Urogynecology Arts of New Jersey
CONDITIONS & TREATMENTS 620 Cranbury Road, Suite 219
East Brunswick, NJ 08816
Phone: 732.651.0005
Fax. 732.651.0053
   
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  JOAN ZACCARDI, DrNP
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  Pelvic Floor Dysfunction


URINARY INCONTINENCE (UI):

     UI is the involuntary loss of urine that may occur with activity ('stress UI'), the sensation of urgency (the feeling of a sudden need to go to the bathroom: 'overactive bladder'), or both ('mixed UI'). It is an extremely common and embarrassing condition effecting women of all ages. The evaluation includes a history, physical exam, analysis of a urine sample, urodynamic testing (a painless test of bladder function), and in some cases, cystoscopy (a procedure to look inside the bladder).

Treatments include:
  • Behavioral Modification: Developing ways of managing one's nutrition and fluid intake along with developing effective coping skills.
  • Pelvic Floor Muscle Rehabilitation: Effectively identifying and strengthening the muscles of the pelvic floor (sometimes referred to as 'Kegel Exercises').This usually requires the assistance of biofeedback techniques under the guidance of a specially-trained physical therapist or nurse practitioner.
  • Medications: Anti-cholinergics and adrenergic agonists (designed to relax the bladder) and estrogens (designed to restore a healthy vaginal environment in post-menopausal women).
  • Botox injections: A 10 minute office procedure performed without the need for anesthesia to address urge incontinence. Patients may resume normal activities immediately after the procedure.
  • Pessary use: Devices made of silicon that are placed in the vagina to give support to the opening of the bladder. Pessary fitting is painless and done in the office.
  • Surgery: For stress UI, a 'pubovaginal sling' is usually the procedure of choice. This 15 minute procedure can be performed on an out-patient or overnight basis under regional anesthesia (anesthesia that goes in the back, i.e. epidural or spinal) thereby avoiding the risks associated with general anesthesia. It is performed with minimal incisions thus allowing for a speedy recover and a minimal disruption to a woman's normal activities. For overactive bladder in those women not responsive to medications, 'sacral nerve modulation' (ex. The Interstim® procedure) or 'peripheral nerve modulation' are effective procedures. Sacral nerve modulation is a 30 minute procedure performed with local anesthesia (anesthesia given directly at the operative sight carrying the lowest risk of any anesthetics) as an out-patient. Again, the recovery is quick. Peripheral nerve modulation is done in the office over a designated period of time (initially once a week for 12 weeks) without anesthesia.
PELVICE ORGAN PROLAPSE (POP):

     POP refers to the loss of support (a 'dropping' or 'sagging') to organs in the vagina such as the bladder ('cystocele'), the rectum ('rectocele'), the uterus ('uterine prolapse') or area where the uterus used to be in women who have had a hysterectomy ('enterocele' or 'apical prolapse'). A woman may have a loss of support at one or a combination of sites and may also have concomitant urinary or fecal incontinence. It is critical to understand that every woman's prolapse is unique. The evaluation includes a history, physical exam, and in some cases urodynamic testing (a painless test of bladder function), and/or cystoscopy (looking inside the bladder). Depending on the findings of the evaluation, each patient has an individual treatment plan devised to address her unique needs and desires.

