Julie Fleming RN
20 Years in ER and ICU
Now Focuses on Women’s Health
Many women suffer in silence with urinary and pelvic problems because they don’t feel comfortable seeking care for such private issues. However, you don’t need to live with any condition, nor should you. You deserve a better quality of life.
When you have questions or need care, turn to Western Michigan Urological Associates. Our sensitive, caring specialists provide answers and treat all female urinary or pelvic health issues.
We take a team approach, drawing on our extensive training and experience. What’s more, we use the most advanced techniques and technology — including laparoscopy, lithotripsy, cryoablation and da Vinci robotic-enable surgery - so be assured that you will receive the best possible care no matter your problem.
- Pelvic Floor Dysfunction
Pelvic Floor Dysfunction — Struggling with pain in your lower back or pelvis? Have pain when urinating or during intercourse? There could be many reasons, but one often overlooked is pelvic floor dysfunction.
The "pelvic floor" is a group of muscles forming a sling across the pelvis. These muscles and surrounding tissues keep pelvic organs (bladder, uterus, and rectum) in place so that they can function properly.
Problems with one or more pelvic organs can occur when the muscles or tissues become weak or tight. In fact, one in five Americans will suffer from pelvic floor dysfunction. Many women report chronic pain as a symptom, with the frequency and intensity greatly affecting their quality of life.
The treatment goal is to relax and/or strengthen the pelvic muscles. Treatment usually combines self-care, medicine, physical therapy and home exercises. Surgery is considered for severe cases.
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Pelvic Floor Dysfunction — Individuals with pelvic floor dysfunction have trouble contracting instead of relaxing the pelvic floor muscles. When this happens during an attempted bowel movement, you are effectively pushing against a solid muscular wall. Statistics say that one out of every five Americans suffers from some type of pelvic floor dysfunction at some time in their life.
- Urinary urgency, frequency, hesitancy, stopping and starting of urine stream, painful urination, or incomplete emptying
- Constipation, straining, pain with bowel movement
- Unexplained pain in the low back, pelvic region, genital area, or rectum
- Pain during or after intercourse, orgasm, or sexual stimulation
- Uncoordinated muscle contractions causing the pelvic floor muscles to spasm
- Interstitial cystitis (IC)
- Pregnancy or childbirth
- Poor posture
- Trauma such as a bad fall
- Certain surgeries
- A detailed history of your symptoms, medical problems, and any possible physical or emotional trauma that may be contributing to their problem.
- Physical examination. Using external and internal hands-on or manual techniques, we evaluate pelvic floor muscle function to determine if you can contract and relax these muscles.
- Urodynamic testing - measures pressure in your bladder when resting and filling. We insert a catheter into your urethra and bladder to fill your bladder with water. A pressure monitor measures and records the pressure within your bladder.
The goal is to relax the pelvic muscles and avoid stressing them. Treatment usually combines self-care, medicines, physical therapy, and home exercise.
- Self-Care — Avoid pushing or straining when urinating and ask your healthcare provider how to treat constipation. Relaxing pelvic floor muscles is important. Using methods such as warm baths at least twice a day helps.
- Medicines — Low doses of muscle relaxants may help.
- Good posture — Maintaining good posture to keep pressure off your bladder and pelvic organs, and using stretching or other techniques such as yoga to avoid tightening and spasms in the other pelvic muscles, also helps.
- Physical therapy — The therapist may do manual therapy or massage both externally and internally to stabilize your pelvis before using other treatment. Manual therapy takes time and patience, and may require one to three sessions per week. Many patients see improvement after six to eight weeks.
- Home exercise. Because the goal of PFD therapy is to learn to control and, especially, relax the pelvic floor, therapists will teach techniques for use at home. This usually begins with general relaxation, stretching leg and back muscles, maintaining good posture, and visualization — part of learning to sense your pelvic floor muscles and to relax them.
Millions of women experience incontinence. Women are especially prone to incontinence due to pregnancy and childbirth, menopause, and their urinary tract structure. Women can also become incontinent from neurologic injury, birth defects, stroke, multiple sclerosis, and physical problems from aging.
No single treatment works for everyone, but many women improve without surgery. Treatment depends on the type and severity of your problem, your lifestyle, and your preferences, starting with the simpler treatment options.
