Urinary incontinence is a common medical condition that affects over 40 million Americans, yet it often goes untreated or unrecognized. The reason for this trend is multifactorial, spanning from embarrassment to speak about this topic to dealing with more acute or morbid conditions that require focused attention.Nevertheless, it is a treatable condition that frequently affects the quality of life of our patients. Incontinence is classified as stress, urge, mixed and overflow.In these notes we will address some particular issues about urge incontinence. Urinary urge incontinence (UUI) is defined as a sudden uncontrollable urge to urinate with or without frequent urination and associated leakage of urine.With urge incontinence, the bladder contracts and squeezes out urine involuntarily.
Accidental urination can be triggered by:
Patients with overactive bladder symptoms, such as urinary urgency, frequency and nocturia, may have associated incontinence over 60% of the time. Though more common in women than men overall, after the age of 70 the prevalence in both sexes is about equal.
There are two bladder abnormalities that are associated to UUI:neurogenic overactivity and detrusor overactivity (DO).Neurogenic bladder occurs when there is interruption in the normal nerve conduction from the brain or spinal cord above the sacrum to the bladder, and results in loss of bladder sensation and motor control.
Conditions associated with neurogenic bladder include the following:
DO can occur due to multiple conditions, and many times as a sequelae of others; frequently, it may be idiopathic.Dysfunctions of the detrusor muscle or nerve pathways is the culprit for the bladder overactivity.
Conditions that can lead to DO include:
Medications, such as diuretics, increase the urgency and frequency of urination in some people, especially the elderly and bedridden.Dosage modification may ameliorate the bothersome symptoms.Dietary habits may lead to significant voiding symptoms.Caffeine (e.g., in coffee, tea, chocolate), carbonated beverages, spicy foods and tomato-based foods can irritate the bladder and cause detrusor instability, resulting in urge incontinence.
The treatment and management of urge incontinence includes nonsurgical and surgical modalities.An important factor, however, is identifying the potentially morbid or life-threatening conditions that may lead to incontinence, such as bladder cancer, recurrent UTI or neurogenic disorders.
Anticholinergics have been shown to be very effective in the treatment of both neurogenic and idiopathic cause of UUI.As a class, side effects include confusion, dry mouth, constipation, dizziness, visual changes and urinary retention to name a few.Beyond medications there are simple yet effective treatments.
Advanced treatment modalities for refractory patients to conservative therapy and anticholinergics are available in the urologic armamentarium.Urological evaluation of these patients most likely will include a cystoscopy, urine cultures and urine cytology to rule out bladder pathology and bladder malignancies. As well, a detailed, computerized assessment study of bladder function called urodynamics may help the clinician in establishing the best treatment option.
Neuromodulation, either via sacral nerve pathways (Interstim) or peripheral nerve pathways (Urgent PC), have been shown to be very effective in the treatment of UUI in patients with refractory disease.These modalities are safe, FDA approved, minimally invasive and provide, through neural pathways, improvement in bladder function.Urgent PC is an outpatient, office-based, nonsurgical therapy that affects the sacral nerve plexus through retrograde pathways (posterior tibial nerve).Interstim utilizes the sacral nerve S3 to provide parasympathetic inhibition, thereby decreasing bladder overactivity. It is based on pacemaker technology, and effective in about 70% of refractory patients.
Injection of botulinum toxin (Botox) into the bladder muscle (intravesical injection) is an experimental treatment for refractory urge incontinence. This treatment has been shown to successfully reduce the instability that leads to urgency in both idiopathic and neurogenic patients.
Surgical urinary diversion is an invasive therapy used mostly for severe patients refractory to all other therapies.
Urinary incontinence is a common but overlooked problem.Urologic evaluation is warranted in refractory patients, or in patients in whom underlying bladder pathology or anatomic abnormalities, such as prolapsed, need to be addressed as well.Intervention beyond medications will significantly improve the quality of life of these patients.
