Patrick Culligan, MD, FACOG, FACS Urogynecologist NYC
Opening Hours : Monday - Friday | 8 am - 4 pm
Contact : 212-746-4600
Urogynecology is a subspecialty within Obstetrics and Gynecology that focuses on disorders of the female pelvic floor such as pelvic organ prolapse (bulging out of the uterus and/or vagina), urinary incontinence, fecal incontinence and constipation. After completing a residency in Obstetrics and Gynecology, Urogynecologists complete fellowship training where they spend several years focusing only on these disorders.
The formal name for our subspecialty is Female Pelvic Medicine and Reconstructive Surgery. Be sure that your urogynecologist is Board certified in Female Pelvic Medicine and Reconstructive Surgery.
Many women incorrectly assume that urine leakage is normal. While the problem of urine leakage is very common, it should never be considered normal. The most commonly quoted study estimates that 11 million American women currently suffer from leakage of urine. However, this estimate may be low. A study of 2800 postmenopausal women (average age 67) funded by the National Institute on Aging found that fifty-six percent of women experienced urinary incontinence at least weekly.
Urinary incontinence is a symptom, not a disease. This means that there are many possible causes of urinary incontinence. The key to treatment is identifying the specific type(s) of incontinence that a woman has through a careful medical interview and focused physical exam. It may also be necessary to perform a special test called urodynamics to diagnose the problem. Urodynamics are necessary if a woman is considering surgery to correct incontinence.
The two most common types of urinary incontinence are stress incontinence and urge incontinence.
Stress incontinence is urine leakage that happens during activity that causes pressure (or “stress”) on the bladder such as laughing, lifting, coughing or sneezing.
Urge incontinence is urine leakage that occurs before a woman has a chance to get to the bathroom in response to an urge to urinate. Women with this type of leakage may also experience frequent urges to urinate and frequent nighttime waking to urinate.
Stress urinary incontinence can be effectively treated with pelvic floor exercises, devices that “block” the loss of urine, or surgery. There are no medications indicated for the treatment of stress urinary incontinence.
Urge incontinence is commonly treated with medications, biofeedback, electrical stimulation to the nerves that control the bladder, or Botox injections. There is even a treatment for urge incontinence that involves placement of an electrical stimulator under the skin (similar to a pacemaker).
The most important thing to remember is that there is a wide variety of non-surgical and surgical treatment options available for all kinds of urinary incontinence. For more specific information on the various treatment options for urinary incontinence and pelvic organ prolapse, click here NON-SURGICAL TREATMENT OPTIONS.
When it comes to treating stress incontinence, not all surgical procedures are created equal. Over the years, literally hundreds of variations of anti-incontinence surgery have been described in medical journals, and some of them didn’t work very well. Fortunately, research studies have identified two basic kinds of surgical procedures that seem to be the “best”: the retropubic urethropexy and the suburethral sling. There is no surgery for incontinence that has a 100% cure rate, but either the retropubic urethropexy or suburethral sling should permanently cure 75-95% of women with stress incontinence. The current “gold standard” treatment for stress incontinence is a surgery known commonly as the “Tension Free Vaginal Tape” (aka TVT). These slings are made from polypropylene mesh, and are placed through a small vaginal incision. The TVT procedure can be performed on an outpatient basis under local anesthesia plus IV sedation (much like the kind of sedation given for a colonoscopy). No surgery, however, should be taken lightly. Some potential complications of surgery for incontinence include difficulty emptying the bladder and development of urge incontinence.
Most of the negative information “out there” about sub-urethral slings can be traced back to one or two poorly designed products that are no longer on the market. These “bad slings” are no longer used. The best synthetic slings are made of a loosely woven polypropylene mesh designed especially for placement under the female urethra. Biomedical engineers have worked to create materials that will provide the necessary support while still allowing for excellent “tissue in-growth.” In other words, your body should grow into all of the “nooks and crannies” of the sling material within weeks of the surgery. While problems with this tissue in-growth can occur, they are very rare. Your doctor will be able to tell you more information about the sling and why. Patient FAQ’s regarding Mid Urethral Slings
We don’t fully understand all the factors that cause urinary incontinence, so it is difficult to recommend ways to prevent the problem. Pelvic muscle exercises (PME) – also known as Kegel exercises – are probably the best way to prevent stress incontinence. CLICK HERE for PME instructions. Another easy thing to try on your own is to avoid eating or drinking things known to irritate the bladder. For a copy of our “bladder diet,” CLICK HERE. The popular exercise program known as Pilates is another promising option for women looking to strengthen their pelvic floor muscles. We recently completed a clinical research study comparing the Pilates methods to a more traditional Kegel-based program for making these muscles strong. While both methods resulted in stronger pelvic floor muscles, the women who were randomized to the Pilates methods felt they received benefits to their entire body as well.
What does “prolapse” mean? The word prolapse simply means displacement from the normal position. When this word is used to describe the female organs, it usually means bulging, sagging or falling. It can occur quickly, but usually happens over the course of many years. There are various types of prolapse, which can occur individually or together. Definitions and pictures of the various types of prolapse (cystocele, rectocele, uterine prolapse and enterocele) may be found by clicking on the GLOSSARY section.
The symptoms depend on which type of prolapse you have. Since prolapse usually occurs slowly over time, the symptoms can be hard to recognize. Most women don’t seek treatment until they actually feel something protruding outside of their vagina. The very first signs can be subtle – such as pain during intercourse or an inability to keep a tampon inside the vagina. As the prolapse gets worse, some women complain of a bulging or heavy sensation in the vagina that worsens by the end of the day or during bowel movements. Some women with severe prolapse even have to push stool out of the rectum by placing their fingers into the vagina during bowel movements.
