Urogynecology Diagnostics

How does our urinary system work?

The body takes nutrients from food and converts them to energy. After the body has taken the food and liquid that it needs waste products are left behind and must be eliminated and are filtered through the urinary system. The urinary system also keeps chemicals, such as potassium, sodium, and water in balance.

• Two kidneys. Their function is to remove liquid waste from the blood in the form of urine, keep a stable balance of salts and other substances in the blood, and produce erythropoietin, a hormone that aids the formation of red blood cells. The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a renal tubule. Urea, together with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney.
• Two ureters. Ureters are narrow tubes that carry urine from the kidneys to the bladder. Muscles in the ureter walls continually tighten and relax forcing urine downward, away from the kidneys. If urine backs up, or is allowed to stand still, a kidney infection can develop. About every 10 to 15 seconds, small amounts of urine are emptied into the bladder from the ureters.
• The bladder is a triangle-shaped, hollow organ located in the lower abdomen. It is held in place by pelvic muscles that are attached to other organs and the pelvic bones. The bladder’s walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. The typical healthy adult bladder can store up to two cups of urine for two to five hours.
• Sphincter muscles. These circular muscles help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder.
• Nerves in the bladder. The nerves alert you when it is time to urinate, or empty the bladder and regulate filling of the bladder.
• This is the tube that allows urine to pass outside the body.

Urodynamic Testing

Intimate Wellness Institute of Virginia uses the most state-of-the-art, research level LABORIE™ multichannel urodynamic testing.  The gold standard to evaluate bladder function and maximize your comfort. This is used to evaluate the bladder itself as well as the urethra, pelvic muscles and nerves.  Most testing includes assessment of bladder filling, emptying, continence as well as correlation with possible pain symptoms.

Why is this test important?

This test is the most objective way to determine the cause of bladder symptoms.  It allows the assessment of the bladder, urethra, abdominal pressures, and pelvic muscles at the same time. This allows Dr. Guerette and his staff to accurately pick the best therapy options for you. Urodynamics can be particularly important if you have complex incontinence symptoms, difficulty emptying your bladder completely, prior bladder surgery, diabetes, or any neurological issues.

How to prepare before your appointment:

• Make a list of any symptoms you’re experiencing. For example, when does urine leakage occur?
• Make a list of any medications, herbs, vitamins supplements you take. Some over the counter supplements can irritate the urinary tract. Also include doses and how often you take medication.
• Prepare a list of questions to ask us. List your important questions first.
• If you take antibiotics daily to prevent urinary infections, continue to do so.
• If you take medicines to calm bladder pain or urgency, please stop taking 5-7 days prior to the test. Common medicines that should be stopped include Ditropan®, Detrol®, Oxytrol®, VESIcare®, Sanctura®, Toviaz®, Enablex, Myrbetriq®, Imipramine, Cymbalta, Pyridium®, AZO, and Uribel.

What to expect:

• No sedation required.
• Empty your bladder normally.
• Urinalysis will be performed.
• A catheter is used to drain the remaining urine, which we then can measure.
• A very small thin tube (catheter), about the diameter of angel hair pasta, will be inserted through the urethra and into the bladder. Another is placed in the vagina and some sticker pads are placed over the pelvic muscles.
• Your nurse will fill your bladder with sterile water and ask questions to see how the bladder responds.
• You will then empty your bladder.

Is it painful?

Testing is not painful; however it may cause some mild discomfort. An anesthetic gel solution is used to numb and lubricate the urethra.  The catheters are very small. You will feel the urge to urinate at the end of the test.

How long will it take?

Our urogynecology diagnostics testing will take approximately 15 minutes.

After the test:

• You may experience slight burning sensation the first few urinations after the procedure.
• If you are irritated, medication is available to minimize these temporary symptoms.

