Tuesday, December 16, 2008

How Pelvic Organ Prolapse Affects Women's Sexuality

I will be giving a talk on January 24, 2009 at Banner Desert Medical Center on this topic. It will review the types of pelvic floor disorders collectively termed "prolapse", and how these afftect female sexuality. It will review what prolapse is, how it occurs, in whom it occurs, how it affects women's intimacy and what can be done about it.

It is sponsored by the Spirit of Women's health series. The fee for whole morning, including two other talks, on boosting immunity and dietary supplements, is $5.

Follow the link here for more info and directions:


Call (602) 230-CARE to register, or call the Spirit office for more information at (480) 512-6205.

Monday, December 15, 2008

Urethral Diverticulum

More on urethral abnormalities.

A urethral diverticulum in women is usually an acquired condition. It is believed to be a gland along the urethra that pushes out and creates an out-pouching. This out-pouching, the diverticulum, may be asymptomatic if small, can contain pus, urinary stones, or even very rarely, a polyp. Regardless, they are believed to form from chronic infection, but remain a relatively uncommon entity.

When large they are palpable on pelvic exam. When present, however, thay usually present with the "Three D's" triad: Dysuria (burning with urination), Dribbling (of urine), and Dyspareunia (pain with sex). Not all three must be present, but a thorough history and physical exam will pick it up. Patients will complain of recurrent UTI's, burning with urination that is not alleviated by antibiotics, pain with sex, urinary stream issues, and the like.

On exam, they may mimic vaginal wall cysts which are congenital. It may simply look like a vaginal wall mass and can be tender. If compressed with a finger during exam, sometimes secretions, such as pus, can be expressed. This would be disgnostic.

If the exam is difficult, or when planning surgery, and x-ray should be obtained and cystoscopy performed.

Some other common symptoms include: irritative urinary symptoms such as frequency and urgency. Dyspareunia is noted in 12-24% of patients, and 5-32% of patients will complain of post-void dribbling. As mentioned, recurrent urinary tract infection is a frequent complaint in one-third of patients. In addition, women may experience pain, hematuria (blood in the urine), vaginal discharge, obstructive urinary flow or inablility to urinate (retention). Stress and urge incontinence may also occur. However, a urethral diverticulum can be asymptomatic in up to 20%.

Sometimes, but not always, during cystoscopy the opening to the diverticulum can be seen within the urethra. Several x-ray tests exist to visualize the diverticulum, but the most reliable is an MRI of the pelvis, which will show the size and location of the diverticulum.

When symptomatic, surgical removal is necessary and is peformed through the vagina.

Friday, December 12, 2008

Urethral Prolapse

It's not quite the same as pelvic prolapse. Pelvic prolapse is the abnormal descent of female pelvic organs into the vagina, or out the vaginal opening. This would include cystocele for the bladder, rectocele for the rectum, enterocele for the small intestine, vault prolapse for the vaginal apex after hysterctomy, or procidentia for uterine descent. It is an abnormal herniation of these organs due to intra-abdominal pressure pushing down on these organs as a result of poor pelvic floor support.

A urethral prolapse, also known as a urethral caruncle, is the mucosal lining of the urethra that protrudes and is visible at the urethral opening. It is not caused by pelvic floor weakness, rather, in women, it is caused by menopause and the low estrogen staus of the vagina and urethra. The prolpase will appear like a small red pimple on the urethral meatus (opening). It is usually of no significance, but its presence indicates hypo-estrogenization.

Uncommonly, it can bleed or cause blood spotting in the urine or cause pain if it gets large. If large, it can cause deflection of the urinary stream. If it doesn't bother the woman, then nothing has to be done. If the vagina is dry already, consideration can be given to applying local estrogen cream to help the prolapse retract and improve the vaginal health. If the urethral prolapse is spotting blood or painful, estrogen cream should be applied. Only when estrogen cream has not worked or if large and painful does the prolapse need to be removed in the operating room.

A urethral prolapse is NOT a polyp of the urethra. Most polyps of the urethra are benign and can be removed surgically. Tumors of the female urethra are rare entities, but present as polyps and are removed as well.

Friday, November 14, 2008

New blog article on Urinary Incontinence

I am now the Urology Health contributor for the Sun Times Online Magazine, which is the online newsletter and blog for the greater Sun Lakes community in Phoenix.

Here is the link to my recent article:


Monday, November 10, 2008

Recurrent Urinary Tract Infections- PART II

What can you do to stop infections? It depends on many things as noted in the previous post on UTI causes.

