Urinary incontinence, pelvic organ prolapse, and other disorders of the pelvic floor affect millions of Americans. When those problems occur, women want to turn to someone whose specialized training and expertise will help them return to normal health as soon as possible.
Dr. R. Keith Huffaker is the region's first fellowship-trained subspecialist in Female Pelvic Medicine and Reconstructive Surgery, also known as Urogynecology.
If you experience...
Incomplete bladder emptying
Pelvic organ prolapse
Urinary tract infections
Other disorders of the female pelvic floor
The Division of Female Pelvic Medicine and Reconstructive Surgery can help.
Getting back to normal with the least invasive path is our main goal for you.No one fully understands all the factors causing incontinence and prolapse, making preventive recommendations difficult. Kegel exercises are possibly the best way to decrease the chance of developing these problems.
Here are some ways you may prevent urinary incontinence and prolapse:
Avoid repetitive heavy lifting
Avoid forceps or vacuum-assisted childbirth
Maintain or return to a healthy weight
If you smoke, quit
Avoid chronic coughing
Consider hormone replacement therapy
We welcome you to call us with any questions you may have about your pelvic health and continence concerns - 423.439.7272.
Urogynecologists specialize in Female Pelvic Medicine and Reconstructive Surgery.
A Urogynecologist is an Obstetrician/Gynecologist who specializes in the care of women with pelvic floor disorders. Some Urogynecologists, such as Dr. Huffaker, completed training in accredited fellowships in Female Pelvic Medicine and Reconstructive Surgery.
The pelvic floor consists of muscles, ligaments, connective tissues, and nerves that help support and control the uterus, vagina, bladder, urethra, rectum, and anus. The pelvic floor can be damaged by childbirth, repetitive heavy lifting, chronic disease, chronic constipation, aging, and many other factors.
Patients with these disorders experience:
Urinary incontinence: Loss of bladder control.
Pelvic organ prolapse: A bulge and/or pressure; dropped uterus, bladder, vagina or rectum.'
Pelvic (or Bladder) Pain: Discomfort, burning or other uncomfortable pelvic symptoms, including bladder or urethral pain.
Overactive Bladder: Frequent need to void, bladder pressure, urgency, urgency incontinence or difficulty holding back a full bladder.
Anal/fecal incontinence: loss of bowel control.
Chronic constipation/inability to empty the rectum
Recurrent urinary tract infections
What Kind of Training Does a Fellowship-trained Urogynecologist Have?
Medical school and a four-year residency in Obstetrics and Gynecology.
Fellowship-trained subspecialists complete an additional three years of training in the evaluation and treatment of conditions that affect the female pelvic organs, and the muscles and connective tissue that support the organs.
Additional training focuses on the surgical and non-surgical treatment of non-cancerous gynecologic problems, as well as contributing research in these areas.
What Treatment Options are Available from a Urogynecologist?
Cure or relieve symptoms of prolapse, urinary or fecal incontinence, or other pelvic floor dysfunction symptoms.
May advise conservative (non-surgical) or surgical therapy depending on your wishes, the severity of your condition and your general health.
Conservative options include medications, pelvic exercises, behavioral and/or dietary modifications and vaginal support devices (also called pessaries).
Biofeedback and Electric Stimulation are treatment modalities that your Urogynecolgist may recommend.
Safe and effective surgical procedures are also utilized by the Urogynecologist to treat incontinence and prolapse.
He or she will discuss all of the options that are available to treat your specific problem(s) before you are asked to make a treatment decision.
Urine leakage is an embarrassing problem that can lead to depression and social isolation. The two main types of urinary incontinence in women are urge incontinence and stress incontinence. Urge incontinence occurs when a woman has a strong urge to get to the bathroom but leaks before doing so, which may happen during the day, at night or both. Stress incontinence occurs with coughing, laughing , exercise, or sneezing, among other activities. Although less common, other types of incontinence exist and can be discussed and treated.
Urinary Urgency and Frequency and Urge Incontinence
A typical woman will urinate up to eight times during a twenty-four hour period including once during sleeping hours. If a person is urinating more often than that, she is said to have urinary frequency. Sometimes, frequency is worse during certain times of day. When a woman has an uncomfortably strong need to void that arises quickly this is called urinary urgency. If she urinates more than once a night and her sleep is being disrupted, this is called nocturia. Women with urgency, frequency, and/or nocturia with or without leakage have overactive bladder symptoms.