Cystoscopy

A cystoscopy is a simple in-office test that enables us to examine directly inside your bladder through our state-of-the art and very small, high precision WOLF™ flexible scope (less than the diameter of spaghetti). This allows us to directly examine the urinary tract, particularly the bladder, the urethra, and the openings of the ureters (tubes from the kidneys to the bladder). Cystoscopy can assist in identifying problems with the urinary tract, such as, infection, narrowing, obstruction, stones, growths, and bleeding. In addition to allowing visualization of the internal urethra and bladder, the cystoscope, if necessary, enables us to irrigate, suction, biopsy and access these structures with surgical instruments.

Preparing for the test

There is no significant preparation but we ask you to be well hydrated prior to the test.  This shortens the duration of the test to aid in your comfort.  We recommend you drink 36 ounces of fluid within 2 hours of the cystoscope.

Why is this test important?

To investigate and diagnose signs and symptoms of:

• Incontinence
• Overactive bladder
• Frequent urinary tract infections
• Congenital abnormalities of the urinary tract
• Traumatic injury of the urinary tract
• Bladder cystitis
• Pelvic pain
• Bladder pain
• Emptying disorders
• Unusual cells found in urine sample
• Blood in urine (hematuria)

The procedure may also be performed in order to:

• Evaluate problems that cannot be seen on x-ray
• Place ureteral catheters
• Treat urinary tract problems (bleeding, stones, tumors)

During the test:

• No sedation required.
• We lie you comfortably on your back with your knees raised apart.
• Our nurse will clean the area around your urethral opening and apply a local anesthetic.
• Cystoscope will be inserted into your urethra and it will slowly glide up into the bladder (only 3-5 centimeters).
• Sterile water will fill your bladder to view the bladder wall.
• The bladder is filled enough to see the internal structures well but NOT to the point of discomfort.
• As soon as exam is over you will be able to empty your bladder.

Is it painful?

A cystoscopy is not painful; however it might cause some mild discomfort.

How long will it take?

A cystoscopy will take 5 to 10 minutes.

After the test:

• Drink two-8-ounce glasses of water each hour for 2 hours.
• Take a warm bath to relieve burning sensation if needed.
• We may give you an antibiotic to take to prevent infection.

Lower Intestinal Tests

Anal Manometry

FPMI uses, high-resolution, state-of-the-art, Laborie equipment to evaluate the rectum and anus.  Anorectal manometry is an in-office procedure that tests your rectums ability to expand and contract. This is needed to assess fecal incontinence, types of constipation, pain and other problems associated to eliminating waste from your body. It is particularly useful for pre-surgical and post-surgical evaluation of the anal sphincter, anorectal pain, pelvic floor dysfunction, and dyssynergia (incorrect use of the pelvic floor muscles). With the anorectal manometry, Dr. Guerette and his staff will measure the pressures of your anal sphincter muscles, sensation in the rectum, and the neural reflexes that are needed for normal bowel movements.

Anorectal manometry provides us valuable information regarding anorectal function. It indicates the, types of treatment and prognosis of treatment, particularly sphincter injuries, and may be used in our biofeedback treatments.

Why is this test important?

Digestive healthcare is important to us, so we need to measure the pressures of the anal sphincter muscles, the sensation in the rectum, and the neural reflexes that are needed for normal bowel movements.

Some of the common disorders anorectal manometry evaluates are:

• Constipation – Anorectal manometry can identify the cause of constipation in patients with suspected obstructive defecation.
• Fecal incontinence – For women, the pudendal nerve or anal sphincter may be injured, particularly during childbirth, which may contribute to weakening of continence mechanisms.
• Pelvic floor Dyssynergia (pelvic outlet obstruction) – Pelvic floor dyssynergia is the failure of your pelvic floor muscles to relax with defecation. “Paradoxical contraction” refers to an abnormal increase of pelvic floor muscle activity with defecation, rather than the normal decrease in muscle activity that is necessary in order to have a normal bowel movement.
• Reduced rectal sensation – Reduced rectal sensation can be associated with problems associated with abnormally increased rectal compliance.
• Anismus – In patients with anismus pain and the obstruction to defecation is due to failure of normal relaxation of puborectalis muscle and the external anal sphincter during straining. This condition is recognized by physiological measurements which show increased activity in the external sphincter on straining.

