Women's Health and Education Center (WHEC)


List of Articles

  • Urinary Tract Injury: Prevention & Management
    The evolution of pelvic surgical procedures has been influenced by uncommon but potentially devastating injuries to the lower urinary tract (bladder and ureters). These injuries are associated with known risk factors, though not all such injuries are predicable or avoidable. Knowledge of anatomy and careful intraoperative ureteral identification are hallmarks in injury prevention. Accurate diagnosis and safe, timely repair of bowel, bladder and ureter is crucial in reducing morbidity, and potentially mortality. This review focuses on the literature regarding the incidence, diagnosis and management of injuries to the lower urinary tract. Diagnosis of such injuries requires careful attention to surgical entry and dissection techniques and employment of adjuvant diagnostic modalities. Identifying the injury intraoperatively reduces postoperative complications and long-term sequalae. The use of cystoscopy and agents that allow for easy discernment of ureteral efflux aid in identifying urinary tract injuries intraoperatively.

  • Current Concepts in Pelvic Floor Anatomy
    Exploring current concepts in pelvic floor anatomy and support. The endopelvic fascia divides the lesser pelvis in a manner that is similar to the way the urorectal septum divides the embryonic cloaca. Connecting descriptions of the geometry of the organs visible by magnetic resonance imaging with descriptions of their individual connections to the endopelvic fascia is also discussed. The study aims to discuss the applied anatomy and embryology of pelvic floor structures. The relevance of pelvic floor to anal opening and closure function discusses new findings with regards to the role of three muscles in the vaginal closure mechanisms. The anal-rectal angle was previously thought to be important in maintaining fecal continence, but its importance has been questioned. More recent studies suggest that fecal incontinence in women is often related to denervation of the muscles of the pelvic diaphragm, as well as to disruption and denervation of the external anal sphincter.

  • Neurophysiology Of The Lower Urinary Tract
    Discussing the normal function and neurologic control of the lower urinary tract in women. The nervous system is arranged into the central and the peripheral systems. The central nervous system includes the brain and spinal cord. Twelve paired cranial and 31 paired spinal nerves with their ganglia compose the peripheral nervous system. The somatic component of the peripheral system innervates skeletal muscle, and the autonomic division innervates skeletal muscle, and the autonomic division innervates cardiac muscle, smooth muscle, and glands. Historically, urologic complications were the main cause of death in spinal cord injury patients. Now their life expectancy is almost normal. Urodynamic diagnosis and guidance toward proper treatment is a key reason for the improved survival. Lifelong urologic surveillance is a central component to the routine care of the spinal cord injury patient. The article outlines neurologic pathways.

  • Urodynamic Assessment: Patient Evaluation & Equipment
    An overall perspective of the urodynamic assessment and have a basic understanding of the principles involved and what to be done looking for with different patient populations. It gives an overview of the procedures to assist healthcare providers in conducting urodynamic assessment. Obtaining a good medical history, concentrating on urologic complaints, is critical to do before embarking on urodynamic assessment. Urodynamics encompasses all the diagnostic modalities used in the evaluation of bladder and urethral function. It describes a number of complimentary tests of varying degrees of complexity that can be performed individually or in combination depending on the clinical circumstances. It has improved our ability to select therapy that addresses the underlying pathophysiology in a rational way. Advances in urodynamics and video-urodynamics has improved our understanding of the normal and abnormal functions of the bladder and sphincter.

  • Urodynamic Assessment: Techniques
    Addressing the various technical aspects, controversies and techniques for performing cystometry. Cystometry (CMG) has been described as the reflex hammer of the urodynamicist. It is not only the method by which the pressure/volume relationship of the bladder is measured, but it is also an interactive process that permits examination of motor and sensory function. The International Continence Society (ICS) had defined certain terms that are used in the reporting of cystometric results.

  • Urodynamic Assessment: Cystometry
    A discussion of basic principles of cystometry, indications, normal and abnormal cystometric parameters. A basic principle of cystometry is the coupling of a manometer to the bladder lumen. A filling medium is instilled into the bladder and, as it fills, intravesical pressure is measured against volume. Testing apparatuses range from simple single-channel methods, which are performed manually or electronically, to complex methods combining electronic measurements of bladder, abdominal, and urethral pressure, together with electromyography and fluoroscopy. A cystometrogram has two phases: a filling/storage phase and an emptying (voiding) phase. The filling phase is subdivided into a brief initial rise in pressure to achieve resting bladder pressure, followed by a tonus limb that reflects vesicoelastic properties of accommodation of the smooth muscle and collagen of the bladder wall. There may be a third increase in pressure, which is attributed to stretching of detrusor muscle and collagenous elements of the bladder wall beyond their limits at bladder capacity. During this third stage, the patient is still able to suppress voiding. A detrusor contraction then is initiated voluntarily and the patient voids.

