John Miklos, MD

Urinary incontinence (leakage) refers to the involuntary loss of urine from the bladder, which constitutes a social or hygienic problem for the individual. Bladder control problems affect about 17 million people in the United States. It can be a cause of anxiety, social embarrassment and may limit ones social and daily activities. Fortunately, most of these conditions can be treated. However the first step to curing this condition is acknowledging the problem and then deciding to see a physician who has been properly trained in treating this condition. 

There are many causes of urinary incontinence. Some of these causes are related to temporary conditions. Once they are treated, the incontinence usually goes away. Temporary causes include: 

Increased dietary intake of caffeine, alcohol, artificial sweeteners and carbonated beverages 

Some other causes of incontinence are not temporary. There is, however, treatment available for many of these conditions. Other causes include: 

Weakness of the muscles that hold the bladder in place 

Weakness of the bladder and or the sphincter muscles 

Overactive or underactive bladder muscles 

Decreases in certain hormones, especially estrogen 

Neurological disorders (ex: Multiple Sclerosis, Parkinson's Disease)  

Urge Incontinence
(overactive bladder, detrusor instability, bladder spasms)

Urge incontinence occurs when someone cannot delay the bladder's message to empty. When this occurs, the person often experiences "the urge" and often the individual can not make it to the restroom on time. This is the most common type of incontinence and is usually readily treated with medication. Patients may experience: 

Difficulty maintaining their urine on the way to the bathroom 

Getting up frequently during the night to urinate 

The need to go to the bathroom at least every two hours

Feeling of a weak bladder or a small bladder



Stress incontinence is the loss of urine during coughing, sneezing, laughing or lifting something heavy. These activities cause an increase in "belly pressure", which forces the urine out of the bladder. Some patients will leak only a few drops while others may leak more than a cup. Stress incontinence occurs almost exclusively in women and is thought to be due to "pelvic (vaginal)
relaxation" from childbirth or aging. Excessive weight can be a contributing factor. Patients may experience: 

Leakage of urine when coughing, sneezing, or laughing 

Frequent trips to the bathroom in order to avoid accidents 

Reluctance to exercise to avoid accidents 

Sleeping through the night but leaking when getting out of bed in the morning 



Overflow incontinence occurs due to an inability to completely empty the bladder. There is a constant or frequent small amount of urine leakage. Essentially, the bladder becomes overfilled and the urine leaks out because the bladder can no longer maintain any more urine. A simple analogy would be like water seeping over the top of a dam because it has met its capacity. Patients may
experience: 

Urinating small amounts and not feeling completely empty afterward 



Many patients have a combination of incontinence types. Especially prevalent are patients with both stress and urge incontinence. These patients experience symptoms of: 

Leakage with cough, sneeze and rise of abdomen pressure 

Leakage which is sudden and with little warning 

Etc. ......please see above for other symptoms



A fistula is defined as an abnormal connection between two organs lined with some type of skin. It most commonly forms between the bladder or urethra and the vagina. Though uncommon in developed countries such as the United States it can occur after surgical trauma, pelvic cancer, pelvic radiation therapy and obstetric trauma. Patients may experience. 

Leakage with cough, sneezing, or rise of abdominal pressure 

All patients should have a comprehensive history and physical examination, which emphasizes the
woman's urogenital tract. A focused physical examination assesses vaginal tissue and neighboring organ support. On a patients' first visit to Dr Miklos' office, some simple, relatively painless tests are conducted and may include the following:

 - a moistened Q-tip or cotton swab is inserted into the urethra. The patient is asked to strain and the change in angle of the cotton swab is measured. The change in angle is proportional to the degree of bladder-neck descent on bearing down or Valsalva maneuver. Although this anatomical defect is associated with stress incontinence it is not diagnostic, and may occur in women with vaginal relaxation without incontinence. 

 - The patient is asked to urinate over a urine catch, which sits on a scale. This test will measure rate of urination, length of urination and whether the urine stream is continuous or intermittent. This test helps determine whether the patient might have an obstruction and interfere with her urinating process. 

 - Upon completion of the uroflowmetry, an ultrasound is performed just above the pubic hairline. This is a quick, painless test that determines the quantity of urine in the bladder. This is helpful in determining if a person empties the bladder completely when urinating. 

 - The patient is then catheterized and the bladder is filled with sterile water via the catheter. The physician can determine if the patient has normal capacity on this filling technique. The catheter is then removed and the physician then asks the patient to cough and strain to determine whether there is stress incontinence. 