Often, constipation, diarrhea, IBS can lead to infections. High bacterial counts in constipated women, or constant soiling of the perineum by diarrhea can increase the risk for vaginal contamination by fecal flora. Constant wiping leads to broken skin and local skin infections can occur that lead to chapped and red vaginal skin/labila skin that resembles baby rash. The vagina will burn, become red and warm and very uncomfortable. Urine contact on this type of skin only makes the burning worse. Women will say "it hurts to pee", but what they really mean is the that stream doesn't burn (dysuria), but that the urine contract on the vaginal skin burns them. This can also be true for women who have urinary incontinence where the the constast wetness of the labia from leaking urine leads to baby rash.

Good hygiene seems obvious but maybe hard to control. Frequently sweating, from working out or hot climates can increase the local bacterial counts. Urinating before and after sex and bathing after sex is always a good idea if infections are noted to occur 1-2 days after sex. Use of sexual instruments or anal sex followed by vaginal sex seems an obvious culprit. Using lubrication during vaginal sex helps to prevent small cuts/brakes in the vaginal skin allowing bacteria to enter.

Tampons keep blood and bacteria in the vagina. Switching to pads sometimes does the trick.

Certain foods and medications can raise the pH of the urine or vagina. Acidification of the vagina or urine can be done by avoiding over-douching, or taking urinary acidifiers that can be found OTC.

Vaginal estrogen is a common medication in post-menopausal women, not only to help rejuvinate the vaginal tissue for sex and lubrication, but also preventing UTIs.

These are just some of the tricks that can be tried. There are many other reasons recurrent infections can occur.

Tuesday, October 21, 2008

Updated Website

Our practice recently completed updating our website: www.urodoc.net

It contains a host of information on a variety of different urological conditions, both male and female. In addition, my article from MD News magazine can be found under my profile.

Monday, September 29, 2008

Physician Blogging and Patient Privacy

This is an excellent topic, timely and important. Physician blogging is an excellent and free way for medical information to flow from physicians to the public and/or current/future patients. However, patient privacy is paramount, and as the disclaimer atop this site indicates, this site is for medical information only. It is not for diagnosis or specific medical advice. Comments can be placed, yet any personal issue can be taken care of, or discussed during a private appointment.

Please read this article on physician blogging and privacy:

Our new updated website is nearing finalization and will have some more information on it.

Nevertheless, my office is located at:

Center for Urological Services, P.C.
4545 E. Chandler Blvd, Suite 300
Phoenix (ahwatukee), AZ 85048
480-961-2325 fax

Sunday, August 17, 2008

Article On Urinary Incontinence

I recently had another article published by AZCentral.com/The Arizona Republic in their "Ask The Expert" column. This time it was on Urinary Incontinence.

Read it here:

Thursday, August 7, 2008

Why Do I Keep Getting Infections?

Female urinary tract infections (UTIs) can occur for a variety of reasons. Firstly, it must be determined if the symptoms the woman is experiencing is truly a UTI ir is it something else mimicking a UTI.

Symptoms of UTIs commonly include:

dysuria (burning w/ urination)
pressure suprapubically or bladder ache
urge incontinence
bad urine odor or color
blood in the urine
body aches/chills
back pain
low grade temperature

Some of the frequent "fake outs" mimicking UTIs are:

Overactive bladder
Interstitial Cystitis
Bladder or Kidney stone
Resolved UTI with persistent symptoms
Pelvic Inflammatory Disease
Enlarged uterus with fibroids pushing on the bladder
Bladder polyp
STD's (urethritis)
Urethral Diverticulum

Sometimes, when women complain of recurrent UTIs, it may be that the originial UTI was undertreated with antibiotics (not long enough), or the antibiotic was not strong enough, or perhaps there are other underlying issues predisposing to UTIs (neurogenic bladder, incomplete bladder emptying, pelvic floor dysfunction, kidney stones, kidney or bladder anomalies).

What are common reasons women develop UTIs?

First sexual intercourse
Sexual intercourse in general
Decreased hormone status (post-menopausal, post-hysterectomy)
Incomplete Bladder Emptying
High urine pH

Up Next: What do you do about it.

Tuesday, July 29, 2008


I am participating in and helping to organize a very large and comprehensive Women's Health Event that will take place at Banner Desert Medical Center. There will be a panel of speakers on all topics related to women's health: Me (the urologist), several gynecologists, and a general surgeon. Some of the topics will be:

Breast health
Ovarian cysts
Heavy bleeding
Pelvic pain
Urinary Incontinence
Pelvic Organ Prolapse

Cost: $5. It is free for Spirit of Women members. It will take place from 9am to 12pm. Refreshements will be served and it is sponsored by many industry supporters. It is a phyisican-organized (not industry) event.

