Down There: When You’re Not Talking About Australia!

Posted by Gerard M. DiLeo, M.D. on Oct 24, 2018 5:53:38 PM

The Great Divide. 


There is a great divide that segregates women away from the rest of mainstream medicine. It is a vague dividing line at best, separating what is “down there” from the rest of the female body. Obstetricians and gynecologists have done what they could to obliterate that dividing line by declaring their women’s health specialty a “primary care” specialty. Nevertheless, a vast chasm opens through which many female patients can fall.

For example, when a woman has pelvic pain, she likely will first visit her gynecologist. When this pain, although pelvic, cannot be attributed to any of her reproductive organs, she is typically bounced around from the OBGYN to a urologist, then on to a surgeon, kidney doctor, gastroenterologist, and finally a pain doctor. Herein spins a sad tale of vicious cycles: she sees a “down there” doctor for pain “down there.” When a diagnosis is elusive, the cluster of organs that share the pelvis all weigh in with their respective specialists, and when they come up just as empty-handed, she is sent to a pain doctor for her pelvic pain. Yet, when the pain doctor sees that her pain is “down there,” she is advised to go (back) to her “down there” doctor. One can only imagine the frustration!

Three truisms are at play:

  1. Pain is pain, wherever it is and wherever it originates.
  2. Gynecologists do not specialize in pain.
  3. Pain doctors usually don’t have a consummate knowledge of gynecology.


Another example of the great divide is the extensive overlapping of gynecology and urology. Among the things that are associated with pelvic pain or pelvic floor dysfunction are urinary problems. After all, the roof of the vagina is the floor of the bladder. Some forward-thinking gynecologists have remedied this component of confusion by incorporating urogynecology testing within their gynecology practices—in their offices, by the very personnel you have come to trust and with whom you have come to feel comfortable. In a GYN practice in which there is no urology testing, more truisms become evident:

  1. Your urinary tract and organs are intimately associated with your reproductive organs.
  2. Due to the overlap of urological and gynecological function and dysfunction, gynecologists who do not incorporate urological testing in their offices may not be providing complete gynecology.
  3. A woman will not likely go to a strange physician (when referred away from her gynecologist to a urologist): thus, problem will remain undiagnosed and persist.


It takes one to know one.

 Unless a gynecologist and a urologist are both telepathic, each will evaluate a woman differently. The gynecologist will evaluate her for GYN problems; the urologist will evaluate her for bladder or other urological problems. But she is the same woman.

A gynecologist who understands and can apply urological concepts to the pelvis and reproductive organs, however, will sum up a conclusion that is more than the mere addition of the parts. This is a holistic approach, and it makes evaluation more thorough, accurate, and intuitive to your doctor. Clearly there is a holistic advantage to being evaluated by the combined GYN-urology approach that in-house urologic testing offers in the intimate world of gynecology.


The second-busiest part of the body: the pelvis.

 Your brain is the busiest part of your body, easily concluded by its need for a fourth of the total glucose needed for the energy it consumes. Next comes your pelvis, though. Consider this—your pelvis has the following systems within it:

  • A large part of your intestinal tract, including much of the small intestines (and appendix) and your entire rectum.
  • Your bladder and the lower part of the urinary tubes running urine to it from your kidneys.
  • Your uterus, tubes, and ovaries.
  • A complex muscular system that controls urinary and anal sphincter continence as well as maintains tone to participate in sexual activities.


All of these systems talk with each other, and when one begins to squawk they can all get going, which contributes heavily to the vicious cycle of doctor-hopping. A physician who can see the big picture can go a long way toward limiting this cycle. When urological testing is incorporated into the usual goings-on of a gynecology practice, there are tangible benefits. It means that the urological and gynecological systems, in spite of their overlap, can be considered holistically, as explained above. This portends well for good care, because it is the natural state of things.


The intangible benefits.

Besides the clinical superiority of combining approaches to pelvic problems by including both GYN and urology, another important aspect of personal medicine is realized: a patient will go to the doctor with whom she has already built a trusting relationship and will be amenable to exploring the urology aspects of her problems with this same physician, not some stranger to whom she might otherwise be referred. There is no understating the importance of this intangible benefit to you: there can be no diagnoses or therapy without the opportunity for a patient to be evaluated. 

