GYN Services

Abnormal Bleeding

  • Amenorrhea is the absence of menstrual periods, it may be either primary (meaning a woman never developed menstrual periods) or secondary (absence of menstrual periods in a woman who was menstruating previously).
  • Genetic  conditions are the most common causes of primary amenorrhea.
  • Amenorrhea may result from disorders of the pituitary,ovaries, hypothalamus, or uterus.
  • Intensive exercising, extreme loss of weight,  physical illnesses  and stress can all result in amenorrhea.
  • Amenorrhea is a symptom and not a disease , so amenorrhea can be prevented only to the extent of the underlying cause  prevented.
  • infertility and  bone loss (osteoporosis) are possible complications of amenorrhea.
  • Treatments to amenorrhea may include surgical correction of anatomical abnormalities, hormone therapies ,medications  and treatment of any underlying conditions which is responsible for amenorrhea.

Primary amenorrhea

Primary amenorrhea is typically the result of a genetic or anatomic condition in younger females who never develop menstrual periods (by the  age 16) and is not Pregnant. Many genetic conditions that are characterized by amenorrhea are circumstances in which few or all of the  internal female organs either fail to develop normally during fetal development or to function properly. Diseases of the pituitary gland and hypothalamus (a region of the brain which  controls  hormone production) can also cause primary amenorrhea since these areas play a critical role in the regulation of ovarian hormones.

Gonadal dysgenesis, is a condition in which the ovaries are prematurely depleted of oocytes and follicles , leads to premature failure of the ovaries. It is one of the most common cases of primary amenorrhea in young women.

Other genetic cause is Turner syndrome, in which women are lacking part of  or all of  one of the 2 X chromosomes normally present in the female. In Turner syndrome  ovaries are replaced by scar tissue and estrogen production is minimal which  results in amenorrhea. Estrogen-induced maturation of the external female genitalia and sex characteristics also fails to occur in Turner syndrome.

Other conditions that may cause  primary amenorrhea include androgen insensitivity (in which individuals have XY male) chromosomes but do not develop the external characteristics of males due to a lack of response to testosterone ), congenital adrenal hyperplasia and polycystic ovarian syndrome .

Secondary amenorrhea

Pregnancy is an obvious and most common cause of secondary amenorrhea. Further causes are varied and may include conditions that affect the ovaries, uterus, hypothalamus, or pituitary gland.

Hypothalamic amenorrhea is caused  by disruption in the regulator hormones which is produced by the hypothalamus in the brain. These hormones influence the pituitary gland, which in turn sends signals to ovaries to produce the characteristic cyclic hormones. A number of conditions can affect the hypothalamus:

  • extreme loss of weight ,,
  • emotional or physical stress,
  • rigorous physical exercise  and
  • severe illnesses.

Other types of medical conditions which can cause secondary amenorrhea:

  • tumors or other diseases of the pituitary gland that lead to elevated levels of  hormone prolactin (which is involved in milk production) also cause amenorrhea
  • hypothyroidism
  • elevated levels of androgens (male hormones), caused by either from outside sources or from disorders that cause the body to produce too high levels of male hormones;
  • ovarian failure (early menopause or premature ovarian syndrome)
  • polycystic ovary syndrome (PCOS)
  • Asherman’s syndrome, a uterine disease caused from scarring of the uterine lining caused due to instrumentation (such as dilation and curettage) of the uterine cavity to manage postpartum bleeding or infection.

When should I seek medical care for amenorrhea?

It is always appropriate to seek medical attention for amenorrhea that is not related to pregnancy or  menopausal transition ( transition is when there is no menstrual periods for 12 consecutive months) and it must  be further investigated to rule out some serious conditions that may result in amenorrhea.


Treatment of both primary and secondary amenorrhea is determined by the specific cause. Treatment goals can be to relieve symptoms of hormonal imbalance, establish menstruation, prevent complications, and/or to achieve fertility , although not all of these goals can be achieved in every case.

Cases in which genetic or anatomical abnormalities are the cause of amenorrhea (mostly primary amenorrhea), surgery may be recommended.

Hypothalamic amenorrhea that is related to loss of weight, excessive exercise, physical illnesses or emotional stress can typically be corrected by addressing the underlying cause. For example, weight gaining  and decrease in intensity of exercise can usually restore menstrual periods in women who have developed amenorrhea due to loss of weight or  intensive exercise who do not have additional causes of amenorrhea. In some cases, nutritional counseling may be of benefit.

