E-Stim - Pelvic Floor Therapy
/ Electronic Impulse Stimulation
Information for patients
who have been referred for electronic pelvic floor
therapy at
Swor Women’s
Care.
This new treatment program was modeled after urogynecology
protocols at the Mayo Clinic. We use computer planning
and electronic impulse stimulation to strengthen and
train the pelvic floor muscles. The treatments are non-surgical
and painless, and provided in our private clinic by our
expert professional staff.
Following your first one hour orientation visit, subsequent
sessions typically last about 45 minutes. Typical pelvic
floor rehabilitation plans require between 5 and 10 visits,
usually on a weekly schedule. It is important to maintain
regular continuity to your visits, as gaps in therapy
will delay your response. An office visit is recommended
with your practitioner after the 5th session to assess
progress.
E-stim and biofeedback for the pelvic floor muscles
is a safe, non-invasive, and effective means to treat
bladder control problems, chronic pelvic pain and other
pelvic floor disorders, including Interstitial Cystitis,
Vulvadynia (Vulvar Vestibulitis), Levator Ani Syndrome
and Vaginissmus (vaginal muscle spasm). It has also been
successfully used in the treatment of irritative voiding
symptoms: urinary frequency, urgency, dysuria, urge incontinence
as well as genuine stress urinary incontinence (SUI).
Biofeedback therapy has been recommended as a first line
treatment for these urinary conditions by The Agency
for Health Care Policy and Research (AHCPR), of the U.S.
Department of Health and Human Services. Many patients
can avoid the need for drug therapy and surgery with
successful outcomes from E-stim.
Biofeedback uses computer-generated
signals to “train” patients
to improve their body function and strength. Biofeedback
techniques are often used in connection with special
pelvic floor exercises to teach Estim patients to strengthen
the muscles of their pelvic floor. In women who suffer
urinary leakage from stress incontinence, this muscle
strengthening improves the support of the bladder, minimizing
leakage from cough, sneeze, exercise, etc. Biofeedback-based
continence training has also proven effective in the
treatment of urge incontinence (inability to reach the
toilet in time) as well as overflow incontinence (related
to incomplete emptying of the bladder).
Biofeedback can also
be used to learn to relax the pelvic floor muscles
in certain cases
of pelvic floor dysfunction
and spasm. Similar to "muscle-contraction" headaches,
excess tension in the pelvic floor muscles can result
in painful intercourse, frequent urination, difficulty
initiating and completing urination, and constant pelvic,
rectal or vaginal pain. Biofeedback is used in this setting
to “train” patients to find, relax, and ultimately
control these spastic muscle groups through specialized
exercises taught during the biofeedback session and then
regularly practiced at home.
In a biofeedback session, an electronic EMG sensor,
about the size of a tampon is placed by the patient into
her vagina. A smaller probe is placed in the anal canal.
The sensors measure muscle activity and connect to the
biofeedback computerized monitoring device, which produces
a measurement and graph of the muscle activity.
Once the patient has learned to recognize and properly
exercise the correct muscle groups, the biofeedback monitor
is no longer necessary. The patient is instructed to
continue the exercise therapy at home on a daily basis.
^Top^
Detecting Cancer of the Cervix- New technology
- 9-4-03
Michael Swor MD
New technology is now available to women in the fight
against cancer. Regular Pap smears have appropriately
become an important part of preventive health care, and
have helped to dramatically reduce the number of American
women diagnosed with invasive cancer of the cervix. In
the rest of the world, cervical cancer is the second
most common cause of cancer death.
Now a new test can be requested in
some clinics, that improves the ability of detecting
precancerous lesions
on the cervix. PapSure® is the only in-office, direct
visual screening test cleared by the U.S. Food and Drug
Administration for all women having a pelvic exam and
standard Pap smear. PapSure® combines the results
of a traditional Pap smear and speculoscopy (a magnified
view of the cervix) using a special light for vaginal
illumination, which helps trained clinicians to visually
identify abnormalities that have the potential to become
cancerous.
Cervical cancer is a serious disease, but unlike breast
cancer, is almost 100 percent preventable with accurate
screening and early detection of dysplasia, a common
condition that, left untreated, can lead to cancer. Risk
factors for developing cervical cancer include poor health
screening, smoking, and unprotected sexual activity.
Certain sexually transmitted diseases dramatically increase
the risks, namely specific strains of HPV (human papilloma
virus).
There are typically no symptoms of precancerous
change in the cervix. Women who undergo regular checkups
and
Pap smears will usually have any abnormality detected
at a precancerous early stage. If checkups are infrequent,
or the Pap smear is not done, improperly obtained or
misread, the early stage problems could be missed, and
the abnormality might progress to cervical cancer. If
that is the case, then a fully curable issue becomes
a potentially life-threatening one.
Some clinical studies
show that traditional Pap smears can have a high false
negative rate. This means that
Pap samples that actually have cervical cancer cells
present may be reported as negative. There are a number
of reasons why a traditional Pap smear may appear normal
even though abnormal cells exist on the cervix. Errors
in detecting cervical abnormalities may occur due to
lesions that don’t “shed” cells from
the surface of the cervix, inadequate cell sampling,
omissions or mistakes in transferring cells to a slide,
and human error in reading the Pap smear slide provided
to the lab. Attention was first focused on the potential for misreading
the Pap smear itself, with instances of incorrectly read
slides making newspaper headlines across the United States.
Accordingly, the first efforts at improving
screening were directed at improving the quality of Pap
smear slide
reading. With an expert gyn examination and experienced
Pap smear collection technique, combined with quality
lab cytology services, the likelihood of missing an abnormality
is relatively small. Any improvement in the process would
be helpful, however.
The Clinical Laboratory Improvement
Act (CLIA) mandated that a limit be placed on the number
of Pap smear slides that an individual technician can
read daily,
and further mandated that a minimum of 10% of the slides must be over-read.
