the workup and the treatment options with you.
The treatment options overlap for these types of urinary incontinence, however, stress urinary incontinence is effectively treated with surgery. This surgery involves placing a sling under the mid urethra and can be done as an outpatient surgery. Overactive bladder does not respond to this surgery, but is better treated with behavioral changes such as diet modification, bladder training, medications, and pelvic floor strengthening.
If a patient has mixed urinary incontinence then your doctor will determine which type is bothering the patient more, and begin the appropriate treatment. Sometimes, patients will do several treatment modalities to cure or significantly improve the problem.
Occasionally, urinary incontinence can be caused by other problems such as urinary tract infection, interstitial cystitis, tumors, stones, neurologic diseases, or even, certain medications. If this is the case, then this problem needs to be treated specifically, thus improving or eliminating the urinary incontinence.
If you have urinary incontinence, you do not have to live with this problem. Please discuss your symptoms with your doctor so that treatment can begin and lead to an improved quality of life.
Interstitial cystitis (IC) also known as painful bladder syndrome (PBS) is described as pelvic pain, pressure or discomfort related to the bladder, typically associated with urinary frequency and urgency, in the absence of infection or other pathology. The exact cause of interstitial cystitis is unknown. Most believe the normal repair of the bladder does not occur in IC patients. Defects in the bladder allow urine contents to leak into the bladder lining, causing irritation and pain.
The most common symptoms of IC are urinary frequency in the day or night or both, urinary urgency, and pain usually in the lower abdomen, urethra or vagina that may be intensified with urination or sex. There is not a specific test for IC because symptoms are similar to other disorders of the bladder. It is important to rule out other causes of these symptoms, such as, urinary tract infections, bladder cancer and endometriosis. Some tests and tools that may assist in diagnosis are:
Cystoscopy and hydrodistention
Course of treatment
Treatment is usually multi-factorial and a stepwise approach is often used. There is no cure for IC so treatment is aimed at symptom relief. Treatment considerations may include:
Diet modification some foods and drinks may be irritating to the bladder, examples include alcohol, tomatoes, spices, chocolate, caffeinated and citrus beverages, artificial sweeteners, carbonated beverages, etc.
Bladder retraining in order to reduce frequency, try to empty bladder on a schedule, lengthening time between scheduled voids
Over-the counter products Prelief, AZO, Cysta-Q, Calcium citrate, etc.
Oral medications Elmiron, antidepressants, antihistamines, pain relievers, antispasmodics, antiseptics
Bladder installations medications placed directly in the bladder to help reduce inflammation and provide relief of symptoms
Pre tibial nerve stimulation (PTNS) - emits electrical impulses to nerves in the lower back to help manage IC symptoms
Bladder distention is used as a diagnostic test sometimes and may give some symptom relief initially.
Surgery last resort
Experimental acupuncture, Botox, Uracyst, URG-101 installations
More information is available at the following sites:
Interstitial Cystitis Association
American Urologic Association
National Institute of Diabetes and Digestive and Kidney Disease
American Urogynecologic Society
Painful Intercourse (Dyspareunia)
When a woman feels pain while having sexual intercourse, it is called dyspareunia. Painful sex is fairly common. Nearly 2 out of 3 women have it at some time during their lives. The pain can range from very mild to severe. To understand the causes of painful sex, it helps to know about the female body. The vagina is a passage that leads from the uterus to the outside of the body. The cervix is the lower, narrow end of the uterus. It protrudes into the vagina. The outside of the female genital area is called the vulva. At the opening of the vagina are the inner and outer labia (or lips). The clitoris is at top of the inner lips. For most women, the clitoris is a center of sexual pleasure. The perineum is the area between the anus and vagina.
Painful sex can have both physical and emotional causes. To understand why the pain occurs, you should know what happens to your body during sex. A woman's body follows a regular pattern when she has sex. There are four stages:
Desire- the feeling that you want to have sex.
