Get the Pelvic ‘Floor-One-One’

**By Kathleen Kobashi, MD, FACS, FPMRS**

While pelvic floor health disorders can seem alienating, it is important to know that you’re not alone and there are a variety of ways to treat bothersome symptoms.

The pelvic floor is a group of muscles in the pelvic region, that can be described as a “hammock” of ligaments that sling between the pubic bone in the front and the tailbone in the back. For women, these muscles and ligaments work to support and control the uterus, vagina, bowel and bladder; whereas for men, they support just the bowel and bladder.

As a multidisciplinary team, the members of the Pelvic Floor Center at Virginia Mason treat virtually every pelvic floor health issue that can be experienced by both men and women. In this article we’ll dive into common health problems associated with the pelvic floor and why maintaining pelvic floor health is so important. Pelvic floor disorders can become huge quality-of-life issues that can interfere with our daily activities. It is vital for us to be aware that there are successful, minimally invasive treatment options available.

Common health issues associated with the pelvic floor

When it comes to pelvic floor health issues, there are several key terms to remember, like incontinence and prolapse. Incontinence is the lack of control of bladder or bowel function resulting in leakage, while prolapse is the displacement or dropping of pelvic organs through a weak pelvic floor, much like a hernia. There are other pelvic floor disorders that may result in the opposite problem of difficulty emptying the bladder or bowel.

Mother and daughter drinking coffeeThe two most common forms of urinary/bladder incontinence are stress and urgency leakage. Stress incontinence is the involuntary release of urine from coughing, sneezing or other similar actions and is commonly (but not exclusively) experienced by women who have had vaginal delivery of babies. Aging, genetics and gravity can also play a role. Conversely, urgency incontinence is exactly as it sounds – when nature calls, you don’t always have a say in when you answer, and it is urgent. This form of incontinence can be caused by the consumption of dietary irritants, such as coffee or wine, that aggravate the bladder, as well as hormonal changes that make the bladder more irritable. In men, urgency can also be related to prostate enlargement.

Fecal/bowel incontinence (aka accidental bowel leakage) is an involuntary loss of bowel control that can result in stool abruptly leaking from the rectum. Disorders associated with bowel function can range from constipation to complete loss of control of the bowel, and everything in between.

Prolapse occurs when pelvic organs – such as the bladder, uterus, bowels, vagina or rectum – drop down into or outside of the anus or vaginal canal. Prolapse can be due to a number of issues, including pregnancy, childbirth, obesity, chronic respiratory issues, constipation and cancer in the pelvic region.

Signs to look out for and when to see your doctor

If you’re concerned you might be dealing with a pelvic floor problem, here are a few signs and symptoms:

  • Urinary/bladder incontinence – symptoms can include leakage of urine with coughing, sneezing or exercise, and can also be associated with a sudden, intense and often uncontrollable urge to urinate. Other lower urinary tract symptoms may include frequent urination, slow or dribbling streams of urine or the inability to completely empty your bladder.
  • Fecal/bowl issues – symptoms can include chronic bloating, constipation, diarrhea or involuntary loss of fecal matter.
  • Pelvic organ prolapse – symptoms can include a feeling of fullness in the pelvic floor or vagina, a feeling that something is “falling” out of the anus or vagina, discomfort with sexual intercourse, urinary or fecal incontinence, a sense of trapping of stool or the inability to completely empty your bowels.

It’s important to note that any combination of the symptoms above can occur.

The importance of pelvic floor health

Given the critical bowel, bladder and sexual functions these muscles support, keeping your pelvic floor healthy and strong is crucial. There are a variety of exercises that can be done to improve overall pelvic floor health and functionality, with some of the more common ones being Kegels. Working your pelvic floor regularly is especially important for women in order to minimize the risk of developing prolapse, incontinence or other pelvic health issues that stem from pregnancy or aging.

If you’re experiencing any one or combination of the symptoms discussed above for an extended period of time, it may be time to call and arrange a visit with your doctor. From there, they can work with you to decide your best course of treatment, whether that’s pelvic floor therapy or proceeding with some tests that can help identify the root cause of your problem and facilitate treatment planning.


Kathleen.KobashiKathleen Kobashi, MD, FACS, FPMRS is board-certified in urology with a subspecialty certification in female pelvic medicine and reconstructive surgery. She is the section head of Urology and director of the  Pelvic Floor Center at Virginia Mason. Dr. Kobashi is a urologist/urogynecologist who specializes in the treatment of pelvic floor disorders, including urinary and bowel incontinence, pelvic organ prolapse, and urinary tract fistulas, with expertise in pelvic floor reconstruction through open and robotic surgery.