Erectile Dysfunction (ED) affects more than 50% of men over the age of forty.This incidence increases dramatically in patients with comorbidities such as diabetes, hypertension, coronary artery disease, peripheral vascular disease, obesity, smoking and excessive alcohol consumption.The introduction of medications such as Viagra, Levitra and Cialis has offered men with mild to moderate ED a reliable and generally safe solution.In addition, it has increased public awareness and discussion of this common problem. The result is that increasing numbers of men with even severe ED are seeking help.Although it is not as simple as taking a pill for many of these men, many other safe and effective options are available and being used successfully. Vacuum erection devices (VED’s) are plastic cylinders (made by several manufacturers) designed to fit over the penis and by using a suction mechanism pull blood into the penis.An elastic band is then deployed from the device around the base of the penis to hold the blood in the erectile bodies of the penis.These devices are safe and can be used indefinitely.They are particularly useful for the patient who does not get fully erect with oral ED medication in that they allow him to complete and hold the erection.VED’s are also useful in erection rehabilitation after radical or robotic prostatectomy to keep the penile tissues stretched and supple as well as in the treatment of peyronies disease which is often associated with penile curvature and calcified penile plaques.??Penile injections and suppositories are designed to deliver prostaglandin directly to the penis which facilitates blood flow into the penis and prevents leakage out of the penis.Suppositories known by the trade name Muse are inserted into the urethra using a small applicator.They then dissolve in approximately 10 minutes delivering the medicine transuretherally into the corpora cavernosa.Injectables known by the trade names Caverject and Edex are injected directly into the corporal bodies with a small needle and work directly.They very effective, even in men with nerve damage from prostate surgery.They are also safe and easy to use.
For those who do not respond to oral medications or injectables minimally invasive surgery offers an excellent option.The inflatable penile prosthesis (IPP) is a safe and effective option for all forms of refractory ED.It is an outpatient surgical procedure whereby two inflatable cylinders are placed within the corporal bodies of the penis and a small pump is placed within the scrotum.The incisions are tiny and hidden within the pubic hair.The complication rate is minimal, and the procedure can be performed under general or spinal anesthesia as an outpatient requiring approximately 30 minutes.
As public awareness about ED has increased so too has patient longevity.The result is that larger numbers of men each year seek treatment for ED.For almost every case there is a solution that provides successful results, minimal risk and a favorable safety profile.Affecting over half of men over the age of forty, ED can often be a sign of other medical problems that may have led to this condition.Despite these trends, most men are still too self-conscious to bring it up with their physicians at the time of their annual physical examinations.Some feel that it is a normal part of the aging process.It is important that patients are asked about their sexual function both to offer them help as well as to potentially uncover other underlying medical conditions.An additional consideration is the fact that if patients do happen to mention their ED and are provided with samples of an oral ED medication, it may or may not work.If it does not work, they are not likely to call back to schedule an appointment for “Viagra not working,” and it may be another year before the problem is addressed again.Therefore, if a patient does have ED, urological referral may be a good option to complete the evaluation, and establish a successful treatment program that includes close follow-up with modifications through the entire range of options when necessary.
One in 10 people are diagnosed with kidney stones during their lifetime. The peak incidence occurs between the ages of 30 to 45.Patients will often present with sudden onset of severe intermittent pain and nausea.Treatment depends upon stone size, location, composition and comorbidities.Stones less than 4 mm usually pass spontaneously while stones greater than 4mm usually require intervention.Stones that are unable to pass are generally treated on an outpatient basis at a urological ambulatory surgery center. Our urology-focused ambulatory surgery center offers cutting-edge minimally invasive technology necessary to treat all types of stones.For example, a holmium laser can provide a focused beam of light to fragment stones with pinpoint accuracy.Latest-generation shockwave lithotripsy machines (ESWL) offer exceptional radiographic imaging necessary to maximize success.These machines work by focusing high-energy shockwaves on the stone while minimizing trauma to surrounding tissue.A urology-specific surgical center will also have the full array of endoscopic equipment such as miniature ureteroscopes, which can be placed through the urethra and advanced all the way up in to the kidney itself to visualize stones for fragmentation.When stones are larger, more invasive procedures are generally necessary, such as a percutaneous nephrolithotomy (PCNL), where the stone is fragmented and removed through a small puncture made through the flank.