  • Urodynamic Assessment: Voiding Studies
    Uroflowmetry is an electronic measure of urine flow rate and pattern. Combined with assessment of postvoid residual urine volume (PVR), it is a screening test for voiding dysfunction. If the uroflowmetry and postvoid residual volume (PVR) are normal, voiding function is probably normal; however, if the uroflowmetry or postvoid residual volume (PVR) or both are abnormal, further testing is necessary to determine the cause. More sophisticated measures of voiding function include a pressure-flow voiding study with or without videofluoroscopy. Electromyography of the striated urethral sphincter may be useful to assess neurogenic voiding dysfunction.

  • Urodynamic Assessment: Leak Point Pressures and Urethral Pressure Profile
    A review of the definitions, methodology, interpretation variables, and clinical applications of these tests. One of the most important concepts to be put forth in recent years is that "adequate storage at low intravesical pressure" will avoid deleterious upper urinary tract changes in patients with bladder outlet obstruction and/or neuromuscular lower urinary tract dysfunction. Application of this concept to patients with storage problems caused by decreased compliance has also resulted in the concept of the "leak point" as a significant piece of urodynamic data. This "detrusor leak point pressure" is not the same as the "abdominal/coughing Valsalva leak point pressure". The latter parameter refers to the vesical pressure produced by straining, which is necessary to overcome sphincteric resistance and produce incontinence.

  • Urodynamic Assessment: Electromyography
    Presentation of pelvic floor electrodiagnostic techniques including surface and needle electromyography (EMG), nerve conduction and terminal latency studies, evoked potentials, and reflex response studies. The clinical, urodynamic, and electrophysiologic findings to be expected with neuropathy in various areas, from the cerebral cortex to the peripheral pelvic floor nerves, are also described. Because of widespread technical advances and great increase in the amount of information about human neuro-urology, concepts are continually undergoing modification and change. This chapter also concentrates on the present aspects of clinically useful knowledge, although modification of many concepts will soon be needed. EMG requires additional expertise but should be considered in the difficult clinical situation.

  • Pitfalls in Urodynamic Studies Interpretation
    Urodynamic studies provide insight into the functioning of individual components of the lower urinary tract, bladder, and urethra, and into their interactions. Debate continues on the role of urodynamic studies in prediction of surgical outcome and in patient counseling before surgery. The purpose of this review is to set forth general principles of pitfalls in urodynamic studies and illustrate with a few representative tracings. The refinement of urodynamic techniques, in the context of rapidly evolving strategies to treat stress urinary incontinence, pelvic-organ prolapse and overactive bladder, has allowed physicians caring for women with disorders of the pelvic floor to bladder function more accurately. This review also highlights some of the ongoing debates over the performance, interpretation, and utility of urodynamic testing, and provides references for further reading on these topics. Problems arise if the urodynamic studies are of poor quality or difficult to interpret, and if repeat testing is required.

  • Health Implications of Urinary Incontinence in Women
    Understanding the best available evidence for evaluating and treating urinary incontinence in women with a focus on overactive bladder (OAB). Prevalence of incontinence appears to increase gradually during young adult life, has a broad peak around middle age, and then steadily increases in the elderly. After the basic evaluation of urinary incontinence, simple cystometry is appropriate for detecting abnormalities of detrusor compliance and contractibility, measuring postvoid residual volume, and determining capacity. The differential diagnosis including genito-urinary and non-genito-urinary conditions and their various managements are also discussed. Although pharmacologic and non-pharmacologic therapies are effective in reducing urge incontinence, neither is curative in some patients.

  • Urinary Incontinence: Introduction & Behavior Modification
    There are various types of incontinence and the role of behavior modification. Overactive bladder (OAB) / urge incontinence is a common condition that becomes even more prevalent as people age. It is associated with significant psychological and physical morbidity as well as increased healthcare costs. The prevalence of stress incontinence represents a spectrum, depending on how incontinence is defined. There is racial and ethnic variation in the prevalence of urinary incontinence in women.