How to prepare before your appointment:

• Purchase a Fleet enema at the drugstore, pharmacy or supermarket.
• 2-4 hours prior to your appointment time, give yourself the enema. Try to hold the liquid in for 15 minutes, but if this is not possible, at least 5 minutes is acceptable.
• You should not eat or drink anything 2 hours prior to your procedure.
• There is no recovery or discomfort after the procedure
• You can drive yourself home without assistance after the procedure.

During the test:

• You will lie comfortably on your back.
• A small (1/4 inch in diameter), flexible tube is inserted slowly through your anal sphincter and into your rectum.
• After the tube is in place, the other end is attached to a machine that will record your muscle contractions and relaxation in your rectum and anal sphincter.
• After the measurements have been taken, the tube is then slowly withdrawn.

Is it painful?

No pain and no sedation is required; there is slight pressure as the tube is being inserted.

How long will it take?

An anal manometry test will take only 5-10 minutes.

Pudendal Nerve Terminal Motor Latency Testing (PNTML)

FPMI uses state-of the art pudendal nerve terminal motor latency testing which is the most common test to evaluate the external nerve that controls the pelvic floor muscles, urinary sphincters, and anal sphincter muscle. It may be done following an anorectal manometry.  

What is the pudendal nerve?

Pudendal nerve is a sensory, autonomic, and motor nerve that carries signals to and from the genitals, anal area, and urethra.

What to expect:

• Our staff will perform a rectal exam with a small electrode taped to the finger.
• The nerve inside the rectum is stimulated with a low electrical current and cause the sphincter muscle to contract.
• Our LABORIE™ computer measures how long it takes for the muscle to contract after the nerve is stimulated.
• A few patients do not feel the stimulus.

Is it painful?

No pain associated is with this procedure.

How long does it take?

PNTML testing takes just 2 to 3 minutes.

Endoanal Ultrasound

With our LABORIE™ endoanal ultrasound we use sound waves to generate an image of soft tissues surrounding the anus and lower rectal canal. Dr. Guerette and his staff will use the ultrasound to establish if there are certain anatomic defects, or tears, in your anal sphincter muscles which are often clinically unrecognized and may be amenable to surgical repair.

Why is this test important?

Our Endoanal Ultrasound improves our ability to diagnose structural lacerations to the sphincter muscle. Significant nerve injury to a muscle can also be associated with muscle atrophy and volume loss.   These findings are critical to counselling you on your treatment options.

Preparation (this is most often performed with anorectal manometry):

• Purchase a Fleet enema at the drugstore, pharmacy or supermarket.
• 2-4 hours prior to your appointment time, give yourself the enema. Try to hold the liquid in for 15 minutes, but if this is not possible, at least 5 minutes is acceptable.
• You should not eat or drink anything 2 hours prior to your procedure.
• There is no recovery or discomfort after the procedure
• You can drive yourself home without assistance after the procedure.

During the test:

• Small probe, about the size of your finger, is inserted into the rectum up to about 6 centimeters and slowly withdrawn to obtain the images.
• There is no aftercare.

Is it painful?

No pain associated with this procedure.

How long does it take?

An endoanal ultrasound takes just 1-2 minutes.

Ultrasound Imaging

What is Pelvic Ultrasound Imaging?

Ultrasound is safe and painless, and produces pictures of the inside of the body using sound waves. Ultrasound imaging, also called ultrasound scanning or sonography, involves the use of a small transducer (probe) and ultrasound gel placed directly on the skin. High-frequency sound waves are transmitted from the probe through the gel into the body. The transducer collects the sounds that bounce back and a computer then uses those sound waves to create an image. Ultrasound examinations do not use ionizing radiation (as used in x-rays), thus there is no radiation exposure. Because ultrasound images are captured in real-time, they can show the structure and movement of the body’s internal organs, as well as blood flowing through blood vessels.

Ultrasound imaging is a noninvasive medical test.

