Pelvic Floor
Services

Female Pelvic Medicine and Reconstructive Surgery is also known as “Urogynecology” or “Female Urology.” Though most pelvic floor conditions are not dangerous to a woman’s health, they can have devastating impacts on a woman’s quality of life. There are a wide variety of evaluation and treatment options. We enjoy helping each of our patients explore which treatments will fit best with their lifestyle, values and goals.

  • Forms

    New Patient form – link

    Bladder Diary – link

  • Resources

    a. General Pelvic Floor Information (specific information on wide variety of issues):

    i. IUGA: International Urogynecological Association. International academically oriented organization of Urogynecologists and Female Urologists including any providers who treat pelvic floor disorders. These are the patient education materials we use most frequently.

    Patient information on a variety of pelvic floor topics in multiple languages

    ii. AUGS: American Urogynecologic Society is a national academic society focusing on pelvic floor disorders.

    Patient information on a variety of pelvic floor topics. Regular and large print are available.

    iii. SUFU: Female Urology Society: academic society focusing on pelvic floor disorders.

    b. Local Resources:


    i. El Camino Hospital Pelvic Health Website


    c. Specific information by condition:

    i. Bladder Pain Syndrome/ Interstitial Cystitis:

    Interstitial Cystitis Association: Nonprofit association providing information about IC/BPS including diagnosis, symptoms, and treatment. Links to current clinical trials etc.

    Interstitial Cystitis Network: Provides information about IC/BPS including diagnosis, symptoms, and treatment. Links to current clinical trials etc. Additionally, offers personalized counseling services.

    ii. Pelvic Pain:

    Chronic Pelvic Pain FAQs Resources from the American College of Obstetrics and Gynecology

    Sexual Health:

    Even though sexuality is an important part of the human experience, we often feel uncomfortable discussing these issues. Here are a few resources if you’re interested in beginning to explore your sexual health. I don’t endorse any specific treatment or guidance presented in the following, but I look forward to discussing any insight or ideas you gain from these resources.

    Books on Sexual Health from the International Society for the Study of Women’s Sexual Health

    Sexuality resource center focused on women’s sexual health. Large array of products as well as online reviews, how-to demonstrations etc

    Though there has been other inaccurate information promoted on Goop, the Goop Lab produced a good episode and compiled resources on sex and pleasure.

    d. General health and wellness:

    Yoga: Helps to strengthen and stretch the pelvic floor

    Yoga with Adriene: Free yoga for all levels which combines humor, physical and mental wellness

    Mediation: Meditation can reduce stress and thereby promote health and healing.

    Headspace offers a free app

    Mindful.org offers information as well.

    Cooking: Learning to use more healthful ingredients can be hard. Here are some good places to start, though many are still quite high in salt. Try omitting salt from the recipes (or cutting in half) and buy low salt beans and broth. Then if you desire you can still add a little at the table. Food salted at the table will generally have a much lower overall salt content.

    Andrew Weil has a restaurant – True Food Kitchen and shares many of the recipes. Including my favorite kale salad – best the next day and impossible to make enough

    Veggie Soul Food: Great conversion of common dishes to vegetarian versions

    101 Cookbooks: Healthy, flavorful vegetarian and vegan recipes

  • Upcoming events

    Check back soon for more information on upcoming events!

  • Pelvic health issues and treatment options:

    a. Bladder Control / Urinary Incontinence

    i. Stress Urinary Incontinence: Stress urinary incontinence is urine leakage that occurs with exercise, cough, sneezing and or laughing. This type of incontinence is common and occurs more often after pregnancy and vaginal delivery, with repeated straining (such as heavy lifting, constipation, chronic cough) and usually worsens with weight gain.