Simultaneously, a number of companies began developing new Pap smear slide
preparation techniques. These liquid-based tests (Autocyte and ThinPrep) are
now available and are also proven to increase the successful early detection
of cervical cancer.
At the same time these lab-based technologies
were being introduced, another type of technology was
being investigated.
This even newer type of test was
an answer to research data showing that some women with cervical pre-cancer,
and even some with cancer, might not "shed" the abnormal cells. If
this is the case, then even when the liquid-based Pap smears are done, and
done correctly, an abnormal lesion on the cervix might not be detected. Rather
than depend on the collection of cells, this new PapSure® test, assesses
the cervix directly, with a closer magnified look, and could truly add to the
accuracy of the Pap smear. Instead of a better Pap, speculoscopy is an extra
test done in addition to the Pap. When combined with the routine Pap smear,
it is known as PapSure®.
While the Pap smear provides a sample
of surface cells, the visual portion of a PapSure® exam
may reveal cervical abnormalities that the Pap smear
alone may not
detect.
Research studies have shown that PapSure® more
than doubles the detection rate of cervical abnormalities
as compared to the Pap smear alone.
This testing is simple
and generally painless. Although is takes a few minutes
longer, there is no additional
discomfort associated with the visual portion of the
PapSure® exam.
PapSure® is indicated in all women
undergoing a pelvic exam and Pap smear. Current guidelines
recommend that
women who are or have been sexually active, or have reached
age 18, should have Pap tests and pelvic exams regularly.
There is no known age at which Pap tests cease to be
effective. Women should discuss how often to have the
gyn pelvic exams and Paps with their physician. Since the test is relatively new,
not all gyn practitioners are trained and offer PapSure®.
Another consideration is that insurance companies may
not pay for this extra
test. The good news is that for what it offers in improved
care, the cost is relatively low (approximately $50).
And, of course, if extra non-invasive testing can reduce
cancer risks, then cost-benefit is measured in lives
saved.
As far as waiting time, the two part
PapSure® gives
immediate results on the visual portion of the exam,
and the same 1-3 weeks results on the typical lab portion
of the exam.
Although PapSure® detects a higher
percentage of abnormalities in the cervix than Pap smear
alone,
not
all of the abnormalities detected by PapSure® are
cancerous cells. If either the visual part OR the lab
part is abnormal, then additional cancer screening tests
will be advised.
If the PapSure® test is abnormal,
then the options that may be discussed include the following: Watch and wait: Many times the most
medically sound decision is to wait carefully and boost
the body’s
own ability to self-correct minor problems. It is not
uncommon to recheck testing in a 2-6 month interval,
if the abnormality seems minor to the trained clinician.
Colposcopy exam: This is a more detailed visual exam
where the physician will examine the cervix using high-power
magnification, light sources and applied liquid solutions.
If anything looks suspicious, a small sample of the tissue
may be biopsied for laboratory testing.
The most significant benefit of PapSure® is confidence.
With PapSure®, patients can be confident that if
any cervical abnormalities exist, even early disease,
an experienced healthcare provider may be able to see
it, even if the Pap smear does not detect
^Top^
Deciding on gyn surgery - 8-30-03
Millions of American women suffer
needlessly from pelvic pain, bleeding problems and
other gynecologic problems.
Medical breakthroughs provide many options for treatment
depending on the cause and extent of the problem and
the individual situation of the patient. Unfortunately
there is a continuous stream of misinformation that creates
controversy and confusion. The internet provides a fantastic
resource of excellent reference information, but users
have to weed through an obstacle course of self-serving,
inaccurate or purposely one-sided “expert” opinion
on any particular issue. There is no better example of
this than in the topic of women’s health. A recent
segment on ABC’s 20-20 program about hysterectomy
accomplished its purpose in getting a reaction from viewers,
but couldn’t have been more slanted. Still, it’s
an important subject that needs thoughtful discussion,
especially if it is a serious medical treatment option
and you are the one considering it.
Hysterectomy is the
surgical removal of the uterus. This is the organ with
the primary function
of receiving
the fertilized egg from an ovary and carrying the developing
fetus to birth. If it’s not doing that, the uterus
is preparing monthly to do the same task. In some women,
significant problems such as pain, excessive bleeding,
or cancer risks bring up the option of hysterectomy.
In most cases there are many options or variations to
consider. These might include removal of one or both
ovaries, vaginal repair work, bladder repair, or other
procedures accomplished at the same time for specific
purposes. Almost all hysterectomies can now be done through
small incisions or a vaginal technique, avoiding large
incisions, higher risks and extended recovery. In many
cases, there are better and less invasive surgical options
where hysterectomy can be avoided or postponed. These
include laparoscopic surgery, laser, endometrial ablation,
myomectomy, hysteroscopy and even removal of a part of
the uterus…the supracervical alternative to hysterectomy.
Of course, for most conditions, there are many considerations
that are non-surgical. Non-traditional medical techniques
may also be advised.
One of the biggest breakthroughs
in recent years is the refinement of the LASH (laparoscopic
supracervical
hysterectomy), which involves removing only a portion
of the uterus with no vaginal incision and only small
incisions in the navel and lower abdomen. The biggest
benefit of this minimally-invasive approach is the fast
recovery and less “down time”. The additional
suggested advantages, although not yet proven, are the
possibility of even less chance for any negative sexual
effects or future bladder/ pelvic support problems. If
Gyn surgery is recommended, and future child-bearing
is not desired, this technique should at least be considered.
Most patients undergoing a LASH procedure are 80% back
to normal after just one week. These patients don’t
have periods anymore, but have an undisturbed vagina
and cervix. If the ovaries are left in place, then hormonal
function should be the same as well.
