At least 1/3 of women will experience problems with continence. It is a very distressing problem because it is difficult to talk about. The fear of social isolation pushes the patient to avoid meeting others for social engagements, eventually sending her into depression. In older women it causes loss of dignity and caregivers; life is also affected negatively upsetting the family dynamics.

What does Incontinence mean ?

The lack of control over your urine and the bowel movement is called Incontinence

What are the types of Incontinence ?

• The loss of urine when you cough, laugh, or sneeze is called Stress Urinary Incontinence.
• A sudden feeling of urgency to urinate which cannot be postponed or controlled, urinating too many times, getting up in the night to urinate more than 2 times – All these symptoms together are called Over Active Bladder
• When you have both the above mentioned symptoms it is called Mixed Incontinence
• When your bladder fills without your being aware of it – and there is leakage, it is called Overflow Incontinence.
• Inability to control your bowel movement is called Fecal Incontinence. It usually happens when there is injury to the muscles around the rectum.

How do we prevent it ?

Sometimes there is no way to prevent it. It depends on the type of body, number of deliveries, instrumental delivery, age, obesity.

• It is helpful to do pelvic floor exercises (PFE) during and after delivery.
• Appropriate diet, sometimes you may be asked to avoid spices, citrus and coffee and tea.
• Avoid obesity
• Don't lift heavy objects
• Make sure that other medical problems such as chronic cough or constipation are under control.

How do we diagnose ?

• CUE and urine culture and sensitivity
• Pelvic Ultrasound
• Physical examination
• Urodynamic testing
• Cystoscopy

Not everybody will need all the tests. Your doctor will determine what tests you will need after discussing your symptoms with you and after the examination.

How do we treat incontinence ?

Treatment of incontinence depends upon the type of incontinence. In the modern day, there are many advanced treatments available to you. Before that you should try simple therapies like lifestyle change, avoid obesity, diet and pelvic floor exercises.

• Sling therapy using mesh
• Botox injection into the bladder
• PTNS (posterior tibial nerve stimulation)
• Sacral Neuromodulation
• Regenerative Medicine

In summary, it is important for you to open up about your symptoms and be patient and take your medicines as prescribed.

What does stress incontinence mean ?

Unexpected loss of urine during everyday activities such as coughing, sneezing, laughing.

Why is it important to know about SUI ?

It affects at least 20% of the women. SUI leads to embarrassing situations and leads to social alienation and especially it is difficult for women to pray and also attend any social function. Unfortunately this is not something they can talk to anybody about.

The idea behind this leaflet is to tell women that they need to be open about and there are many simple treatment options available.

How do you get Stress incontinence ?

The most common reason is pregnancy and childbirth. This causes a disturbance in the areas of the vagina and bladder and causes the loss of support to the tube that carries the urine(urethra). Other causes are obesity, chronic cough, constipation and heavy lifting, all of which increase the pressure inside the abdomen. Inherited factors are also responsible for SUI.

What is the mechanism of normal urination ?

The bladder is a very stretchable organ and can accommodate 600ml to 1liter of urine. When the bladder starts filling up and reaches a certain level, the bladder sends signals to the brain. The brain in turn decides whether the person is in a socially acceptable situation to empty her bladder. If it is not acceptable, the brain signals the bladder to relax. When the suitable opportunity arrives, it sends a message to the bladder to empty it.

How do you diagnose it ?

When you tell your doctor about your symptoms, he will be led to the conclusion that you have SUI. You also should tell your doctor if you have any urgency or fecal incontinence. Make sure that you find a doctor with whom you can speak freely without embarrassment.

Do you need any testing ?

Your doctor might ask you to cough when he/sher is examining you. You will be asked to keep a bladder diary to note how many times these accidents happen. This indicates the severity of the problem.

How do we treat this ?

Maintain appropriate weight. Avoid obesity. Treat any treatable condition such as constipation, chronic cough, lifting weights, stop smoking should be followed.

You must do pelvic floor exercises (PFE) regularly. Your doctor might decide to use an advanced system of training your pelvic muscles (CTS2000, Prometheus), which will help you do this correctly.

If you are very old or medically ill or do not like surgery, your doctor might fit you with a silicon device called “pessary”. This will remain inside you and you will be taught how to clean it and put it back in.

The last option is surgical. It is minimally invasive and done from below. A small strip of a very light mesh is to be passed behind the urine tube(urethre) to give it more support. Your doctor will explain to you in more details about this.

