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Women's & Pelvic Health

Pelvic Prolapse

Pelvic Prolapse

When an organ becomes displaced, or slips down in the body, it is know as prolapse. Pelvic prolapse, a type of pelvic floor disorder, affects about one-third of all women over their lifetime. Women may sometimes refer to pelvic prolapse as their “dropped bladder” or “fallen uterus.”

The pelvic floor is a group of muscles that form a kind of hammock across your pelvic opening. Normally, these muscles and the tissues surrounding the pelvic organs keep them in place. The pelvic organs include your bladder, uterus, vagina, small bowel and rectum. However, in the case of pelvic prolapse, the muscles weaken or become stretched, causing the organs to “droop” and descend outside the vaginal canal or anus. This may be due to childbirth, but most cases occur in older women.

Education/General Information

Pelvic prolapse may be referred to in these ways:

  • Cystocele: A prolapse of the bladder into the vagina, which is the most common condition
  • Urethrocele: A prolapse of the urethra, the tube that carries urine out of the body
  • Uterine prolapse
  • Vaginal vault prolapse: Prolapse of the vagina
  • Enterocele: Small bowel prolapse
  • Rectocele: Rectum prolapse

The causes of pelvic prolapse are varied. Anything that puts increased pressure on the abdomen can lead to prolapse, such as:

  • Pregnancy, labor and childbirth (the most common causes)
  • Obesity
  • Respiratory problems with a chronic, long-term cough
  • Constipation
  • Pelvic organ cancers
  • Surgical removal of the uterus (hysterectomy)
  • Genetics

The symptoms of pelvic prolapse vary depending on which organ is drooping. These might include:

  • A feeling of pressure, discomfort or fullness in the pelvic or vaginal area that may be worsened by physical activities
  • A backache low in the back
  • Painful intercourse
  • A feeling that something is falling out of the vagina
  • Urinary problems such as leaking of urine or a chronic urge to urinate
  • Constipation or loss of bowel control
  • Spotting or bleeding from the vagina

Diagnosis

Pelvic prolapse is most often discovered during a routine pelvic exam or Pap smear. A variety of tests may be performed to confirm pelvic prolapse, including:

  • Diagnostic tests, such as urinalysis and urodynamic study to evaluate the cause of urinary incontinence
  • Urinary tract X-ray (intravenous pyelography)
  • Computed tomography (CT or CAT) scan of the pelvis
  • Ultrasound of the pelvis
  • Magnetic resonance imaging (MRI) scan of the pelvis

Treatment

Treatment of pelvic prolapse varies depending on the type and severity of the prolapse, and may include:

  • Changes to your diet and fitness routine, such as Kegel exercises that strengthen the pelvic floor muscles
  • Insertion of a pessary, a rubber or plastic device designed to relieve symptoms and provide support
  • Surgical procedures to either repair the affected area or organ or to remove the fallen organ, such as a hysterectomy

Incontinence

Incontinence

Urinary incontinence, or uncontrolled urine loss, is more common than most people think. In fact, more than 17 million Americans have urinary incontinence, with more than 80 percent of incontinence cases occurring in women. But, urinary incontinence is not a normal process of aging and can occur in women and men of all ages.

Under normal conditions, the bladder stores urine until it is voluntarily released. This involves a complex interaction between the brain, spinal cord and bladder. Anything that interferes with this interaction can make a person incontinent.

Incontinence is not life-threatening, but it does have negative social implications. You may lose your self-esteem and experience depression, anxiety and feelings of helplessness. Your fear of urine loss may become an obsession. You may lose your sense of sexuality. You may distance yourself from friends and loved ones or limit social interaction outside the home. The good news is that incontinence can typically be corrected or improved to the point that it no longer interferes with daily activities.

Education/General Information

Anything that interferes with the normal processes of the urinary system can cause incontinence. Factors contributing to incontinence include medical conditions such as urinary tract infections, diabetes, arthritis, Parkinson’s disease and Alzheimer’s; surgical problems such as birthing procedures, pelvic surgery, hysterectomy and multiple abdominal surgeries; medications such as cold and hay-fever medications, certain high blood pressure medications, pain medications, muscle relaxants and medications for depression and/or anxiety; certain exercises such as high-impact aerobics; or any injury to the nerves that control the bladder or activity that weakens the pelvic floor.

There are five different types of urinary incontinence. The most common types are stress, urge and mixed incontinence.