Women with PCOS (polycystic ovary syndrome) may benefit from treatments that reduce the level or activity of male hormones.

Dopamine agonist medications such as bromocriptine  can reduce elevated prolactin levels, which may be responsible for amenorrhea. Consequently, medication levels may be adjusted by the individual’s  physician if appropriate.

Assisted reproductive technologies and the administration of gonadotropin medications (Drugs that stimulate follicle maturation in the ovaries) which can be appropriate for women with some  types of amenorrhea who wish  to become pregnant.

Birth Control

Throughout time people have used birth control methods for many years. In today’s society, medicine has grown miraculously. Which has provided us with many safe and effective birth control methods.

For many of us, finding the proper birth control method is very important to us. When trying to choose, take the time to learn about each method, so it can guide you to make the right decision. Above contains a list of different birth control methods, which will provide you with more information.

Barrier Methods of Birth Control:


Emergency Contraception (EC)

Combined Hormonal Birth Control Methods

Vaginal ring

Contraceptive Skin Patch


Birth Control Injection



The Pap test ( Pap smear) detects cancers and precancers in the cervix (the lower part of the uterus that opens into the vagina). Precancers are cell changes that might become cancer if not treated the right way. Most health insurance plans cover Pap tests or cervical cancer screening at no cost .

What is a Pap test?

A Pap test is to check the cervix for abnormal cell changes. The cervix is the lower part of the uterus (or womb), which opens into the vagina. The cell changes can develop on the cervix if not found and treated, can lead to cervical cancer. Cervical cancer can almost always be prevented by having regular Pap tests .

Why do I need a Pap test?

A Pap test can save your life by finding early signs of cervical cancer. When caught early, the chance of successful treatment is very high for cervical cancer is very high. Pap tests can also detect abnormal cervical cells before they turn into cancer cells. Treating these abnormal cells can help prevent most cases from developing into cervical cancer. Getting a Pap test is one of the most important things you can do to prevent cervical cancer.

Do all women need Pap tests?

Most of the women ages 21 to 65 should get Pap test as part of routine health care. You should have a Pap test even if you are not currently sexually active,. Women who have gone through menopause (when a woman’s periods stop) who are younger than 65 still need regular Pap tests.
Women who do not have a cervix (usually because of hysterectomy), and also who do not have a history of cervical cancer or any abnormal Pap results, do not need Pap tests. Women ages 65 and older who have had three normal Pap tests in a row without any abnormal results in the last 10 years do not need Pap tests.

Who does not need a regular Pap test?

The only women who do not need regular Pap tests are:

Women ages 65 and older who have had three normal Pap tests in a row without any abnormal test results in the last 10 years, and have been told by their consulting doctors that they don’t need to be tested anymore.
Women who do not have a cervix ( because of hysterectomy) and who do not have a any history of cervical cancer or abnormal Pap results.
All women should speak to a doctor before stopping regular Pap tests.

I had a hysterectomy. Do I still need Pap tests?

  • It depends on type of hysterectomy (surgery to remove the uterus) you had and also your health history. Women who have had a hysterectomy should consult with their doctor about whether they need routine Pap tests.
  • If you no longer have a cervix because you had a total hysterectomy for reasons other than cancer, you do not need Pap tests.
  • If you had a hysterectomy because of abnormal cervical cells or cervical cancer,then you should have a Pap test yearly until you have three normal tests.
  • If you had your uterus removed but you still have a cervix ( type of hysterectomy is not common), you need regular Pap tests until you are 65 and have had three normal Pap tests in a row with no abnormal results in the last 10 years.

How often do I need to get a Pap test?

It depends on your age and health history. Consult with your doctor about what is best for you. Most women can follow these guidelines:

  • If you are between ages 21 and 29, then you should get a Pap test every 3 years.
  • If you are between ages 30 and 64, then you should get a Pap test and HPV (human papillomavirus) test together once every 5 years or a Pap test alone once every 3 years.
  • If you are 65 years or older, then ask your doctor if you can stop having Pap tests.
  • Some women may need more frequent Pap tests than others . You should talk to your doctor about getting a Pap test more often if:
  • You have a weakened immune system because of chemotherapy ,organ transplant or steroid use.
  • Your birth mother was exposed to diethylstilbestrol (DES) while pregnant.
  • You have had treatment for abnormal Pap results or cervical cancer in the past.
  • If you are HIV-positive. Women who are living with HIV which causes AIDS, are at a greater risk of cervical cancer and other cervical diseases. The U.S. Center for Disease Control and Prevention (CDC) recommends that all HIV-positive women get an initial Pap test, and get retested 6 months later. If both Pap tests are normal, HIV-positive women can get yearly Pap tests in the future.