There continues to be controversy
regarding sexual function and gyn surgery. Most research,
practical experience
and common sense suggest that with current techniques
and well-informed patients, the potential for negative
effects is very unlikely. Actually many procedures are
done with the goal of improving pelvic pain and/or sexual
function. If pain, extreme menstrual periods, fear of
unwanted pregnancy or pelvic support problems contribute
to sexual problems, then an improved sex life is anticipated.
Exceptional situations, such as major cancer surgery,
radical life-saving procedures and sudden surgical menopause
from the removal of both ovaries in younger, premenopausal
women might be expected to impact sexuality in a negative
way. Unfortunately, these much less common scenarios
are the ones that receive most of the attention when
the “negatives” of gyn surgery are debated.
In some of these cases, or any individual situation where
sexual issues result or develop, a full effort at correcting
problems is warranted. What is known about female sexuality
suggests that contributing factors are complex, and much
of the human sexual response is perception. The brain
is the most important sex organ as evidenced by the “non-pelvic” causes
of the majority of sexual problems, the existence of “wet
dreams” and surprisingly satisfactory function
seen in many people with spinal cord injuries, major
pelvic trauma or sensory-motor loss from disease.
The
bottom line is this…when
significant gynecologic problems warrant corrective
action, find a reputable
specialist that is trained, certified, highly-experienced
and fosters a sense of trust. Review all available options,
including surgical and non-surgical methods. Allow for
a thorough workup and evaluation. Consider a second or
even third opinion. If possible, try the simplest and
least invasive approach first. In the care of a qualified,
board-certified gynecologist, one can anticipate successful
outcomes in the vast majority of cases. As with any important
decision, your own knowledge and confidence helps tremendously
in making the right choice. Michael Swor MD
Assistant Clinical Professor
Department
of OBGYN
University of South Florida College of Medicine
^Top^
New Ideas in Pelvic Pain and Bladder Problems
- 9-04-03
Michael Swor MD
One of the problems of current specialized medical care
for women involves the separation of bladder and gynecologic
conditions. Women with frequent urination, urgency and
recurrent bladder infections are often referred to Urologists.
When pelvic pain is the main complaint, it is usually
the Gynecologist that does the evaluation. Two common
disorders can cause symptoms that affect both bladder
function and the reproductive tract. One of these conditions
is endometriosis, and the testing and treatment for this
condition is well-understood. The other condition has
been poorly understood until recently, yet may affect
as many as 8 million American women. This condition is
known as Interstitial Cystitis (IC). Recent research
has opened a new chapter in the diagnosis and treatment
of IC.
Endometriosis
One of the most commonly diagnosed causes of pelvic
pain in women is endometriosis. In this chronic condition,
tissue that acts like the lining inside the uterus grows
outside the uterus and is responsible for painful periods,
painful intercourse, infertility and a number of other
symptoms. Endometriosis can occur early in the female
life cycle and can be suggested by the pattern of symptoms.
Pelvic examination and ultrasound can reveal clues about
the presence of endometriosis, but the actual diagnosis
typically requires a procedure known as diagnostic laparoscopy.
The gynecologist uses a narrow telescope-like device
to carefully look inside the abdominal and pelvic body
cavities through an incision in the navel to actually
see the endometriosis implants. This procedure is done
under anesthesia and gives the specialist an opportunity
to treat the disease at the same time with surgical tools
including lasers. Special drug treatment is also available
and even birth control pills, Depoprovera and other therapy
is potentially helpful in the treatment. Some doctors
specialize in gynecologic problems such as endometriosis
and careful, aggressive management usually results in
successful outcomes and preservation of the uterus and
ovaries. Untreated, the condition gradually progresses,
and can result in disabling pain, scarring and occasionally
the need for more extensive surgery. Although many natural
remedies have been tried, none have proven to be of significant
benefit. Since pregnancy temporarily stalls the progression
of endometriosis, we see more women with this condition
in our current society than we did in the days of early
and frequent childbearing.
Interstitial Cystitis
IC used to be a rare
diagnosis, but a new understanding of the condition
has provided an
improved ability to
identify women (and men) who suffer from this progressive
and often disabling disease process. The typical IC patient
complains of bladder urgency, frequency and symptoms
of bladder infection (UTI or cystitis). Many patients
have some kind of pain associated. The pain of IC can
be in any location in the lower abdomen, pelvis, vagina
or external genital areas. The pain syndrome often flares
with cycles, and tends to gradually worsen over the course
of one’s life. Symptoms can also include vaginal
irritation, burning and painful intercourse.
IC develops when the natural mucus barrier protection
in the bladder lining starts to break down. This allows
the normal high levels of potassium in urine to diffuse
into the nerves and muscle fibers in the bladder wall
and surrounding tissues. The potassium damages the nerve
and muscle cells, causing pain and poor function. The
bladder begins to feel more urgency and decreased capacity.
Treatment is aimed at improving the mucus barrier and
decreasing the concentration of potassium. The nerve
and muscle tissues can then regain strength and function.
Since there is a relationship with
the body’s
allergic response, flare-ups can also occur during the
allergy seasons. Traditional testing such as cystoscopy
and even laparoscopy is not effective in finding the
problem. Researchers have discovered a new test that
is very accurate in determining when IC is present. The
test is offered to patients who have a high score on
a bladder symptom/ pelvic pain questionnaire that was
developed by experts on the condition. Because much of
what is known about IC is new information, the disorder
is frequently misdiagnosed as endometriosis, chronic
UTI/Cystitis, vulvodynia, chronic yeast infection and
a number of other diseases. Many other patients with
IC are left without any specific diagnosis or treatment.
Without proper care, the process worsens, and symptoms
increase. Later stages of the disorder are more difficult
to reverse and damage can become permanent. With a careful
evaluation, simple testing and brand-new treatment programs,
up to 80% of people that suffer from IC can get significant
improvement and lead normal lives.