Many women regain urinary control by changing a few habits and exercising to strengthen muscles that hold urine in the bladder. If behavioral treatments fail, we may consider medicines. For some women, surgery is the best choice. We first seek to use minimally invasive procedures when possible.
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Incontinence: For the urinary system to do its job, muscles and nerves must work together to hold urine in the bladder and then release it at the right time. Urinary incontinence (UI) is loss of bladder control and the accidental loss of urine. Some people may experience mild leaking while others may have uncontrollable wetting.
- Stress incontinence — loss of urine when you exert pressure — stress — on your bladder by coughing, sneezing, laughing, exercising or lifting something heavy. Stress incontinence occurs when the bladder's sphincter muscle weakens. In women, physical changes from pregnancy, childbirth and menopause can cause stress incontinence. In men, removing the prostate can lead to this type of incontinence.
- Urge incontinence - a sudden, intense urge to urinate, followed by an involuntary urine loss. Your bladder muscle contracts. This alert may be a few seconds to a minute. You may need to urinate often, including throughout the night. Urge incontinence may be caused by urinary tract infections, bladder irritants, bowel problems, Parkinson's disease, Alzheimer's disease, stroke, injury or nervous system damage associated with multiple sclerosis. If there's no known cause, urge incontinence is also called overactive bladder.
- Overflow incontinence - being unable to empty your bladder, resulting in frequently or constantly dribbling urine. You may produce only a weak urine stream when trying to urinate. This incontinence may occur in people with a damaged bladder, blocked urethra or nerve damage from diabetes and in men with prostate problems.
- Mixed incontinence - symptoms of more than one type of incontinence may be diagnosed as mixed incontinence.
At different ages, males and females have different risks for developing UI. In childhood, girls usually develop bladder control at an earlier age than boys, and bedwetting - or nocturnal enuresis - is less common in girls than in boys. However, adult women are far more likely than adult men to experience UI because of differences in the pelvic region and changes from pregnancy and childbirth.
- Using medications such as diuretics, estrogen, benzodiazepines, tranquilizers, antidepressants, hypnotics, and laxatives.
- Poor overall general health - specifically diabetes, stroke, high blood pressure, smoking history, Parkinson's disease, back problems, obesity, Alzheimer's disease and pulmonary disease.
- Nerve Problems - Any disease, condition, or injury that damages nerves can lead to urination problems. Nerve problems can occur at any age.
- People who have had diabetes for many years may develop nerve damage that affects their bladder control.
- Stroke, Parkinson’s disease, and multiple sclerosis affect the brain and nervous system, so they can also cause bladder-emptying problems.
- Spinal cord injury may affect bladder emptying by disrupting nerve signals needed for bladder control.
- Women who have given birth (either via cesarean section or vaginal delivery) have much higher rates of stress incontinence than women who never delivered a baby.
- Women who developed incontinence during pregnancy or shortly after delivery have higher risk of sustained incontinence than those who did not.
- Having more babies also increases the risk.
- Menopausal women can also suffer from urine loss due to decreased estrogen levels.
- Prostate problems — As the prostate enlarges, it may squeeze the urethra and affect urine flow. The lower urinary tract symptoms (LUTS) associated with an enlarged prostate involve changes or problems with urination, such as a hesitant, interrupted, weak stream; urgency and leaking or dribbling; more frequent urination, especially at night; and urge incontinence.
- Radical prostatectomy — The surgical removal of the entire prostate gland — called radical prostatectomy — for prostate cancer may lead to erection problems and UI.
- External beam radiation — This prostate cancer treatment may result in either temporary or permanent bladder problems.
- Vaginal infections
- Certain weak pelvic muscles
- Pregnancy and childbirth
- Blocked urethra due to an enlarged prostate
- Urinary tract infections
- Effects of certain medications
- Diseases and disorders involving the nervous system muscles (such as multiple sclerosis, Parkinson’s disease, spinal cord injury and stroke)
- Overactive bladder
- Weak muscles that hold the bladder in place
- Weak sphincter muscles surrounding the urethra
- Birth defects
- Some surgeries
- Bladder diary - We may ask you to keep a bladder diary for several days. You will record how much you drink, when you urinate, the amount of urine you produce, whether you had an urge to urinate, and the number of incontinence episodes.
- Urinalysis (urine test) — A urine sample is examined for signs of infection and traces of blood or other abnormalities.
