Monthly Archives: July 2014

Bladder lifts 101

As I await my surgery this morning, which is a biological graft bladder lift, I thought I would take the opportunity to discuss bladder lifts.  What they are and the various options.

As we age, and especially if we have had vaginal deliveries, the bladder can start to fall.  The ligaments that surround the bladder get stretched out and the vaginal wall isn’t strong enough alone to support the bladder anymore.  This is called a cystocele.  It is sort of like a hernia in the vagina.

The symptoms may be a bulging in the vagina, a feeling that you are sitting on a ball, difficulty emptying your bladder, recurrent urinary tract infections, and some women even have to push their bladder up to be able to empty it.  We fix it when it the bulging becomes too great a bother, the bladder cannot empty well at all, or there are a lot of bladder infections.

The first thing we’ll try is a pessary.   This is like a donut that we can insert in the office that will literally push the bladder up where it belongs.  When fitted properly, it will stay in place but you won’t be able to feel it.  This can be a long-term solution or a temporary measure until surgery.   The maintenance on it is to come in to the office every 8 weeks to have it cleaned and to check the vaginal walls.

Surgically, there are four main options:

  1. Traditional tissue plication.  This is the old-fashioned lift where we simply stitch the walls of the vagina tighter to make a shelf for the bladder.  It works for a lot of people, but the failure rate is reported in some studies as high as 40%, so that’s why we started looking for other alternatives.   You may know someone who has had numerous bladder lifts.  It is still an option, however, and is done quite frequently.
  2. Biological graft placement.  This procedure uses tissue that has been processed to make a supportive sheet about 3X4 inches in size.  The two main ones that I use are Xenform, which is made from calf skin and looks like a sheet of pure collagen, and Repliform which is made from human cadaveric skin.  The cells are taken out of the graft to make it just a sheet of collagen and to prevent spread of any disease at all.  These grafts supplement your natural tissues which have been proven to be weak.  I put these in with a vaginal procedure.
  3. Mesh graft placement.   Mesh??   “The mesh from those lawyer commercials?”  Yes, the mesh from the commercials. It is still a good option.   There have been no recalls of mesh at all.   It does have to be done properly, and I reserve it for the patients who have failed other techniques.   Having done hundreds of mesh implants, I can tell you that it works very well and patients do well.  It’s not perfect, but, then again, no surgery is.
  4. Robotic bladder lift.   This procedure is approached from above with scopes through the abdomen, in contrast to the other three methods which are all done through the vaginal wall.  This method is usually done in conjunction with the gynecologist doing a hysterectomy.  The robot helps me sew the mesh onto the vagina more efficiently and precisely.

All of these surgeries typically involve one night in the hospital and low levels of pain.  You do have to avoid heavy lifting or heavy exercise for about six weeks afterwards while you heal.

And there you have it.  I use all of these options regularly.  It just depends on the patient: how bad the cystocele is, her age, prior surgeries, the health of the vaginal wall.  That’s where I spend time getting to know you, evaluating you and what you need.

Please call our office if you would like a consultation about your bladder:  281-717-4003.   This is what we do!



What IS Female Urology????

When I first signed up for a urology rotation in medical school, I thought I was going to spending the next 6 weeks seeing old men with prostate cancer.  I really was not interested in urology at that time, but I needed something to fill my fourth year schedule. What I really wanted to do was anesthesiology: putting in IVs and breathing tubes, lots of fun procedures.

