Pelvic Disorders

Pelvic prolapse or vaginal vault prolapse is a disease process characterized by the herniation of pelvic organs, bladder (cystocele), rectum, (rectocele), small intestine (enterocele), uterus, or vagina. These organs herniated due to weakening of support structures muscles and ligaments in the pelvis. As women age, enter menopause, have multiple childbirths, pelvic surgery, or radiation to the pelvis, then structures in the pelvis can fall. Roughly 11% of women will require surgery for prolapse over their lifetime.

Symptoms can include slight pressure to heavy pain in the pelvis or vagina. Patients may notice a bulge in the vagina, and may even have to reduce this bulge in order to urinate or defecate. Moreover, stress incontinence (leakage upon coughing, straining, etc.) can occur because the weakened pelvis muscle and ligaments also comprise the urinary sphincter that prevents leakage. Furthermore, patients can also complain of straining to urinate, constipation, and dyspaurenia (painful intercourse), back pain and can have recurrent urinary infections.

Diagnosis begins with a thorough history and physical exam. A qualitative and quantitative assessment is obtained to determine the degree of prolapse. A urinalysis is useful to evaluate blood in the urine or infection. Also, a post void residual is obtained to ensure the patient is emptying and has not suffered bladder damage. Cystoscopy can be useful to evaluate the anatomy of the bladder and urethra. A Q-tip test determines the angle and strength of the urethra to determine the possible anti-incontinence procedure. Finally, urodynamics can give a comprehensive evaluation of the bladder and pelvic floor.

The robotic assisted abdominal sacrocolpopexy combines the advantages of the minimally invasive approach utilizing the Da Vinci robot with the noted advantage of the superior strength of the ligament overlying the sacral promonotory. After the patient has undergone anesthesia, five small 5-10 mm incisions are made on the abdomen. The physician will control the robot arms through a console positioned across from the patient's bedside. A polypropylene or Gortex mesh is used to suspend the vagina cuff to the sacral promonotory. The patient can also have an anti-incontinence (prevention of urinary leakage) procedure (Burch, TVT, etc.) if necessary.

Several advantages are noted utilizing this technique. First, durability, with 10 year success rates quoted in the literature around 90% using the standard open procedure. Also, the inherent advantages of the Da Vinci robot, 10 times magnification, and 7 degrees of freedom translates into minimal blood loss, average 1 day hospital stay, better cosmetics, minimal post op pain, return to normal function sooner, and the ability to operate on elderly patients and patients with multiple health problems.

One of the most challenging urological disease conditions for patient and doctor alike is chronic pelvic pain. If you are frustrated by this problem you are not alone. Chronic pelvic pain includes the syndromes chronic prostatitis and interstitial cystitis/painful bladder syndrome. It can affect both men and women. Symptoms vary but usually include urinary frequency and urgency, pain and/or pressure perceived to arise from the bladder. Frequency usually involves urinating several times throughout the day and night, sometimes even several times an hour. At times, pain is associated with bladder filling and can be severe, and it may be relieved by voiding. Sometimes, a trigger can be identified. It can be a certain type of food or it can be a stressful situation. In women, it may be associated with the onset of a menstrual cycle. Patients may see several doctors before they are diagnosed. The diagnosis of this condition is usually made after excluding other identifiable causes such as a urinary tract infection, bladder cancer , prostatitis, and endometriosis. The proposed pathophysiology suggests that there may be an initial insult—possibly trauma or infection that sets up tissue injury in the bladder/prostate. This further promotes inflammation and release of cytokines and upregulation of pain fibers. Subsequently, this causes the bladder lining to be “leaky” and very sensitive to the urinary toxins and can causes over sensitivity with the pain fibers. Also of interest, many people may suffer with other chronic pain conditions such as fibromyalgia, irritable bowel syndrome, migraines and painful intercourse and pelvic floor spasm.

Treatment should be based on a multidisciplinary approach. Pharmacology, behavior and lifestyle modification, and dietary changes are implemented. Of note, it is found that if patients exhibit myofascial pain or a hypertonic pelvic floor, then physical therapy is extremely beneficial. Pelvic pain syndromes require a multidisciplinary approach with realistic goals agreed on by the patient and doctor.