  • Stress incontinence is urine leakage caused by coughing, sneezing, exercising, lifting or strenuous activity. Stress incontinence can result from childbirth or certain surgeries and exercises that weaken the pelvic floor.
  • Urge incontinence occurs when people experience sudden, overwhelming urges to urinate and often feel that they cannot wait to reach the bathroom. Urge incontinence can be the result of urinary tract infections, diabetes, Parkinson’s disease, Alzheimer’s disease, lack of estrogen, prior bladder surgery, medication or injury to the nerves that control the bladder. Urge incontinence also can develop without any apparent cause.
  • Mixed incontinence is a combination of both stress and urge. The cause of both forms may or may not be related.

Less common forms of incontinence are functional and overflow incontinence.

  • Functional incontinence occurs in people who are unable or unwilling to use a toilet. Severe illness, arthritis and confusion can all lead to functional incontinence.
  • Overflow incontinence is when the bladder is never empty after urination, even though it may feel as if it is. Because the bladder does not completely empty, excess urine can spill out. Certain diseases, surgical procedures and medications that lead to other types of incontinence can also lead to overflow.

Diagnosis

To correctly diagnose your incontinence, pay attention to the activities, situations and conditions that cause difficulty controlling your bladder. This will help your doctor determine the type of incontinence you suffer from. You should also keep a “voiding diary” to keep track of fluid intake and bladder activity and share it with your physician to improve diagnosis and treatment.

Some or all of the following tests may be recommended to ensure accurate diagnosis:

  • Urinalysis
  • Residual urine measurement
  • Cytoscopy
  • Stress test
  • Urodynamic testing

Treatment

Incontinence is not a life-threatening problem, but it can be a social problem. Thankfully, incontinence can be treated and, in most cases, corrected or improved so that it is no longer a health and social problem. Incontinence can be treated in one of three ways:

  • Numerous medications have been developed in the past 10 years to treat incontinence, and these developments have significantly improved the treatment process. Many of these medications can decrease and even eliminate the uncontrolled loss of urine in patients. Medications used to treat overactive bladder work by relaxing the bladder muscle and making it less sensitive. These medications include Detrol, Ditropan, Urispas, Levsin, Bentyl and Tofranil. The most common medicine prescribed for stress incontinence is estrogen, which is most effective in postmenopausal women. Medications for other types of incontinence include Flomax, Hytrin and even Botox.
  • Biofeedback, or special exercises and training programs, can be helpful and effective in treating incontinence and improving bladder control. Certain exercises, known as Kegel exercises, strengthen the sphincter and pelvic floor. These exercises must be done correctly and consistently in order to be effective. Gradually prolonging the time between visits to the toilet, known as bladder retraining, can also be effective when coupled with reasonable fluid intake. Eliminating foods and liquids such as caffeine, alcohol and spicy foods, which can irritate the bladder muscle, may decrease symptoms.
  • Surgery is an option for patients who have not been helped by biofeedback and/or medication or who are not candidates for those treatments. Surgery can be approached in one of three ways: through the lower abdomen, through the vagina or by injecting a liquid “bulking agent” around the urethra.
    • Surgery through an incision in the lower abdomen is effective for correcting stress incontinence. However, the recovery time can be quite long, requiring six to eight weeks of limited activity following the procedure. In the past 10 years, this procedure has been performed more and more using a laparoscope, which lessens the recovery time.
    • Surgery through the vagina, or “sling surgery,” is performed by making a vaginal incision and placing a strip of tissue, or “sling,” either above or beside the urethra. The sling provides support for the urethra and sphincter muscles and adds compression to the urethra. Sling surgery can be performed on an outpatient basis with less recovery time. It is currently the most frequently performed surgery for stress incontinence. Surgery through the abdomen and through the vagina have excellent results, with 85 percent of patients being dry after five to 10 years.
    • Surgery using “bulking agents” does not require an incision. A thick liquid compound is injected around the urethra to compress and close the urethral channel. The advantage of this procedure is that there is only a 24-hour period of limited activity required following the surgery. However, the disadvantage is that the effects generally last for only one month to one year.
    • Another surgical procedure called sacral nerve stimulation with InterStim is also an option for incontinence patients. This is a minimally invasive procedure in which a neurostimulator is implanted over the hip and used to reprogram the nerves that control the bladder. This procedure has been shown to correct or significantly improve urge incontinence in 70 percent to 80 percent of patients who have failed other treatments. 