^Top^
Ovarian Cancer: Identifying Risks
and Getting Special
Testing
Michael Swor MD
The risk of Ovarian Cancer for the average woman is
1.4% in the US. With certain genetic factors, the risk
increases to between 20 and 60%. This risk is unacceptable
and requires close watching at the least.....special
testing and even preventative surgery at the most. Certain
families have been identified as very high risk. These
families are originally from Iceland, Netherlands, Sweden
and Central or Eastern (Askenazi Jewish) European.
High Risk Questions:
Has anyone in your family had breast cancer under the
age of 35, or colorectal, uterine or ovarian cancer?
Do you meet the 3-2-1 Rule for needing
genetic testing advice?
Are there 3 family members
affected with either colorectal or ovarian cancer,
in 2 different
generations, with one under the age of
50 ???
There are 3 main genetic syndromes that increase the
risk of Ovarian Cancer and Colorectal Cancer. They are:
- the
breast-ovarian cancer syndrome
- site-specific
ovarian cancer syndrome
- HNPCC-
hereditary non-polyposis colorectal cancer syndrome
The first two are related to BRCA 1 and 2 gene mutations.
The third is a separate mutation and leads to a high
risk of right sided colon cancer and endometrial (uterine)
and ovarian cancer.
When assessing risk, only certain types of Ovarian Cancer
are included, and your doctor can help determine which
types.
We offer testing in patients with extra concerns or
risks for Ovarian Cancer. This includes pelvic exam,
CA 125 blood tests and Clinician-performed vaginal ultrasound,
which is done by the doctor in the office. New blood
testing will also be available soon, and might prove
even better than current methods being used.
While birth control pills have been shown to reduce
ovarian cancer risk, hormone replacement might increase
the risk slightly. The use of Talcum powder in the genital
area is also a risk factor, although cornstarch is safe.
Past use of fertility drugs was once considered a risk
factor, but now is not a reason for increased concern.
Recent information revealed by clinical study suggests
that certain patients should consider prophylactic (preventative)
surgery such as laparoscopic oophorectomy after child-bearing
is complete, especially near or at menopause. In this
procedure, the ovaries and tubes are removed through
small incisions using scopes and lasers in an outpatient
setting. This procedure reduces the risk of ovarian cancer
by 90% and breast cancer by 50% in patients with certain
high risk factors.
For more information:
1. see the National Cancer Institute
website at www.nci.nih.gov or
call the cancer information service at 800-422-6237 2. visit www.ovarian.org or
call toll free 888-682-7426 and order a copy of "what
every woman should know about ovarian cancer" 3.
take an on-line risk assessment test at www.wcn.org
^Top^
Urinary
Incontinence
Urinary incontinence is the involuntary
loss of urine to the degree that it causes a problem.
It affects
millions of many millions of Americans, and occurs
predominately in women. The risk increases with age,
but causes significant problems in many young and active
patients. A number of factors have been identified,
including:
- Immobility
- Decreased mental status
- Certain medications,
such as diuretics
- Smoking
- Low fluid intake
- High
Impact physical activities
- Diabetes
- Stroke and
other neurological disease
- Decreased estrogen levels
- Pelvic muscle weakness
- Pelvic support defects
-
Pregnancy, childbirth and episiotomy
- Poor bladder
habits
Effective management includes full assessment by careful
history, physical examination, urine testing, bladder
function testing, discussion of reversible causes,
treatment options and an individualized care plan.
Please see our website for more information and health
links at our home page at www.sworcare.com
Types of Incontinence
Stress Incontinence - signs and symptoms include the
loss of small to medium amounts of urine during coughing,
sneezing, laughing, or other physical activities. The
most common form of incontinence in patients with pelvic
support problems is called Genuine Stress Incontinence
(GUI)
When patients experience continuous leaking at rest
or with minimal exertion, this suggests Intrinsic Urethral
Deficiency. (ISD)
Urge Incontinence - signs and symptoms include the
loss of urine with an abrupt and strong desire to urinate;
usually loss of urine on the way to the bathroom. This
type of incontinence is called Detrusor Dysenertia
or Detrusor Instability (DI)
When patients experience an involuntary loss of urine
without symptoms, this suggests Involuntary Sphincter
Relaxation (ISR)
When patients experience elevated post-void residual
(inadequate emptying), this suggests Detrusor hyperactivity
with impaired bladder contractility (DHIC)
Mixed Incontinence (MUI) - combinations of stress
and urge incontinence
Overflow Incontinence (Overflow )- problems caused
by factors such as poor bladder muscle function, certain
drugs, neurological conditions (stroke, diabetes, etc),
severe pelvic prolapse and other blockage issues
Functional Incontinence (FI) - bladder leakage due
to physical impairments or disabilities
Reflex Incontinence (Reflex) - neurological dysfunction
due to problems such as inflammation, radiation changes,
radical surgery and spinal cord damage
Your Workup for Incontinence may include:
- The degree of symptoms, determining mild moderate
or severe incontinence
- A bladder health survey
-
Medical and Drug History
- Urinalysis or dipstick urine
- Bladder event Diary
- Pelvic Examination, cough test,
q-tip test
- General and mental health evaluation
-
Resting and Active Pelvic tone measurements
- Urodynamics
testing
- Pelvic Vaginal Ultrasound
Once the testing and examination are completed, the
Overall Assessment will be determined and a treatment
plan recommended
What is Urodynamics Testing?
Preparation for the testing includes arriving to
the office at your appointment time with a full bladder
but DO NOT DRINK ANYTHING FOR 30 MINUTES PRIOR TO YOUR
SCHEDULED APPOINTMENT TIME. Please avoid any bladder
irritants, such as caffeine beverages. If you have
any symptoms of a urinary tract infection, such as
urgency, burning or dark cloudy urine, please advise
the staff. You know your body better than we do so
try to plan your fluids accordingly. The testing will
take approximately an hour to complete, and will involve
emptying, filling and holding a full bladder momentarily.
We will also attempt to recreate the same types of
events that cause problems with your bladder control.