 - The urine obtained at the time of catheterization is tested for blood and bacterial infection. 

The physician may recommend other testing or more sophisticated urodynamics to provide for accurate diagnosis and treatment for particular types of incontinence. Advanced Urodynamic testing is usually performed if the patient is not responding to conservative therapy and/or is considering surgery. 

Advanced Urodynamic Testing is a series of tests and/or x-rays that give a detailed look at the function of the bladder, urethra and sphincters. This helps to diagnose any problems with storing urine or voiding. Urodynamic testing involves having a small catheter placed in the bladder (via the urethra), the vagina or the rectum. Most patients consider urodynamic testing painless. 




The bladder is filled with approximately 10-15 ounces of sterile water. Bladder pressures are recorded to determine whether the patient has spontaneous contractions (bladder spasms). After the filling phase the patient is asked to cough and any urine leakage is recorded. Simultaneous coughing and urine leakage is consistent with stress urinary incontinence. 




The final portion of the study involves having the person urinate on a special commode with the catheters still in place. 

The entire test takes approximately 20-30 minutes. Other tests such as leak point pressure and urethral closure pressures are also performed during advanced urodynamic testing.

Copyright ©2000, 2001 Dr. John R. Miklos
All text and images in this article are property of Dr. John R. Miklos and may not be reproduced in any way without permission

Articles

Urinary incontinence (leakage) refers to the involuntary loss of urine from the bladder, which constitutes a social or hygienic problem for the individual. Bladder control problems affect about 17 million people in the United States.

Incontinence

 Pelvic Floor Exercises (Kegel exercises)



This is the exercise which, when done faithfully and correctly, can help decrease the urgency a patient may have and help with both urge incontinence and stress incontinence. The pelvic floor muscle is like a hammock that stretches from the pubic bone in the front to the tailbone in the back. This set of muscles supports the organs of the pelvic region, which include the bladder, large intestines and uterus. Since this muscle is often not exercised, it is generally weak to begin with, which contributes to urinary symptoms. Childbirth will weaken this muscle more because during vaginal delivery, the child's head and body push under the pelvic floor muscle and stretches it extensively which causes temporary additional damage/weakening. Learning to do these exercises can help with incontinence, however to perform these exercises effectively the patient must first identify the correct muscles. 

Two methods of identifying the correct muscles: 

While urinating stop the flow of urine by tightening the pelvic floor muscles. Do not  perform these exercises while urinating, since this can lead to difficulty in voiding. Stopping and starting the stream as a person voids is a popular misnomer and should not be done. Patients may elect to try to stop the stream once or twice to check for contraction of the correct muscle. 

Place a finger in the vaginal opening and attempt to squeeze the finger. Upon squeezing, the patient should feel a tightening around her finger. She has identified the correct muscles that are to be exercised. 

One key point is that patients do not want to use other muscles, such as the abdomen, legs or buttocks. It is important to isolate the muscles only to further increase their strength. If you are moving these muscles or holding your breath, you are probably trying too hard! 

Concentrate just on the pelvic floor muscles and do the best you can. This contraction will get easier with practice. One exercise program is described below: 

Attempt to contract and hold the muscle squeeze for 10 seconds 

Perform 10-15 contractions and relaxation

It may take awhile to work up to a 10 second hold. In the beginning, you will probably not be able to hold for more than five or six seconds and that is all right. Between each contraction, relax for 10 seconds. This allows the muscle to rest adequately to be able to perform well for the next contraction. If you do not relax the muscle well enough, the muscles will tire quickly. By faithfully doing your Kegel exercises, you should see an improvement in your symptoms starting in four to six weeks. 





Vaginal Cones - are miniature weights which are placed into the vagina and help pelvic floor exercises. 






There are several new non-surgical products on the market for female stress
urinary incontinence. Brand names are listed: 

 - This type of device creates enough suction to keep the walls of the urethra together during stressful activities where someone might otherwise leak. The patient places a small amount of Vaseline-like material on the suction cup and places it in the area of the urethral opening, which is just above the vaginal opening. The placement does not have to be exact and once the device is in place the labia fold over it and the device cannot be seen or felt. When the patient needs to urinate, the suction cup is easily pulled off. The device is washed with soap and water and dried and is re-usable. 