There are two types of pelvic ultrasound we use:

• Abdominal (transabdominal)
• Vaginal (transvaginal, endovaginal) for women

A Doppler ultrasound exam may be part of a pelvic ultrasound examination.

Doppler ultrasound is a special ultrasound technique that allows the physician to see and evaluate blood flow through arteries and veins.

 

What type of ultrasound do we use?

With our GE™ 3D pelvic ultrasound, our probes are able to create detailed images of your pelvic floor structures. Our 3D ultrasound distinguishes your pelvic organs, muscle and fascial components. We can identify the urethra, levator ani muscle, pelvic organs, prolapse, and surgical implants used in continence procedures or pelvic reconstructive surgery. This is non-invasive technology that Dr. Guerette and his staff provides to elevate the standard of care for his patients.

What are some common uses of the procedure?

In women, a pelvic ultrasound is most often performed to evaluate the:

• Uterus
• Cervix
• Ovaries
• Fallopian tubes
• Bladder

Ultrasound examinations can help diagnose symptoms experienced by women such as:

• Pelvic pain
• Abnormal bleeding
• Other menstrual problems

And help identify:

• Palpable masses such as ovarian cysts and uterine fibroids
• Ovarian or uterine cancers

A transvaginal ultrasound is usually performed to view the endometrium, the lining of the uterus, and the ovaries. Transvaginal ultrasound also provides a good way to evaluate the muscular walls of the uterus, called the myometrium. Sonohysterography allows for a more in-depth investigation of the uterine cavity. Three-dimensional (3-D) ultrasound permits evaluation of the uterus and ovaries in planes that cannot be imaged directly. These exams are typically performed to detect:

• Uterine anomalies
• Uterine scars
• Endometrial polyps
• Fibroids
• Cancer, especially in patients with abnormal uterine bleeding

We also use 3-D ultrasound to visualize positions of pelvic organs, muscle defects, and foreign objects in the pelvis such as mesh from incontinence and pelvic organ prolapse procedures.

How should I prepare?

You should wear comfortable, loose-fitting clothing for your ultrasound exam. You may need to remove all clothing and jewelry in the area to be examined.

You may be asked to wear a gown during the procedure.

• Have a full urinary bladder.
• 32 to 40 ounces of clear fluid should be ingested one hour prior to your exam, and finished within a 15-20 minute time period.
• Try not to empty your bladder.
• This exam should take 10 minutes.

How long does it take?

Ultrasound imaging may take just 5-15 minutes.

How is the procedure performed?

For most ultrasound exams, you will be positioned lying face-up on an examination table that can be tilted or moved.

After you are positioned on the examination table, the sonographer will apply a warm water-based gel to the area of the body being studied. The gel will help the transducer make secure contact with the body and eliminate air pockets between the transducer and the skin that can block the sound waves from passing into your body. The transducer is placed on the body and moved back and forth over the area of interest until the desired images are captured.

There is usually no discomfort from pressure as the transducer is pressed against the area being examined. However, if scanning is performed over an area of tenderness, you may feel pressure or minor pain from the transducer.

Once the imaging is complete, the clear ultrasound gel will be wiped off your skin. Any portions that are not wiped off will dry to a powder. The ultrasound gel does not stain or discolor clothing.

Transvaginal

Transvaginal ultrasound is performed very much like a gynecologic exam and involves the insertion of the transducer into the vagina after you empty your bladder. The tip of the transducer is smaller than the standard speculum used when performing a Pap test. A protective cover is placed over the transducer, lubricated with a small amount of gel, and then inserted into the vagina. Only two to three inches of the transducer end are inserted into the vagina. The images are obtained from different orientations to get the best views of the pelvic organs. Transvaginal ultrasound is usually performed with you lying on your back, possibly with your feet in stirrups similar to a gynecologic exam.

What will I experience during and after the procedure?

A clear water-based gel is applied to the abdomen. A transducer is moved back and forth over this area until the desired images are captured.

Ultrasound examinations are painless and easily tolerated by most patients.

Risks

For standard diagnostic ultrasound, there are no known harmful effects on humans.

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