Urge urinary incontinence is urine leakage that occurs before a woman can get to the bathroom in response to an urge to urinate. This is usually due to uncontrolled spasms or contractions of the bladder muscle (the detrusor). Various causes of urge urinary incontience exist. Typically, no specific illness is identified. Various treatment options exist.
Stress Urinary Incontinence
Stress urinary incontinence (SUI) occurs with periods of increased abdominal pressure, such as with laughing, coughing, sneezing, lifting, bending, or exercising. SUI is related to loss of support and loss of function of the bladder neck and uretha. These structures act as a valve to keep urine from leaking out when abdominal pressure increases. Loss of this support is often related to childbirth, smoking, repetitive physically-strenuous work, accidental pelvic injuries, or inherited tissue weakness. Sometimes SUI is accompanied by the loss of pelvic organ support, known as pelvic organ prolapse. In these cases, a woman may note a "dropped uterus," pelvic pressure or discomfort, or a vaginal bulge, among other symptoms.
The amount of leakage and associated activities vary. Some leak only with certain specific activites, while others leak with most activities. The volume of urine leakage also varies. Women with more constant or severe leakage or who have had previous bladder or prolapse surgeries may have intrinsic sphincter deficiency (ISD), a severe form of SUI.
Can SUI be treated?
Yes! Multiple treatment options are available depending on the causes and severity.
Pelvic floor therapy, biofeedback, coping strategies and exercises (Kegels) are available to strengthen your pelvic muscles. Biofeedback helps improve pelvic floor muscle control by letting you see or hear when you are using the pelvic muscles correctly.
A variety of surgical repairs exist to support the urethra and/or "bladder neck." Choosing among the different surgical techniques depends on the experience and training of your urogynecologist and the exact nature of your problem. You and your urogynecologist must decide on the specific surgery together.
Several kinds of support devices exist including pessaries, urethral devices and tampons.
Some women find a tampon provides effective support for the urethra, thus improving bladder control.
Urethral devices are placed in the urethra like a cork or plug.
Pessaries for urinary incontinene are silicone rubber devices that are placed in the vagina to support the bladder neck. Most women can learn to care for their pessaries themselves.
You and your Urogynecologist must work together to plan your treatment. Many women choose to try non-surgical options first. When these prove unsatisfactory, surgical options can be explored. Remember, you are not the only one with this problem and that you do not have to "just live with it!"
Will I ever be dry again?
No treatment option is perfect. While most patients can get substantial improvement, some continue to leak but markedly less so. About 75-80% of patients are still satisfied with surgical results 5 years later. Many will continue to do well thereafter. The 5 year mark is a convenient research point. Longer-term studies show the majority of women followed 10 to 20 years are still satisfied.
Dysuria is a pain that occurs while urinating, often due to a urinary tract infection (UTI). Other causes include infection of the urethra (urethritis), herpes, and painful bladder syndrome/interstitial cystitis (PBS/IC).
Some when have trouble starting urination (hesitancy) and/or difficulty emptying the bladder. Urinary control and emptying involve complex interactions of the brain, spinal cord, bladder, urethra, pelvic floor muscles, and connective tissues. Medications can affect control and emptying. Pelvic floor surgery is also a common cause.
Patients who cannot empty may eventually start to leak urine due to overflow incontinence. Patients may have a feeling of lower abdominal or pelvic fullness or bladder pain possibly with frequent, small volume urination as well as leakage.
You may have the condition Pelvic organ prolapse if you are experiencing...
Uterus, vagina, rectum and/or bladder support loss and bulge or fall out of the vaginal opening.
Abdominal, pelvic, or back pain
Heaviness or pulling sensation
Vaginal or pelvic pressure
Difficulty emptying the bladder
Difficulty emptying the bowel and problems with sexual intercourse
A woman with prolapse may describe that she feels like she is "sitting on a ball." The defects are similar to hernias and are called rectocele, cystocele, enterocele and uterine prolapse. Often they occur together.
What will happen if I just ignore this problem?