How can I prepare for a Pap test?

  • Some things can cause incorrect or false Pap test results.
  • For two days before the test do not:
  • Use tampons
  • Use vaginal creams, suppositories, or medicines
  • Use vaginal deodorant powders or sprays
  • Have sexual intercourse
  • Use Douche

Can I get a Pap test when I have my period?

No. Doctors suggest you schedule a Pap test when you do not have your period. For Pap test the best time is 10 to 20 days after the first day of your period.

How is a Pap test done?

Pap is a simple and quick test ,Your doctor can do a Pap test during a routine pelvic exam. Your doctor will insert an instrument called speculum into your vagina and will open it to visualise your cervix , Then use a special stick or brush to take a few cells from the surface of and inside the cervix. The cells taken are placed on a glass slide and sent to lab for testing. A Pap test may be mildly uncomfortable but should not be painful. You also may have some spotting afterwards.

When will I get the results of my Pap test?

Usually it takes two to three weeks to get Pap test results. Most of the time,the test results are normal. If it is an abnormal test result then your doctor will contact you to schedule more tests. There are many reasons for abnormal Pap test results. Abnormal Pap test results do not always mean you have cancer.

My Pap test result was abnormal What happens now?

It can be scary to know that your Pap test results are “abnormal.” But an abnormal Pap test results usually do not mean you have cancer. Most often there is a small problem in the cervix. If results of the Pap test are unclear or show a small change in the cells of the cervix, your doctor may repeat the Pap test immediately,after 6 months, or a year, also may run more tests.
Few abnormal cells will turn into cancer. Treating those abnormal cells that don’t go away on their own can prevent almost all cases of cervical cancer. If you have abnormal results, talk with your doctor about the details. Your doctor should answer any questions you have and explain anything you don’t understand. Treatment for abnormal cells is often done in a doctor’s office during a routine appointment.
If the test finds more serious changes in the cells of the cervix, then the doctor will suggest more tests. Results of these tests will help your doctor to decide on the best treatment possible.

My Pap test result was a “false positive.” What does this mean?

Pap tests are not always perfect. There is a chance you get False positive and false negative results . This can be confusing and upsetting .
False positive. A false positive Pap test occurs when a woman is told she has abnormal cervical cells, but the cells are not actually cancerous or abnormal. If your doctor says your Pap results were a false positive, then there is no problem.
False negative. A false negative Pap test is when a woman is told her cells are normal, but there is actual problem with the cervical cells that were missed. False negatives delay the discovery and the treatment of unhealthy cells of the cervix. But having regular Pap tests boosts your chances of finding any problems. Cervical cancers usually take few years to develop. If abnormal cells are missed at one time on pap test , they will probably be found on your next Pap test.

How can I lower my chances of getting cervical cancer?

You can lower your chances of getting cervical cancer in several ways:

Getting regular Pap tests. Regular Pap tests help your doctor to find and treat any abnormal cells before they turn into cancer.

Get an HPV vaccine (if you are 26 or younger). Most cases of cervical cancer are caused by a type of HPV that is passed from one person to another through genital contact. Most women never know they have HPV as it usually stays hidden. While it sometimes goes away on its own, it can also cause changes in the cells of the cervix. Pap tests usually detect these changes.

Be monogamous. Having sex with just one partner can also lower your risk of cervical cancer.

Use condoms. Condoms are best way to prevent any sexually transmitted infection (STI), including HPV, the cause of most cases of cervical cancer, is to not have vaginal, oral, or anal sex. Using condoms during sex lower your risk of getting HPV and other STIs. Although HPV can also occur in female and male genital areas that are not protected by condoms, research shows that condom use is linked to lower cervical cancer rates.


Gonorrhea, Chlamydia, and Syphilis

What are chlamydia, gonorrhea and syphilis?

Chlamydia, Gonorrhea, and syphilis are sexually transmitted infections (STI). These three STIs can cause serious long term complications if they are not treated on time especially for teenagers and young women.

What causes gonorrhea and chlamydia?