But, the anesthesia rotation was already spoken for. So, now what? Well, I was planning to be a gynecologist, so I thought, well, at least if I do urology, then I’ll get more exposure to the pelvic anatomy. Get a refresher course on all the blood vessels and structures. That will be helpful, right? Even if it is just old men and their prostates.
Well, I couldn’t have been more wrong. Even then I didn’t realize just how wrong I was. Now as I sit here practicing not just urology, but 100% female urology, it is ironic that I thought that it was only prostates!
Of course, urology does encompass prostates in men. It includes everything in the urinary tract from the kidneys through the bladder and out the urethra. Urologists have medical treatments and all kinds of surgeries to treat patients. We treat patients from birth through death, men and women, boys and girls for everything from bedwetting to terrible cancers. It is a great variety surrounding that one part of the body. That’s the reason I fell in love with urology and switched from my pursuit of gynecology.
Female Urology, of course, focuses on the female urological tract. We don’t have prostates, so we don’t need to worry about that (thank God!), but we do have other issues. The most common issue that we have is overactive bladder and incontinence. God made us with short urethras (the pipe that the urine comes through) and a big opening in our pelvis muscles to allow us to have babies. If that opening gets stretched out, such as after having babies, then we start to have problems with organs dropping and having a difficult time controlling our urine. Sometimes it happens even if one has had only C-sections, or has no children.
Female urology is here to help with that! We have everything from physical therapy to medications to surgery to pacemakers, Botox and more. It is a very exciting time because we have some very effective treatments for this now, whereas ten years ago, the options were very limited. You don’t have to live with those pads your whole life!
That is not all that Female Urology entails. It also includes urinary tract infections, painful bladder conditions, kidney stones, evaluation of blood in the urine, slow urinary stream, bladder and kidney tumors, and more.
There is even now a subspecialty, in which I am certified, called Female Pelvic Medicine and Reconstructive Surgery, which focuses on certain conditions of the pelvic floor, especially prolapse (dropped organs) and incontinence. There are even more advanced surgeries that can be used to treat these conditions, including robotic surgery, which I have been doing for several years with beautiful results (beautiful from a pelvic surgeon’s perspective!).
Over the last twelve years, I have narrowed my urology practice down to females only. I couldn’t be more pleased with my choice. I get to treat some lovely women and see them get their life back: from a life of pads and worrying about where every bathroom is to urine control. And for others, it is helping them with infections, pain, stones, or reassuring them that the blood found in the urine isn’t serious for them. Female Urology is my complete career focus and my mission.

Exhausted, but worth it: Week One of New Practice

Well, we’ve almost completed our first week of the new practice!  Oh, boy!  I am pretty exhausted.   And I feel like I have ADD.  One minute I’m discussing surgery with a patient, the next fine-tuning the process of ordering tests, next hanging a scope sterilization caddy on the wall, next minute learning about Google Adwords.

It’s like when you are trying to clean your house and you move the blanket to your bedroom, only to see a cup that needs to go to the kitchen, and in the kitchen is your child’s backpack that needs to go to their room.  Like that.  But it’s every day, all day. 7a-7p. I am not really stopping for meals, just working and grazing.

It’s all-consuming.  I can’t stop thinking about the new practice and trying to get every little thing just the way that I think it should be.  I know that the day is coming when I will again mostly be spending my time practicing medicine, my first love, and spending less time on the business part, which I like, but it wears me out.  It doesn’t feed my soul the same way.

I do love it, though.  Building something.  Creating a business and a place of healing.  Helping people with their bladder problems. Yes, I’m a doctor who hasn’t lost the drive and satisfaction to help people.  That is what keeps me from burn-out.  Keeps me going no matter what frustration comes along.  It is just the best feeling to have a patient smiling and hugging you, because she doesn’t need to wear pads anymore.

I love that I’m also able to employ some great women and (hopefully) help them realize the life that they dream of.  And I couldn’t do any of this without their dedication.  I truly get so much more from them than I give to them.  We have a great team, and everyone has the vision to fulfill the mission of our practice.  And we have a lot of silly fun as seen on the Facebook page.

Some of the challenges and frustrations that we’ve encountered:  Well, day one, the Comcast internet wasn’t working.  In fact it has gone down a couple more times since then.  We have a new modem now, so hopefully that will help.  And hey, Comcast sent me a $20 credit today!  Internet is essential because our medical records are cloud-based.  Thank goodness that Methodist has a free guest wifi.  Otherwise, I’d have to pay for a backup internet service.

Challenge two:  As much as we tried to learn the new Kareo electronic health records (EHR) ahead of time, there is just no way to know all the ins and outs until you go live.  Day 4 now, it is getting much easier.  We have figured out some good shortcuts.

Challenge three:  Today we started using our Phreesia pads.  I was hoping they would be ready Monday, but they weren’t.  Another lesson in letting go of the desire for perfection!  These are like ipads that patients use to check in and pay their co-pay.  Very cool.  At first, they didn’t work too well, but by the end of the day we were starting to see the light.  Patients seem to like them.  Decreasing paper waste!

We started out the week with one patient per hour so that we would have plenty of time to figure everything out and that was key.  I’m still going to limit the number of patients for a while until we really start to feel like we are getting efficient.  The patients have been so wonderful and patient with us.  Sweet ladies.