- Blood test - A blood sample is checked for various chemicals and substances related to incontinence causes.
- Post void residual (PVR) measurement - You urinate (void) into a container that measures urine output. We will then check the amount of leftover (residual) urine in your bladder using a catheter or ultrasound. A large amount of leftover urine may mean a blockage in your urinary tract or a problem with your bladder nerves or muscles.
- Pelvic ultrasound — may be used to view other areas of your urinary tract or genitals and examine for abnormalities.
- Stress test - a test in which you cough vigorously or bear down so we can watch for urine loss.
- Urodynamic testing — measures pressure in your bladder when resting and filling. We insert a catheter into your urethra and bladder to fill your bladder with water. A pressure monitor measures and records the pressure within your bladder.
- Cystogram — In this X-ray of your bladder, a catheter is inserted into your urethra and bladder. Through the catheter, we inject a special dyed fluid. As you urinate, X-ray images help to show problems with your urinary tract.
- Cystoscopy — A thin tube with a tiny lens (cystoscope) is inserted into your urethra to check for — and possibly remove — abnormalities in your urinary tract.
Treatment depends on the type of problem and what best fits your lifestyle. It may include simple exercises, medicines, special devices or procedures. In most cases, we will suggest the least invasive treatments first.
- Behavioral Treatment — For some people, avoiding incontinence is as simple as limiting fluids at certain times of the day or planning regular trips to the bathroom — a therapy called timed voiding or bladder training. As you gain control, you can extend the time between trips. Bladder training also includes Kegel exercises to strengthen the pelvic muscles, which help hold urine in the bladder.
- Medicines can affect bladder control in different ways. Some medicines help prevent incontinence by blocking abnormal nerve signals that make the bladder contract at the wrong time, while others slow urine production. Still others relax the bladder. Before prescribing a medicine to treat incontinence, we may look at changing a prescription you already take. For instance, diuretics are often prescribed to treat high blood pressure because they reduce fluid in the body by increasing urine production. Some people may find switching from a diuretic to another blood pressure medicine take care of incontinence.
- Biofeedback — uses measuring devices to help you become aware of your body’s functioning. By using electronic devices or diaries to track when your bladder and urethral muscles contract, you can gain control over these muscles. Biofeedback can supplement pelvic muscle exercises and electrical stimulation to relieve stress and urge incontinence.
- Neuromodulation — For urge incontinence not responding to behavioral treatments or drugs, stimulating nerves to the bladder leaving the spine can be effective in some patients. We will need to test to determine if this device would be helpful to you.
- Catheterization — If you are incontinent because your bladder never empties completely — overflow incontinence — or your bladder cannot empty because of poor muscle tone, past surgery, or spinal cord injury, you might use a catheter to empty your bladder. A catheter is a tube you insert through the urethra into the bladder to drain urine.
- Male sling — In a sling procedure, we create a support for the urethra by placing a strip of material under the urethra and attaching the strip ends near the pelvic bone. The sling keeps constant pressure on the urethra so it does not open until you consciously release the urine.
- Artificial urinary sphincter is a device placed completely inside the patient's body to provide simple and discreet urinary control.
- Mid-urethral sling — Treats female stress incontinence by placing a narrow strip of mesh within the body to support the urethra. Continence can be achieved immediately following the procedure.
- Urethral bulking involves injecting natural bulking agents around the urethra to increase outlet resistance and achieve continence. Bulking can be done in our office without the need for an anesthetic.
Stones — If you’re one of the millions of Americans who has suffered from stone disease, you know an attack can be excruciating. Stone disease is quite common, but with help, reoccurrence can be held to a minimum. Western Michigan Urological Associates can alleviate immediate pain and develop a long-term prevention strategy to help keep the disease from flaring again.
Left alone, many smaller stones pass through the urinary tract within a few days by increasing fluid intake, pain and nausea control, and medicine to promote stone passage.
For larger, difficult or multiple stones, we may consider a number of different stone removing strategies. A procedure called lithotripsy uses shock waves to break up a large stone into smaller pieces that can then pass through the urinary system. Small endoscopic instruments can also be used to remove stone fragments without incision.
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Kidney stones can form when urine contains too much of certain substances. These substances can create small crystals that become stones. Kidney stones are common. A person who has had kidney stones often gets them again in the future.