 - is an inter-urethral insert. This product requires the patient to insert a small catheter/plug into the urethra (tube that the urine travels through from the bladder to the toilet). These devices are comfortable to wear and when the patient needs to urinate, she pulls on a string, much like a tampon, to remove the device. When finished urinating, a new device is replaced in the urethra. There is a higher rate of urinary tract infections with this product versus the ones listed in the prior paragraph. 

- can also be used for stress incontinence activity based leakage. Placing a tampon in the vagina acts as a support or buttress for the urethra and bladder. Supporting this area can reduce urine leakage with coughing, sneezing, bearing down (Valsalva maneuver) or exercising.


Comparing Sizes - Q Tip, tampon and Reliance® urethral insert.






Collagen is a naturally occurring protein found in humans and animals. When it is injected into the tissue around the urethra, it adds bulk and helps it close tightly to prevent urine leakage, especially urine leakage associated with activity (Stress Urinary Incontinence). Most patients will leak much less or not leak at all after collagen therapy. Some patients will need to have one or more injections done at a later date because the body will absorb some of the collagen material. The length of time between injections varies with each patient. Some need to be re-injected after a few months and some after a few years. 





Collagen Injection - Used for bulking up and tightening the urethra. This is a minimally invasive technique of treating stress urinary incontinence.



More than 150 operations have been described in medical literature for the treatment of Stress Urinary Incontinence. Unfortunately many of these operations, which are commonly performed throughout the world, have very poor surgical cure rates. A common misnomer of surgical cure is the surgeon is performing a bladder tack operation. Actually the goal for most of these surgeries is to stop urinary leakage and this is accomplished by supporting the urethra. The urethra is the tube that allows urine to be expelled from the body. In an attempt to support the urethra, actually the vagina under and beside the urethra is the area which the operation takes place. The two most successful operations described and researched in the literature are: Pubovaginal Sling procedure and the Burch urethropexy (colposuspension) procedure. These two operations are commonly called the SLING and the BURCH procedures. Though some doctors may argue which is the better of the procedures, there are too many variables for this question to ever be answered scientifically. By narrowing the choice to these two operations the patient is getting one of the most successful operations described in the literature. Interestingly, the most common operation still performed in the United States is the anterior repair and/or Kelly plication. 



Anterior repair (colporrhaphy) has been used to treat stress incontinence in conjunction with a bladder and urethra drop (cystourethrocele) for years. Although this operation is commonly used for both incontinence and anterior vaginal wall relaxation, it is probably not the operation of choice for most patients. It is a minimally invasive operation that is done through an incision in the anterior vaginal wall but only has a cure rate of 20-30 % for stress urinary incontinence. The poor cure rate associated with the anterior repair is quite discouraging and often forces a patient to have a second surgery. Most urogynecologists or urologists would not recommend this operation, as their procedure of choice, for cure of stress urinary incontinence. Many surgeons who perform both sling and Burch procedures will choose the most appropriate operation based upon the individual patient's needs and urodynamic testing results. 


A sling procedure is done to create support where the urethra connects to the bladder (a.k.a. bladder neck). A sling is especially effective for the woman who has the diagnosis of Intrinsic Sphincter Deficiency (ISD) where the sphincter muscle is ineffective at holding urine in the bladder during certain "stressful" activities such as coughing, sneezing or exercising. There are many different types of "sling" operations described in the literature. The slings differ in the type of material, sutures, and points of anchoring. The decision on the type of sling utilized is surgeon dependent. The sling is placed under the bladder neck and is secured to a point of attachment (bone, abdominal wall, and ligament) through a vaginal incision. Therefore, when the woman coughs or sneezes, the bladder does not have as much motion now that the "backboard" is in place and so she will not experience any leakage. This procedure is done in the operating room under anesthesia and the patient goes home either the same day or the following day. The most recent efficacy statistics for patients undergoing pubovaginal sling procedures is upwards of approximately 85% for patients who have had the surgery 10 years ago. A sling procedure is considered "curative" for the female patient. 