You can also undergo a surgery wherein the abdomen is cut and sutures are placed next to the urethra and suspended to the tissues around the bone in front of the body.

There are many women who have to go to the bathroom frequently and also cannot control the urine before they reach the bathroom. This group of conditions have been given the name OAB, i.e Overactive bladder.

OAB is a very distressing condition that affects women of all ages, particularly women who are older. It's a condition wherein you have to rush to the bathroom many times, during the day or night and sometimes leak urine before they reach the toilet. This is quite distressing to the patient and embarrassing. It is also a problem of caretakers of the old people

1. What does OAB mean ?

OAB is a group of symptoms which have been put under the umbrella of the term OAB.

• If you have use the bathroom more than 8 times during the day (FREQUENCY)
• If you have to get up more than twice to use the bathroom (NOCTURIA)
• If you feel like urinating all the time or you feel that you have satisfactorily emptied the bladder (URGENCY)
• feel the urge to urinate but cannot control urination before you reach the toilet (URGENCY WITH INCONTINENCE)

2. What causes OAB ?

There is disturbance of the nerves and muscles surrounding your bladder. These muscles and nerves control the normal way of urination. Some of the conditions that disturb this are:

• Pregnancy and childbirth
• Pelvic surgery (operating close to the bladder)
• Medications, you may be taking for other problems
• Natural aging process (lack of hormones due to menopause)
• Obesity
• The amount and type of diet for example coffee, tea
• Undiagnosed UTIs
• Unknown factors

3. How does the normal bladder work ?

The bladder is a very stretchable organ and can accommodate 600ml to 1liter of urine. When the bladder starts filling up and reaches a certain level, the bladder sends signals to the brain. The brain in turn decides whether the person is in a socially acceptable situation to empty her bladder. If it is not acceptable, the brain signals the bladder to relax. When the suitable opportunity arrives, it sends a message to the bladder to empty it.

4.How do you diagnose it ?

Your doctor will hear and document your symptoms and may advise some tests :-

• CUE (complete urine examination)
• Bladder diary: This involves recording what and how much you drink and the quantity of urine that you pass as well the number of times that you have to go to the bathroom including the day and night. This is very helpful to the doctor in correctly understanding your problems.
• Post void residual urine: Ultrasound measurement of post void residue. ie how much urine is left in your bladder after you empty it. It should not be more than 100ml. Another way to measure the post void residue is for your doctor to pass a catheter into your bladder after you have emptied your bladder.
• Urodynamic testing: This kind of test is able to examine the activity of the bladder muscle and the pressure inside while you are urinating and also while your bladder is being filled slowly with sterile fluid.

When your bladder muscle squeezes inappropriately, it can be detected in a graphic form and hence helps confirm the diagnosis. It requires a Urodynamic machine, a Uroflowmeter and a few thin catheters to put in your bladder.

5.How to treat OAB ?

There has been a surge of treatment options that are modern and available to you. The basic prevention techniques are still important.

• Lifestyle changes (weight loss)
• Physical therapy: There are advanced machines that are available which can not only train you not only to do the pelvic floor exercises(PFE) correctly, but also selectively stimulate the pelvic muscles.
• Bladder training: When you have gotten into the habit of going to the bathroom very often, it is important to break this pattern. Bladder training helps you hold more urine in your bladder by extending the time between the voiding gradually. Your doctor will give you more information regarding this.
• Medications: There are many medications which can relax the bladder. Some of these can cause side effects like dry mouth and constipation. It is important to anticipate these side effects and to take sips of water frequently and treat constipation independently. Your bladder may improve in a few months and you may be able to get off the medications. However it is also possible that you may end up taking medications for a long time.

6.What if the above treatments don't work?

You have other options :-

• Botulinum toxin:This is a toxin normally known as “BOTOX” and is used to treat wrinkles in cosmetic field. This relaxes the bladder and the effect may last for upto 9 months; thereafter you will require on e more injection. However there is a risk of having difficulty, emptying the bladder temporarily. Your doctor will give you more information on this.
• Posterior tibial nerve stimulation (PTNS) : By targeting the nerves that control the bladder and stimulating them, we are able to relax the bladder. This requires an instrument called “Urgent PC”. During this procedure, an acupuncture needle is placed at a key location on your leg and is stimulated. The treatment lasts for 30 minutes and needs to be done weekly for 12 weeks.
• Sacral Neuromodulation: It is a very effective but expensive procedure .its success rates are 80%. It involves putting a pacemaker I the buttock region with electrodes going into your sacrum to control your symptoms. This will last 10-20 years and will stay in your body just like a pacemaker to the heart.

