Patrick Culligan, MD, FACOG, FACS
What is a Urogynecologist?
A urogynecologist manages clinical problems associated with dysfunction of the pelvic floor and bladder. Pelvic floor disorders affect the bladder, reproductive organs, and bowels. Common pelvic floor disorders include urinary incontinence, pelvic organ prolapse and fecal incontinence. Increasingly, Urogynecologists are also responsible for the care of women who have experienced trauma to the perineum during childbirth.
There is some crossover with the subspecialty of Female Urology – these doctors are urologists who undergo additional training to be able to manage female urinary incontinence, pelvic organ prolapse and interstitial cystitis/PBS. In addition, there are colorectal surgeons who have a special interest in anal incontinence and pelvic floor dysfunction related to rectal function. Contemporary urogynecological practice encourages multidisciplinary teams working in the care of patients, with collaborative input from urogynecologists, urologists, colorectal surgeons, elderly care physicians, and physiotherapists. This is especially important in the care of patients with complex problems, e.g. those who have undergone previous surgery or who have combined incontinence and prolapse, or combined urinary and bowel problems. Multidisciplinary team meetings are an important part of the management pathway of these women.
Urogynaecologists manage women with urinary incontinence and pelvic floor dysfunction. The clinical conditions that a urogynecologist may see include stress incontinence, overactive bladder, voiding difficulty, bladder pain, urethral pain, vaginal or uterine prolapse, obstructed defecation, anal incontinence, and perineal injury. They may also care for women with vesico-vaginal or rectovaginal fistulae with specialist training, and in conjunction with other specialties.
Patients will usually be assessed using a combination of history taking, examination (including pelvic examination and assessment of prolapse using validated systems such as the Pelvic Organ Prolapse Quantification [POP-Q] system) and assessment of quality of life impact using validated questionnaires, including the assessment of sexual function using Pelvic Organ Prolapse/Incontinence Sexual Questionnaire IUGA- Revised [PISQ-IR]. A bladder diary is often used to quantify an individual’s fluid intake, and the number of voids per day and night, as well as the volume the bladder can hold on a day-to-day basis. Further investigations might include urodynamics or a cystoscopy. Treatment usually starts with conservative measures such as pelvic floor muscle training, fluid and food modification or bladder training. Drug therapies can be used for overactive bladder, which may include antimuscarinic drugs or beta 3 receptor agonists – both of these help to control the urgency that is the key component of overactive bladder. If medications fail, more invasive options such as injections of botulinum toxin to the bladder muscle, or neuromodulation are other options for symptom relief. Surgical treatments can be offered for stress incontinence and/or uterovaginal prolapse if pelvic floor muscle training is unsuccessful.
Urogynecological problems are seldom life-threatening, but they do have a major impact on the quality of life of affected individuals. Urogynecologists will usually use quality of life improvement as a treatment goal, and there is a major focus on optimising symptoms using conservative measures before embarking on more invasive treatments.