Health & Fitness

New frontier: Botox in the bladder to help stop that urge


Women have new help when it comes to those taboo topics like incontinence and pelvic organ prolapse. While urology is a male-dominated field, there is a growing subspecialty that deals with conditions stemming from the unique anatomy of the female urinary tract and reproductive system.

Dr. Yvonne Koch, a urologist at Mount Sinai Medical Center, specializes in the urological conditions that commonly affect females.

"My subspecialty is female urology, and voiding dysfunction. These are problems that tend to affect more women than men. My practice is approximately 70 percent women and 30 percent men," Koch said.

As part of her subspecialty, Koch sees women with pelvic floor dysfunctions, urinary tract infections and bladder infections.

The official title for the subspecialty is Female Pelvic Medicine and Reconstructive Surgery, a board certification that is relatively new.

Dr. Eric Hurtado, a urogynecologist at Cleveland Clinic Florida in Weston who is also certified in Female Pelvic Medicine and Reconstructive Surgery, says the subspecialty has been board-certified for about three years.

"It's a real conversation stopper at parties," Hurtado said of his profession. "I tell people I like plumbing," he added.

Leaking "pipes" are no laughing matter for women. Stress incontinence, leakage when you cough, laugh or exercise, is different from urge incontinence, in which the bladder contracts when it's not supposed to, causing women to wet their pants.

Both doctors mentioned numerous treatment options such as therapy, medications and minor surgery.

For stress incontinence, Koch said, "we can do cognitive therapy, we can do slings, we can inject bulking agents in the urethra."

Patients can also do Kegel exercises, contracting the muscles that control urine flow, to help strengthen the pelvic floor. Hurtado recommends doing a set of Kegel exercises three to five times a day, holding for 10 seconds, then relaxing for 10 seconds, and repeating 10 to 15 times. "Compliance is the hardest part," he said.

For urge incontinence, "physical therapy and oral medications can help. There are approximately seven medications on the market for this problem. If that doesn't help, we can also put Botox in the bladder or use an InterStim device," Koch said.

InterStim is a pacemaker-type device placed under the skin that sends electrical impulses to the nerves to modify the impulses to the bladder. Another procedure is posterior tibial nerve stimulation, called PTNS.

"Sometimes, people with a little bit of both types of incontinence need what we call multimodality, a little bit of this and a little bit of that," Koch said.

Even less talked about is pelvic organ prolapse in which "the muscles can no longer support the pelvic organs from below," Hurtado said.

"One in nine women in the U.S. will have surgery for pelvic floor prolapse," Hurtado said. Yet many patients have no idea if their grandmother, for instance, had the same problem. It's just not something people discuss.

The most common symptom is a protrusion, something coming out of the vaginal opening. There can also be pelvic pressure or trouble moving bowels or urinating. Hurtado said.

"A lot of women who have prolapse also have incontinence and vice versa," Hurtado said.

Not all cases require surgery. When it's needed it can be done vaginally, laparoscopically, robotically or as open abdominal surgery. You can use your own tissues and ligaments or mesh for reinforcement, Hurtado said.

There are pros and cons for all the methods although there are fewer and fewer doctors inserting mesh vaginally as there are more complications of the mesh coming through the pelvic wall, Hurtado said.

"It's important to customize your surgery to the patients, how active they are, how old. When you use your own ligaments and tissues, there's a little higher failure rate, especially for your active patient," Hurtado said.

"Everything has a little bit of Catch-22. Otherwise, we'd all do the same thing every time," Hurtado said of treating pelvic organ prolapse.

"There's a lot to be learned," Hurtado said, adding, "It's a new frontier of medicine."