    Treatments

    a. Weight loss: Weight loss has been shown to improve urinary incontinence. In one well done trial, women losing an average of 17lbs, had only half as many incontinence episodes (Phelan 2012).

    b. Pelvic floor muscle training – can be done with or without a physical therapist. Studies demonstrate that pelvic floor muscle training cures over half of women with incontinence. Most women find they must continue to do these exercises, or the incontinence will return.

    c. Pessary or vaginal insert: A pessary or vaginal insert can be useful for patients who experience incontinence during situations. Vaginal inserts may be tried during exercise or any other situation that usually results in incontinence. In well-done trials women using pelvic floor muscle training had better results than with a pessary, but some women may prefer to try a pessary (Richter 2010)

    d. Surgeries: Several surgeries are available for stress urinary incontinence. The first thing to decide is how the patient and provider feel about the use of synthetic mesh. Mesh was developed in order to make repairs stronger and longer lasting. It is used in other areas of surgery such as for hernia repair.

    i. Midurethral slings: Midurethral slings using mesh are considered by most Female Pelvic Medicine and Reconstructive Surgeons to be the standard of care in the United States. In fact, the American Urogynecologic Society and the Society of Female Urologists created a statement supporting the continued use of mesh midurethral slings.

    ii. They are one of the most well studied procedures that we do and there is a large amount of data on their safety and effectiveness. However, there are known risks to using a permanent implant and every patient has the right to decide together with their surgeon, what will best satisfy their goals and values.

    iii. Autologous fascial sling: For women who do not want a permanent mesh implant, strong tissue called fascia may be taken from the abdomen or thigh to be used for the sling surgery. This recovery generally takes a little longer, which is why many women and physicians prefer to use mesh.

    iv. Burch colpopexy: Burch colpopexy is performed by elevating the tissue on either side of the urethra to a strong ligament in the pelvis. Traditionally this was performed open. Smaller trials of laparoscopic Burch suggest that it is likely as good as the open procedure.

    v. Urethral bulking: Urethral bulking is a procedure that can be done in the office or the operating room. It can be helpful for women with incontinence secondary to intrinsic sphincter deficiency (this is when the urethra doesn’t move – is fixed in place and with very low urethral pressures) and women who are too ill or do not want to undergo surgery. It is not as effective as sling or Burch procedures, but usually 2/3 of women will have at least moderate improvement.

    ii. Urge Urinary Incontinence and Overactive Bladder Urge urinary incontinence is urine leakage that occurs with urgency or the strong desire to urinate. This type of incontinence is common and occurs more often as women age. In addition women with diabetes or other chronic conditions which cause nerve damage are at higher risk of urge incontinence.

    Treatments

    a. Bladder training: Bladder training is a simple, low risk treatment for urge incontinence. It starts with completing a bladder diary. Then your physician will make a personalized voiding schedule. After following this schedule for several months, more than half of women will see significant improvement in their incontinence.

    b. Diet and lifestyle modification: Though this is an understudied area, many women find that decreasing caffeine intake, stress reduction and other changes help with urinary urges and urge incontinence.

    c. Complimentary and Alternative Medicine: Recently a trial of hypnotherapy demonstrated excellent improvement and was similar in effectiveness to medications at one year.

    d. Medications: Medications can be helpful for managing urinary urgency incontinence. Medications may be used together with other treatments. Anticholinergic medications may cause issues when taken long term, so we commonly use these medications to gain control of the issue while working on other therapies for long term improvement.

    e. Neuromodulation: Two types of neuromodulation are approved to treat urgency urinary incontinence:

    i. Posterior tibial nerve stimulation: Posterior tibial nerve stimulation uses a gentle electrical pulse to simulate the spinal roots that control the bladder. An acupuncture needle is placed at the ankle and stimulation is performed for 30 minutes once per week for 12 weeks. This has an excellent safety profile.

    ii. Sacral nerve stimulation: In this procedure a permanent lead is placed through the S3 sacral foramina to stimulate the nerves that control the bladder. Patients keep a diary of their improvement for two weeks and if they have a 50% decrease in incontinence or frequency episodes, a battery is implanted.

