Female Pelvic Medicine Procedures

Vaginal Hysterectomy

A vaginal hysterectomy is the removal of the uterus through the vagina. There is no incision in the abdomen and no need to use a laparoscope. The removal of the uterus includes the cervix and the uterus. The Fallopian tubes and ovaries are not routinely removed in a vaginal hysterectomy. A vaginal hysterectomy is the current clinical standard for the management of uterine prolapse.

Is a hysterectomy required for a prolapse repair?

Not every prolapse repair requires a hysterectomy. A hysterectomy is required in prolapse when the cervix becomes elongated at 5 cm or longer into the vaginal canal. At consultation the need for a hysterectomy is addressed with the help of a handheld mirror.

Is having a hysterectomy a cause of menopause?

No. The uterus does not have a role in menopause. Menopause is caused by the lack of production of estrogen by the ovaries.

Can a vaginal hysterectomy be used for other indications outside of prolapse?

Yes. With a degree of pelvic relaxation a vaginal hysterectomy offers a safe and effective method to treat intractable abnormal uterine bleeding and uterine fibroids. The size of the uterus and the degree of pelvic relaxation determines the feasibility of a vaginal approach for a hysterectomy.

Is the vaginal approach safe for a hysterectomy?

A vaginal hysterectomy offers the lowest incidence of one of the most feared postoperative complications after a hyterectomy, thromboembolic complications (Blood clots). Most patients undergoing a vaginal hysterectomy are discharged from the hospital within 24 hours.

What type of anesthesia is required for a vaginal hysterectomy?

A vaginal hysterectomy can be performed under general, spinal or epidural anesthesia.

Removal of Fallopian Tubes at Time of Hysterectomy

The removal of the Fallopian tubes offer protection against ovarian cancer. The detection of premalignant cells in the epithelia of the fallopian tubes has revolutionized the theories on the genesis of ovarian cancer. Fallopian tube removal has been proposed during surgery for benign disease, for example in women in whom hysterectomy is indicated. Such “prophylactic” or “opportunistic” salpingectomy procedures could prevent carcinoma development in later years.

Cystocele Repair

A cystocele is a distention and detachment of the support of the anterior aspect of the vagina (the roof of the vagina). The most common symptoms of a cystocele is a bulge coming through the opening of the vagina. The bulge is most prominent after physical activity and in the early stages can be associated to urine loss with effort (urinary stress incontinence). As the bulges progresses and becomes larger it causes difficulty to urinate, a sensation of incomplete bladder emptying and urinary retention. The repair of a cystocele is a surgical procedure with the use of absorbable sutures. The procedure is done under anesthesia in an outpatient basis. A cystocele repair is not a cosmetic procedure (anterior vaginaoplasty) , it is a medically indicated procedure intended to resolve the sensation of a vaginal bulge and its associated effects. The recovery requires no strenuous activity for four weeks and no intercourse for six weeks after surgery. The use of a synthetic non-absorbable mesh implant for the treatment of a cystocele has shown to be effective in decreasing a same site recurrence. We do not use transvaginal mesh as it is not available since it was decommercialized.

Rectocele Repair

A rectocele is a bulge through the vagina resulting form the weakness, stretching and distention for the layer of tissue separating the vagina from the rectum. A rectocele can be an isolated problem or it can be associated associated to other types of prolapse, most commonly to a cystocele in about 80% of patient s with a cystocele. I addition to a vaginal bulge a rectocele can present with symptoms of incomplete defecation, the need to assist a bowel movement with pressure in the vagina or perineum, difficult defecation and at times with fecal incontinence. A rectocele repair is an outpatient surgery. It is not a cosmetic procedure or a vaginoplasty (a plastic repair of the vagina), it is a medically indicated procedure intended to resolve the sensation of a vaginal bulge and its associated effects. The recovery requires no strenuous activity for four weeks and no intercourse for six weeks after surgery.

Enterocele Repair

An enterocoele is a bulge through the vagina resulting form the weakness, stretching and distention for the layer of tissue separating the vagina from the lining of the abdominopelvic cavity. An enterocele can present as an isolated type of prolapse defect or it can be associated associated to other types of prolapse, most commonly to a post hysterectomy vaginal vault prolapse. An enterocoele originates in the apex of the vagina and is a frequent cause of post-surgical prolapse recurrences. The repair of an enterocoele is an outpatient procedure almost always done in combination with the repair of other prolapse defects. An enterocoele repair is not a cosmetic procedure, it is a medically indicated procedure intended to resolve the sensation of a vaginal bulge. The recovery requires no strenuous activity for four weeks and no intercourse for six weeks after surgery.

Repair of Post-Hysterectomy Vaginal Vault Prolapse

A prolapse of the vaginal vault after a hysterectomy results from the lack of support in the uppermost position of the vagina. The main symptom is a bulge protruding through the opening of the vagina. The most common clinical symptom is a visible or palpable soft mass in the vagina following a hysterectomy. This prolapse can happen immediately after a hysterectomy or years after. Management includes watchful observation, a pessary or surgery. A pessary is a device used in general gynecologic practice. A pessary is not a cure for prolapse. Surgical management is elected based on impairment of quality of life and symptoms.
The repair of a vaginal vault prolapse include vaginal, laparoscopic and open procedures. A vaginal approach is used in over 80% of the cases. Established laparoscopic, robotic or open approaches include the use of a graft. The current clinical standard for non-vaginal approaches is the use of a polypropylene mesh graft. Transvaginal repairs include the use of sutures, absorbable and non-absorbable.