Banner Desert Medical Center is located in Mesa at Southern Ave and Dobson Rd. Take the Southern Ave exit from the 101 highway and go east 1 mile.

Call ahead for seating reservations: 602-230-2273

See you there!

Saturday, July 12, 2008

"You're Injecting It Where???"

What happens if a woman has Stress Incontinence and cannot have a sling done? Perhaps there is a history of radiation, multiple failed prior operations, or of the bladder contraction is too weak as noted on urodynamics, then there is another choice.

By the time they come to see me, most female patients want something done about their stress incontinence, since it's bothersome enough to be inhibiting life or lifestyle. Slings are quite minimally invasive with a high success rate and short recivery time, but if they are not indicated. . .

Placing an injection of a bulking material into the urethra is another valid treatment for stres incontinence. Think of it like bulking up someone's facial lips with collagen: they become fuller. So too, the urethra. The product that has been around the longest is Collagen, but it suffers the same fate in the urethra as the lips: the body reabsorbs it rather quickly, usually within 3-6 months, where less than 20% of patients still notice any improvement by 12 months.

Because it is painful, injections are performed under anesthesia. No incisions are made. A cystoscope is placed into the urethra and thorugh a long but ver small needle, the material is injected under the urthral lining.

This is the before image of a female urethra looking through a scope.

This the after image once the collagen is injected under the urethral lining causing it bulk up and occlude the opening.
Other various materials have been designed inorder to improve on the durability of collagen. The ideal agent is biocompatible, cost effective, is not rejected by the body or migrates within the body, is minimally invasive and of course effective.
Durasphere is gel carrier with carbon beads that is injected. Overall effectiveness is not much better. Once injected, the gel is reabsorbed so that bulking volume is lost, and the carbon beads can, though rarely, migrate.
Another agent, Coaptite, is a gel based material, composed of microscopic spherical particles made of calcium hydroxylapatite. It has the consistency of toothpaste and is injected the same way.
At twelve months, about 80% of women are either still dry or "much improved", and fails in about 10%.
The procedure usually takes about 15-20 minutes and its out-patient. Usually between only 2-4 cc of material is needed to acheive an effect. The effect is noted right away.
Most women will experience a little blood in the urine for about 24hrs. Buring with urination is also common for 24hrs. Infection and urinary retention are possible but uncommon.
I have used all three agents and have found the best success with Coaptite. Even in patients with NO bladder contraction on urodynamics, I have had NO patients with prolonged urinary retention (>1week), who have had to self-catheterize themselves after urinating to ensure adequate bladder emptying. I have patients who are more than 2 years out from injection with durable results.
It is not superior to sling in treating Stress Incontinence but it is a nice alternative. One other interesting thing about it is that the procedure can be repeated if incontinence recurs.

Saturday, June 7, 2008

New Video of Dr. Karlovsky describing InterStim therapy

Recently, Banner Health posted a video of me describing InterStim for the treatment of Overactive Bladder.


InterStim is appropriate and indicated for those patients that have failed medications for OAB or cannot tolerate them, in addition to urinary retention not due to obstruction (such as after hysterectomy that leads to a weakened bladder).

Test stimulation is done in hte office and takes about 30 minutes.
Assessment of the device takes 1 week. If patients noted a >50% improvement in urinary frequency, urgency or urge incontinence, then the patient can qualify for permanent implantation.

The permanent implant device is a small, round, smooth battery that resembles a pacemaker, about the size of a half dollar. It is placed under sedation and local anesthesia as an outpatient procedure, and takes less than an hour. It is placed under the skin in the right upper buttock.

Monday, May 5, 2008

Cystocele Images

This is good image of a cystocele seen from the side.

Below is an image of a cystocele seen from the front. It appears to be a grade II.

Cystoceles are graded on a scale of I-IV.

Grade I: Mild bulge with straining only

Grade II: Bulge noticable at rest but not protruding out

Grade III: Bulge is at the vaginal opening

Grade IV: Bulge protruding past the opening.

"Is My Bladder Dropping?"

This is a common question that is asked by many women if they have any urinary incontinence problems.

Urinary incontinence can occur simply on its own as Stress Incontinence (urine lost with excerise or any other activity), or Urge Incontinence (urine lost with uncontrollable urge, Overactive Bladder). Your bladder may be in the normal anatomic position and you may still experience incontinence. This is a totally separate issue, "the leaky faucet" problem, that itself can be treated: see blogs posted below.