Dr. Miklos has been trained to perform a number of different types of sling operations utilizing various types of material, sutures and points of anchoring. Currently he chooses to offer his patients an extremely minimally invasive sling operation known as the TVT or tension free vaginal tape sling he learned in Stockholm, Sweden in 1998. This type of sling has been performed in Europe for more than 6 years with great success. Dr Miklos was the first surgeon in the Southeastern United States to perform the operation and serves as a preceptor to teach this operation to Urologists, Urogynecologists and Gynecologists throughout the world. In June 2000, Dr Miklos traveled to Russia to introduce the TVT sling operation to his colleagues at the University of Moscow. Dr. Miklos chooses the TVT sling for his patients because the operation is/has: 

Minimally invasive (two incisions of 1/3 inch on the pubic hairline) 

Minimal pain (40% of patients will not need a pain reliever after 24 hours) 

Same day or next day discharge for 98% of patients 

Performed under local anesthesia and IV sedation 

Minimal postoperative need for catheterization 



First described in 1961, by John Burch this procedure has stood the test of time and is currently considered one of the two most curative operations for the treatment of Stress Urinary Incontinence. It is used for both primary and recurrent stress incontinence and has a cure rate of 80-90%, 5-15 years following surgery. This procedure can be performed through a larger abdominal wall incision (i.e. Laparotomy) or through small abdominal incisions using cameras and TV screens (i.e. Laparoscopy). Despite the surgical approach, or size of incision, the operative technique for urinary incontinence should remain the same. In an attempt to support and stabilize the urethra, sutures are placed in the vaginal wall beside the urethra and anchored to the Coopers ligament of the pubic bone. Routinely, two sutures are placed on each side of the urethra, one at the mid-level of the urethra and one at the level of the urethra bladder junction (i.e. bladder neck). 



Dr. Miklos prefers to use a laparoscopic approach to Burch urethral stabilization. Since 1993, he has performed more than 500 of these operations with minimal complications or blood transfusion. He prefers this method for his patients because it is/has: 

Allows for repair of other vaginal wall relaxation (cystocele, enterocele, uterine, vault prolapse) 

Allows direct access for paravaginal (cystocele) repair---more than 90% of patients with Stress Urinary Incontinence have these defects that should be repaired thereby eliminating a second surgery.

Certain foods and beverages have been shown to contribute to urgency, frequency or urge incontinence. Caffeine and alcohol are big offenders! Many people are unaware of how much caffeine they ingest in a single day. They often just remember the one or two cups of coffee that they drink in the morning, forgetting the cola drink with lunch and the cup of tea in the afternoon. Foods, beverages and products which should be avoided: 

Women with mild or intermittent symptoms may require only reassurance and simple measures such as decreased fluid intake and avoidance of the above irritants. The majority of patients will require further treatment. 



Many patients with urge incontinence often can be treated effectively using medication and bladder re-training. There are a number of medications available to treat urge incontinence. Some of the more common anti-cholinergic or anti-spasm medications are: 

Ditropan XL (slow releasing - one tablet per day) 

Contraindications or reasons why the above medications should not be taken include: 

Acute (narrow) angle glaucoma---untreated 

Estrogen is also considered a helpful medication in the treatment of urinary incontinence. It works by increasing the blood supply to the vagina and urethra making the urethra more substantial and watertight. 



This involves urinating on a set schedule during the day regardless of the need or urge to void. For example, a patient would urinate every two hours during the waking hours. This is an attempt to pre-empt the urge incontinence episodes before they occur. However, there is no goal at increasing the interval between voids. This form of behavioral therapy is useful in older adults or other individuals for whom bladder retraining is not an option. 



Many people with urgency, frequency and urge incontinence can be helped through the use of bladder re-training. Bladder re-training involves urinating on a set schedule during the day. The patient goes to the bathroom by the clock only, not the urge to void. For example, if the patient normally goes to the bathroom every hour or less during the day, they would start this technique by voiding every hour. After one week one should increase the time interval between voids by 30 minutes so one is now voiding every 1 hour and 30 minutes. After one week the interval is increased by another 30 minutes. This exercise is continued until the interval between voids is 3-4 hours. The patient may void at anytime during sleeping hours. This retraining program encourages the bladder to retain more urine without bladder urgency or spasms. 



Patients get the urge to urinate as the bladder signals the brain by sending a message through the spinal           cord. This is just a message about the filling status of the bladder; it is not a direct order to urinate. Believe it or not, a patient can and in fact, should wait, to void. The worst possible time to try to get to the bathroom "in time" is when one really has to go. A lot of people will leak especially the closer that they get to the bathroom. In an attempt to suppress the urge, patients should contract their pelvic floor muscles (i.e. Kegel exercise). Tightening and relaxing the pelvic floor muscle in rapid succession will help until the urge subsides. This will help to kick in a natural reflex that quiets down the bladder. 