This is a problem that is quite uncomfortable for women and is adelicate thing to talk about. It also causes a lot of emotional distress and disturbs her sex life.

1. What is pelvic organ prolapse?

The pelvic organs-uterus, rectum, bladder and vagina, are supported and kept inside the body by a sling of muscles and tissue. This is called the pelvic floor and is located at the bottommost part of the body. Weakening of this sling lets the organs slide out causing pelvic organ prolapse .

2. What causes the damage to the sling or pelvic floor ?

• Child birth - most common cause
• Chronic cough
• Constipation
• Lifting heavy weights constantly
• Obesity

3.What are symptoms of pelvic organ prolapse?

• Bulge in the vagina
• Inability to pass urine
• Losing urine on coughing
• Constipation
• Pulling pain in lower abdomen

4. How is it diagnosed?

• The problem most of the time self evident.
• Further examination is done by straining and also in the standing position to assess the severity of POP
• Post void residual urine: Ultrasound measurement of post void residue. ie how much urine is left in your bladder after you empty it. It should not be more than 100ml.
• Another way to measure the post void residue is for your doctor to pass a catheter into your bladder after you have emptied your bladder.
• Urodynamic testing to evaluate the bladder function is important to prevent postoperative problems like Stress Urinary Incontinence.
• Pelvic ultrasound to make sure that there are no masses in the pelvis pressing on the uterus/bladder.

5. How do you treat this condition?

The treatment of Pelvic Organ Prolapse has to be tailored depending on the age, physical condition and the wishes of the patient.

Not every patients needs surgery. There are many other options: -

• Physical therapy to strengthen the muscle – including the electrical stimulation
• Silicon rings and discs placed in the vagina preventing the organs from descending these are called pessaries
• Surgical intervention by experienced gynec surgeons or urogynaecologist to take measures from it happening again.

Sexual dysfunction is not a freely discussed problem in our country. But it does exist. It can affect women of all ages. This leads to disharmony in the family and personal life.

1. What is sexual dysfunction?

Difficulty in having sex, either due to pain or due to a distorted genitalia or due to inability of the male to perform. Painful intercourse is called “Dyspareunia”. In the Indian cultural setting, sex education for girls or boys has not been encouraged. This leave smany women in the dark about what happens in a sexual intercourse. They are left to hear second hand from their aunts and cousins and develop a phobia about it. So when they try sexual intercourse for the very first time, because of the predominant fear, their pelvic muscles and inner thigh muscles go into a spasm. This is called “Vaginismus”.

In the process of the development of the genitalia, there is a thin membrane that covers the entry into the vagina. This is called the “Hymen”. Most of the times, it is partial and sometimes it is complete. This can cause difficulty or pain during intercourse.

Some couples may have relationship problems which can result in dissatisfaction in sex, either in the man or the woman.

2. What can be done about it ?

• A positive step has been the introduction of sex education in the curriculum.
• Physical therapy for vaginismus.
• Counseling
• Very rarely a surgical incision may have to be given in the hymen to allow for intercourse. This will be done under anesthesia.

1. What is IC ?

IC is a chronic bladder problem.

The bladder holds urine after your kidneys filter it and before you pee it out. This condition causes pain and pressure below the belly button. Symptoms can come and go. Or they may be constant. Interstitial cystitis causes urgent, often painful bathroom trips. The woman may have to pee as many as 40-60 times a day in severe cases. It can even keep you up at night.

2. How does it present ?

The symptoms vary from person to person. They can change every day or week or linger for months or years. They might even go away without any treatment.

Common symptoms :

• Bladder pressure and pain that gets worse as your bladder fills up.
• Pain in your lower tummy, lower back, pelvis, or urethra (the tube that carries urine from the bladder out of your body)
• Pain in the vulva, vagina, or the area behind the vagina.
• The need to pee often (more than the normal 7-8 times daily)
• The feeling you need to pee right now, even right after you go
• Pain during sex.

The bladder pain, a woman feels with IC can range from a dull ache to piercing pain. Peeing may feel like just a little sting, or it can feel like serious burning.

All people with it have an inflamed bladder. About 5% to 10% of people get ulcers in their bladder(Hunner's ulcers). The symptoms can be worsened by :

• Some foods and drinks
• mental and physical stress
• period.