Unfortunately, many stones formers do not receive the appropriate prevention after the acute stone crisis has resolved.With correct preventive dietary counseling and selective medical therapy, a stone remission rate of 90% can be achieved.Risk factors for recurrent stone formation includes young age, gender (male), race (Caucasian), family history of stones, recurrent urinary tract infections, gout and osteoporosis.The cornerstone of prevention involves a chemical stone analysis, basic blood work and a 24-hour urine collection.The two most common stones are composed of calcium oxalate (82%) or uric acid (8%).A careful dietary history and review of all over-the-counter and prescription medications should also be completed.
Low-to moderate-risk stone formers will have an excellent result with dietary and fluid management alone.All stone formers should increase their urine output to greater than 2,500 cc.Calcium oxalate stone formers should avoid foods high in oxalate such as chocolate, nuts, black pepper and spinach.If patients have a history of osteoporosis or osteopenia they should stay on calcium supplementation with calcium citrate.If not, then calcium supplements should be avoided unless a screening bone density test later reveals problems with low bone density.A low-salt diet will further reduce the risk of future stones.Increasing dietary citrate with fresh lemon, lime, orange or pineapple juice will also inhibit stone formation.?People who form uric-acid stones should follow a low-purine diet and minimize intake of beef, fowl and shellfish.Uric-acid stone formers often require urinary alkalization with medications such as potassium citrate.The goal of alkalization is a urinary pH between 6.5 to 7.0.Uric-acid stones often cannot be visualized on routine X-rays and therefore require diagnosis by CT or ultrasound.Unlike the more common calcium-based stones, uric-acid stones can often be dissolved with medical management without the need for surgical intervention.
All patients with kidney stones should be referred to a urologist for management and prevention.High-risk stone formers generally placed on long-term medical therapy and dietary restrictions.These patients are followed up on an annual basis for routine X-rays, urinalysis and repeat 24-hour urine collections.
Kidney stones can be a very painful and often recurrent problem.Sudden onset of severe pain often occurs at the worst possible times.Kidney stones often are caused by underlying metabolic disorders and proper evaluation is essential for stone prevention.
A vasectomy is a permanent, surgical birth control procedure for men that halts the release of sperm by transecting the tube — called the vas deferens. This specialized tube delivers sperm from the testicles. After a vasectomy, sperm is still produced, but it is just reabsorbed by the body, which is what happens to excess sperm naturally.
A no-scalpel vasectomy (NSV) procedure differs from conventional vasectomies in the methodology. Instead of an incision being made, the urologist makes a single, tiny puncture that is less painful and heals easier. As mentioned, both conventional and no-scalpel vasectomies are generally permanent (see “Reversals” below for exceptions), with a 99.85% effectiveness rate.
The NSV is generally a brief procedure, generally taking between 10 and 15 minutes. It can be done under sedation in our ambulatory surgery center or under local anesthesia in the office. For patients who chose to have it done in the office, a local anesthetic is applied to a specific area of the scrotum (typically Xylocaine, which is related to Novocaine). Once the area is completely desensitized, a tiny puncture is made in the scrotum. The surgeon then locates the vas deferens, which is then transected and clipped. Afterwards, the puncture may be sutured, but it is typically unnecessary being only 2 to 3 millimeters in size. The site heals quickly with littletono scarring.
Simply arrive at the specified time to the office, after having filled your prescriptions for pain pills and antibiotics. Bring underwear that provides good scrotal support, like a jockstrap or tight briefs. Please do not eat or drink for 3 hours before the NSV procedure, if it is to be done in the office, andnothing after midnight the night before, if it is to be done in the surgical center under sedation.
For the rest of the day: There should be minimal discomfort. In fact, your scrotum will be desensitizedfor several hours as a resultof the anesthesia. Please rest and stay off your feet, wear underwear that provides good support and apply ice or cold packs to the scrotum to keep the swelling down. After 48 hours: You can return to work after a day or two, provided that your work doesn’t require heavy lifting or strenuous labor. After 1 week: You will generally want to wait a week before havingintercourse, to give the area a chance to heal properly. *IMPORTANT NOTE:If your intimacy partner is a female and is fertile, there is a chance that she can get pregnant. It is advised that you wait until all the residual sperm is cleared out (which typically takes 6 to 8 weeks and 15 to 20 ejaculations) before performing intercourse. After eight weeks: Return to our office to have a test on your sperm count. Note that eliminating residual sperm depends more on number of ejaculations and less on matter of time. Once sterility is confirmed, you may safely discontinue other forms of birth control. Also, note that vasectomy does not protect you or your partner from the transmission of sexually-transmitted diseases.