- Severe pain that starts and may go away suddenly
- Pain in the belly area or side of the back
- Pain that moves to groin area (groin pain) or testicles (testicle pain)
- Abnormal urine color
- Blood in the urine
- A swollen kidney or kidneys, causing pain, often severe
- Some stones tend to run in families. Patients with family members who suffer from stone disease have a 2.5 times greater risk of developing stones than those without stone-forming family members.
- Bowel disease such as Crohn’s disease or inflammatory bowel disorder
- Gastric bypass for obesity
- Renal tubule defects
- Analysis of the stone to determine type
- Uric acid level
- Urinalysis to see crystals and red blood cells in urine
- If you’ve had more than two or three stones in your lifetime, we may suggest a metabolic profile (24-hour urine chemistry test) to better understand the reason for your stone disease.
Varies depending on the type of stone and symptoms.
- Extracorporeal shock-wave lithotripsy — used to remove stones slightly smaller than a half an inch located near the kidney. This method uses ultrasonic waves or shock waves to break up stones so the body can more easily pass the stones.
- Percutaneous nephrolithotomy — used for large stones in or near the kidney, or when the kidneys or surrounding areas are incorrectly formed. The stone is removed with an endoscope inserted into the kidney through a small opening.
- Ureteroscopy - utilizes tiny fibrotic telescopes to remove stones without incision.
CANCER - Although not as common as in men, kidney or bladder cancer can affect women. Blood in your urine is often a first sign. Because this symptom is related to many issues, you should see a specialist.
If you believe you may have cancer or have already received a diagnosis, Western Michigan Urological Associates has the expert knowledge and compassionate care you need. We provide world-class care from the initial visit and evaluation through treatment, recovery and follow-up consultations.
We start with a complete patient assessment and diagnostic evaluation. Then, our experienced team members work to create a treatment plan tailored to you, using the most advanced techniques, including da Vinci robotic and minimally invasive laparoscopic surgeries, cryoablation, radiotherapy and chemotherapy. We will ensure you receive the smoothest, most efficient and best care possible.
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The prostate is the walnut-sized organ located just below the bladder and in front of the rectum that produces fluid that makes up a part of semen. Cancer can develop in this organ. Prostate cancer is the most commonly diagnosed cancer in men, and second only to lung cancer in the number of cancer deaths. Prostate cancer tends to occur most commonly in men over age 50, and greater than 65% of all cases are diagnosed in men 65 years and older. The incidence of prostate cancer increases with age.
The American Cancer Society and American Urologic Association recommend prostate cancer screening starting at age 40 for most men. Generally, prostate cancer is symptomatic at early states. Depending on your screening results a prostate biopsy may be recommended.
- Being 40 years old or older
- African-American background
- Having a father, brother, or son who has had prostate cancer
- About 90% of prostate cancers are diagnosed at a localized stage (cancer confined to prostate without evidence of spread).
- Digital rectal exam (DRE): We contour a gloved finger into the rectum to feel the prostate’s size, shape, and hardness.
- Prostate specific antigen test (PSA): The prostate makes a substance called PSA. This test measures the PSA level in the blood, which may be higher in men with prostate cancer. However, other conditions such as an enlarged prostate, prostate infections, and certain medical procedures may also increase PSA levels.
Several treatment options are effective for men with prostate cancer. We look at each patient individually to determine the right approach to care.
- Active surveillance (observation) is used in some cases of low-risk disease, as well as among older patients for whom active treatment with surgery or radiation therapy may not be possible or necessary. Active surveillance is most often used because some prostate cancers may never become life threatening.
- Radical retropubic prostatectomy (RRP) - involves removing the prostate gland and surrounding lymph nodes through a small open incision above the pubic bone. The procedure can be used to treat a range of prostate cancer, including low, intermediate and high-risk localized prostate cancer. Depending on the stage and risk, radical retropubic prostatectomy can be performed with nerve-sparing. Nerve-sparing prostatectomy provides the best chance of return of erections following surgery in men with good erectile function before treatment.
- Robotic-assisted laparoscopic prostatectomy (RALP) is the most common surgical treatment for prostate cancer. This approach uses laparoscopy as well as small surgical working elements that replicate human hand movement. Generally, RALP means less blood loss, a lower chance of a needed blood transfusion, decreased pain after surgery, and shorter recovery.