Complex Urodynamic Testing

Our urodynamic testing unit has been established for almost twenty years. It has performed over ten thousand studies with space, staff and equipment dedicated to the study of voiding abnormalities, incontinence and voiding dysfunction. The unit follows the International Continence Society standards of urodynamic testing with emphasis on establishing a retrievable medical records of the performed studies. The Laborie multichannel system allows for concurrent electromyography during multichannel studies, a feature that has proven useful in the management of voiding dysfunction. A urodynamic study is not painful. Our trained technical staff performs the procedure under direct physician supervision. The procedure begins by instructing you to urinate in privacy on a canister connected to an electronic recording device. The results are transferred using bluetooth technology to our computer. Once the initial portion, called a complex uroflowmetry is completed you will be assisted to be positioned in our comfortable Sonesta urodynamic bed. A small catheter, the size of a No. 8 spaghetti will be inserted in the bladder using lidocaine gel as an anesthetic. A second catheter, of the same size will be inserted into the rectum allowing for the accurate recording of the abdominal pressure. Alternatively, in patients without vaginal prolapse the rectal catheter may be inserted in the vagina. Your bladder will be filled with a physiologic solution and you will be prompted to report the first sensation of bladder filling, the first desire to urinate, the feeling of strong desire to urinate and finally the maximum tolerable volume. The reported volumes are entered in real time on the computerized record. You will be asked to identify the feeling of urinary urgency. Any episodes of spontaneous or induced loss of urine will be recorded. In patients with urinary incontinence the study aims at reproducing the episodes of incontinence to be used in determining the most effective treatment for the type of incontinence defined by the clinical history and confirmed by the urodynamic study. The voiding phase of the study will be done in privacy. Our technician will instruct you to urinate in the cannister with the catheters in place. Once in privacy you will proceed to empty the bladder with the generated data being uploaded in real time to the computer. A measurement of the continence mechanism pressures a the level of the urethra (the tube that brings the urine from the bladder) will be done at the end of the procedure. The results of the study will become part of your medical record, retrievable at the time of consultation.

Midurethral Slings for Urinary Stress Incontinence

A midurethral sling for the treatment of urinary stress incontinence is the most studied and researched continence surgery in history. The material used in midurethral slings is polypropylene, a suture material used in the operating room for over fifty years. The efficacy and durability of a midurethral sling has been established through studies lasting as long as 17 years with cure rates over 85%. A midurethral polypropylene sling is the current clinical standard for the surgical treatment of urinary stress incontinence. A with all implants there is a risk of revision of the implant. The rate of revision at ten years ranges from 0.7%-3%.

Revision of Implant Surgery

Revisions of implants used in prolapse and urinary incontinence are rare. As a matter of comparison the rate of revision for a polypropylene is significantly lower than the rate of revision for a dental, hip, knee or breast implant. In those rare cases in which a revision is required a systematic assessment of the risks and benefits of the revision procedure is required. Any type of revision should be performed by a surgeon with expertise not only in the anatomical site but also on the characteristics of the implants itself. As a general rule, if the surgeon has no experience implanting the device it should not be removing it. Dr. Sepulveda has one of the largest experiences in the world using the different generations of continence devices. New techniques using laser scalpels offer a minimally invasive alternative to those patients requiring a revision. Surgical planning with the use of ultrasound assessment of the devices and its position in the pelvic area will serve the patient and the surgeon well at the time of the surgical intervention.

Management of Recurrent Urinary Tract Infections

A urinary tract infection is an infection of the urethra, bladder and/or kidneys. The most common urinary tract infection is known as an uncomplicated cystitis. Urinary tract infections are clinically identified by the presence of dysuria (pain on urination), urinary tenesmus (a continued bothersome desire to urinate even with an empty bladder), pain in the bladder area and occasionally blood in the urine. Utinary tract infections can be recurrent with a diafgnosis of recurrent urinary tract infections being defined as three urinary tract infections in one year or two in six months. The most common bacteria identified in urine cultures of women with a urinary tract infection is Escherichia coli. E coli is present in the bowel where it plays a role as part of the normal bacterial population in the colon. Our approach to the treatment and resolution of recurrent urinary tract infections includes lifestyle changes, exclusion of clinical conditions that predispose to persistence, treatment of underlying conditions, suppression of persistent bacterial colonization and the treatment of episodic infections in a cost effective manner.

Office Cystoscopy

A cystoscopy is a procedure to look at the urethra and bladder. It consist in the placement of a thin lens attached to a camera and a monitor to facilitate a visual assessment. The procedure is done at the office with the use of an anesthetic lidocaine gel. No systemic anesthesia or sedation is required and there is no downtime. The information obtained from a cystoscopy at the office is used in the management of clinical bladder and urethral symptoms. A cystoscopy is a procedure required in the evaluation of microscopic hematuria (presence of three or more red blood cells in the microscopic analysis of a properly collected specimen of urine).