Risks of No-Scalpel Vasectomy
One of the major advantages to a no-scalpel vasectomy procedure is the low risk of complications. However, no surgical procedure is risk-free. The most common risks include:
We should also mention unintended pregnancy. This isn’t so much a risk of the procedure, as a failure of some patients to realize there will be residual sperm in the system that must be eliminated through ejaculation before sperm count will reduce to zero.
The more common after-effects will disappear as the area heals, while ice and scrotal support will ease symptoms. The more serious side effects, like infection, are rare. It is advisable to avoid NSAID (non-steroidal anti-inflammatory) drugs like aspirin, which can increase the chance of internal bleeding.
Impact on Sexual Function
A no-scalpel vasectomy procedure is purely mechanical. In other words, the only change to the body is to block the delivery of sperm. Testosterone production is not affected at all. Therefore, sex drive and potency (i.e., the ability to have and maintain an erection) will remain unchanged. Additionally, the ability to ejaculate is still active because seminal fluid is produced separately from sperm. The volume of ejaculate will change very minimally.
Benefits of No-Scalpel Vasectomies
Reasons to Consider a No-Scalpel Vasectomy
There are nearly as many reasons to consider a vasectomy as there are to opt out of the procedure. Many men choose to have a vasectomy because they don’t want to use other forms of birth control or because pregnancy represents potential risks, like passing on serious hereditary conditions or endangering the mother’s well-being. On the other hand, because a vasectomy is generally permanent, it is important for men to be sure this is the right decision for them. Our specialists are happy to discuss your situation so we can help you understand the procedure, its benefits and its implications. Please contact us to schedule an appointment.
Prostate Cancer is rarely the same in each individual and needs to be treated according to the disease. After diagnosis is made, we offer a full spectrum of treatment options including da Vinci® Robotic Prostatectomy, High Dose Rate Brachytherapy and Cryoablation Therapy.
da Vinci® Robotic Prostatectomy
Dr. William Figlesthaler with the da Vinci® S Surgical System
Six years ago at Naples Community Hospital, William M. Figlesthaler, MD, FACS, successfully performed the first da Vinci® robotic prostatectomy in southwest Florida. Since that time, he has performed over 3000 of these cases at both Naples Community Hospital as well as Physician's Regional Medical Center, Pine Ridge. The experience and results from it has lead to a broad referral base, including physicians and patients from the Southwest coast of Florida, as well as from nearly every state and from around the world.
Dr. Figlesthalerhas mastered and then modified the original da Vinci® prostatectomy procedure to enhance the return of bladder control and sexual function, as well as, to cut down on operative times and minimize blood loss while optimizing cure.
The da Vinci's camera provides three dimensional viewing and also magnifies the surgeon's vision by ten times while he uses the tiny instruments to perform microdissection of the cavernosal nerves which run along the prostatic capsule. This technique allows for return of erectile function post operatively. In addition, the ability to maneuver throughout the surgical field with seven degrees of freedom allows the bladder neck and urinary sphincter muscles to be spared while detaching the cancerous prostate. Operating through keyhole incisions minimizes pain and blood loss thus allowing a rapid return to normal activities. Most patients are discharged to home the day following surgery and begin driving with in a week or two.
In experienced hands this miraculous technology provides patients with an outstanding option for successful treatment of prostate cancer, while allowing for a rapid return to the quality of life they deserve.
High Dose Rate Brachytherapy
With the patient under general anesthesia, a template is used to guide the placement of a number of needles into the prostate by passing the needles through the skin in the area between the scrotum and anus. A CT scan is obtained to determine the position of each needle relative to the prostate. This information is then transferred into the treatment planning computer and a treatment plan is formulated. A computer controlled machine then runs a tiny radioactive pellet out into each individual needle. The radioactive pellet is then stopped at pre-determined locations within each needle for a pre-determined period of time to deliver a precisely sculpted dose of radiation to the entire prostate. A second application is delivered later the same day. The needles are then removed and the patient goes home. A second set of two applications is typically delivered a few weeks later.