Arousal- physical changes take place. Your vagina and vulva get moist and the muscles of the opening of the vagina relax. The clitoris swells and enlarges. The uterus lifts up, and the vagina gets deeper and wider.
Orgasm- the peak of the response. The muscles of the vagina and uterus contract and create a strong feeling of pleasure. The clitoris can feel orgasm, too.
Resolution- the vagina, clitoris, and uterus return to their normal state.
The arousal stage is important because this is when your vagina prepares itself for your partner to enter you. If any part of this natural pattern does not happen, you may feel discomfort or pain with sex.
During sex a woman may feel pain in the vulva, at the opening of the vagina, within the vagina, or deep inside. Vulvar pain is pain felt on the surface (outside) of the vagina. Vaginal pain is felt within the vagina. Deep pain can occur in the lower back, pelvic region, uterus, and bladder. Different types of pain have different causes. It's important to find the cause because you may have problems that need medication, surgery, or counseling.
Pain can occur when some part of the vulva is touched. The vulva may be tender or irritated from using soaps or over-the-counter vaginal sprays or douches. Other causes include scars, cysts, or infections.
Vaginal dryness. The most common cause of pain inside the vagina is lack of moisture. This can occur with certain medications, with certain medical conditions, or because you are not aroused. It can occur at certain times of your life such as during or just after pregnancy, while breast feeling, or near or after menopause.
Around menopause, estrogen levels become lower. As a result, vaginal tissue may get thinner and drier. This may cause discomfort during sex. Some menopausal women take estrogen therapy to relieve the dryness. You can also buy water-soluble lubricants that help moisten the vagina.
Vaginal dryness can be normal and occur when you are not aroused enough during sex. You should discuss with your partner what makes you feel aroused. Often it is helpful for a couple to use a cream, jelly, or vaginal suppository to provide vaginal lubrication needed for sex. However, never use any kind of oil- such as petroleum jelly or baby or mineral oil- with latex condoms. These substances can dissolve the latex and cause the condom to break. Water-based cream or jelly is safe for use with condoms.
Another cause of vaginal pain is vaginitis - an inflammation of the vagina. The most common symptoms of vaginitis are discharge, itching, and burning of the vagina and vulva. Vaginitis has many possible causes, such as yeast or bacterial infection. Vaginitis can be treated with medication that you take by mouth or place in the vagina.
Vaginismus is a spasm of the muscles at the opening of the vagina. It causes pain when your partner tries to enter the vagina. In some cases, vaginismus is present the first time a woman has- or tries to have- sex. The pain also may occur during a pelvic exam.
Pain that starts deep inside may be a warning sign of an internal problem. Pain that happens when the penis touches the cervix can have many causes:
Pelvic inflammatory disease (PID)
Problems with the uterus
A pelvic mass
Bowel or bladder disease
Scar tissue (adhesions)
A pelvic exam often gives clues about the causes of deep pain. Your doctor may suggest laparoscopy to look into your abdomen and at the reproductive organs. Laparoscopy also can be used to treat some of these problems.
Pain during sex sometimes can be linked to a state of mind. Emotional factors, like memories or fears, can keep you from relaxing. Some women may feel guilty having sex. Or, some women may be afraid of getting pregnant or getting a sexually transmitted disease (STD). Sometimes, a past bad sexual experience, such as rape or sexual abuse, may be the cause. All these factors may make it hard to relax during sex. This prevents arousal and lubrication.
Some women may feel pain during sex if they are having problems with their partner. It's a good idea to talk about your concerns with your partner and your doctor. Your doctor may suggest that you see a counselor to help you cope with your problems.
Pain during sex is a sign there may be a problem. Talk to your doctor about the pain so that the cause can be found and treated as soon as possible. Proper treatment can help you enjoy your sex life.
Paula's Program, RN, BS, BCB, PMD
What are Kegel Exercises?
Kegel exercises are designed to strengthen the muscles of the pelvic floor that support the bladder and close the sphincters (urethral or anal muscles that contract to stop urine, gas, or stool from coming out.)