Management of Chronic and Interstitial Cystitis

Chronic and interstitial cystitis are inflammatory conditions of the bladder characterized by bladder, pelvic pain and urinary symptoms in the presence of a negative urine culture. Our approach to the diagnosis and multimodal management of chronic and interstitial cystitis is done in accordance with the treatments guidelines of the American Urological Association.

Treatment of Chronic Pain of the Vulva-Vulvodynia

Vulvodynia is persistent, constant or episodic pain in the vulva, entrance to the vagina and or clitoral area. The condition may appear spontaneously or associated to chronic pelvic pain, chronic bladder pain or previous surgery. At evaluation we aimed to determine the triggering factors as well as underlying conditions. Most cases of Vulvodynia do not have a single factor causing. The treatment aims at comfort, reduction of impact in quality of life and resumption of social and sexual activities. The management of vulvodynia is multifactorial. Various modalities are used including physical therapy, pain modulators and local treatments. Dr. Sepulveda holds a certification as a Pelvic Rehabilitation Practitioner from the prestigious Herman & Wallace Pelvic Rehabilitation Institute and a subspecialty certification in Female Pelvic Medicine and Reconstructive Surgery. Both certifications have allowed him to help and assist patients and doctors in the evaluation and management of vulvodynia.

Management of Painful Intercourse-Dyspareunia

Painful intercourse is a common condition affecting one in four sexually active women. The clinical presentation of dyspareunia is commonly seen as progressive with those persistent cases seen at dedicated consultations. Frequently dyspareunia can present as the clinical manifestation of an underlying disease such as Genitourinary Syndrome of Menopause, post-surgical abnormal wound healing and pelvic pathology. The impact of dyspareunia in the physical and mental well being can be manifested in an avoidance of intimacy, problems with relationships and isolation. The evaluation of dyspareunia is times at establishing a differential diagnostic list, a process of elimination of clinical causes in an effort to identify a cause and design treatment.

Fistula Repair

A fistula is an abnormal communication between two organs caused by abnormal healing, lack of blood supply or tissue damage. In the pelvis the communication between the bladder and the vagina is called a vesicovaginal fistula. When the communication is between the rectum and the vagina it is called a rectovaginal fistula. The most common cause of a vesicovaginal fistula in the developed world is surgical, most commonly following a hysterectomy. Fistulous defects following a vaginal delivery are the most common cause of rectovaginal fistula. Fistulae are classified as simple or complex depending on size and site. Post surgical and post onsterical fistula respond well two surgical therapy with a high frequency of cure or resolution. The most favorable outcomes are seen when the preoperative surgical planning considers the associated factors into the fistula formation and persistence. Dr. Sepulveda has repaired fistulae for twenty-five years. He has continued his education in fistulae care under the tutelage of world experts from Africa and Egypt though courses sponsored by the International Continence Society at King’s College in London,UK. With his expertise and experience Dr. Sepulveda has help patients and surgeons in this community take care of vesicovaginal and rectovaginal fistulae for decades.

Repair and Revision of Painful Episiotomy

An episiotomy is an incision performed in the perineum (the area between the vagina and the anus) to facilitate the vaginal delivery of a baby. There are two types of episiotomies, midline and mediolateral. The most common episiotomy performed in the US is a midline episiotomy. Midline episiotomies in general heal well and without painful sequaleae. Mediolateral episiotomies are usually larger and require a longer period of healing with frequently seen fibrosis and pain. As in all incisions a risk of scar, deformation and persistent pain exist. The most common complaint after an abnormally healed episiotomy is painful intercourse and an aesthetically unpleasing scar. In rare cases a suture granuloma (abnormal scarring over a partially absorbed suture) may be found to be very tender. The surgical revision of an episiotomy scar requires preservation of the anal sphincter, excision of the abnormally scarred tissue and in selected cases the use of platelet rich plasma (PRP). The use of autologous PRP delivers platelet derived growth factor, vascular endothelial growth factor, epidermal growth factor, insulin-like growth factor fibrin, fibronectin and vitronectin, all naturally produced healing factors when applied at concentrations above the baseline physiologic level.

Anorectal Physiology Testing

Anorectal physiology testing is indicated in patients with defecatory dysfunction. The study assessed the neurologic interaction of the anorectum, rectal capacity, rectal compliance and sphincteric function. Anorectal physiology testing is useful in the evaluation of obstructed defecation, constipation and neurogenic conditions leading to bowel dysfunction. The procedure is done at our pelvic floor laboratory. There is no downtime.

3D Pelvic Floor Ultrasound

A three dimensional evaluation of the pelvic floor is useful in the assessment of the musculoskeletal structures associated to urinary, defecatory and support function. The ultrasound evaluation of the pelvic floor also serves in the planning of a surgical strategy to treat pelvic organ prolapse. Due to its high resolution the evaluation of implants such as meshes is enhanced by a direct visualization of the implant in place. There is no downtime with this procedure which is performed at our office.