We encourage your feedback during the testing to get
the most information possible.
The first test is a Uroflow study. In a private testing
room, you will urinate in a special commode and measurements
will be taken by the computer. These measurements give
Dr. Swor information regarding the amount of urine
output, amount of time, and whether or not there was
hesitancy or stopping and starting of urination.
You will then be asked to move to the examination
table. A small catheter will be placed into the bladder
which will measure the residual amount of urine (if
any) left in the bladder. Another catheter will be
placed in the vagina to measure pelvic pressures during
the rest of the testing.
The bladder will then slowly be filled while the computer
records pressures, volumes and events, such as coughing,
straining and leaking. The results tell us important
information about how the bladder functions properly
or improperly. This allows us to determine the type
of problem you have and how we might help you improve
your control and voiding ability.
At any time before, during or after testing, you should
tell us about any significant discomfort or problem
you are having. Following the tests, we will give you
an antibiotic pill and specific instructions to help
you. After the tests are reviewed by Dr. Swor, a treatment
plan will be provided at a followup visit. This plan
may include exercises, home therapy, medication, biofeedback,
electronic therapy, minimally invasive surgery or a
referral to a urologist if we feel additional testing
or more significant surgery is required.
The Treatment Plan may include:
- dietary and nutritional and behavioral modification
- Antibiotics for infection
- Short term Estrogen therapy
such as Estring, vagifem inserts, estrace cream, pills
or
patches
- a non-hormonal, natural hormone “boost”
- medication
advice (such as being careful with the use of diuretics)
- bladder health advice (avoiding irritants such as
caffeine)
- bladder training
- Kegel exercise or home
resistance exercise (using a pelvic toner device)
-
biofeedback and electronic stimulation bladder therapy
- pessary or vaginal device placement
- medications
for urge incontinence such Detrol LA, Ditropan XL,
Elavil/ Nortriptyline 25-100mg
- medication for stress
incontinence such phenylpropanolamine 25-100 BID, Sudafed
15-30 TID
General Treatment Guidelines
Urge Incontinence (DI, DHIC, ISR) - training, therapy,
medication such as Detrol LA, Ditropan XL, Elavil or
Nortriptyline 25-100 mg/ day medication Side effects
can include- dry mouth, visual, constipation
GSI - Exercises, therapy, medication, hormonal treatment,
pessary, surgery such as minimally invasive SurX procedure,
or Laparoscopic Burch procedure medication such as Phenylpropanolamine
25-100 mg bid, Sudafed or ephedrine 15-30 mg tid medication
Side effects can include- anxiety, insomnia, sweating,
arrhythmia, HTN
Mixed - Exercise, therapy, hormonal, device, trial
medication
ISD - Urologic surgery (sling or bulking procedures)
Obstructive overflow - Obstruction relief with pessary
or surgery
Non-obstructive overflow - further workup, may require
catheter therapy
Reflex, Neurological and Unresponsive to therapy further
evaluation and general medical treatment
Bladder training
Scheduled Voiding/ Habit Training - timed scheduled
voiding every 3-4 hours while awake or individualized
to the
patient’s needs
Prompted Voiding - as above, but prompted by someone
other than the patient
Urge Control - reteaching the bladder to overcome
initial urges to void the bladder contracts at certain “fill” levels
giving the sensation of needing to void- by “holding” through
the early urge sensations, the bladder “learns” to
become fuller before a real need to empty occurs -
this training can be more effective by adding the use
of
Kegel exercises, home resistance therapy
with the pelvic toner or office electronic therapy
Techniques for urge control involve:
1. noting an initial urge
2. stopping current activity
3.
rapidly contracting and relaxing the pelvic floor muscles
4.
deep breathing and biofeedback techniques
5. walking to
the restroom in a controlled manner once the urge has
gone away
6. This program relies on the fact that the
pelvic floor muscles can inhibit the bladder.
Home therapy
* Up to 80% of patients who regularly practice home
behavioral training and exercises will see improvement
in their bladder control. The results may take several
months, but some improvement should be noticed within
a few weeks. Even better success has been seen with
the use of resistance exercising using the pelvic toner
device or the office electronic pelvic toning and biofeedback.
Our philosophy is the team approach, starting simple
and having realistic expectations.
* Home therapy is safe, easy to learn, and has no
known ill-effects. These therapies have also been seen
to improve general pelvic support and sexual response.
Pelvic Muscle Rehabilitation
The pelvic floor muscles
and pelvic support are assessed by exam and, if insufficient,
can be strengthened
and improved with various techniques. Strong pelvic
support and pelvic floor muscles are important
in general well being, bladder control and sexual function.
Many women are unable to isolate and contract their
pelvic floor muscles and so have no defense mechanisms
when stress or urgency incontinence occurs. Your
pelvic floor muscle function is assessed during
your
examination.
Kegel Exercises
The pelvic floor muscles are the muscles you use to
stop urine flow during voiding, and you can identify
them by practicing stopping the flow during voiding.
Dr. Kegel described an exercise program for these specific
muscles many years ago that is commonly practiced by
patients today. This is done by "drawing in" or "drawing
up" the muscles in the region of the bladder,
vagina and rectum. The muscles of the abdomen, thighs
and hips should remain relaxed. Many patients mistakenly
contract their buttock and/or abdominal muscles.
Try to contract the muscles with a little more strength
each day. Do not strain too hard or continue the exercise
so long that it causes fatigue or aching of the muscles.
If continuous exercise causes fatigue, it is better
to exercise one or two minutes and rest several minutes.
The effort to exercise weakened vaginal muscles may
be difficult and tiresome the first day, or in some
cases, the first five or six days. With moderate efforts
and continued practice and exercise, a gradual increase
in the strength of the muscles will be noted.
Pelvic floor contractions are entirely private and
can be performed at any time and in any place or position.