Your pelvic area is the portion of your body between your hips. At the bottom of your pelvis are several layers of muscle that stretch between your legs. These muscles attach to the front, back, and sides of the pelvic bones. You can identify these muscles by trying to stop your urine stream. Once you have learned how to identify these muscles, do not regularly perform Kegel exercises while urinating because this may eventually weaken the muscles and worsen your symptoms. You can also place a finger into your vagina, practice a Kegel exercise, and see if you can feel the muscles squeeze your finger. Some women squeeze the wrong muscles. Place a hand on your buttock, thighs, or abdomen to make sure you are not exercising these muscles instead of the internal muscles of the pelvic floor. Try squeezing these muscles while lying, sitting, and standing to see which position best helps you to isolate these muscles. It may help to think of pulling up or pulling into your body rather than just squeezing all the muscles of your pelvis.
How Do I Exercise Pelvic Muscles?
To exercise the pelvic muscles, begin by quickly contracting and relaxing the pelvic muscles. You should try to do 4 to 5 sets of 10 contractions each day. When you are comfortable performing quick pelvic muscle contractions, begin contracting and holding the pelvic floor muscle contraction for 5 seconds before relaxing. Once you are comfortable with holding the pelvic muscle contraction for 5 seconds, increase the hold time for 10 seconds before relaxation, this should be done in 4 to 5 sets of 10 contractions as well. Make sure you completely relax your muscles in between each ³contract and hold.² If you are holding for 5 seconds, you should relax your muscles for 5 seconds before contracting the muscles again.
A pessary is a plastic ring, similar to a vaginal contraceptive diaphragm, which is used to either lift the bladder or to apply some compression to the urethra during activities that are known to cause leakage. They are successfully used for the treatment of uterine prolapse. They are a low risk treatment option when compared to surgery for symptomatic prolapse and urinary incontinence. About half of the women who are successfully fitted with a pessary will continue to use it on a long-term basis. Typical pessary users are women who:
Need temporary support during exercise
Have mild symptoms and want to avoid surgery for the moment
Have health problems that make the risks of surgery too great
Need to delay surgery and are uncomfortable from their prolapse
There are numerous shapes and sizes of pessaries to meet the individual support requirements of different patients. Seeking care from a provider with a wide selection of pessaries may improve the chances of getting a comfortable fitting pessary. Not all women can have their prolapse successfully supported by a pessary. Situations such as scarring, a surgically narrowed or shortened vagina or very weak pelvic floor muscles can cause pessaries to fall out or be uncomfortable. Pessaries do require ongoing care to avoid problems with vaginal infection, ulceration or bleeding. A neglected pessary can result in erosions through the vaginal wall into the bladder or rectum.
In the ideal circumstance, a woman is taught how to remove, clean and reinsert her pessary at regular intervals. This can be as often as nightly or as infrequently as once per week depending upon the type of pessary and the overall health of the vaginal skin. Pessaries are not appropriate for women who cannot come for regular follow-up visits to the doctor¹s office. They should be avoided in women with dementia or those who have persistent vaginal erosions.
Frequently, vaginal estrogen cream, tablets or a ring are prescribed to women who use a pessary to strengthen the vaginal skin, especially for those in menopause. This will reduce the risk of developing any vaginal skin erosion or ulceration. If a woman cannot take care of her pessary, she will be advised to come to the office for removal, cleaning and vaginal exams every two to three months. If problems arise with infection or erosions, the visits may become more frequent.
The cost of a pessary is about $40 to $80 and this is not usually covered by insurance companies.
Certain vaginal creams may be helpful to improve some common urogynecologic problems.