Both gonorrhea and chlamydia are caused by bacteria. The bacteria passed from one person to another person through vaginal, anal or oral sex. Gonorrhea and chlamydia often occur together.

Where do these infections occur?

Gonorrhea and chlamydia infections can occur in the mouth, urethra, reproductive organs and rectum. In women, the most common place is the cervix (the opening of the uterus).

At what age do these infections most commonly occur?

Although chlamydia and gonorrhea can occur at any age, young women and teenagers who are sexually active are at greater risk of both infections.

What are the symptoms of gonorrhea and chlamydia?

Women with chlamydia or gonorrhea often have no symptoms. When symptoms from either of the infection do occur, they may show up couple days to 3 weeks after infection. They may be very mild and can also be mistaken for a urinary tract or vaginal infection. The most common symptoms in women include the following:

  • A yellow vaginal discharge
  • Painful or frequent urination
  • Rectal bleeding, discharge, or pain
  • Vaginal bleeding between menstrual periods

How are gonorrhea and chlamydia diagnosed?

To find out if you have gonorrhea or chlamydia, your health care professional may take a sample of cells from your throat, cervix, then urethra, or rectum where the infection may occur. Gonorrhea and chlamydia can be detected by doing a urine test.

What are the complications of infection with gonorrhea and chlamydia?
Both gonorrhea and chlamydia can cause pelvic inflammatory disease (PID), an infection that occurs when bacteria move from the vagina into cervix upward to the uterus, ovaries, or fallopian tubes. After a woman is infected with gonorrhea or chlamydia and if she does not receive treatment, it can take anywhere from days to few weeks before developing PID.

How is infection with gonorrhea and chlamydia treated?
Chlamydia and Gonorrhea both are treated with antibiotics. You will need to be retested 3 months after treatment to see if the infection is completely gone.

What causes syphilis?

Syphilis is caused by bacteria. It differs from gonorrhea and chlamydia because it occurs in different stages. It is spread more easily in some stages than in others.

How is syphilis spread?

The bacteria that because syphilis enter the body through a cut in the skin or through contact with a sore from syphilis known as a chancre. Because this sore commonly occurs on the vulva, vagina, anus, or penis, syphilis most often is spread through sexual contact. It can be spread by touching the, warts, rash or infected blood during the secondary stage of infection.

What are symptoms of syphilis?
Symptoms of syphilis differ by stage:

  • Primary stage—Syphilis will first appear as a painless chancre. This sore goes away without treatment anywhere between 3–6 weeks.
  • Secondary stage—The second stage begins as chancre which is healing or several weeks after the chancre has disappeared, when a rash might appear. The rash usually appears on the soles of the feet and palms of the hands. Flat warts may also be seen on the vulva. During this stage, there might be flu-like symptoms. This stage is highly contagious.
  • Latent and late stages—The rash and other symptoms of syphilis will go away in a few weeks or months, but disease still is present in the body. If untreated, the disease may return in its more serious form years later.

How is syphilis diagnosed?

In the early stages of syphilis, discharge from open sores is examined to see if syphilis bacteria are present. In later stages, a blood test can be done to check for antibodies to the bacteria.

What are the complications of syphilis?

Late stage syphilis is a serious illness., neurologic problems, Heart problems and tumors may occur, leading to brain damage, paralysis, blindness, and even death. The genital sores caused by syphilis also make it easier to become infected with and can transmit human immunodeficiency virus (HIV).

How is syphilis treated?

Syphilis is treated with antibiotics. If Syphilis is diagnosed and treated early, long-term complications can be prevented. The length of treatment will depend on how long a person has had the syphilis.

Can these STD’s be prevented?

You can take few steps to avoid getting chlamydia, gonorrhea, or syphilis. These safeguards also help protect against other STIs:

  • By using a condom, both male and female condoms are sold over the counter in drug stores. They will help protect against STIs.
  • Limiting your sexual partners. With more sexual partners you have over a lifetime, the higher your risk of getting STIs.
  • Knowing your partner’s sexual history. And ask whether he or she has had STIs. Even if your partner has no symptoms, he or she still may be infected.
  • Avoiding contact with any sores on the genitals.

Genital Herpes

What is genital herpes?

Genital herpes is a (STI) sexually transmitted infection which is caused by a virus called (HSV) herpes simplex virus. Infection with HSV can cause painful blisters and sores around the lips, genitals, or anus. Sometimes, infection with HSV causes no sores. It is possible to have HSV and not know it. There is no cure yet, but the infection can be managed for some extent.