"Cystocele" is the term used when the bladder drops from its normal anatomic position. It can occur with incontinence, or on its own. Essentially, the support structures under and next to the bladder become weakened and allow the bladder to push down into the vagina. This leads to a bulge a woman can feel or even see. Many women say they feel they're "sitting on ball", or see something protruding from the vagina. This is more pronounced at the end of the day. If it's uncomfortable, some women will try to push it back in.

Higher grade cystoceles that cause pain, discomfort, or bulge outward and protrude past the vaginal opening should be surgically corrected. Often, many cystoceles are mild and only occur with straining and may not warrant any treatment at all.

Sometimes cystoceles can mask stress incontinence if the urine becomes trapped in the vagina by a kinked urethra, or even have trouble evacuating the bladder leading to a constant sense of urgency and incomplete emptying. Infrequently, this can lead to UTIs.

The most often sited reasons for cystocele formation are: menopause, childbirth, chronic cough conditions (asthma, smoking), and genetic. Sometimes cystoceles occur by themsleves or inconjunction with other organs that protrude from the female pelvis: rectocele (rectum protruding), vaginal vault prolapse, procidentia (uterine prolpase).

Next topic: How do we treat cystoceles?

Saturday, April 19, 2008

Post operative Retention & Urodynamics

One of the less common complications after sling surgery is "post-op retention", essentially, not being able to urinate right away, or rarely, for a awhile.

Hence the use of urodynamics pre-operatively. Urodynamics is like a "stress-test" for the bladder. Instead of getting on a treadmill and running to check your heart, during urodynamics, the patient sits on a commode and the voiding cycle is tested. It usually takes about 20 minutes.

A pediatric catheter is placed into the bladder and another one the same size is placed in the rectum (yes!, but not very far). Also, some patch electrodes are placed on the groin. The bladder catheter serves to fill the bladder and detect bladder pressure during urination, and the rectal catheter assists with the calculation. The patch electrodes help discern if during urination there is adequate sphincter opening or not.

During the test, the patient is asked to cough or strain to provoke a leak to test the "leak pressure".

During bladder filling, the capactiy and compliance of the bladder are gauged.

All in all, its an excellent road map for the urologist trying to determine pre-op parameters in order to help predict outcomes after surgery, or even if surgery should not be done in the first place.

I find it to very useful, and reliable since we have seasoned techs (female) who perform the tests daily.

Getting back to post-op retention. . . As long as the patient has an adequate bladder contraction and voids reflexively (the "normal way") without straining to get the urine out, then post-op retention is unlikely. Factors that can contribute to it include:

Poor bladder functionality/contraction
Strain pattern void
Post op pain
Other simultaneous procedures performed: cystocele repair, vault prolapse repair, hysterectomy
Overtightening the sling
Age > 70 (in my practice)- this doesn't mean these women can't void- but they may need a urinary catheter for a few days to a week or perform self-cath for about he same time until the bladder "wakes up"

Long-term urinary retention after a sling is very uncommon these days. Current mid-urethral slings are placed "tension free"- (hence the acronym TVT= tension free tape) have very low long term retention rates. It also greatly depends on who's doing the sling surgery- to make it "just right"- not too tight or not too loose. Since modern day slings are not stitched or anchored to fascia or bone, retention is uncommon.

Older slings, such as "bone-anchored slings" or pubo-fascial slings" are fixed to structures and require some degree of guesswork/finesse/luck/experience to place it just right.

In terms of TVT-type slings of the modern age, if the sling is SLIGHTLY to snug, women will notice a weakened stream, intermittent stream, incomplete emptying or urgency/frequency. New onset urgency after sling is less than 10%, and the majority do resolve within 3 months. Even a weak stream does improve after 2-12 weeks as the bladder accomodates to the sling.

What if it still too tight?
If after 3 months there are still problems, this can be confirmed by repeat urodynamics, and if the bladder is "obstructed", then the sling should be cut.

Does this compromise the effect of the sling and lead to recurrent incontinence? It can happen in 20-50% of women. The sling should be cut at the 6 o'clock position and allow lateral release of the sling. There should still enough scar laterally on both sides to keep the urethra supported.

It pays to go someone who does MANY.

Coming next. . . .Cystocele (Bladder Drop)

Sunday, April 6, 2008

How Long is Recovery after a Sling?

Sling procedures for Stress Urinary Incontinence usualy take about 20-30 minutes and are performed as an outpatient.