Treatments include:
  • Behavioral Modification: Developing ways of managing one's activity level and changing the way a woman goes about doing her daily routines to take pressure off the pelvic structures.
  • Pelvic Floor Muscle Rehabilitation: Effectively identifying and strengthening the muscles of the pelvic floor (sometimes referred to as 'Kegel Exercises'). This usually requires the assistance of biofeedback techniques under the guidance of a specially-trained physical therapist or nurse practitioner.
  • Medications: Estrogens (designed to restore a healthy vaginal environment in post-menopausal women).
  • Pessary use: Devices made of silicon that are placed in the vagina to give support to organs in the vagina. Pessary fitting is painless and done in the office.
  • Surgery: Each woman's surgery is uniquely tailored to address the extent and location of her prolapse and any other concomitant problems. Dr. Mokrzycki’s superb training enables him to perform most surgeries either vaginally (without the need for abdominal incisions) or robotically through extremely small abdominal incisions. In any event, the current controversy surrounding mesh materials in vaginal reconstruction can be avoided by employing conventional techniques of repair and non-mesh-related grafts. These procedures are usually performed under regional anesthesia (giving the anesthesia in the lower back, i.e. 'spinal' or 'epidural'). Avoiding abdominal surgery, if possible, obviates the need for general anesthesia leading to a much safer operative experience and faster recuperation period. Most surgeries can be performed in less than 60 minutes in an outpatient surgical facility while others may require a simple overnight stay in the hospital. Return to activities like driving a car, going outdoors, or climbing stairs after vaginal surgery generally occurs within a few days rather than weeks. Return to work and other more strenuous activities normally occurs after 2 to 6 weeks, depending on the specific patient and any underlying medical conditions.
FECAL INCONTINENCE (FI):

     FI is the involuntary loss of gas or stool via the rectum and anus. Some women are given no warning prior to their episodes of FI, while others recognize when FI is going to happen but are unable to contract their rectal muscles adequately. FI is an extremely common and embarrassing condition for women. Evaluation of FI includes a history, physical exam, testing of the nerves of the pelvis, and anal endosonography (a painless test providing a 'look' at the status of the anal muscles that control bowel continence).

Treatments include:
  • Behavioral Modification: Developing ways of managing one's bowel habits through nutritional and dietary manipulation along with developing effective coping skills.
  • Pelvic Floor Muscle Rehabilitation: Effectively identifying and strengthening the muscles of the pelvic floor (sometimes referred to as 'Kegel Exercises'). This usually requires the assistance of biofeedback techniques under the guidance of a specially-trained physical therapist or nurse practitioner.
  • Medications: Designed to promote more effective bowel function.
  • Surgery: For FI caused by a separation of the anal muscles, a 'sphincteroplasty' (bringing together and overlapping the ends of the muscle) is usually the recommended procedure. This procedure is typically performed through an episiotomy-like incision using regional anesthesia (giving the anesthesia in the lower back, i.e. 'spinal' or 'epidural'). The surgery takes approximately 45 minutes and involves a short stay in the hospital. The recuperation period is patient dependent but usually takes about 4 to 6 weeks. Sacral nerve stimulation (The Interstim®Procedure), described above in the Urinary Incontinence section, is now FDA approved for patients suffering from fecal incontinence. This procedure has revolutionized our approach in treating this debilitating and embarrassing condition!

 

INTERSTITIAL CYSTITIS (IC):

     IC is a common bladder condition causing urinary frequency (urinating > 7 times per day), urgency (the sudden sensation that one must go to the bathroom) and in some cases pain without evidence of a bladder infection. In fact, IC is commonly mistaken for recurrent bladder infections leading to the inappropriate use of antibiotics. The cause of IC is unknown. The evaluation of IC typically includes a history, physical exam, analysis of a urine sample, cystoscopy under anesthesia (a procedure which looks inside the bladder while the patient is asleep) and in some cases, urodynamic testing (a painless test of bladder function).

Treatments include:
  • Behavioral Modification: Recognizing how a women's specific diet may be exacerbating her IC and developing ways of managing one's nutrition and fluid intake. Also, developing effective coping skills is a critical component of therapy.
  • Pelvic Floor Muscle Rehabilitation: Effectively identifying and strengthening the muscles of the pelvic floor (sometimes referred to as 'Kegel Exercises'). This usually requires the assistance of biofeedback techniques under the guidance of a specially-trained physical therapist or nurse practitioner.
  • Medications: Pentosan Polysulfate (Elmiron®) is FDA approved for the treatment of IC and is the cornerstone of treatment. It helps restore the damaged lining of the bladder. Dimethylsulfoxide is the other FDA approved medication for IC that helps relieve bladder discomfort. There are other classes of medication (anti-cholinergics, antihistamines and antidepressants) used to treat the symptoms of IC.
  • Surgery: For those patients with suboptimal responses to medical therapy, there are some procedures that have shown promising results. Cystoscopy with hydrodistention is a quick, out-patient procedure that has provided symptomatic relief to many patients with IC. Sacral nerve modulation (ex. Interstim®) is FDA approved for the symptoms of bladder urgency and frequency. There have been studies demonstrating significant relief in the setting if IC in appropriately selected patients. This is a 30 minute procedure performed with local anesthesia (anesthesia given directly at the operative sight carrying the lowest risk of the anesthetics) as an out-patient.