One of two things will likely happen. The problem will either stay the same or get worse. If prolapse is noticed by a patient soon after having a baby, it will often improve. Otherwise, it is unlikely to do so. The one exception to that rule can occur shortly after having a baby. “New” prolapse (noticed by a patient or doctor in the early postpartum period) will often get better within the first year after the delivery.
Treatment of prolapse is based on a patient's symptoms. Rarely, severe prolapse can cause urinary retention leading to kidney damage or infection. In this case, prolapse treatment is necessary. Patients should be the ones to decide when to have their prolapse treated. If you choose to watch (observe) prolapse, here are some suggestions:
Get yearly pelvic exams and call between visits if you have worsening symptoms. You might also avoid heavy lifting; maintain or return to a healthy weight; quit smoking; avoid constipation; and consider hormone replacement therapy.
Your doctor should measure your prolapse in a systematic way to monitor changes over time.
We understand that surgery is not always the answer.
Deciding to Have Surgery
You, the patient, must decide along with your physician whether or not to have surgery for your bladder, bowel and/or prolapse problems. Every patient's situation is different.
You and your urogynecologist can create a plan that works best for you. This depends, in large part, on your individual problems. Women typically seek treatment whenever theyr symptoms have negative a impact on their lives. Uncontrollable urine leakage, while common, is not something you just have to 'learn to live with it.' Seeking medical help does not mean that you have to have surgery right away. Some women start with conservative treatment like physical therapy. Some later choose surgery; others do not.
Depending on the experience and training of your urogynecologist and the exact nature of your problem, various non-surgical or surgical options may be appropriate. No single operation is perfect for every patient. Some surgical options for various types of prolapse are listed below. Your examination, preferences, expectations, and general medical condition must be considered when choosing among surgical options.
Sometimes, the examination in the operating room is slightly different than the office examination. If so, your urogynecologist may decide to add a procedure during or possibly not do something previously planned. Surgery to correct urine leakage is often performed along with prolapse surgery.
There are two main categories of prolapse surgery:
The goal of all reconstructive surgery is to restore normal anatomy with or without performing a hysterectomy while giving the patient her best chance at normal quality of life including vaginal intercourse. The most important part of a prolapse repair is to restore the support of the top of the vagina. Three common procedures that do this are the sacral colpopexy, uterosacral ligament fixation, and sacrospinous ligament fixation. Repairing an enterocele is often part of these operations.
Anterior repairs (anterior colporrhaphies) correct cystocele (anterior/front of the vagina).
Rectocele repairs (posterior coloprrhaphies) correct rectoceles (posterior/back of the vagina).
Surgery for uterine prolapse is similar to the ones mentioned above for repairing the top of the vagina. They can all be performed with or without the uterus in place. You and your doctor should discuss the reasons for and against hysterectomy at the time of prolapse surgery.
Obliterative surgery closes vagina completely. These procedures are very effective in getting rid of prolapse, but vaginal intercourse is no longer possible. Women must be certain that they no longer want to have intercourse before having one of these operations. These surgeries are typically less invasive and quicker than reconstructive surgery.
The hospital stay usually lasts one to three days. Many women have difficulty urinating immediately after surgery and have to go home with a catheter in place to drain the bladder. These catheters are usually necessary for only 3 - 7 days. Prescriptions for pain medicine will be provided. After surgery, patients should “take it easy” for 6 weeks to allow proper healing. This means no lifting more than 8 pounds (the weight of a gallon of milk), no vaginal intercourse, and no exercise other than walking.
The amount of time necessary for you to "bounce back" from surgery varies by patient and type of surgery. If an abdominal incision is necessary, you will probably have more pain than if your procedure is performed laparoscopically or vaginally. However, some patients are not good candidates for the vaginal or laparoscopic approaches. Again, you and your doctor should discuss this.
Recovery should not be taken lightly. Proper healing is important for good long-term surgical results. This is true even for minimally-invasive prolapse and incontinence surgery.
The goal of continence or pelvic reconstructive surgery is to restore normal anatomy permanently. None of these procedures are successful all of the time. According to the medical literature, failures occur in approximately 5 - 30% of women who have prolapse surgery. If this occurs, it is usually a partial failure requiring no treatment, pessary use, or less extensive surgery. Patients who follow recommended activity restrictions for at least 6 weeks after surgery give themselves the best chance for success.