Is there more than one virus that can cause genital herpes?

HSV are two types that can cause genital herpes, HSV-1 and HSV-2. HSV 2 is the most common cause of genital herpes. HSV-1 usually causes cold sores that appear on the lips, mouth, and eyes, but it is becoming more common especially in young women.as a cause of genital herpes

How common is the herpes virus?

About one in six adults, At least 50 million people in the United States are infected with HSV. Genital herpes is more common in women than in men.

How does infection with the herpes virus occur?

HSV is spread usually through direct contact with herpes sores, usually during oral, vaginal or anal sex. HSV can be present on the skin even if there are no sores. If a person comes into contact with the virus on an infected person’s skin, he or she can become infected from that.

After a person is first infected, HSV stays in the body and It travels to nerve cells near the spine and stays there until something triggers HSV to become active again. When this happens, the virus then travels along the nerves, back to where it first entered the body then causes a new outbreak of sores and blisters which is called as recurrence. The virus can be passed to others during a recurrence period.

How long does it take after infection with herpes virus for symptoms to appear?

When a person is first infected with HSV, symptoms appear about 3–10 days after the virus enters the body.

What are the symptoms of first herpes outbreak?

At first, there may be flu like symptoms, such as fever, chills, fatigue, muscle aches and nausea. Sores may appear as small, fluid-filled blisters on the buttocks, genitals or other areas. The sores often are grouped in clusters, and the areas where the sores appear may be tender and swollen. If sores are on the genitals, a burning feeling or stinging while urinating is common.

The first outbreak of genital herpes may last up to 2–4 weeks. During this time, the sores break open and release fluid. After few days, the sores will become crusted and then heal without leaving scars.

What are the symptoms of recurrent herpes outbreaks?

When an outbreak is about to happen again, there may be itching, burning or tingling near where the virus first entered the body. Pain may be felt in the buttocks, lower back, thighs, or knees. This is called a prodrome. A few hours later, sores may appear. In recurrent outbreaks, usually there is no fever or swelling in the genital area. Sores heal more quickly within 2–7 days in most cases. Recurrent outbreaks usually are less painful. Outbreaks usually are most frequent in the first year after infection. For most people, the number of outbreaks will decrease over time.

Are the symptoms of herpes virus infection the same for everyone?

No it’s not the same for everyone. Many people infected with HSV have no symptoms. When symptoms do occur, they will vary with each person. Some people have painful outbreaks with many sores and Others may have only mild symptoms that may go unnoticed.

How is genital herpes diagnosed?

To diagnose genital herpes Laboratory tests are needed. If sores are present, a fluid sample is taken from a sore. The sample is tested to see if it contains the HSV virus if so, what type of HSV. Blood tests can also be helpful if sores are not present. These tests detect antibodies that the body produces to fight the virus. Blood tests also can show the type of HSV.

How is genital herpes managed?

Antiviral medications which are taken during an outbreak can shorten the length and severity of the outbreak. suppressive therapy Is When taken on a daily basis, they can decrease the number of outbreaks.  In some cases, suppressive therapy can prevent outbreaks for a long time. It also reduces the risk of giving herpes to someone else.

How can I avoid passing the herpes virus to my sexual partners?
If you have genital herpes, you need to take steps to avoid spreading(passing) HSV to your sexual partners:

  • Tell your sexual partners that you have genital herpes. Even if your partners do not have sores, still they may want to be tested. The blood test for herpes can be done when there are no sores are present. You also should tell your future partners of before having sexual contact.
  • It is still possible to pass HSV to someone else even when you do not have sores. The virus can be present on skin that looks normal, including right before and after a outbreak. Using male latex condoms (or polyurethane for those who are allergic to latex) may reduce your risk of passing or getting HSV, but they do not provide complete protection against HSV. Areas of skin which have the virus but are not covered by the condom can still spread the infection. Suppressive therapy can reduce the risk of passing the infection to a partner.
  • Be alert to the prodromal symptoms that signal an outbreak coming. Avoid sexual contact from the time you feel these symptoms until a few days after the scabs have gone away. Wash your hands with soap and water after any contact with sores. This will keep you from reinjecting yourself or passing the virus to someone else.

People with HSV-2 infection have an increased risk of getting (HIV) human immunodeficiency virus if they have sex with a partner infected with HIV. Taking suppressive therapy does not lower this risk.