I say we’re off to a good start!  I think we are all tired and longing for the smooth-running machine that we all know we are capable of.  It will take some time, but each day gets a little easier.  It’s like the beginning of a run when you are sucking wind and just want to slow down or stop. BUT, if you can get past mile 3, the breathing gets easier, you reach your stride, and then you are cruising for the long run.


On the Edge of Tomorrow…

It is the eve of the opening of my solo private practice, Houston Female Urology!  I cannot believe it is actually happening.  I am sort of in a state of shock, actually.

This is a REALLY big deal.  I think most people don’t appreciate what goes into opening a medical practice.  It’s not only starting a business, but also a medical practice.  Not only did I have to buy computers and printers and office supplies, but also exam beds, lights, cotton swabs, major equipment, etc etc. I have numerous government regulations on medicine to learn and to comply with.  I had to sign up for Medicare and all the insurance companies, a job so big that I outsourced to a firm that does only that. I have spent a lot of savings to get this business going. It really is a big deal, and a risky proposition.

I have dreamt of having my own office for female urology for several years.  I’ve been in a prestigious urology group in Houston for twelve years, since I finished my residency training in 2002.  While I really enjoyed being in the group, I could see the need for an office where women could come in for urologic care and know that they are the full focus of the office, as most urology has traditionally been geared toward men.  Women have sought me out as a urology doctor who is a woman, and my practice has naturally become more and more focused on female urology over the years. So, it just seemed like a very natural next step in my medical practice.   And, most of all, I love female urology.  I think it is fascinating.

Many of my colleagues think I am completely crazy to open a solo practice in the current state of medicine today. (Maybe I am crazy!)  In the world of medicine today, the payments get smaller and smaller; the regulations increase; it takes so much time and effort to collect from the insurance companies.  It is like a game that we have to play with them. The business side of medicine is very difficult.  That is why most doctors just want to work for a hospital and not have to deal with it.

But the drive inside of me tells me that I have to take this risk.  I only have one life to live, and I don’t want to have any regrets.  Life is an adventure to be lived with passion.  This drive that has not subsided for several years, and it is time now to jump in.  I see many colleagues in solo practice who are doing well.  I am confident that I have what it takes to succeed, with God’s help.  And if it doesn’t work out, I’m OK with that!

Planning has been going on for a long, long time, but the last few months, and especially the past few weeks, have been incredibly intense.  I have had to learn so much about business in general, the medical regulations, and all the various, endless choices that go into setting up a practice.  I was prepared for it because I researched what I would need to do.  Even so, it is a bit overwhelming: everything from phone system “trunks” to what kind of printer do I need (laser or inkjet?) to picking out exam lights and tables.  It goes on and on!  I can’t believe how many different types of betadine swab options there are!

It’s been a fun journey!  My staff has really given their all, and we’ve enjoyed this time of setting up. (Free lunch every day from our great drug reps!)   Sometimes things don’t go as planned…the electrical outlet doesn’t work where we set up the water cooler, the paper towel holders don’t fit now that we added upper cabinets, the computer system isn’t quite working.  As much as I want everything to be perfect, I have to keep my eyes focused on what really matters, and let go of trying to be too much in control. It’s a good lesson for my soul.  I’m so glad we planned a soft opening so that we have more time to work out the kinks and not be running ninety to nothing from the start.  We’ll be super-busy before long!

None of this would have been possible without the great people who have helped me.  My staff is incredible.  Truly they are the greatest asset of my practice, and I can’t imagine doing this without them.  But even more than my amazing staff, my family has been so ultra-supportive.  My husband has not waivered one bit in helping me and boosting me, even when I faltered and had a brief moment of buyer’s remorse or when I get impatient when he is trying to advise me on something.  He has brought his expertise as an entrepreneur to help me with my new venture.  And my two children- wow.  They are my biggest cheerleaders.  I don’t want to forget my parents and sister and friends as well!  They are pushing me along the way with encouraging words and prayers.  I am so so blessed.

So…the chairs and signs arrived at the very last moment.  We have all the essentials in place.  Staff are ready.  The electronic medical record has been painstakingly customized by my physician assistant.  The billing systems are in place.  We have a working water cooler!  We borrowed speculums from our colleagues since ours didn’t come in (thank goodness for friends!). It’s all good.

Tomorrow morning at 8:00 we will have the ribbon-cutting and then start the actual business of seeing patients, ready or not! At this point, I can only pray that God will bless this practice, as I use the gifts, talents and passion that He has given me to bless the people that walk through our door.  Tomorrow starts the next chapter of my life!