There is a lot of "hype" in the press regarding the use of natural supplements to promote prostate health. The unfortunate reality is that, despite the use of these herbal compounds, over 70% of men over the age of 50 will be affected by enlargement of the prostate. This condition, referred to as benign prostatic hyperplasia (BPH), results in a broad spectrum of progressive signs and symptoms. Fortunately, the condition is highly treatable and correctable when addressed in a timely fashion.
Frequent urination, getting up at night to urinate, urgent urination and later, weak urinary flow, incontinence, renal failure and sexual dysfunction are all potential problems. The cause of this condition is largely genetic and is linked to the male endocrine system. With advancing age the balance between testosterone, dihydrotestosterone and estrogen changes. In addition, the behavior of the various hormone receptors becomes modified and results in the stimulation of hyperplastic prostate gland growth.
Prostate cancer is not caused by BPH, nor is the presence of BPH associated with the increased incidence of prostate cancer. Because men with significant BPH are more likely to seek medical attention, however, they are also more likely to be screened for and diagnosed with a coexisting silent prostate cancer.
The basic understanding of how BPH develops has led to effective medical treatment options. Drugs including Flomax, terazosin and doxazosin are alpha receptor blockers which effectively relax the smooth muscle of the prostate gland and allow better opening of the bladder neck and prostatic urethra during urination. Avodart and finasteride are 5-alpha-reductase inhibitors and through a hormonal mechanism arrest the growth of the prostate, and may even cause a reduction in size. These two classes of drugs are often used in combination very effectively, and in some cases are also combined with a mild anticholinergic drug similar to oxybutinin to control the overactive bladder symptoms that often accompany BPH.
The use of these anticholinergic drugs in the treatment of BPH must only be considered if urodynamic studies confirm that the bladder is emptying adequately, and in combination with Flomax or another alpha blocker. If not, significant urinary retention may occur. The patient prefers to avoid lifetime medical therapy, there are several safe and affective treatment modalities. In cases where medical management is suboptimal or when
Transurethral microwave therapy (TUMT) is a safe and effective treatment used to ablate the obstructing prostate tissue under local anesthesia in an office setting. After cystoscopic examination and urodynamic studies, a preselected treatment catheter is inserted into the bladder and tiny heating coils are used to raise the temperature of the prostate tissue along the urethra and bladder neck just high enough to denature the cell membrane proteins. Over the next few days this tissue then gently sloughs leaving an open channel. The procedure is safe, performed under local anesthesia and can be done while the patient is on warfarin, aspirin and or Plavix.
Another safe and effective approach is Transurethral photoselective vaporization of the prostate (PVP), also known as "Greenlight Laser Therapy." This technology is based on using the wavelength of a KTP laser, which targets hemoglobin and therefore selectively vaporizes the prostate cells while simultaneously maintaining hemostasis. The result is immediate, and although a general anesthetic is required, the procedure times are brief and performed on an outpatient basis.
Similar to TUMT, PVP/Greenlight can also be performed on blood thinners in many cases, and is effective on very large prostate glands. Both of these procedures require brief foley catheterization 1-3 days, and have a very low risk and side effect profile, including the preservation of erectile function.
BPH is perhaps the most common disease process affecting the aging but otherwise healthy male. Fortunately, there are many options to adequately evaluate and effectively treat this condition. The result is preservation of quality of life including freedom from bathroom mapping as well as the preservation of renal and sexual wellness. Thorough evaluation includes screening for prostate cancer as well as urodynamic studies, which help to rule out other causes for the presenting signs and symptoms. When basic dietary recommendations and medical therapy are ineffective in the primary care setting, urological consultation should be encouraged.