3. Who can get IC ?

IC/BPS affects men and women of all cultures, socioeconomic backgrounds, and ages. Somewhere between 3% to 6% of adult women have some form of IC and as many as 90% of people with IC are women. Although, the risk of getting it goes up with age, these days, growing numbers of men and women are being diagnosed in their twenties and younger.

4. What causes IC ?

It’s not clear why it happens, but there are several ideas :

• A problem with bladder tissue(damaged GAG layer) lets toxic things in the urine irritate your bladder.
• Inflammation causes your body to release chemicals that cause symptoms.
• Some toxic substance in the urine damages the bladder.
• A nerve problem makes your bladder feel pain from things that usually don’t hurt.
• Your immune system attacks the bladder.
• Another condition that causes inflammation is also targeting the bladder.
• Other suggested etiological causes are neurologic, allergic, genetic, and stress-(psychological). In addition, recent research shows that those with IC may have a substance in the urine that inhibits the growth of cells in the bladder epithelium.

5. How is it diagnosed?

There’s no test for interstitial cystitis. A diagnosis of IC/BPS is one of exclusion, as well as a review of clinical symptoms.

If you go to your doctor complaining about bladder pain along with frequency and the urgency to urinate, the next step is to rule out what else it could be. We first need to rule out urinary tract infections, bladder cancer, sexually transmitted diseases, kidney stones and endometriosis.

The following tests can rule out other conditions :

• Urinalysis and urine culture. You’ll be asked to pee in a sterile container. It’ll be sent to a lab to check for infection.
• Postvoid residual urine volume. Using an ultrasound, this test measures the amount of pee that remains in your bladder after you go to the bathroom. Another way to measure the post void residue is for your doctor to pass a catheter into your bladder after you have emptied your bladder.
• Cystoscopy. A thin tube with a camera is used to see the inside of the bladder and urethra. This is usually done only if there is blood in the urine or if treatment doesn’t help.
• Bladder and urethra biopsy. A small piece of tissue is taken under cystoscopic guidance and tested.
• Bladder stretching. Your bladder is filled with liquid or gas under low pressure, to stretch it out. You’ll be under anesthesia. Sometimes this is also used as a treatment. This is done with a cystoscopy.

6. How to treat this ?

For about half the cases, interstitial cystitis goes away by itself. Among those who need treatment, most find relief and get their lives back to normal.

Treatment is mainly about symptom control. It usually takes weeks or months to calm the symptoms.

(1) First-line treatments — Lifestyle modifications that help reduce the symptoms like :-

• Retrain the bladder to hold more urine/ a little longer.
• Reduce the stress; Try any of the relaxation techniques.
• Education to avoid dietary triggers like spices, caffeine, alcohol and citrus..
• Wear loose clothing
• Do low impact exercises (walk,stretch)
• Self care (diet modification).
• Quit smoking.

(2) Second-line treatments:—

• physical therapy: To help retlax your pelvic muscles.
• oral medications (amitryptiline, cimetidine or hydroxyzine, pentosan polysulfate),

(3) Third-line treatments — This requires a Cystoscopy.

• Treatment of Hunner's ulcers (laser, fulguration or triamcinolone injection),
• Hydrodistention (low pressure, short duration)
• Bladder instillations (DMSO, heparin, or lidocaine).

(4) Fourth-line treatments:—

Neuromodulation : (sacral or pudendal nerve): The doctor implants a device that delivers small electrical shocks to your nerves to change how they work.

(5) Fifth-line treatments:—

• Cyclosporine A: This drug supresses your immune system.
• Botulinum toxin (BTX-A): This temporarily paralyzes the bladder muscle to help relieve some of the pain.

(6) Sixth-line treatments :—

surgical intervention : In very rare cases when nothing else works, this may be an option. This is a complex operation that diverts urine away from the bladder.

Even if IC treatments don’t work for you, pain management using painkillers, acupuncture, or other methods can keep symptoms at bay. Here is where we can take the help of 'Pain management specialists'.

These are not uncommon in women. However women use all kinds of traditional remedies .They are unaware of the lifestyle and dietary changes and the newer advances that have been made in the treatment.

The following are the types of defaecatory dysfunctions :-

(1) CONSTIPATION: Constipation could be due to various reasons:

Slow transit in the intestine Stricture in the rectum Fissure in the anus Dehydration Medications(Sedatives) Low fiber diet.

How is it treated?

The treatment depends largely on the type. So;

• the first step is to find out the cause of constipation.
• Drink adequate amounts of water.
• Increase dietary fiber
• Increase physical activity.
• Medications as per your doctor's discretion.