 Gynecologists that offer urodynamic testing eliminate an obstacle to your being evaluated, diagnosed, and adequately treated by keeping this additional aspect of women’s health in-house for you.


Two specialties, one window; many complaints, one body.

 The vagina is a portal that has other portals. Your gynecologist can approach not only your gynecological and reproductive systems through it, but also your urological status as well as the entire pelvis, which is nothing more than the lowermost part of the entire abdomen. Just like pelvic organs can talk with each other, so can abdominal organs, so pain in areas near the liver, gall bladder, stomach, spleen, and pancreas may mislead a non-gynecologist with false clues.

To illustrate the interrelations between the numerous pelvic/abdominal organs, consider this:

 Women with chronic pelvic pain, by percentages, will also complain of the following:


  • Painful bladder syndrome: 20%.
  • Painful sex: 80-90%.
  • Irritable bowel syndrome 40%.
  • Migraine headaches: 40%.
  • TMJ (temporomandibular joint disorder): 40-50%.
  • History of childhood sexual abuse: 40%.
  • Depression: 30%.
  • Other issues, including fibromyalgia and social anxiety disorder:10-20%.


Thus, it is easy to see that everything is connected, from the bladder to the brain, anatomically, physiologically, and psychologically. It is also easy to understand how unless a woman is evaluated by a team, especially the more overlapping are the symptoms, it becomes more likely she will fall through the great divide identified above. Unfortunately, there are no combined gynecologist-urologist-gastroenterologist-psychiatrist-neurologist-ENT doctors. While that would be ideal, the days when one person can know everything died in the Renaissance. Still, of all of these related complaints, no two are more intimately associated than the systems accessible through the vagina: again, the gynecologist who does urological testing as part of his or her practice.


Urodynamic testing.

What exactly can a gynecologist offer—urology-wise—in the GYN office? 90% of the preliminary explorations into urological complaints can be done by your familiar gynecologist and staff. Two types of urinary incontinence require accuracy in diagnosis, for one type can be treated medically and the other surgically. It is important to know that you won’t have an operation to fix a problem that can be fixed with medicine. Unnecessary surgery is a mistake that can happen when urologic testing is not done for urinary incontinence. Alternately, taking medicine for something that can only be fixed mechanically with surgery will waste your time and expose you to side effects unnecessarily. How can your gynecologist tell the difference?


  • Physical exam.                                                                                                                                                                     Simply observing how the support for your urethra—the tube from which urine exits—changes with bearing down can help identify when that support is distorted by this action. This is the actual beginning of urodynamic testing because it is the first appraisal of how your urinary tract actually functions—live and in person! Urinary continence depends on the integrity of your sphincter intactness, and when distortion of the anatomy weakens that integrity by shifting forces abnormally, urine will leak. This is a mechanical problem that can only be fixed mechanically—that is, remedied surgically—to reinforce that sphincter integrity by assuring the anatomical support, even when stressed by laughing, coughing, sneezing, or straining.


  • Urodynamic testing.                                                                                                                                                               This is the ultimate deciding factor. Anatomy is one thing, but the bladder is also controlled by a complicated balance between two different nervous systems—the sympathetic and the parasympathetic nerves of your autonomic nervous system. The urge to urinate is stimulated by pressure against the bladder walls, and the nerves stimulate the smooth muscle of the bladder to contract and the sphincter to relax. Any hypersensitivity or hyposensitivity of the nerves can interfere, causing urge incontinence, stress incontinence, or even urinary retention. Worse—and where urodynamic testing is most helpful—is when there is a mix of anatomical and neurologic problems. The more complex the problem, the more is necessary complete information.


What is involved in urodynamic evaluation?

 In the privacy of your doctor’s office there are electronic devices that can measure the pressures in your bladder when it is full and when you have the urge to urinate. These measurements are recorded and the patterns evaluated that indicate in what ways you may be experiencing problems. Forewarned is forearmed: one can easily appreciate how being informed on the front end can help the therapeutic process throughout the treatment, whether it be by physical therapy and Kegel’s exercises, medication for your autonomic nervous system, surgery, or all in a combined approach when there is a complex assortment of co-morbidities.


Is it uncomfortable?