    g. Botox: In this short office procedure, the bladder is numbed and then Botox or Onabotulinum Toxin A is injected into the bladder through a cystoscope. This procedure must be repeated every 6- 12 months.

    h. Surgery: Rarely, if none of the above treatments work, surgery such as clam cystoplasty may be done to increase the amount of liquid the bladder can hold.

    iii. Mixed Urinary incontinence: It is very common for women to have both urge urinary incontinence and stress urinary incontinence. Women find the most relief starting with treatment for whichever is most bothersome. Treatments are often combined for full relief.

    b. Pelvic Organ Prolapse: Pelvic organ prolapse occurs when the pelvic floor muscles and connective tissue become weak or tear. Any portion of the vaginal walls may fall downwards, pulling with it the organ (bladder, rectum, or uterus) directly behind that wall. This is similar to what occurs with a hernia. When researchers examine healthy women after childbearing more than half will usually have some small degree of prolapse.

    i. Causes: Prolapse is usually caused by a combination of factors such as aging, stressors (such as pregnancy, childbirth, chronic constipation, and repetitive heavy lifting) as well as genetics. Genetics can also be a factor for developing prolapse. The female organs can begin to push through the vaginal opening which is when women usually begin to have symptoms.

    Common symptoms of Pelvic Organ Prolapse:
    1. Vaginal or pelvic pressure
    2. Lower abdominal or lower back pain
    3. An obvious or physical “bulge” protruding from the vaginal opening
    4. Difficulty with urination due to a physical “kinking” of the urethra
    5. Difficulty with defecation due to a possible stool-trapping rectocele
    6. Having to “splint” or push the vaginal organs back into place in order to empty the bladder or have a bowel movement
    7. Difficulty with intercourse or painful intercourse
    8. A worsening of symptoms with standing, lifting or coughing

    Treatment: Pelvic organ prolapse is generally not dangerous and some patients choose watchful waiting. Large studies show that prolapse will not necessarily get worse and may even improve slightly with decreases in pressure such as resolving constipation, stopping heavy lifting or weight loss. However, there are several treatment options available and women report high levels of satisfaction after finding the one that best suits them.

    1. Home exercises: Home exercises have not been well studied for the treatment of prolapse, but may work in a similar manner to physical therapy and may be beneficial.

    2. Pelvic Floor Physical Therapy: Studies have demonstrated that pelvic floor physical therapy improves prolapse in some women and may be used by women who want to avoid pessaries and surgery.

    3. Pessaries: A pessary is a small silicone device that is worn inside the vagina. Similar to eyeglasses, a pessary will not “fix” prolapse in the long term, but offers an immediate solution. When a pessary fits correctly the women will not be able to feel it in the vagina. The most common type of pessary is a ring with support. Some women chose to remove the pessary before being intimate, while others report that they do not need to.

    4. Surgical Management: There are many different surgical options for prolapse. Some repairs use the body’s own tissues while others use types of mesh to strengthen the repair. In 2011 the FDA released a statement about transvaginal placement of surgical mesh for pelvic organ prolapse. This brought all meshes into the spotlight. Like many medical therapies mesh has both benefits as well as potential drawbacks. Vaginally placed mesh (transvaginal mesh) is known to have the highest risk of problems. Abdominally placed mesh as well as the mesh for urinary incontinence surgery continues to be widely used because it is effective and has low risk of complications. Experts in this field have strong opinions both for and against the use of mesh, but majority regard mesh an excellent option for most patients. The decision of whether to use mesh is a personal one based on each woman’s goals and values.

    c. Complications of prior pelvic floor surgeries: As surgical experts we have experience performing repeat surgeries when the condition has recurred. In addition, we have expertise in mesh removal, as well as correcting surgical injuries to the urinary tract.

    d. Accidental bowel leakage (ABL): Many women with ABL find it difficult to discuss with their physicians. Although it may be embarrassing and upsetting, you are not alone. Up to 15% of women in the general population suffer from ABL. ABL is most often due to injury to pelvic floor nerves and the muscle of the anal sphincter. This circular muscle normally functions to keep stool and gas from escaping. Childbirth and or anal surgery can cause injuries that lead to ABL over time. Post evacuation staining is common if stools are loose or incomplete evacuation occurs.