The simple answer to this question is NO. There are many factors that seem to contribute to the development of prolapse, and almost none of them are things you can control. Genetics definitely plays a major role. Vaginal deliveries can predispose certain women to develop prolapse, but we haven’t learned how to identify these women BEFORE they have children. Other conditions that seem to go along with the development of prolapse are severe obesity, pelvic tumors and chronic constipation. Repetitive heavy lifting may contribute to prolapse as well.
No, there are two other choices – to do nothing about it or wear a pessary. A pessary is worn in the vagina like a diaphragm. Pessaries come in many different shapes and sizes all designed to support the prolapsed pelvic organs. Many women are completely satisfied using a pessary for years – avoiding surgery all together.
The ideal way to use a pessary is to insert it each day as part of your morning routine, and take it out for cleaning each night. When this is not possible, women come to the office about four to six times a year for an exam and pessary cleaning. Even when a pessary is worn almost continuously, vaginal infections are rare. CLICK HERE for a picture of the various pessaries available.
Probably. It may not happen quickly, but if left untreated, pelvic organ prolapse usually gets worse. However, treatment of prolapse should be based on your symptoms. In rare cases, severe prolapse can cause urinary retention that progresses to kidney damage or infection, When this occurs, prolapse treatment is considered necessary. In most other cases, patients should be the ones to decide when to have their prolapse treated – based on the symptoms they are having.
Depending on the extent of your surgery, you may need to spend the night in the hospital. Some women have difficulty urinating immediately after the surgery and have to go home with a catheter in place to drain the bladder. These catheters are usually only necessary for 1-3 days. Most patients require at least some prescription strength pain medicine for about 1-2 days after surgery. Following any of our surgeries to correct urinary incontinence or prolapse, we ask that patients take it easy for 4-6 weeks to allow proper healing. This means no lifting more than 8 pounds (the weight of a gallon of milk), no intercourse, and no exercise other than walking. CLICK HERE for more information about what to expect after surgery.
The goal of continence or pelvic reconstructive surgery is to recreate normal anatomy permanently. However, none of these procedures are successful 100% of the time. According to the medical literature, failures occur in approximately 5 – 15% of women who have prolapse surgery. In these cases, it is usually a partial failure requiring no treatment, pessary use, or surgery that is much less extensive than the original surgery. Patients who follow our recommended restrictions for 6 weeks after surgery probably give themselves the best chance for permanent success. If a failure of surgery occurs it will feel like a new bulge coming out. Failures tend to happen within the first year after the operation – so if you make it past the 12 month point without experiencing a failure, you are probably “out of the woods.” Your doctor may want to use synthetic mesh material to reinforce your surgery. The mesh is designed to decrease the chance of surgical failure.
Not exactly. In 2011 the FDA did issue a warning about the use of vaginal mesh. Click FDA Notification ABOUT VAGINAL MESH to read the FDA information. While it is true that vaginal mesh placement can result in problems such as “erosion” and pain, we feel that the benefits of mesh need to be considered as well. If your doctor is considering the use of synthetic mesh to reinforce your prolapse repair, you will be informed about all the risk and benefits of doing so. Ultimately the choice will be yours to make. Please read the recent publication, The Rapid Evolution of Vaginal Mesh Delivery Systems for the Correction of Pelvic Organ Prolapse by Dr. Culligan regarding the use of vaginal mesh.
The daVinci robot is a wonderful surgical tool designed to make laparoscopic surgeries easier to perform. If your doctor thinks a laparoscopic surgery is an option for you he/she will probably want to use the daVinci technology – most likely to perform a “sacrocolpopexy.” If your doctor thinks that it would be best to take a vaginal approach when doing your operation, the daVinci robot would not be used. We try to use a “minimally invasive” approach for our prolapse operations whenever possible – both the laparoscopic approach and the vaginal approach are considered “minimally invasive.”
Yes, if you are going to have surgery to correct the prolapse, bladder testing (called urodynamics) must be done first. That’s because the prolapsed portion of your vagina may be pushing on your urethra and preventing urine leakage. If that is the case, having the prolapse corrected can give you a new problem – urinary incontinence. The only way to tell whether a continence procedure is needed at the time of prolapse surgery is to perform urodynamics while holding the prolapse up in its normal position.
If you choose to use a pessary, your sex life shouldn’t change, except for the fact that the pessary usually needs to be removed prior to intercourse. If you have reconstructive surgery to correct prolapse, we recommend that you refrain from intercourse for 6-12 weeks after your operation to allow proper healing. After the waiting period, getting used to having intercourse might take some time, but most patients report a good sex life afterwards – sometimes they even report better sex life after surgery. Urogynecologists in general have much to learn about the way our operations change the sex lives of our patients, so in our practice we are continually conducting research studies in this area. You may be asked to participate in such a study – which would only involve your filling out anonymous questionnaires.
When prolapse is very severe , one surgical option is to completely close the vagina. This procedure (called colpocleisis or colpectomy) is less invasive than reconstructive surgery, which makes it especially useful for patients with severe medical conditions. Of course, intercourse is impossible after having this procedure, so it is only appropriate for patients who are ABSOLUTELY sure that they never want to be sexually active again. We usually only consider this option for women who are more on the elderly side.
Treating prolapse and incontinence is challenging and very rewarding. Every patient has a unique set of symptoms, disorders and expectations, so we must individualize each treatment plan. Unlike most specialists, Urogynecologists have the opportunity to diagnose a condition; plan treatment based on the patient’s lifestyle and preferences; and follow up on the patient after treatment. It’s rewarding to see patients back after successful treatment, because they are usually very happy with their improved quality of life. Also, we enjoy the challenge of improving patient care through medical research. Since our specialty is relatively new, there are many questions that still need to be answered through research studies.