Pelvic Floor Stimulation (Electrical Stimulation)



This technique involves stimulation of the pelvic floor musculature using vaginal or rectal plug electrodes. Stimulation of nerve fibers leads to inhibition of bladder contractions. Physicians, Nurse Practitioners, or Physical Therapists that specialize in pelvic floor dysfunction often deliver this type of treatment. 





Electrical Stimulation - Innova electrical stimulation unit (Empi, Minneapolis, MN) 


Electrical Stimulation Application - This illustration shows the electrode in place, within the vagina. The stimulator will pass a mild current of electricity through the electrode which stimulates the pelvic floor muscles to contract. This is a passive way of performing pelvic floor exercises.



Sacral Nerve Stimulation (SNS) is a relatively new surgical procedure to treat urge incontinence that is not responsive to other treatments and therapies. SNS is a two-phase treatment therapy. By stimulating the sacral nerve, the signals that regulate the bladder are better in control and able to allow decreased urgency and more urine to be held in the bladder. This procedure involves having a testing procedure done first to determine the effectiveness of the treatment. 

The testing portion entails placing a small wire into the lower back to the area of the sacral nerve. Once in place, the wire is taped to the person's back and connected to a small portable stimulator unit that is about the size of a pager. The person then keeps a log of their urinary symptoms and voiding episodes to determine if the treatment is effective. After discussion with the physician, the decision to implant the device is agreed upon. 

The surgical procedure for implant of the Interstim® SNS therapy takes about two to four hours. There are two or three incisions: One in the lower back, the other one or two incisions is where the implantable pulse generator (IPG) is placed. The patient stays overnight in the hospital and the device is programmed one week later in the office. The patients use a hand held programmer to increase or decrease the level of stimulation. The stimulation feels like a pulsing or tingling in the rectum or vagina. This procedure is totally reversible if the patient chooses to have it removed. 




SANS UNIT - Percutaneous Ankle Nerve Stimulator



The FDA has recently approved a new minimally invasive method of peripheral nerve stimulation, which affects bladder control. The device works via a needle placed near the ankle about three fingerbreadths above the inside anklebone. The needle ties in with the tibial nerve, which ascends to the sacral (tailbone) nerve complex. The percutaneous Stoller Afferent Nerve Stimulation System (perQ SANS UNIT) is low-frequency electrical stimulation that is applied for 30 minutes once a week for approximately 12 weeks. After this initial trial of therapy, the patient's therapy is tritated from every week to every other or every third week, depending on the patient response. 

Clinical trials have suggested success rates as high as 80%. Success was defined by study design as at least a 25% reduction from baseline in daytime or nighttime frequency. Side effects from the treatment were classified as transient and resulting from insertion of the very fine needle. No serious adverse results have been reported. 


SANS Unit - An acupuncture needle is placed in the nerve behind the ankle and is stimulated to modulate nerve impulse going to the bladder from the sacral nerves. 

Download a SANS Procedure brochure by 

Treatments for Overflow Incontinence Overflow

Overflow incontinence in men commonly occurs due to benign prostate hypertrophy (enlarged prostate). This condition causes obstruction to the urethra and inhibits complete emptying of the bladder. Women do not have a prostate but can have overflow incontinence because of: 

Bladder neck obstruction due to uterine/vaginal prolapse 

Bladder neck obstruction due to strictures (rare) 

Bladder neck obstruction due to previous anti-incontinence surgery

For certain patients, the bladder has limited or no ability to contract to empty. These patients include those who may have neurological diseases as well as other diagnoses. Since the bladder muscle has weakened too much, it is important to empty the urine to prevent either infection or kidney damage as well as decrease the irritative voiding symptoms of frequency and urgency or urge incontinence. These patients learn to catheterize themselves on a schedule usually two to four times a day. They use a small, clear, flexible catheter that is much softer than catheters used in the hospital setting. The procedure is done with clean, not sterile, technique and is best learned by sense of touch and not by use of mirrors. 

Vaginal Prolapse Treatment - Improving Bladder Neck Obstruction



Severe uterine and vaginal relaxation can cause a kinking of the urethra at the bladder neck. These patients will not be treated effectively by urethral dilation. The kinking of the urethra and bladder neck must be removed. This can be accomplished by using non-surgical management (i.e. pessary) or by surgical correction of the vaginal prolapse. The surgery procedure chosen is dependent upon: 

Desire to maintain fertility (maintain uterus) 

This is the exercise which, when done faithfully and correctly, can help decrease the urgency a patient may have and help with both urge incontinence and stress incontinence. The pelvic floor muscle is like a hammock that stretches from the pubic bone in the front to the tailbone in the back.