Some ideas for good Kegel times are:
- At red traffic lights.
- During commercials or
while watching TV.
- Anytime you have to wait (especially
standing).
- After coughing, sneezing, laughing, lifting,
climbing stairs, straining
- Before arising in the
morning or after retiring at night.
- During each of
three meals.
- Each time you go to the bathroom (Average
6 times a day).
Quality is more important than quantity. Slowly contract
the muscles as you would in making a hard fist, not
just closing your fingers but clenching to bring in
every muscle fiber. About 5 in a series, holding each
contraction for about 5 seconds--then rest a while.
Always end with an uplifting contraction.
Resistance Pelvic Toner Device
Once regular Kegel exercises are mastered, or when
an accelerated program is desirable, we suggest using
a device to assist in developing stronger pelvic floor
muscles. We recommend the clinically-evaluated Pelvic
Toner that can be purchased very reasonably and used
with confidence. Ask our staff for information.
Sometimes a patient is unable or unwilling to try
home therapy, or it has been unsuccessful or if an
even more accelerated program is desired. In this case,
we suggest biofeedback and electronic pelvic toning
therapy in the privacy of our office, with a nurse
therapist acting as evaluator and trainer. This therapy
is done with the use of state-of-the-art technology
recently imported from Europe. See the next section
for more information.
Office Pelvic Floor Evaluation and Rehabilitation
Swor Women’s Care now offers state-of-the-art
technology for those who want or need biofeedback techniques
and electronic pelvic floor therapy.
If during your evaluation, the pelvic floor muscles
are found to be extremely weak or that you have difficulty
identifying the muscles or contracting them with Kegels,
then this therapy is ideal. Our nursing staff will
act as your "personal trainer". We will measure
the strength of the pelvic floor at rest and while
contracting. We may use visual aids called "biofeedback" techniques.
These are techniques that help you locate and isolate
the pelvic floor muscles for maximal benefit. Then
electronic pelvic floor stimulation and strengthening
will be done during 30 minute sessions for 5 of 7 days.
Biofeedback - Electronic or mechanical instruments
are applied and information is displayed about neuromuscular
and/or bladder activity in regard to pelvic muscle
exercises. This is effective in enabling and motivating
patients to learn voluntary muscle control by direct
observation of the biofeedback.
Electronic stimulation - Application of electrical
current through the placement of a vaginal probe which
is effective in improving muscle contractility and
efficiency.
This will be done in addition to home therapy techniques
and may help in more severe cases to avoid the need
for pessaries and/or surgery. Further sessions may
be recommended based on response and needs of the individual
patient.
Minimally Invasive Surgery
At Swor Women's Care, we offer several techniques
for treating pelvic floor and incontinence problems,
depending on the nature and severity of the abnormality.
Dr. Swor has over 15 years of surgical experience in
treating these problems, and is currently trained in
some of the newest proven techniques. A chosen procedure
may be done vaginally or laparoscopically in an outpatient/same
day arrangement with a short anticipated recovery phase
and low complication rate. Long term improvement is
anticipated in 85% of our surgically treated patients.
The latest technique for healthy patients with mild
to moderate stress incontinence is the SurX procedure.
Small incisions are made vaginally or laparoscopically
and radiosurgical frequency is used to treat the bladder
neck to tighten and strenghten it. For more information
on this new technology, see www.surx.com
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Is your problem endometriosis??
1. Do you experience severe pain or cramping before
or during your period?
2. Do you have increasing pain around ovulation time?
3. Do you have pain with deep penetration during sex?
4. Is your cervix sensitive when you have a pelvic
exam?
5. Are your cramps getting worse instead of better?
6. Do you have difficulty getting pregnant, but it
isn't a male factor or ovulation problem?
If you answered "yes" to these questions,
You have a significant chance of having a progressive
condition called endometriosis. If you come to us for
evaluation, we advise bringing a personally written
Gyn history (this should be in your own words, and
should include a brief description of your pain: when
it occurs, duration, location and a basic overview
of physical symptoms you experience and treatment history).
Endometriosis can cause scarring, infertility, bleeding
internally, bladder symptoms and even pain with bowel
movements. There are drugs that can help, but surgery
is generally recommended to diagnose initially and
treat aggressively.
Dr. Swor specializes in evaluating and treating endometriosis.
We review your description of the problem, do a careful
examination and a vaginal probe ultrasound at our office.
If endometriosis is suspected, it should be diagnosed
AND treated with specialized laparoscopic surgery.
Dr. Swor developed a very successful and innovative
procedure, that uses small incisions, a narrow scope
inserted under anesthesia, a special laser and other
high tech tools. He uses this laser vaporexcision procedure
to thoroughly remove endometriosis spots and cysts
from all areas of the pelvis. The procedure is an alternative
to hysterectomy for many women, and is done on an outpatient
basis at an award-winning surgery center in Sarasota,
Florida. Patients can expect to recover to 90% "normal" activities
in 3-4 days. Fibroids, cysts and infertility problems
can be treated with similar techniques. Hysterectomy
and/or removal of ovary or ovaries and appendix can
be done with similar techniques. Treatment of unexpected
bladder leakage can also be treated with laparoscopy
as well.
Ovary with "chocolate cyst" endometriosis
Endometriosis Surgery- the Laser Vaporexcision™ alternative to Hysterectomy
Endometriosis (“endo” for short) is a common cause of pelvic pain, affecting millions of American women. It can occur at any stage during the reproductive age range (12-55+) and typically gets worse over time. Tissue growths can develop primarily in and around the pelvic area and sometimes even in far reaches of the body. These growths of cells act just like the lining inside of the uterus, growing and shedding in sync with the menstrual cycle. This causes pain and scarring and sometimes interferes with fertility and the function of other organs, such as the bladder and digestive tract. Common symptoms are painful periods, painful ovulation, sexual pain and infertility. Often there is pain or problems with bladder, digestive and bowel function.