Vaginal rejuvenation surgery has become a growing trend not only in the United States but worldwide. As women remain healthier and more youthful into later years, the negative effects on the pelvic anatomy as a result of childbirth, hormone deficiency, and aging are all challenges that can now be effectively addressed. In some cases it is necessary to revise prior surgical procedures or scars from bad episiotomies. In other cases and often concomitantly, vaginal rejuvenation surgery can be used to restore the proper caliber and tone to the vaginal canal that has become “loose” due to the reasons listed above. The field of vaginal rejuvenation is a highly specialized field with relatively few surgeons who are properly trained in performing these delicate procedures. Vaginal rejuvenation as a discipline includes a broad array of different approaches to reconstituting normal esthetic anatomy as well as function and support to the vagina and surrounding organs. Successful outcomes call for a combination of both surgical and nonsurgical approaches which may include physical therapy and biofeedback, hormone replacement along with specific corrective surgical procedures. When surgery is indicated, specific objectives are identified in a private consultation with physician and patient so that all related concerns and defects may be addressed simultaneously. Issues related to vaginal rejuvenation may include bladder and bowel dysfunction, and require a thorough evaluation, including computerized urodynamic studies, pelvic ultrasound or cystoscopy along with a thorough history and pelvic examination. Successful results include the correction of both the functional and cosmetic defects of the vagina and pelvic organs. When these clinical goals are addressed and met, the result is often a renewal of both self esteem and intimacy for affected women. Listed below are a number of related procedures along with a description of the defect and indications for corrective surgery.
Vaginal Relaxation Surgery
Pregnancy and vaginal childbirth often result in some form of relaxation of the vaginal supporting tissues. This can produce varying degrees of vaginal relaxation. A lax or “loose” vagina can often cause sexual dysfunction for both the woman and her male partner due to suboptimal contact during intercourse. Women can also develop significant loss of vaginal wall support leading to various degrees of vaginal prolapse. Most commonly they will experience the development of a cystocele (fallen bladder) which gives rise to urinary tract dysfunction including bladder infections and incontinence. They may develop a rectocele (rectum pushing into the vagina) which can lead to bowel dysfunction, including both constipation and, in some cases, loss of fecal control. In addition they may experience uterine prolapse (fallen uterus) which may actually protrude from the vagina while sitting or standing. In addition to causing urinary and fecal problems these vaginal prolapse conditions can also have a negative impact on sexual performance. Vaginal relaxation surgery may address both the tightening of the vaginal canal as well as the correction of the prolapse. In cases where the patient is also experiencing urinary incontinence, corrective procedures such as a pubo-vaginal sling are also performed in the same setting. These surgical procedures are performed using a combination of surgical tools including laser and electrocautery to minimize peri-operative bleeding and surgical trauma, and are most often performed on an outpatient basis.
This procedure will correct the function and appearance of the the inner lips (labia minora) of the vagina. The reasons women may consider reductive labiaplasty are related to the large or asymmetric appearance of the tissues in some cases that may cause discomfort in clothing during physical activities or intercourse. Not uncommonly, the large asymmetric appearance of the labia may also make some woman feel self-conscious which has the potential to adversely affect their sexual intimacy. The surgery consists of removing the excess skin with carefully planned surgical tailoring using combination of laser, fine surgical scalpel, and plastic surgical scissors.
Unhooding of the Clitoris
Normally the prepuce (clitoral hood) is anatomically designed to protect the clitoris against undue abrasion and overstimulation, and naturally retracts during intercourse thereby leaving the highly innervated surface of the clitoris exposed. Sometimes women either have a small clitoris or the preputial skin is thickened making it impossible for the clitoral glans to be exposed during intercourse. Often these women have difficulty in achieving orgasm. Corrective surgery involves the careful removal of the excessive skin overlying the clitoris.
This procedure restores the delicate hymenal tissue to a virginal state. The surgery is very successful with minimal risk or discomfort.
Labia Majora Augmentation Surgery
Some women may have very thin outer vaginal lips and would feel more comfortable if they were fuller. This is easily achieved in a similar way that lips on the mouth are made to look fuller. The labia majora can be made to look fuller with bulking agents or the woman’s own fat obtained by liposuction from such areas as the mons pubis. The skin surrounding outer vagina and perineum can also be treated with combination injections of bulking agents and laser resurfacing to restore a more youthful appearance of the region.