How can the herpes virus affect pregnancy?

If a woman is pregnant infected with HSV, it can be passed to the fetus during birth through the woman’s infected birth canal. This is most likely to occur if a woman first becomes infected with HSV during pregnancy and in a woman who has her first outbreak during late in pregnancy. But it also can occur during a recurrent outbreak in a woman who was infected before pregnancy, although the risk is lower.

If you already have sores or warning signs of an outbreak during the time of delivery, you may need to have a cesarean delivery to reduce chance of infection to the newborn. The decision depends on many factors, including where the sores are on your body and whether the fetus would come into contact with sores during delivery.

Can I still breastfeed my baby if I have the herpes virus?

Yes, you can, in most cases. The herpes virus cannot be passed to a baby through breast milk. However, the baby could get infected by touching a sore on your body. Make sure sores that the baby could come into contact with are covered when you hold your baby or while breastfeeding. Wash your hands with soap and water before and after feeding the baby. If you have sores on your breast, you should not breastfeed your baby from that breast.

Pelvic Mass


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The field of Urogynecology is dedicated to the treatment of women with pelvic floor disorders such as urinary or fecal incontinence and prolapse (bulging or falling) of the vagina, bladder and/or the uterus.

Urinary incontinence (leakage of urine) is a very common condition affecting at least 10-20% of women under age 65 and up to 56% of women over the age of 65. While incontinence also affects men, it occurs much more commonly in women.

The causes of incontinence are multifactorial and may involve factors both within and outside the lower urinary tract. Urologic, gynecologic, neurologic, psychologic, environmental, and iatrogenic factors may all play a role. Several potentially reversible causes may contribute to transient as well as to chronic incontinence.

Urinary incontinence refers to the inability to stop urine from flowing from the body. It often indicates that the urethra cannot close completely, making it unable to prevent urine from leaking from the bladder.

What is Stress Urinary Incontinence?

Stress urinary incontinence, or SUI, occurs when urine leaks from the bladder when pressure is exerted in the abdominal area. It can occur when the muscles supporting the urethra or bladder have been weakened. It can make it hard to live a normal life; those with this condition have a difficult time doing simple things such as climbing the stairs, laughing, or sneezing without experiencing urine leakage.

It’s nothing to be ashamed of. Just as some lose their ability to see or hear, the urinary tract can stop working perfectly for some people. It is a perfectly natural occurrence and it is no reason to be embarrassed.

Many people think that SUI is a condition associated mainly with aging. This cannot be farther from the truth: SUI affects women young and old. A number of factors could be the culprit, including pregnancy, vaginal childbirth, menopause, gynecologic surgeries, and even strenuous exercise. And, no matter how much you’d want it to, it won’t get better on its own.

Normal urination consider as follow:

The ability to hold urine and maintain continence is dependent on normal function of the lower urinary tract, the kidneys, and the nervous system. Additionally, the person must possess the physical and psychological ability to recognize and appropriately respond to the urge to urinate.

The process of urination involves two phases: 1) the filling and storage phase, and 2) the emptying phase. Normally during the filling and storage phase, the bladder begins to fill with urine from the kidneys.

The bladder stretches to accommodate the increasing amounts of urine. The first sensation of the need to urinate occurs when approximately 200 ml of urine is stored. The healthy nervous system will respond to this stretching sensation by alerting you to the need to urinate, while also allowing the bladder to continue to fill.

The average person can hold approximately 350 to 550 ml of urine. The ability to fill and store urine properly requires a functional sphincter muscle, controlling output of urine from the bladder, and a stable bladder wall muscle (the detrusor muscle).

How SUI is treated:

The good news is that SUI is 85%-90% treatable. Most of those who suffer from it can return to normal, active lives.

After a patient has been diagnosed with SUI through urodynamic testing, all of the surgical options available are discussed. The two most commonly used treatment methods are the sling procedure and the Burch procedure, which are the most effective options available according to the American Urology Association. The urodynamic study and physical examination will determine which procedure is best for each patient.

Mixed Incontinence

Many people have symptoms of both stress incontinence and urge incontinence. This combination is often referred to as mixed incontinence. Many studies show that mixed incontinence is a more common type of incontinence in older women.