I councel patients to "take it easy" for 72 hours after the procedure. Most women can go back to work thereafter (as long as work is not very physically demanding usually)

I advise patients to not do any heavy exercise for 2-3 weeks (biking, aerobics, spinning, hiking) but walking is acceptable.

No sex, baths or pools for 6 weeks!

If any other vaginal prolaspe problem exists, these can be repaired at the same time. And most are outpatient as well.

A web review of an article I've published

Here is a web review of an article I've published on mesh use in pelvic floor repair by a comprehensive urology website:


It has also been sited as a reference in other publications also reviewing pelvic floor repair and mesh.



Friday, March 28, 2008

Talk on Stress Urinary Incontinence

I will be giving an informal 1 hour talk on female stress urinary incontinence on April 9th at 7pm. It is part of the Chandler Regional Hosiptal "Boomerang" series on various health topics. It is open to public.

It will take place at the Morrison Building on the campus of Chandler Regional Hospital, located at the corners of S. Dobson Rd and Frye Rd in Chandler.

Tuesday, March 11, 2008


My practice is featured this month at the electronic Health Expo hosted by KKNT 960AM.

The site is http://www.azexpocenters.com/

Click on my link to watch a short video of me describing my practice and specialty.

In addition, I will also soon be featured at the Banner Health website in their Ask The Expert video speaking about Interstim and bladder neuromodulation. Update to follow.

What is Female Urology?

This is a good question. For a long time prior to the entrance of women physicians into the field of Urology, a "Female Urologist" was a urologist who dealt with female urological problems, such as urinary incontinence, bladder prolapse, recurrent urianry tract infections, bladder pain, and voiding dysfunction. In some regard, the subspecialty of Female Urology is akin to Urogynecology. Similarities exist and there are some differences.

Urologists graduate from a usualy a 5 or 6 year surgical traininf program after medical school. Usually it is 1 or 2 years of general surgery training and then 4 years of Urology. In addition, after completion of residency, 1 or 2 years of fellowship training is undertaken in the subspeciaty of Female Urology. These programs focus mainly on incontinence, treating complications, complex urodynamic evaluation, prolapse repair with an emphasis on research and publication.

Gynecologists graduate from a 4 year training program. Those that wish to subspecialize under take a urogynecology fellowship that is typically 3 years. They also focus on incontinence, complications, and prolapse.

Fellowships differ widely depending on the interest and focus of the program director, whether urology or gynecology. Certain programs incorporate some technologies or techniques that others don't. Most of us attend the same academic meetings to keep up on the lastest advances and research.

In my practice I incorporate the use of mesh or grafts in order to bolster pelvic prolapse repair such as cystocele, vault repair or rectocele. Often when not used, cystocele will fail approximately 30% by 3 years. Conversely, despite the success of mesh, it can lead to nonhealing in 6-20% depending on the mesh, the surgery and the surgeon. Some pelvic surgeons will use such grafts but many don't. Surgeon comfort level is also important, that is, can the surgeon use such a product well.

Urologists have the advantage of dealing with the bladder from early in training. Treating bladder injury, dysfunction, removal or replacement are standard things learned in training. Gynecologists operate on the vagina and perform hysterectomies. Our two subspecialties crossover somewhere in the middle. In my fellowship I operated with a urogynecologist at least once a week.

Recurrent urinary tract infections, hematuria (blood in the urine), complex voiding dysfunction (as a result of radiation, surgery, or neurological injury), and non-obstructive urinary retention are best dealt with by a urologist who can repair/reconstruct the bladder, urethra, ureters, and remove such organs if required. All things considered, incontinence and prolapse treatment is often the most fun part of Female Urology, and is very often successful if done well by the well-trained pelvic surgeon.

Friday, February 8, 2008

Interstim III

Interstim neuromodulation is a very viable option for refractory overactive bladder symptoms: urgency, frequency and urge incontinence, as well as urinary retention that is not from obstruction.

It just got easier!

Interstim can be placed as a test lead in the office, while awake of course (and with some local anesthesia) as temporary leads. Usualy two are placed, one into each S3 foramen. The lead are superthin and are taped to the skin for easy removal once the test week is over. The leads are connected to the pulse generator box the same way.

This method averts the Stage I procedure which is done in the operating room. If testing is succcessful with the office-placed leads, the patient can skip to Stage II, that is, implantation of the permanent lead and battery generator in the operating room.

It's been around 10 years. About 2/3-3/4 of patients will respond, and can have dramatic improvement in their quality of life because the bathroom is not the main thing they worry about.

More to come. . . Chronic constipation treated with InterStim???