A careful evaluation by a specialist will typically uncover tenderness, scarring or lumps on pelvic exam. Vaginal ultrasound, performed by a gyn expert, will sometimes “see” signs of “endo”. The diagnosis is most often made by laparoscopic surgery, using a small lighted scope to view the pelvic and abdominal organs and tissues. This is the perfect time to aggressively treat endometriosis by removing the “spots” and nodules of abnormal tissue.
Unfortunately, few surgeons are prepared or skilled in the removal or “excision” techniques that provide successful treatment. In other words, not all laparoscopy is equal. A simple “diagnostic” laparoscopy only “sees” what the problem is. An aggressive “operative” laparoscopy done by an advanced laparoscopic gyn surgeon combines quality treatment with making the correct diagnosis.
Detecting and treating endometriosis is tricky and takes time and experience. Sometimes the growths or spots can be difficult to see. The most obvious endo tissue growths are the most advanced, late-stage black “powder burn” lesions. But in earlier stages they can also be clear, red, white, or brown in color. It can also “hide” inside the ovaries, ligaments and places like the appendix and the wall of the bladder or rectum. Small lesions can be very inflammatory and trigger major nerve pain. There can also be significant scarring and tissue damage from endo. When laparoscopic surgery is done, the goal should be to see and treat ALL lesions by removing them. Whenever possible, this should be done with the goal of preserving the important organs and reproductive function. Taking into consideration the wishes of the patient, only in the most extreme cases should complete hysterectomy be done.
If the bladder, bowel or appendix are involved, then those areas should be aggressively treated as well. Completely excising all endometriosis growths provides an excellent chance of successful treatment and reduces the chance of future scarring or more surgery. For 25 years, I’ve called my surgical technique for this “laser vaporexcision™”. I use a carbon dioxide laser to remove and vaporize endo from the surrounding normal tissues. If necessary, I will treat the bladder, rectum, bowel, deep pelvic areas and if necessary, remove an involved appendix. The laser minimizes thermal injury to healthy tissues and keeps scarring to a minimum.
I also use hydro-dissection technique, where saline is injected around lesions to provide a temporary protective cushion for normal tissues. When large areas are treated or the internal ovary is involved, repair work may be required to get the best results. Often specific “pain nerves” will be lasered for relief. These techniques are called LUNA (Laser Uterosacral Nerve Ablation) and PSN (PreSacral Neurectomy). Patients with retroverted or “tilted” uterus will often benefit with uterine suspension, where the uterus is “lifted” into a better position by tightening certain ligaments. Even when the surgery does involve hysterectomy, I use the same extra techniques to treat ALL involved areas and endo lesions. Since 2007, I have added robotic surgery technology for appropriate patients.
As Dr. Andrew Cook describes in his book, STOP ENDOMETRIOSIS AND PELVIC PAIN: WHAT EVERY WOMAN AND HER DOCTOR NEED TO KNOW, “The pervasive misunderstanding as to what constitutes good endometriosis surgery is a huge part of why so many women with endo continue to live lives of pain and suffering. Excision and Vaporization of Endometriosis is used by all of the top endo surgeons…. It is the most effective way of removing endometriosis from the body and deserves to be the surgery of choice for endo."
As with any medical treatment, and especially surgical treatment, special expertise and experience really count when seeking optimal outcomes. As I say, just like with airline maintenance, there are no good shortcuts or discount deals. For the best results, see the best doctor and get the best care you can find.
Michael Swor, MD, founder of Swor Women’s Care and medical director of Physician Care Clinical Research in Sarasota, Florida, is a gynecologist and advanced gyn surgery specialist. He has over 25 years of experience treating women with complex health problems such as endometriosis. An assistant clinical professor at the University of South Florida in Tampa and Florida State University, he has provided women’s health lectures and training to thousands of professionals throughout the country. His special interests are advanced technologies, surgical safety and patient education programs.
Dr. Swor and his staff are known for their compassion, dedication, and holistic philosophy.
Hysterectomy and Alternatives in 2010
Every year, over 400,000 American women have surgery to remove part or all of the uterus. We say that these are hysterectomy-related surgeries. Sometimes, a related procedure will be done at the same time, such as removing one or both ovaries, or some type of pelvic repair. Unfortunately, there is much confusion when discussing gyn surgery, so we like to be specific about what procedure is actually being discussed in any scenario. A hysterectomy in one woman may be completely different than a similar sounding procedure in another woman.
The least invasive and simplest hysterectomy-type procedure is the LASH or LSH. A laparoscope is used with other small instruments through tiny incisions to remove only the abnormal part of the uterus. Patients are 85% recovered in 10-14 days and can resume normal activities. It is not actually a hysterectomy because only a portion of the uterus is removed. The ovaries are left in place and although no more periods or pregnancies occur, this does not create menopause and most women describe less hormonal difficulties or PMS.
A TLH or total laparoscopic hysterectomy is when the whole uterus is removed with laparoscopic technique. Recovery takes 1-2 weeks longer because there is an incision in the vagina that has to heal. LAVH or laparoscopic-assisted vaginal hysterectomy is similar, but part of the surgery is done vaginally. A TLH or LAVH is usually preferred over LASH if there is disease in the cervix or pelvic pain as a major factor.
For the last 3 years, we have added a new option to many gyn surgeries. This new technology is robotic assistance, where we use laparoscopic techniques and also the daVinci robot. The high tech instruments and increased optics and magnification with daVinci are a benefit for many women having laparoscopic procedures and we have had excellent results with our patients.
Sometimes, these surgeries are done without laparoscopy, through an open incision (TAH) or vaginally (TVH). An abdominal approach is often chosen when cancer is present or very large masses. Recovery is longer and risks are higher. A vaginal approach is often used when the primary problem is prolapse or pelvic support problems.