If you are going to have surgery to correct prolapse, bladder testing (called urodynamics) may be indicated. That's because the prolapsed portion of your vagina may be pushing on your urethra and preventing urine leakage. If so, correcting the prolapse can give you a new problem - urinary incontinence.
If left untreated, pelvic organ prolapse either gets worse or stays the same. The one exception to that rule can occur shortly after having a baby. This will often get better within the first year after the delivery.
Treatment of prolapse should be based on your symptoms. In rare cases, severe prolapse can cause urinary retention that progresses to kidney damage or infection, When this occurs, prolapse treatment is necessary. Otherwise, patients should decide when to have their prolapse treated, based on how much they are bothered by it.
Operations for prolapse and incontinence can be performed with or without a hysterectomy. Hysterectomy is often performed along with these operations for a variety of reasons. In some cases, removing the uterus first makes the rest of the surgery easier. In other cases, there is another reason, such as excessive bleeding, to remove the uterus.
At the ETSU Division of Pelvic Medicine and Reconstructive Surgery, Dr. Huffaker and his staff offer diagnostic studies, minimally-invasive vaginal surgery as well as abdominal and laparoscopic procedures, including:
We perform this procedure in the office for evaluation of certain problems with the bladder and urethra. This test involves inserting a very small camera into the bladder and is usually quick minimal discomfort. Click here to read more.
Available in-office to evaluate the pelvic organs, using the latest in 2-dimensional and 3-dimensional imaging.
Sacral Nerve Modulation
We offer implantable sacral nerve modulation (InterStim). This is for patients who have failed more simple treatments for urinary urgency, urinary frequency, and urinary retention.
Pelvic Muscle Rehabilitation
We offer pelvic floor therapy and biofeedback for your pelvic floor muscles. This can be very helpful and resolve many symptoms without surgery.
Procedures for urinary incontinence
Tension-free vaginal tape
Other advanced urinary incontinence procedures
Vaginal reconstructive surgery
Native tissue repairs utilizing the patient's own tissue and thus minimizing the use of foreign bodies
Restores vaginal anatomy and support for pelvic organs
Prior to your appointment, you may be asked to complete a bladder diary or questionnaire. Please bring this with you to the appointment.
Unless otherwise directed by your doctor, you should take your normally scheduled medications.
You may eat and drink prior to the study.
The series of tests typically take less than one hour.
You will be able to resume all previous activities, including driving, upon complete of the urodynamics studies. Your physician will decide which of the tests are appropriate for you.
Before your test is performed, your urine will be checked for signs of infection. If you have a urinary tract infection, your studies may be cancelled and rescheduled until after your infection has been treated.
Please arrive for the study with a comfortably full bladder.
Plan to arrive about 20 minutes before your scheduled appointment and try not to void in the hour leading up to your study. If you are uncomfortable holding your urine that long, please void and we will modify the test by ﬁlling your bladder with ﬂuid at the appropriate time to ﬁnish your study.
Please call us before your test if you have any questions.
Dr. R. Keith Huffaker, a native of East Tennessee, is the region's first first fellowship-trained subspecialist in Female Pelvic Medicine and Reconstructive Surgery (FPMRS), also known as Urogynecology.
He completed a three-year accredited fellowship at Scott & White Memorial Hospital and Clinic/Texas A&M Health Science Center where he trained with national and international leaders in FPMRS. He received his Doctor of Medicine degree from ETSU's James H. Quillen College of Medicine followed by residency in OB/GYN at the University of Tennessee, Knoxville.
Dr. Huffaker has authored several research manuscripts which have been published in various peer-reviewed journals.
Dr. Huffaker is committed to providing integrated, compassionate care for patients with pelvic floor disorders. He brings expert training in minimally-invasive vaginal reconstructive surgery as well as non-surgical treatment options.
As the region's only major academic health center, we offer in-office cystoscopy, urodynamics, pelvic floor therapy, biofeedback and ultrasound for diagnosing and treating pelvic floor disorders.
We are conveniently located across from Johnson City Medical Center. As the region's only major academic health center, we offer in-office cystoscopy, urodynamics, pelvic floor therapy, biofeedback and ultrasound for diagnosing and treating pelvic floor disorders.