(2) Fecal Incontinence

This is a very distressing problem in many women. It is the inability to hold your bowel movement. It could be loss of gas, liquid stools or solid stools.

What are the causes?

• Obstetrical anal sphincter injury
• Neurological conditions
• Congenital

How do we diagnose it?

• History and physical examination.
• Endoanal ultrasound
• MRI, if needed.

How do we treat?

• Lifestyle modification: diet and exercise.
• Surgical intervention
• Sacral neuromodulation.

(3) FISTULAE (GENITAL)

A fistula is an abnormal communication/tract between two different channels. They could be between:

• the vagina and rectum (Rectovaginal fistula)
• the vagina and bladder (Vesico vaginal fistula)
• the vagina and ureter (Uretero vaginal fistula)

They happen because of:

• obstetric injuries (prolonged or obstructed labor)
• injury during pelvic surgery
• infections
• inflammatory bowel disease
• cancer in the genital region
• after radiation therapy.

How to diagnose:-

• history and physical examination
• vaginal speculum examination
• proctoscopy
• tampon staining check
• occasionally contrast studies
• CT scan
• MRI scan (Not all of them are required for everyone).
• Surgery is the mainstay of treatment.
• This can be done under regional anesthesia either through the vagina, rectum or the perineum. Also the perineum is appropriately recontructed.

Urodynamic testing is a procedure that looks at how well the bladder( the bag that stores urine) is working and it also reproduces your symptoms and confirms the diagnosis. For example, you may think that you are leaking when you cough or strain, but the real reason could be an inappropriate contraction of the bladder. This way you would have avoided an unnecessary surgery for SUI.

When do I need urodynamics?

Many a time, the puzzle isn't solved.

You may be having symptoms of losing urine on coughing as well as urgency and frequency. UDS will help determine which problem is greater.

The testing is also done when

• Your doctor suspects more than one cause for the incontinence
• Feel frequent and/or urgent need to urinate
• Weak or intermittent (stopping and starting) urine flow
• Have frequent urinary tract infections
• You feel you are not able to empty the bladder completely
• You are considering having surgery.
• The ultimate goal of urodynamics is to aid in the correct diagnosis of lower urinary tract dysfunction based upon its pathophysiology.

Procedure

Some urodynamic tests are relatively simple and can be done in a doctor's office. Other tests require expensive and sophisticated instruments to measure the amount of pressure experienced by thebladder and urethra.

You should come for the test with a full bladder (if possible). You will be asked to urinate into a special commode chair or funnel. This test, called uroflow will measure the volume of urine that comes out, the rate and the pattern of the urine flow.

Next, a catheter (a small soft tube) will be placed into your bladder to drain out all the leftover urine (Post void residue).

Through a catheter, your bladder will be filled and the pressure inside your bladder and the response of the bladder muscle as it is being filled will be measured. At the same time, an estimate of the pressures outside the bladder( intra abdominal pressure) will be measured by inserting another small soft tube, or catheter, into the rectum or the vagina. The measurement of these pressures during filling is called a Cystometrogram (CMG) or Pressure flow study.

As the bladder fills, the different pressure measurements will be recorded and you will be asked questions about the way your bladder feels as it is filling, such as the first urge to urinate, the volume till the point of ubcontrollable urge or involuntary urination.

Your bladder will be filled with either a sterile water type fluid or a fluid that can be seen on x-ray. Filling your bladder should not hurt. You may also be asked to cough and push or bear down to check for any leakage.

Provocative tests

The functioning of the bladder is also assessed in situations like:

• Hearing to running water
• Immersion of hands in cold water
• Application of cold water pack to the forehead.

More sophisticated testing uses electrodes placed in the rectum to measure the electrical activity of the muscles while the bladder fills. This test is not commonly done.

Results

Normal: The amount of fluid left in the bladder after urinating, when you feel the urge to urinate, and when you can no longer hold back urine are within normal ranges.

Abnormal: One or more of the following may be found:

More than a normal amount of fluid remains in the bladder after urinating. A large volume of urine remaining in the bladder suggests the flow of urine out of the bladder is partially blocked or the bladder muscle is not contracting properly to force all the urine out (overflow incontinence).

The bladder contains less fluid or more fluid than is considered normal when the first urge to urinate is felt.

You are unable to retain urine when the bladder contains less than the normal amount of fluid for most people.

Before and/or after your test you may receive an antibiotic as a precaution to prevent infection.

In closing: After your urodynamics are completed, your doctor will review all the information and discuss the results with you. Then you and your doctor will decide on the best plan of treatment for you.