Unless specifically added to the plan, the ovaries are left in place as with LASH for any hysterectomy. This is a very important point since the ovaries are separate organs and treated individually for every patient. The only reason to remove both ovaries during a hysterectomy, is if there is a specific problem with both ovaries, or advanced menopause or a special risk of ovarian cancer. In fact, there is an estimated 50% risk reduction in ovarian cancer with LASH or hysterectomy when the ovaries are left in place.
When excess bleeding is the main problem, there are other alternatives to hysterectomy-type procedures. There are hormonal treatments, a special IUD device and ablation or heat treatment to the uterine lining. When fibroids are the main problem, the treatment can be directed at only the fibroids, with embolization, ultrasound, or myomectomy (fibroid removal- usually with laparoscopy). When bladder leakage, prolapse or pelvic support is the main problem, then repair can be done with or without hysterectomy.
All women have to go through the process of menopause, which most commonly occurs when the ovaries either stop reproductive function (natural menopause) or are both removed (surgical menopause). With simple LASH or hysterectomy, periods stop but menopause occurs naturally, usually around age 45-55, which is best for most women. Of course women often have surgery after menopause has already occurred, but we know that the ovaries still produce low levels of hormones well into menopause. For this reason, it may be beneficial to preserve the ovaries unless menopause is advanced.
Obviously, when gyn problems are significantly affecting a women’s lifestyle, the treatment options are complex, and there are best alternatives for each individual.
Hormone Supplements for Menopause
The Perimenopause is that transitional time from around 35 or 40 until age 60 or older. Fluctuations and changes in hormone production are the main cause of difficulties during this time. The ovaries are the main source of female hormones, but as they become less productive, other areas of the body can help. Some women have few symptoms and a very smooth progression. However, many women will experience menstrual irregularity, hot flashes, night sweats, sleep disruption and anxiety/depression.
There can also be changes related to low vaginal estrogen, such as dryness, sensitivity and bladder weakness. In women who have surgical removal of both ovaries, changes could be more abrupt. Every woman is different and hormonal swings can occur frequently and with no real predictable pattern. This makes hormone testing less meaningful in most cases, so I rely more on signs, symptoms, and a scientific understanding of the process.
Each woman has a very individual situation that benefits greatly by good general health and prevention, diet, exercise and guidance from a knowledgeable women’s health expert. The process is constantly progressing, and available options continue to evolve, new information is accumulated and people and attitudes also change. This means that effective help must be re-evaluated on an ongoing basis, at least annually and often more frequently.
Nutritional and Herbal therapy have been used in place of and in addition to hormonal treatment for many years. The potential benefit of healthy and “natural” ingredients is attractive to many people. These treatments have generally not been as well studied and researched as pharmaceutical products. There is however a growing body of evidence to suggest the safety and benefit of many non-prescription and herbal products, especially those from well-known and reputable companies. When the choice is to try these products, I advise starting conservatively, using small dosages. A simple regimen or formula is probably safer than a complex mixture. There are several well-accepted herbs and supplements currently in the market and a variety of products and ideas. We can offer advice and suggest appropriate steps with a non-hormone approach.
“Natural hormones” and “bio-identical” are popular buzzwords today. Although used interchangeably, they mean different things. Most hormones, herbs and even pharmaceuticals are derived from natural plant or animal sources. If a hormone is exactly as found in nature, it’s bio-identical. If exactly as found in your body, we say “human-identical”. Obviously, for a hormone supplement, this seems ideal.
Over 25 years, an entire industry has been created by some pharmacists who produce a custom-made formula with a doctor’s prescription, using any of a variety of ingredients in any chosen dosage. This is the age-old method called “compounding”. The benefit here is that a custom product can be created for each individual patient and adjusted accordingly. This offers significantly more choice in designing a supplement, hormone or drug for a particular purpose. The disadvantage is that a particular formula may not have any clinical research backing or testing and the patient and the physician must have trust in the pharmacist who is actually compounding the product in their store or lab. There may be much more variation in one batch to the next and certainly from one pharmacy to the next.
Pharmaceutical company factory-made products are known for their consistency and standardization although there is not as much variety and choice in ingredients. In order to have a patented product, these companies have to have a unique formula or method of drug delivery. Even slight variations in a chemical compound can dramatically change the way one works, so in general, I suggest using human-identical hormones.
There is major controversy (and misunderstanding) related to the use of hormone therapy. The use of estrogens and progesterone-like compounds have been implicated in a few studies with serious health risks. Your women’s health specialist can discuss this information and how it relates to you as an individual. Despite stories in the media, many scientists have found the hormone-scare reports to be faulty. I have found no valid scientific literature to suggest that human estrogen or pure progesterone in menopausal supplement doses will cause major disease such as cancer. Quite the contrary, there are significant health benefits for many women. I think the research shows that estrogen is protective against cardiovascular disease, osteoporosis and the function of the brain. Natural progesterone has a protective effect on tissues as well. If human estrogen and progesterone caused disease, then the younger (and particularly pregnant) patients would be having more problems. We know that any estrogen can promote the growth of certain already existing tumors but it would be unlikely that cancer is caused by pure estrogen and I think the research supports this idea. Again, I am talking about human estrogen and progesterone, not chemically-altered variations. Also, keep in mind that we purposely use some altered variations to actually treat cancer and other diseases. Unfortunately, for all of us, we will continue to get confusing reports in the media, on-line and even from biased or uninformed professionals.
Many options for hormone therapy are commercially available in pills, capsules, patches, creams and other topical forms. In theory, a topical treatment such as a patch or cream would be more physiologic and is therefore preferred by many of us. Again, I think the research supports this idea.
A variety of other dosage forms for hormone therapy can be prepared by specialized pharmacists to meet the specific needs of individual women. Compounding also can provide unique ingredients not available commercially “off the shelf”, but usually there is a higher cost. We can recommend several local pharmacies for compounded hormones and products, and we also work with several mail order pharmacies.
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