  Robotic Surgery for Benign Gynecological Conditions


FIBROIDS

     Fibroids are abnormal growths of uterine muscle. They may cause a variety of symptoms including bleeding, pain, and pressure on neighboring organs like the bladder. If non-surgical treatments have failed, surgical removal of the fibroids alone (robotic myomectomy) or of the uterus as a whole (robotically assisted vaginal hysterectomy or robotic supracervical hysterectomy), can be performed through small incisions resulting in a speedy recovery.

ENDOMETRIOSIS

     Endometriosis is a condition where the inner most layer of the uterus (the endometrium; the area responsible for a woman's monthly period), implants outside of the uterus. This implantation may occur in the ovary, the fallopian tube or any other neighboring structure. Unfortunately, this 'transplanted' tissue remains active and responds to a woman's normal hormonal cycle (i.e. this tissue will bleed into the structures in which they've implanted). This leads to the symptoms of pain, discomfort and pelvic dysfunction normally associated with this condition. Similar to fibroids, if non-surgical treatments have failed, minimally invasive robotic procedures can be performed through small incisions to destroy the endometriotic implants and address the adhesions they have caused. The recovery period is usually brief.

OVARIAN CYSTS

     Ovarian cysts are abnormal growths in one or both ovaries. Aside from causing pain and discomfort, ovarian cysts, in some cases, can be cancerous and evaluation for malignancy is imperative. Evaluation and treatment of ovarian cysts can usually be successfully performed robotically through small incisions. This can usually be done as an out-patient basis with a fast post-operative recovery period.

  Restorative Vaginal Reconstruction


     There are many vulvar and vaginal conditions that are bothersome to women and interfere with normal activities such as exercise and intercourse. These conditions can usually be diagnosed via a simple, yet thorough pelvic examination and remedied through minimally invasive procedures. These procedures generally can be performed with local or regional anesthesia on an out-patient basis. This allows for a fast recovery thus minimizing interference with a woman's lifestyle. These include, but are not limited to:

CLITOROPLASTY: refers to the removal of redundant and excessive clitoral tissue. This tissue may cause discomfort, pain, and/or interfere with exercise or sexual satisfaction.

HYMENOPLASTY: refers to the resection of an abnormally developed hymenal ring, or, conversely, the 're-establishment' of a hymenal ring which has separated. The former condition typically results in severe pain since these women (usually teenagers) have an obstruction in the vaginal area causing their menstruation to 'back up'. The 're-establishment' of a separated hymenal ring is usually requested for cultural reasons.

VULVOPLASTY: refers to removal of excessive tissue on the sides of the vagina or revision of a scar from a previous surgery or circumcision procedure.

LABIOPLASTY: refers to the removal of redundant or excessive labia minora. Excessive tissue of the labia minora may interfere with intercourse or cause discomfort when doing activities affecting the pelvic area such as bike riding.

VAGINOPLASTY: can imply a 'tightening' of the vaginal area in those women experiencing laxity (a loose sensation usually due to vaginal childbirth) or, conversely, a 'widening' of vaginal tissue in women with a congenital malformation or scar tissue from previous surgery.

PERINEOPLASTY: refers to a 'tightening' or conversely, a 'widening' of the area between the lower part of the vagina and the rectum. It is typically done in conjunction with and for the same reasons as a vaginoplasty.

FISTULA REPAIR: refers to surgery to close an abnormal 'hole' or communication between 2 organs, such as the bladder and the vagina ('vesicovaginal' fistula) or the rectum and the vagina ('rectovaginal' fistula'). These fistulas can be the result of a difficult and complicated labor, previous surgery, or pelvic trauma.