Estrogen creams are commonly used in postmenopausal women to improve the suppleness, elasticity, and lubrication of the vaginal and vulvar tissues. These creams are topical estrogen only and do not largely get absorbed throughout the body. They are not considered systemic hormone replacement therapy. Estrogen cream is often prescribed for women with pelvic support problems to prepare for surgery and enhance healing and support after surgery, perhaps even enhancing results of surgery and decreasing the chance of failure. Estrogen creams may also be helpful in pessary patients to decrease the formation of ulcerations or discomfort in the vagina. These creams may help women with painful intercourse as well. There are alternatives to the cream for topical vaginal estrogens such as Vagifem, a vaginal pill absorbed locally in the vagina and Estring, a ring that is placed in the vagina and left there for 3 months at a time.
Neuropathy cream may be prescribed for patients with painful intercourse secondary to vulvodynia. Usually this cream is compounded especially for the patient¹s situation and is applied to the affected area daily.
Lubricants may be helpful for women having vaginal dryness or pain with intercourse. Our office recommends Silicone based lubrication for many women, especially if the current lubrication is not working. Our office has some of these special lubricants available for sample and/or purchase. If you are experiencing problems in this area, ask one of our doctors for more information. The cost ranges from $5 to $30.
Pelvic organ prolapse occurs when the normal support of the vagina is lost resulting in sagging or dropping of the bladder, urethra, cervix and rectum. As the prolapse of the vagina and uterus progresses, women can feel bulging tissue protruding through the opening of the vagina.
Causes and Risk Factors
By studying large numbers of women with and without prolapse, researchers have been able to identify certain risk factors that are believed to predispose, cause, promote or worsen prolapse. The strength of our bones, muscles and connective tissue are influenced by our genes and our race. Some women are born with weaker tissues and are therefore at risk to develop prolapse. Caucasian women are more likely than African American women to develop prolapse. Loss of pelvic support can occur when any part of the pelvic floor is injured during vaginal delivery, surgery, pelvic radiation or back and pelvic fractures during falls or motor vehicle accidents. Hysterectomy and other procedures done to treat prolapse are also associated with future development of prolapse. Some other conditions that promote prolapse include: constipation and chronic straining, smoking, chronic coughing, and heavy lifting. Obesity like smoking is one of the few modifiable risk factors. Women who are obese have a 40-75% increased risk of prolapse. Aging, menopause, debilitating nerve and muscle diseases contribute to the deterioration of pelvic floor strength and the development of prolapse.
We do not know exactly how common pelvic organ prolapse is because most of the research has been on women who come seeking health care. Nearly half of all women between the ages of 50 and 79 have some form of prolapse. The lifetime risk that a woman will have surgery for the correction of prolapse or urinary incontinence in the United States is about 11%. We also know that as many as one third of these women will undergo repeat corrective surgery for these conditions. Approximately 200,000 procedures for correction of pelvic prolapse are performed each year in the United States. We believe that is just the tip of the iceberg as many women mange their prolapse without surgery.
Some loss of support is a very common finding on physical exam in women, many of whom do not have bothersome symptoms. Those who are uncomfortable often describe the very first signs as subtle - such as an inability to keep a tampon inside the vagina, dampness in underwear, or discomfort due to dryness during intercourse. As the prolapse gets worse, some women complain of:
A bulging, pressure or heavy sensation in the vagina that worsens by the end of the day or during bowel movements
The feeling that they are sitting on a ball?
Needing to push stool out of the rectum by placing their fingers into the vagina during bowel movement
Difficulty starting to urinate, a weak or spraying stream of urine
Urinary frequency or the sensation that they are not emptying their bladder well
The need to lift up the bulging vagina or uterus to start urination
Urine leakage with intercourse
Types of Prolapse
Anterior Vaginal Prolapse (also known as cystocele)
This type of prolapse occurs when the wall between the vagina and the bladder stretches or detaches from its attachment on the pelvic bones. This loss of support allows the bladder to prolapse or fall down into the vagina.
