Urogynecology

Loss of urine or pelvic pain need not be part of your middle years. Female pelvic support problems—including incontinence, voiding and bowel difficulties, and vaginal prolapse—can be managed successfully thanks to advances in urogynecology.

Prolift® for Prolapsed Pelvic Organs

Pelvic organ prolapse occurs in women when the muscles and tissues that hold the pelvic organs in place begin to weaken. Subsequently, the uterus, bladder and rectum may press against the vaginal walls, causing them to protrude into the vagina. Symptoms include back or pelvic area pain as well as urine leakage or difficulty in starting to urinate. Pelvic organ prolapse also can cause bowel problems, including constipation, or a sensation of vaginal bulging or heaviness. Women who have had multiple vaginal births are at greatest risk for pelvic organ prolapse, which occurs in some form (cystocele, rectocele and/or uterine prolapse) in half of women older than 50.

For women with moderate to severe symptoms, a new surgical technique uses the Gynecare Prolift® Pelvic Floor Repair System to restore the prolapsed organ or organs to a correct position. Greenville Hospital System University Medical Center (GHS) urogynecologist Jeffrey B. Garris, M.D., FACOG, FACS, was the first physician in the United States to receive certified training on the system, and he has performed more Prolift repairs than any other urogynecologist in the Upstate.

The Gynecare Prolift system uses a piece of synthetic nonabsorbable mesh, similar to that used in hernia repair. The soft material can be positioned in one to two hours, less than half the time required for the traditional operation to repair pelvic prolapse. Patients may have regional or general anesthesia.

Using minimally invasive techniques, the surgeon makes very small incisions inside the vagina and inserts the mesh so that it is woven like straps through the pelvis. Initially the mesh is held in place by friction created by these straps, and then body tissues quickly grow into the pores of the mesh, creating the final support.

Patients go home the following day. “Prolapse can be devastating for some women,” said Dr. Garris. “Prolift relieves symptoms, and it restores normal pelvic anatomy and quality of life.”

TVT Secur® for Stress UI

GHS also offers a minimally invasive surgical treatment for stress urinary incontinence (UI), a condition that afflicts up to half of U.S. women on occasion and 10 percent frequently. Stress UI is the unintentional loss of urine during periods of bladder pressure or stress. It occurs with coughing, sneezing, standing and lifting, among other circumstances, and is the most common type of incontinence.

Tension-free vaginal tape (TVT) surgery, also known as suburethral sling surgery, has become the most popular operation to treat moderate to severe stress UI during the past decade. The latest modification of TVT is called TVT Secur.

TVT Secur involves the placement of a polypropylene mesh sling below the urethra to offer hammock-like support, preventing involuntary urine loss. After a few weeks, body tissue grows into the mesh, permanently supporting the sling.

Whereas the standard tape had to be threaded through to the urethra from behind the pubic bone, TVT Secur is shorter (only eight centimeters long) and can be pushed into position through a small incision in the vagina. This approach, which causes less tissue trauma, can be performed in less than 30 minutes using local anesthesia. Patients can go home a few hours after the procedure and have a short recovery time.

Dr. Garris, who was the first physician in the Upstate trained to use TVT Secur, said it “builds on the success and safety of the TVT procedure with a less invasive approach that offers minimal pain and easier recovery.”

InterStim® for Urge UI

For patients who suffer from incontinence when they have the urge to urinate, GHS offers InterStim Therapy, among other treatment options. Described as a pacemaker for the bladder, InterStim Therapy works by sacral neuromodulation.

The InterStim device consists of a lead connected by an extension wire to a battery-operated stimulator (about the size of a half dollar). The lead is implanted adjacent to the sacral nerves, which govern the reflexes that control the bladder, sphincter and pelvic floor muscles. InterStim Therapy mildly stimulates these nerves, helping the patient control her bladder.

This device is typically implanted under the skin of the upper buttocks below the beltline. The rate, frequency and amplitude of the stimulation are programmable, and patients can adjust stimulation within certain parameters with a hand-held remote. Developed by Medtronic Inc. and FDA-approved since 1997, InterStim Therapy has been in the mainstream for several years. Dr. Garris is a national InterStim preceptor and one of very few physicians in the Upstate offering this therapy.

Before he places the device, candidates test its effectiveness with an external stimulator at home, tracking progress with a voiding diary. If the testing phase is successful, the minimally invasive implantation procedure, which takes 30 to 60 minutes, can be performed while a patient is awake or under anesthesia. Complications include mild discomfort, infection, transient electrical shock, lead migration and change in bowel function, but these are not common and are generally resolvable. Stimulation can be discontinued or the device removed at any time.

InterStim is not indicated for fecal incontinence and defacatory disorders, though clinical studies show promise for such use.