    Treatments

    1. Behavioral therapies: Includes a stool diary to identify possible dietary causes, timing bowel movements, and the possible addition of insoluble fiber (food and supplements)

    2. Pelvic Floor Physical Therapy: Strengthens the muscles of the pelvic floor which surround the anal opening. Biofeedback can be also be incorporated.

    3. Sacral Nerve Neuromodulation: Outpatient surgical implantation of a small device that reduces stool loss by stimulating the nerves which control the rectum, anus and pelvic floor.

    4. Anal Sphincter Repair: Surgical repair of an injured (torn) anal sphincter muscle. This is most effective when done immediately following the injury. In the first-year success is around 80%, but unfortunately often decreases over time. Many women will continue to have issues controlling flatus, even after a successful repair.

    5. Other therapies: Other therapies including a posterior anal sling, artificial anal sphincters and anal bulking agents have been used to treat fecal incontinence. Complications with these therapies have prevented their widespread adoption.

    e. Recurrent urinary tract infections can be frustrating and uncomfortable. Imaging or cystoscopy may be needed to ensure that the infections are not caused by some other factor (kidney stone, mesh etc) There are a number of options including hormonal therapy to improve the tissue microenvironment, medications that sterilize the urine, low dose prophylactic antibiotics etc.

    f. Bladder or urethral pain: Bladder pain syndrome or IC/BPS is a common condition in which women experience pain and urgency similar to urinary tract infections. They may be treated with antibiotics, but the symptoms never really improve. Mind/ body, dietary changes, medications, office procedures and surgeries may be used to treat symptoms.

    g. Issues with sexual health

    i. Why do sexual problems occur?

    1. Tissue health: Menopause, tissue radiation and a number of skin conditions can cause discomfort, decreased lubrication and decreased enjoyment of sexual intimacy. Medical therapies are available to improve vaginal tissue health

    2. Lubrication: Key to decreasing pain and improving function. KY and Astroglide may be used. For women with sensitive skin coconut or olive oil will also work well. There can never be too much lubrication!

    3. Pain: Pain can interfere with the enjoyment of intimacy, but also with our body’s response cycle. Treatment is twofold – improving the pain and restoring the normal sexual response cycle. Treatment is based on the source of the pain and may include medications, physical therapy or other procedures.

    4. Desire: Women can experience changes in desire throughout their lifetimes. These may be due to life stressors, relationship issues, health problems, or may come up out of the blue.

    ii. How do I know if I have a sexual problem? Basically, if there has been a change in your sexual health that is bothering you, treatment is available. Some women have a decline in sexual activity at certain times in their life, however, if it is not bothersome treatment is not needed. Everyone is different- there is no ‘normal’.

    iii. What can be done to treat sexual problems? Many treatments are available including behavior changes, counseling, pelvic floor physical therapy and medications.

    h. Urinary retention or difficulty emptying

    i. Treatments:

    1. Pelvic floor physical therapy with biofeedback: Some emptying problems improve with physical therapy and bladder training

    2. Sacral nerve stimulation: In this procedure, a permanent lead is placed through the S3 sacral foramina to stimulate the nerves that control the bladder. Patients keep a diary of their improvement for two weeks and if they have a 50% decrease in incontinence or frequency episodes, a battery is implanted.

    i. Fistula: Abnormal connections between the bladder, urethra, ureters or rectum and vagina can cause leaking of urine or stool. These issues may be caused by childbirth or occur after surgery. Treatment is surgical to close the connection.

    j. Urethral problems including diverticula: Urethral diverticula are cysts of the Skene’s gland which burst into the urethral lumen. They are usually treated surgically, but observation is an option if there are not associated infections or other issues.