Incontinence Treatment

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It is easier to understand uterine and vaginal wall relaxation (prolapse) if one has a working knowledge of normal anatomy. The support system of the uterus, urethra, bladder and to some degree the rectum is the vagina, specifically the "fascia". The vagina is a fibromuscular tube (fascia) covered with vaginal epithelium (skin). It is this fascia which is responsible for the integrity and vaginal wall strength. The fascia is the support system of the vagina. This fascia is elevated and suspended and attached to muscles and ligaments of the pelvis. A simple analogy to the vaginal wall, skin and peripheral attachment is the floor you may be standing upon. The integrity, strength or support (fascia) of the floor is the concrete or wood and the carpet (skin or epithelium) on the support is the vaginal epithelium (vagina skin). The vaginal epithelium (skin) very little support function and primarily acts as a covering. 

The floor you are standing, like the fascia, is a complete piece of material which supports anything that sits or stands upon it. The floor, as does the fascia, must be attached to something to give it a point of attachment and further strength. Peripherally the floor is attached to the walls and foundation of the house. Likewise the vagina is attached to certain ligaments and muscles so it remains supportive. 

Anterior vaginal wall prolapse (cystocele and urethrocele) - 

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The anterior vaginal wall supports the bladder and the urethra. The anterior vaginal wall supportive layer is called the pubocervical fascia. It is named based upon its two ends of attachment. It is attached distally to the pubic bone area and proximally to the cervix if the uterus has not been removed. The pubocervical fascia is also attached laterally (on both sides) to the pelvic floor muscles specifically the obturator internus muscle. As long as this vaginal wall stays in place the bladder and urethra will stay in its normal anatomical position. 
Patients with cystocele or cystourethrocele may experience: 

When there is break in the pubocervical fascia there is a loss of support of the urethra and/or bladder resulting in: 

Cystocele: Loss of support at the level of the bladder. "bladder drop" 

Urethrocele: Loss of support at the level of the urethra. Can be diagnosed by doing a Q-tip test and often coexists with stress urinary incontinence.

Cystourethrocele: Loss of support of both the urethra and bladder. These two conditions most commonly coexist. 

To better understand the lack of bladder and urethra support, we need to appreciate the support of those organs by viewing them from an aerial view (i.e. looking downwards on the vagina). Normal support shows the pubocervical fascia (support system of the anterior vaginal wall attached to the arcus tendineus (a tough canvas-like material overlying the muscles) on the pelvic side wall. 

If there is a break in the pubocervical fascia anywhere throughout its length or at its attachment to the arcus tendineus it will result in a lack of support of the bladder or urethra. A break in the pubocervical fascia (support system) can be in the middle of the fascia (midline defect), apically (where anterior vaginal wall meets the cervix) or laterally (paravaginal defect). Surgical correction of cystocele and urethrocele depend upon the specific area of break: 

Midline defects - site specific repair or anterior repair (colporrhaphy) 

Paravaginal defects - paravaginal repair (MOST COMMON) 

Transverse defects - site specific repair 

 Picture yourself standing in the middle of a room, on a wooden floor which is covered with carpet. Suddenly someone cuts a hole in the wooden floor directly beneath you, leaving the carpet intact. Your feet and body would begin to sag into the hole, but you would not fall through because of the support of the carpet. 

This is an example of a midline defect - the bladder falls into the hole or defect of the pubocervical fascia (i.e.. wooden floor). Now the bladder's only support, in this specific area, is the vaginal skin (carpet). The problem or defect here is not the entire floor, it is only the hole in the floor which is directly beneath you. Therefore this is the area or portion of the pubocervical fascia (i.e. wooden floor) which needs to be repaired. 

The surgical repair of this defect can be found under "

Example of paravaginal or lateral defect:

 (MOST COMMON DEFECT) If you were standing on a floor and someone took a saw and cut the attachment of the floor to its wall on each side, the floor would begin to sag. The wooden floor is completely intact without any central or midline defects. Therefore, the problem is not the integrity of the floor directly beneath you, but its attachment to the walls on each side of the room. 