• Urinary tract infections
• Blood in the urine (hematuria)
• Loss of bladder control (incontinence) or overactive bladder.
• Unusual cells found in urine sample
• Need for a bladder catheter
• Painful urination, chronic pelvic pain, or interstitial cystitis
• Urinary blockage such as from stricture, or narrowing of the urinary tract
• Stone in the urinary tract
• Suspected Unusual growth, polyp, tumor, or cancer.
• Recurrent urinary tract infections.

Complications after cystourethroscopy are few. These generally involve minor pain related to the procedure and the small risk of postoperative urinary tract infection. These risks usually are negligible with use of local anesthesia and single-dose prophylactic antibiotics

A Pelvic Muscle Rehabilitation program incorporates a variety of treatment techniques for Urinary or Fecal Incontinence .

These include:-

• Behaviour modification: an education on diet, fluid intake, and other lifestyle changes to enhance pelvic organ function.
• Bladder/Bowel Training—learning to empty the bladder or bowel by the clock, rather than by desire.
• Pelvic Muscle Exercises—exercises designed to strengthen the pelvic floor muscles
• Electromyography (EMG) and Rectal Pressure therapy—an instrument that utilizes an intracavity vaginal or rectal sensor to train the patient to voluntarily contract or relax the pelvic floor muscles correctly as well as document strength gains from treatment session to session.
• Electrical Stimulation therapy—an instrument that utilizes an intracavity vaginal or rectal sensor to passively contract the pelvic floor muscles or calm an overactive bladder by delivering a weak, painless electrical current.
• Electromyography(EMG)_Electromyography (EMG) is a method of assessing and treating pelvic muscle dysfunction.

Pelvic muscle rehabilitation may assist muscles that have increased tension even when the patient or clinician cannot detect it. This is particularly true of pelvic floor muscles as denervation damage may lead to impaired sensation. High levels of resting activity and muscle spasms may only be visualized using EMG.

Muscle training that utilizes EMG may improve the effectiveness of muscle relaxation efforts while strengthening weak pelvic muscles and reducing pain. This involves placement of a sensor in the vagina or rectum or external patch electrodes around the perineum.

Additionally, a targeted frequency of electrical stimulation can be used to calm an overactive bladder.

For most pelvic muscle dysfunctions, electrical stimulation does not need to be used long term.

Results have shown that once the patient can perform an effective voluntary muscle contraction with moderate strength, transitioning to an unassisted pelvic floor strengthening program is sufficient for maintaining muscle strength.

Incontinence: There are several medications available for Overactive bladder and including nocturia. A detailed knowledge of the side effects profile is necessary and which a subspeciality training gives in choosing medicines depending upon the age.

Management of fecal incontinence and constipation with medications is a balancing act. Familiarity with the medications available and when to use them are things that the urogynecologist knows.

Psychiatric and neurological consultations and medications may be necessary in Bladder pain syndromes.

• Sling procedure: Here the tube that carries the urine (urethra) is supported by inserting a thin ribbon of delicate synthetic mesh into which the tissue grows in . It will be a permanent part of the body. The surgery is performed through the vagina and does not require a cut on the belly.
• Paraurethral injection of synthetic material at the bladder neck to control loss of urine while coughing and sneezing. It is the preferred method in old women and in those in whom anesthesia could be dangerous.
• Posterior Tibial nerve stimulation: Usually done for Overactive bladder. An acupuncture needle is inserted into the tibial nerve on the leg and is stimulated for 30 minutes. This is indirectly supposed to positively influence the nerves going to the bladder. This treatment is done for a minimum of 6weeks.
• Bladder Instillation: Bladder instillation with certain medications for control of bladder pain syndromes (BPS) .
• Botox injections into the bladder - to control overactive bladder. This requires cystoscopy and is done in the operation theater under anesthesia.
• Excision/Fulguration of Hunner's ulcers or injection of Steroid during cystoscopy.
• Cannulation of the ureter in diagnosis of ureteral injury.
• Insertion of pessary: A silicon device shaped like a dish that goes into the vagina to keep the organs from coming out in women who are not candidates for surgery, retain their fertility or just do not want surgery. This is usually performed in the office and instructions are given to the patient as to the cleaning and reusage of the pessary.
• Sacral Neuromodulation: This is when a pacemaker is inserted into the lower part of the body in the buttock area to control the symptoms of OAB, Fecal incontinence as well as Interstitial cystitis(BPS).

Major Surgical Procedures