Symptoms of Mixed Incontinence

Because mixed incontinence is typically a combination of stress and urge incontinence, it shares symptoms of both. You may have mixed incontinence if you experience the following symptoms:

  • Leaking urine when you sneeze, cough, laugh, do jarring exercise, or lift something heavy.
  • Leaking urine after a sudden urge to urinate, urinating while you sleep, after drinking a small amount of water, or when you touch water or hear it running.

Causes of Mixed Incontinence

Mixed incontinence also shares the causes of both stress incontinence and urge incontinence.

Stress incontinence often results when childbirth, pregnancy, sneezing, coughing, or other factors lead to weakened muscles that support and control the bladder or increase pressure on the bladder, causing urine to leak.

Urge incontinence is caused by involuntary actions of the bladder muscles. These may occur because of damage to nerves of the bladder, the nervous system, or muscles themselves. Such damage may be caused by certain surgeries or diseases such as multiple sclerosis, Parkinson’s disease, diabetes, stroke, or an injury.

Other medical conditions, such as thyroid problems and uncontrolled diabetes, can worsen symptoms of incontinence, as can certain medications such as diuretics.

Diagnosis of Mixed Incontinence

If you have problems with incontinence, it’s important to speak with your doctor, who can diagnose the type of incontinence you have and devise a treatment plan. Your doctor may have you keep a diary for a day or more as a record of when you urinate — purposely or not. You should note the times you use the toilet and the amount of urine (your doctor may have you use a special measuring pan that fits in the toilet seat) and when you leak. You may also record fluid intake.

Your diary entries along with answers to your doctor’s questions will help make the diagnosis. These questions may include:

  • How often do you go to the bathroom?
  • When you get to the bathroom, do you have trouble starting or stopping the flow of urine?
  • Do you leak urine constantly or only during certain activities?
  • Do you leak urine before you get to the bathroom?
  • Do you experience pain or burning when you urinate?
  • Do you get frequent urinary tract infections?
  • Have you had a back injury?
  • Do you have a medical condition such as Parkinson’s or multiple sclerosis that could interfere with bladder function?

Your doctor may also perform a physical examination and look for signs of damage to the nerves that supply the bladder and rectum. Depending on the findings of the examination your doctor may refer you to a neurologist (a doctor who specializes in diagnosing and treating diseases of the nervous system) or perform tests.

These may include:

  • Bladder stress test. Your doctor checks to see if you lose urine when coughing. This could indicate stress incontinence.
  • Catheterization. After having you empty your bladder, the doctor inserts a catheter to see if more urine comes out, meaning you are unable to empty your bladder completely.
  • Urinalysis and urine culture. Lab technicians check your urine for infection, other abnormalities, or evidence of kidney stones.
  • Ultrasound. An imaging test is performed to visualize inner organs such as the bladder, kidneys, and ureters.

If the diagnosis is still not clear, your doctor may order urodynamic testing. This can help provide information on bladder contractions, bladder pressure, urine flow, nerve signals, and leakage.

Another test used to confirm a diagnosis is cystocopy, which examines the inside of the bladder and urethra with a small scope called a cytoscope.

Detrusor overactivity is the most common cause of UI in the elderly, occurring in 40% to 70% of those who present to the physician with complaints of incontinence. Patients with detrusor overactivity have early, forceful detrusor contractions, which occur well before the bladder is full. This creates its clinical hallmark “the abrupt sensation that urination is imminent, whether or not leakage ensues” and frequency. Patients with detrusor overactivity describe frequent losses of small to moderate volumes of urine. The PVR urine volume is typically normal (<51 mL). Detrusor overactivity can be found in conditions of defective central nervous system inhibition or increased afferent sensory stimulation from the bladder. Examples of disorders, which impair the ability of the brain to send inhibitory signals, include strokes, masses (tumor, aneurysm, hemorrhage), demyelinating disease (multiple sclerosis), Alzheimer’s disease, and Parkinson’s disease. Increased afferent stimulation from the bladder can result from lower urinary tract infections (cystitis), atrophic urethritis, fecal impaction, or uterine prolapse. Benign prostatic hyperplasia is a common cause of detrusor overactivity in men. It can also produce symptoms of urinary outflow obstruction. Impaired detrusor contractility alone is an uncommon cause of UI, though it occurs in patients with diabetic neuropathy, spinal stenosis, and spinal cord injury. It has been diagnosed in conjunction with detrusor overactivity in almost one third of nursing home patients. Patients with detrusor hyperactivity with impaired contractility experience urge symptoms, but the PVR urine volume is high (>100 mL).