  • Pelvic Floor Muscle Rehabilitation
    Pregnancy and vaginal delivery have been considered main risk factors in the development of pelvic floor disorders and in the development of stress urinary incontinence. Urinary incontinence alone represents a $ 26 billion economic burden. There appears to be an increase in demand for care of these disorders that is disproportionate to the net growth of the population. In order to restore function of the pelvic floor muscles after childbirth, women in most industrialized countries have been encouraged to perform pelvic floor muscle exercises. Postpartum pelvic floor muscle training has been demonstrated to be effective in the prevention and treatment of stress urinary incontinence in the immediate postpartum period. Many education techniques have been described, and physiotherapists skilled in uro-gynecology frequently use pelvic floor exercises, biofeedback, and electrostimulation techniques.

  • Lower Urinary Tract Infections
    Women are prone to urinary infections, especially before puberty and after the menopause. The main effect of infection on vesicourethral function is that 25% of the patients have uninhibited detrusor contractions with associated urethral relaxation. E. coli endotoxin causes these findings in many patients. In many patients urethral striated sphincteric spasm results, creating a vicious cycle of retention, obstructed voiding and repeated infection. The treatment is elimination of the infection by antimicrobial agents. Prevention of recurrent urinary tract infections is vital.

  • Evaluation of Urinary Incontinence
    Urinary incontinence can be a symptom of which patients complain, a sign demonstrated on examination, or a condition that can be confirmed by definitive studies. The history and physical examination are the first and most important steps in the evaluation. A preliminary diagnosis can be made with simple office and laboratory tests, with initial therapy based on these findings. For the vast majority of women presenting with complaints of urinary incontinence who have not had prior failed anti-incontinence operations or the history of neurologic disease, the simple evaluation may be all that is needed. With a detailed history, physical examination and the neurologic examination of the lower extremities and perineum, a diagnosis can usually be established accurately in approximately 90% of patients. If complex conditions are present or if surgery is being considered, definitive specialized studies are necessary.

  • Medical Management of Voiding Dysfunctions
    Recent advances in the understanding of the neurology and neuro-pharmacology of the lower urinary tract indicate that a multiplicity of different types of drugs influence the physiological activity of the bladder and urethra. Although behavior modification improves or cures most patients with detrusor instability, pharmacologic therapy remains the most popular mode of treatment. In women between the ages of 15 to 60 years, the prevalence of voiding dysfunction is about 5-25%. 12 to 38% of women are over the age of 60. 69% of women are over the age of 18 with the symptoms of urinary incontinence, and the incidence of urge incontinence among this group is about 46%. Because the cause of detrusor instability is unknown, the response to treatment is often unpredictable and the side effects are common with effective doses. In general, drugs improve detrusor instability by inhibiting the contractile activity of the bladder.

  • Understanding Overactive Bladder (OAB) In Women
    Overactive bladder (OAB) is a common medical condition that can erode a woman's psychological and social well-being, and may have serious health consequences if left untreated. Therapy may include non-pharmacologic techniques, medication or a combination. Usefulness of pharmacotherapy may be limited by adverse reactions such as dry mouth, although newer medications such as ER oxybutynin and tolterodine tartrate may have slightly fewer side effects. Appropriate early intervention, which includes identifying the disorder, is a key factor in slowing the progression of detrimental changes in the lower urinary tract.

  • Interstitial Cystitis (IC): A Comprehensive Review
    It is important to improve the necessary knowledge of healthcare providers to make the correct and early diagnosis of interstitial cystitis (IC). Also, even for clinicians who are aware of interstitial cystitis (IC), some patients present with atypical symptoms or co-morbid conditions that make the correct diagnosis challenging. It is also important to note that, whereas IC may present as urgency and frequency without pain, the presence of pain is required for the diagnosis. This review summarizes discussions of issues identified as being of concern in several surveys, interviews, and question-answer sessions at professional educational activities.

  • Pelvic Organ Prolapse: An Overview
    Pelvic organ prolapse is a very common gynecological condition - it is estimated that 50% of women who have had even one childbirth, lose pelvic floor strength and about 10 to 38% of these women, between 15 to 60 years of age suffer from full blown prolapse. The incidence increases with advancing age. Unfortunately, only 1 in 5 patients are able to access medical care for their symptoms. Every year nearly 2.04 women per thousand year's risk are hospitalized for prolapse and almost 338,000 undergo surgical interventions for the disorder. This high incidence places a severe social and economic burden on the society.

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