Female Urinary Incontinence: Know the Non-Mesh Alternatives

**By Una Lee, MD**

It is important for all women to be educated on how their urinary tract works and options that exist when problems occur. A mid-urethral mesh sling is a common surgery that treats stress urinary incontinence. It has been one of the standard surgical treatments for stress incontinence since 1997.  The synthetic mesh sling works by acting as a “hammock” under the urethra, helping to keep it closed with activities like coughing or sneezing. However, women should be aware that there is an infrequent but known risk of minor, moderate or serious complications associated with mesh sling surgery. Many women ask if there are alternatives to mesh slings. Absolutely!

First, a quick review of incontinence basics. Urinary incontinence is the leakage of urine that can occur in women of all ages, and commonly occurs or worsens after childbirth. White Curls womanThere are difference types of urinary incontinence, including:

  • Stress incontinence – leakage with physical activity, like laughing or coughing
  • Urgency incontinence – leakage that occurs when you have a strong urge to urinate and are rushing to the bathroom
  • Mixed urinary incontinence – a common condition of having both stress and urgency incontinence
  • Post-void dribbling – leakage after you urinate
  • Incontinence without sensation – leakage that occurs with no awareness

The type of incontinence is important, because different treatments target different types.  Also, the amount of leakage – mild, moderate or severe – will also affect treatment options.

Starting with the least complicated, conservative management may be appropriate if urinary leakage is mild, infrequent, not very bothersome and can be controlled with pads. For many women, no treatment is a valid choice.

Weight loss is another non-surgical opportunity.  Studies have shown that modest amounts of weight loss (5 percent of total body weight) can significantly decrease urinary incontinence. For many women this is motivating and encouraging, while promoting their overall health.

Stopping smoking is another effective step.  Smoking and the chronic cough associated with tobacco use can make urinary leakage worse. Abdominal pressure from frequent coughing will in turn increase pressure on the pelvic floor and urethra, causing leakage.

Pelvic floor physical therapy with a qualified physical therapist who specializes in urinary incontinence is a totally natural option. You learn how to identify and strengthen your pelvic floor muscles correctly and how to use this skill to prevent leakage. This therapy is known to be effective and is a skill you can use for life.

Incontinence pessaries are medical grade discs that are placed in the vagina to support the urethra. The size and shape is custom fitted to you, and it is removable and comfortable. It is a good non-surgical option to try.

Urethral bulking is an injection into the inner lining of the urethra, which improves the sealing abilities of the inner part of the urethra. While not generally permanent, it’s an effective treatment for the right patient.

The Burch procedure preceded sling surgery as a standard stress incontinence treatment. Instead of creating a hammock supporting the urethra, sutures are placed for support and elevation. While not as effective as the sling procedure, the Burch procedure remains an option for some patients.

A variation on the sling procedure known as the autologous fascial sling has been around for years and has stood the test of time. A strip of fascia, or connective tissue, is harvested from your thigh or lower abdomen, then placed to support the urethra. While this surgery is effective, durable and safe, the downside is that it’s more invasive and requires longer healing time.

Enrolling in a clinical trial may be an option for some patients. Eligible participants volunteer and are fully informed of the study’s process and potential risks and benefits. Participants are advised to talk to their health care provider before participating in a clinical trial.  One study is currently investigating using muscle-derived, regenerative cells to treat stress urinary incontinence. For more information on participating in clinical trials, click here.

Vaginal laser treatments, using a carbon monoxide (Co2) laser, are used as a therapy for vaginal dryness and atrophy. Currently, there is not enough evidence to support the claims that they treat stress urinary incontinence. Additionally, laser treatments are costly and typically not covered by insurance.

Medications for urinary incontinence generally help with urgency incontinence and overactive bladder symptoms, but not stress urinary incontinence. So they can help with that “gotta go” feeling and resulting leakage, but not with leakage that happens during Zumba class. These medications are designed to help with bladder control. Most are prescription, so ask your doctor if bladder medications are appropriate for you. One treatment, the oxybutynin transdermal patch, is available over the counter. Side effects can occur with these medicines, with about 20 to 40 percent of women remaining on the medication in one year’s time.