Most women do not have symptoms when the anterior vaginal prolapse is mild. As it progresses outside the opening of the vagina, the prolapsed bladder may not empty well which can lead to urinary frequency, night time voiding, loss of bladder control and recurrent bladder infections. Strengthening pelvic muscles may improve the support to the bladder and neighboring organs and reduce symptoms. In addition, women can get temporary support by wearing a device called a vaginal pessary. It works much like a knee or ankle brace would support a weak joint. When these efforts are inadequate surgery is available to elevate the bladder and other internal organs to their proper position.
Posterior Vaginal Prolapse (also known as rectocele)
Weakening and stretching of the back wall of the vagina allows the rectum to bulge into and out of the vagina. Most often, the damage to the back wall of the vagina occurs during vaginal childbirth, although not everyone who has delivered a child vaginally will develop a rectocele. Mild rectoceles rarely cause symptoms. However, straining with constipation puts significant pressure on the weak vaginal wall and can further thin it out. Avoiding constipation may prevent progression and also reduce symptoms from the rectocele. Some women may find benefit from pelvic floor muscle strengthening and vaginal pessaries. When these low risk interventions are insufficient to relieve symptoms, surgery is performed to reinforce the posterior vaginal wall.
When the supporting ligaments and muscles of the pelvic floor that keep the uterus in the pelvis are damaged, the cervix and uterus descend into and eventually out of the vagina. Often, uterine prolapse is associated with loss of vaginal wall support (cystocele, rectocele). When the cervix protrudes outside the vagina, it can develop ulcers from rubbing on underwear or protective pads. There is a risk that these ulcers will bleed and become infected. As with other forms of prolapse, it is not until the uterine descent is bothersome that treatment is necessary. Women who have uterine prolapse often report pelvic pressure, the need to sit or lay down to relieve the discomfort, a sensation that their insides are falling out, difficulty emptying their bladder and urine leakage. Strengthening the pelvic muscles with Kegel exercises, avoiding heavy lifting, constipation, and weight gain may reduce the risk of progression of uterine descent. Additional treatment options include pessary devices which provide support when worn or surgery, and/or use of estrogen vaginally.
Vaginal Prolapse after Hysterectomy
If a woman has already had a hysterectomy, the very top of the vagina (where the uterus used to be) can become detached from its supporting ligaments. This can result in the tube of the vagina turning inside out. This condition is also known as vaginal prolapse. Depending upon how extensively the top of the vagina is turning inside out, one or several pelvic organs (such as the bladder, small and large bowel) will prolapse into the protruding bulge. Symptoms depend on which organs are prolapsing. When the bladder is involved, women report difficulty in starting to urinate, and emptying their bladder well. If it is the bowel then many report the need to push up the vaginal bulge and strain to have a bowel movement. Skin sores may develop if the bulge is rubbing on pads or underwear. A pessary may provide support for the bulge, otherwise surgery is recommended.
Paula is a registered nurse and is active in our Urogynecology practice. She is a member of SUNA, Society of Urologic Nurses Association, and is certified in biofeedback for pelvic floor disorders. She performs our urodynamic procedures to help in the diagnosis of bladder function disorders. She also performs our Pre Tibial Nerve Stimulation (PTNS) to help treat patients with over-active bladder, urinary retention, and fecal incontinence. Paula has found PTNS to be successful in treating 80% of patients with over-active bladder. Her real passion lies with Pelvic Floor Assessment and Biofeedback. She has performed more than 275 Pelvic Floor Assessments and has found that over the age of 40, most women have a weak pelvic floor. Paula teaches these patients to perform correct Kegel exercises and with the biofeedback program, has helped most patients to increase the strength of their pelvic floor and decrease their incontinence symptoms.
Paula is an amazing nurse and compassionate person who works very closely with our patients on issues that are very personal and sensitive. She is very interested in the Urology part of our practice and is driven to help patients succeed in accomplishing their goals. Our patients love working with Paula and report very positive experiences regarding her treatment programs. One patient that was having painful intercourse completed Paula's Biofeedback course and afterwards shared that she could finally share intimacy with her husband again. She was thrilled with the results and the care she received from Paula.