Overactive Bladder

overactive bladder

Overactive bladder is a type of bladder-control problem that affects more than 33 million Americans of all ages. It occurs when the detrusor muscle of the bladder contracts more often than necessary, even when the bladder is not full. This constant contraction causes sudden, overwhelming urges to urinate.

Though overactive bladder is a common medical condition, many patients may feel ashamed or embarrassed to discuss it. However, it is important to communicate with your doctor about your overactive bladder so it can be properly treated. It is not a normal part of aging. Overactive bladder can be treated with medication, behavior modification and changes in diet. In rare cases in which these treatments do not work or cannot be used, another treatment called sacral nerve stimulation with Interstim is available.

Educational/General Information

The common symptoms of overactive bladder are frequency (the need to urinate often), urgency (the sudden, uncontrollable need to urinate), nocturia (the need to urinate often at night) and urge incontinence, or wetting accidents. You may feel as if you can’t wait to reach a toilet and you may lose urine on the way. At times, you may leak urine without any warning at all. Patients with overactive bladder feel the need to urinate extremely often. They often have sudden, uncontrollable needs to urinate, even at night.

A bladder can become overactive because of infection that irritates the bladder lining. The nerves that normally control the bladder can also be responsible for an overactive bladder. Other causes can include drug side effects, neurological disease or stroke. Overactive bladder may also be associated with bladder cancer, urinary tract infections and enlarged prostate. In other cases, the cause may be unclear. Risk factors include aging, obstruction of urine flow, inconsistent emptying of the bladder and a diet high in bladder irritants, such as coffee, tea, cola, chocolate and acidic fruit juices.

Diagnosis

To get a diagnosis of overactive bladder, your doctor starts with a complete health history to learn about other urinary conditions you’ve had in the past and when the problem started. Questions your doctor may ask about your overactive bladder include:

  • How often do you urinate?
  • How often do you leak urine, and how severely?
  • Do you feel any pain or discomfort while urinating?
  • For how long has the urge or urinary incontinence been occurring?
  • What medications are you taking?
  • Have you had any recent surgery or illnesses?

Keeping a voiding diary at home can help you answer these questions and help with an overactive bladder diagnosis. Each day, write down how much you drink, when you urinate, how much you urinate each time, and whether you ever feel an urgent need to go.

Your doctor will then examine your abdomen, pelvis, genitals and rectum. You might also be given a neurological exam to look for problems in your nervous system that could affect your ability to urinate.

There are also a number of tests that may be performed to diagnose overactive bladder, including:

  • Urinalysis or urine sample
  • Bladder stress test and/or Bonney test to find out if you are leaking urine
  • Cystoscopy to look for cysts and growths in the bladder
  • Urodynamic testing
  • Voiding cystourethrogram to identify structural problems in the bladder and urethra

These tests can help diagnose whether your condition has something to do with an infection or other illness, a blockage or poorly functioning bladder muscles. Knowing the cause of your overactive bladder can help your doctor decide on the right treatment for you.

Treatment

 There are many options for the treatment of overactive bladder:

  • Behavior modification consists of techniques that help strengthen and train pelvic muscles. Behavior modification techniques include bladder training, Kegel exercises and biofeedback. Bladder training, which can help control wetting accidents as well as frequency and urgency, consists of instruction about normal and abnormal urination and scheduling of urination. Kegel exercises can help reduce or cure leakage by strengthening the sphincter muscles and the muscles of the pelvic floor. Biofeedback therapy may be used to help ensure that the pelvic floor muscles are properly exercised. Biofeedback equipment is used to identify muscles that need to be exercised.
  • Medication is prescribed either in conjunction with behavior modification or after behavior modification has been tried unsuccessfully. The drugs most commonly prescribed by doctors to treat overactive bladder are Detrol-LA and Ditropan-XL. These drugs, also known as anticholinergic drugs or antispasmodics, prevent involuntary contractions of the bladder muscle by relaxing and stabilizing the muscle. Another medication called Tofranil, most often used for depression, can also help by calming the bladder.
  • Doctors often recommend that overactive bladder patients limit their intake of caffeine and alcohol, which can irritate the bladder.
  • Some people do not benefit from or cannot tolerate behavior modification or medications. For these people, sacral nerve stimulation with InterStim is an available treatment option. This is a procedure in which a neurostimulator device is inserted under the skin, near a nerve that affects bladder function, and sends electrical pulses to the sacral nerve. The sacral nerve affects bladder control muscles, and stimulation of this nerve can help improve overactive bladder. After the device is implanted, it can run for five to 10 years.
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