Treatment with vaginal estrogen helps treat thinning tissues in the vaginal area. By improving the quality of the tissues, symptoms of urinary urgency can improve. Some women report their incontinence improves as well.

Botox injections in the bladder can dramatically help women who have leakage of urine that is associated with urgency, but are not effective for stress urinary incontinence.

Bladder pacemakers, also known as InterStim therapy, regulate bladder signals by stimulating the sacral nerves located near the tailbone. This electrical stimulation helps the brain and bladder communicate for better urinary control. The implants help reduce urinary urgency and resulting leakage, urinary frequency and urinary retention (the inability to empty the bladder).

Urinary incontinence is a common, costly and important quality of life issue for women. Gaining a thorough understanding of the condition is the first step.  Given the sensitive nature of these bodily systems and their impact on women’s lives, knowing the range of treatment options is key to making the right choice for you.


Lee_UnaUna Lee, MD is a urogynecologist/urologist dedicated to women’s health. Dr. Lee and her partners in the Urology Department at Virginia Mason offer all FDA-approved treatments for urinary incontinence, with the knowledge and experience to support the best outcomes.      

When Laughing Leads to Leaks: Dealing with Stress Urinary Incontinence

**By Una Lee, MD**

laughingWhat is stress urinary incontinence?

Have you ever laughed so hard you leaked urine? Do you leak urine when you run, dance, or work out? If you do and it happens consistently, you may have stress urinary incontinence (SUI). SUI is a type of incontinence caused by pressure from a physical activity, including laughing, sneezing, or coughing. The pressure generated by the activity overwhelms the strength of the urinary sphincter muscle, and suddenly you feel a leak. Stress urinary incontinence is common among women and treatable.

What causes SUI?

SUI results from weakened muscles, including those that that support the bladder (pelvic floor muscles) and those that regulate the release of urine (urinary sphincter). In women, poor function of these muscles may be caused by tissue or nerve damage during delivery of a baby. Sometimes, SUI symptoms from this damage may begin soon after delivery or occur years later. A weakness of the urethra unrelated to childbirth can also cause SUI.

Can SUI be treated?

If it happens enough that it bothers you or affects your ability to enjoy exercising or being active, then lifestyle or behavior changes are the first things to try. Limit your fluids, especially alcoholic and caffeinated beverages which irritate the bladder, and empty your bladder before going on that hike or taking that exercise class.

Kegel exercises, which help strengthen your pelvic floor muscles and urinary sphincter, can be guided by a doctor or physical therapist to be more effective. Just like any other exercise routine, consistency is the goal for seeing results.

For some women a vaginal pessary is an option. A vaginal pessary is a disk fitted by your doctor that helps support the urethra to prevent leakage during activity. Pessaries are often used for people who also have pelvic organ prolapse. There are now over-the-counter, disposable versions of urethral support available.

Material injected into tissues around the urethra, in a relatively noninvasive procedure, can improve the sphincter’s ability to close. However the procedure is not a permanent repair, and most people will require repeat injections. Other surgical options include adding support (your own tissue or a thin strip of mesh) under and around the urethra to recreate urethral support. So when an activity causes increased pressure, there is a “backboard” to help close the urethra and prevent leakage.

SUI Clinical Trial

Clinical trials are research studies that identify what is safe and if a particular treatment works to improve a specific health condition. Participation is voluntary, and participants are educated on the possible benefits and potential risks. If you suffer from a particular health condition, such as SUI, participating in a clinical trial may be an option for you.

Currently, Virginia Mason is participating in a global clinical trial (with sites across the U.S. and Europe) of a new investigational procedure for SUI patients. It is called the Autologous Muscle Derived Cells for Female Urinary Sphincter Repair clinical trial. The trial is evaluating the safety and efficacy of using cells derived from a woman’s own muscle tissue (autologous cells) to potentially strengthen the sphincter muscle that helps control urine flow.

The science behind the trial – the idea that injected cells may help restore tissues of the urinary passage – represents an emerging area of study known as regenerative medicine.  In regenerative medicine, specific types of cells are delivered to diseased tissues or organs for the purpose of restoring the tissue or organ function.

For more information about the Autologous Muscle Derived Cells Female Urinary Sphincter Repair study, visit researchsui.com or clinicaltrials.gov.


Lee_Una
Una Lee, MD
, is board certified in Urology and subspecialty certified in Female Pelvic Medicine and Reconstructive Surgery at Virginia Mason.