 Think about what is done in the GYN office and how special instruments, tables/stirrups, and methods are used to make what could be an uncomfortable experience a routine part of a healthy lifestyle. This is why when something like urodynamic testing is offered by your gynecologist, the same mindset that wants you to leave the office unscathed by gynecology also wants any other testing offered to be easily tolerated. When an office is geared specifically for these purposes, smooth applications of these diagnostics can occur for you.

Truth be told, no one really wants her urethra or bladder manipulated or even brought up, but when troubling urinary abnormalities interfere with a quality of life, giving in to the testing needed is not so bad when your doctor’s office is outfitted with the right equipment, his or her staff trained thoroughly, and when comfort is considered an integral part of the methods used. You must remember that your doctor and the staff want you to remain a happy patient, and you’ll be pleased to know that the technology used for urodynamic testing has been designed with the same mindset your gynecologist uses with all of the other things done in the office, from pregnancy and obstetrics to gynecological evaluations.


When is it time to ask about urodynamic testing?

 Actually, your doctor will probably be asking some leading questions that will be a tip-off. Your answers and other information you volunteer, however, can start you on the recovery process from even the most troubling urinary signs and symptoms:


  • Stress incontinence: losing urine when you laugh, cough, or sneeze.
  • Urge incontinence: losing urine when you can’t make it to the restroom in time. This is a result of nerve dysfunction and can be treated with medications that affect the autonomic nervous system.
  • Urinary retention: inability to completely empty your bladder. This also is a result of nerve dysfunction and can be treated with medications that affect the autonomic nervous system.
  • Urinary frequency: this can result from any of the above bulled points but can also be due to over-hydration, the cure for which is limiting fluids in the presence of proven normal urodynamic results. Occasionally, it can be due to hormonal abnormalities or by overuse of diuretics (“fluid pills) used for hypertension or swelling (edema). Infections can also be the culprit as well (as below).
  • Frequent urinary tract infections: the human body hates standing water, be it behind the eardrum of a child or in your bladder. When it happens, it can be a site in which bacteria can colonize and cause an infection. You may not even know you have urinary retention except for frequent urinary tract infections, which is not normal.
  • Pelvic pain due to painful bladder syndrome: pelvic pain can be caused by any number of your body’s systems, isolated or in combination; but one in particular causes what is called “painful bladder syndrome,” or PBS. With PBS, there is a low-level baseline pain all of the time, which peaks with urination or a full bladder. No one knows for sure what causes this, but it probably has something to do with an exaggerated permeability of your bladder wall to chemical mediators of pain that normally are quiet unless there is injury.
  • Painful sex: called “dyspareunia,” this may be due to the mechanical striking of the bladder during intercourse. In such cases, there may be prolapse of the bladder which causes it to lose its anatomical support, hanging like a punching bag for whatever may be coming its way (discrete reference intended).
  • Other painful bladder symptoms, due to urinary tract infections, which can be treated with antibiotics, or cases of “sterile cystitis,” which can respond to anti-inflammatory medications. (It is noteworthy, especially with this particular bullet point, that there is considerable overlap of signs and symptoms in the urinary tract.)
  • Fecal incontinence: losing feces or gas when you laugh, cough, or sneeze. This is a surgical problem, but diagnosis requires the use of rectal manometry, part of the testing that can accompany urodynamics.


 “Down there”

 The vagina is a natural point of weakness. It may seem ugly to compare it to a hernia, but over time, support for the structures associated with the vagina (bladder, rectum, and even the uterus when prolapsed) can distort and weaken to muck up the works. With normal aging, gravity takes its toll. With straining—from constipation to childbirth—damage to the integrity of the connective tissue fibers can occur. Even simple things, like lifting grocery bags, pulling open the garage door, or even slamming that tennis ball for a winner, can summate over time to cause a cumulative weakening of this area. Gravity is augmented by the extra weight of early pregnancy or uterine fibroids which can cause complete pivoting of the uterus, distorting the anatomy of everything else around it.

 Our species was never meant to get past the age of 40, so things like coronary artery disease, menopause, and—yes—urinary problems associated with support issues are new to us from an evolutionary standpoint. Luckily, our big brains have come up with ways to cope with, if not completely remedy, these wear-and-tear failings. Such remedies, however, must have a direction, and urodynamic testing is crucial for that direction. The fact that it is now offered in the comfort-conscious atmosphere of your trusted gynecologist is a bonus!


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Topics: Urodynamics Testing, UroGynecology

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