Posterior vaginal wall prolapse (rectocele) - 

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The supportive layer of the posterior vaginal wall is called the rectovaginal septum or rectovaginal fascia. It is attached distally to the perineal body, laterally to the levator ani muscle and proximally to the cervix (if uterus is present). When a break in the rectovaginal septum is present the rectal wall will come into contact with the vaginal skin and create a bulge on the posterior bottom side of the vagina. The bulge will usually increase in size with bearing down (Valsalva maneuver) especially when having a bowel movement. Patients with a rectocele may experience: 

Protrusion coming from the posterior vaginal wall 

Repositioning of body during bowel movements

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The uterosacral ligaments primarily support the upper 20% of the vagina (apex) and the uterus. When the uterosacral ligaments break the uterus begins to descend into the vagina. Further uterine descension pulls the rest of the vagina down resulting in apical tears of the anterior (pubocervical) fascia and posterior (rectovaginal) fascia from its points of lateral attachment. Anterior vaginal wall lateral tears are called paravaginal defects and results in cystourethrocele. Continued uterine and vaginal prolapse can result in a complete uterine and vaginal prolapse such that the uterus falls outside the vaginal opening and the vagina falls inside out. 

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Vaginal vault prolapse usually refers to an apical vaginal relaxation in an individual who no longer has a uterus (post hysterectomy). As the apex of the vagina continues to descend it pulls the rest of the vagina down resulting in apical tears of the anterior and posterior fascia from its lateral points of attachment. Continued descent of the vaginal apex may result in complete eversion of the vagina. Complete eversion of the vagina means that the once highest point in the vagina is now the lowest point hanging out of the vagina.

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Enterocele occur primarily in patients who have had their uterus removed (hysterectomy). The anterior vaginal wall (pubocervical) fascia and posterior vaginal wall (rectovaginal) fascia separate and intestines can push directly against the vaginal skin. The herniation at the apex of the vagina is known as an enterocele.

Patients with a large enterocele, vaginal vault prolapse and uterine/vaginal prolapse may experience: 

Increasing pain/discomfort with prolonged standing 

Decreased pain/discomfort upon lying down 

It is easier to understand uterine and vaginal wall relaxation (prolapse) if one has a working knowledge of normal anatomy. The support system of the uterus, urethra, bladder and to some degree the rectum is the vagina, specifically the "fascia".

Vaginal Prolapse Relaxation

The word Laparoscopy simply means visual examination of the  abdomen by means of a laparoscope. Laparoscopy (often called "belly  button surgery", endoscopy, or key hole surgery) is a surgical technique  involving small incisions in the abdomen through which major surgical  procedures can be performed. One of the incisions is made in the  umbilicus ("belly button"). 

           A laparoscope (something like a small telescope) is placed  through this incision and attached to a small video camera. The video  image is viewed on a television monitor in the operating room. Moving  the laparoscope closer to the pelvic organs magnifies the area under  investigation or operation. Laparoscopy has been around since the 1850's  and has evolved into a surgical technique used primarily for making  diagnosis. In 1989 the world's first hysterectomy was performed using a  laparoscope. Many advanced surgical procedures have been performed and  perfected since that time.

           Dr Miklos utilizes Laparoscopy in uterine removal as well as  vaginal reconstruction and support of the bladder and the urethra.

 - Traditional types of surgery  usually require large abdominal incisions. Laparoscopic procedures are  usually performed through mini incisions. 

 - Most laparoscopic cases are done  as outpatient (< 23 hours). Major operations using a traditional  incision (laparotomy) often require a hospital stay of 3-5 days  

 - Since laparoscopic surgery  does not require the abdomen to be opened with a large abdominal  incision, the patient takes less time to heal, requires less pain  medication and is able to resume a more active lifestyle within a  shorter period of time. 

 - Due to the small  abdominal incision less internal scarring or adhesions can form. These  adhesions can be a source of abdominal or pelvic pain after surgery.  Laparoscopy significantly reduces the scar formation (adhesions) and  internal abdominal pain associated with these adhesions.

All text and images in this article are property of Dr. John R.         Miklos and may not be reproduced in any way without permission

The word Laparoscopy simply means visual examination of the abdomen by means of a laparoscope. Laparoscopy (often called "belly button surgery", endoscopy, or key hole surgery) is a surgical technique involving small incisions in the abdomen through which major surgical procedures can be performed. One of the incisions is made in the umbilicus ("belly button").