- Radical perineal prostatectomy involves removing the prostate through an incision in the area between the scrotum and anus. Perineal prostatectomy is relatively uncommon, but is still used in certain cases, such as in larger patients in which getting to the prostate from pelvis would be difficult.
- 3D conformal and Intensity-Modulated Radiation Therapy - Radiation therapy can be used to manage low and high-risk cases. This approach targets the prostate with the aid of imaging guiding to more accurately deliver radiation dose to the prostate with less radiation exposure to surrounding tissues.
- Interstitial prostate brachytherapy places small radioactive pellets, or “seeds” into the prostate. Generally, this treatment can be used for small to normal sized prostates.
Kidney cancer tends to occur most commonly in individuals older than age 40 and is more frequent in men than women. Most kidney cancers occur spontaneously, although some result from hereditary conditions.
Local kidney cancer - Roughly 60% of kidney cancers are diagnosed at a localized stage (cancer confined to kidney without spread). Localized cancers may not have symptoms or may be associated with hematuria (blood in the urine), flank pain or abdominal discomfort. Surgery is the most effective treatment.
Advanced kidney cancer - Approximately 40% of kidney cancers are diagnosed at an advanced stage that has spread to surrounding structures, lymph nodes or metastasis to more distant sites. Common sites of metastatic spread include the lung, bone and brain.
- Blood in urine, which may make urine look rusty or darker red
- Side pain that doesn’t go away
- A lump or mass in your side or abdomen
- Weight loss for no known reason
- Family history — People with a family member who had kidney cancer have a slightly increased risk. Certain conditions that run in families also can increase risk.
- Urinalysis (urine test) - checks urine for blood and other disease signs
- Blood tests — checks blood for several substances, including creatinine. A high creatinine level may mean the kidneys aren’t functioning properly.
- Ultrasound — sound waves that create a picture of your kidneys and nearby tissues can show a kidney tumor.
- CT scan - a series of detailed pictures of your abdomen show your urinary tract and lymph nodes, and may show if cancer is present in your kidneys, lymph nodes, or elsewhere in the abdomen.
- MRI - this large machine with a magnet linked to a computer creates detailed pictures of your urinary tract and lymph nodes. You may receive an injection of contrast material. An MRI can show cancer in your kidneys, lymph nodes or other tissues in the abdomen.
- IVP - a dye, injected into a vein in your arm, travels through the body and collects in your kidneys. The dye makes the kidneys show up on x-rays. A series of x-rays tracks the dye’s movement through your kidneys to your ureters and bladder. The x-rays can show a kidney tumor or other problems.
- Active surveillance of small, early-stage, low-risk kidney cancers may be an option for those not interested in (or candidates for) surgery or ablative therapy. Active surveillance may be appropriate for older individuals with small kidney tumors for whom surgery risk is too great.
- Ablative therapies use radiofrequency energy and extremely low temperatures to cause tissue destruction. Ablative therapy is most commonly used in older or medically unhealthy patients for whom surgical risk is too great.
- Partial nephrectomy - removal of the tumor without removing the entire kidney - is often recommended for smaller kidney tumors, in patients with a single kidney or tumors in both kidneys. We may also recommend this procedure for patients with diabetes or hypertension to preserve as much renal function as possible. This can be done through a conventional (larger) incision or with a robotically assisted laparoscopic approach.
- Radical nephrectomy consists of removing the entire kidney with the surrounding tissue. This approach is most often used in cases in which a partial nephrectomy is not possible because of tumor size or location. Radical nephrectomy is also the standard treatment for high-risk kidney cancers.
Bladder Cancer tends to occur most often in individuals older than age 60 and is two to three times more common in men than in women.
There are two broad categories:
- Non-muscle invasive bladder cancer — Approximately 70% of patients have non-muscle invasive cancer.
- Muscle-invasive and advanced bladder cancer — Between 20% and 25% of bladder cancer cases are muscle-invasive.
- Blood in the urine (hematuria)
- Painful urination
- Urinary frequency
- Urinary urgency
- Abdominal pain
- Bone pain or tenderness
- Lethargy or fatigue
- Urinary incontinence
- Weight loss
- Cigarette smoking — increases bladder cancer risks nearly fivefold. As many as 50% of all bladder cancers in men, and 30% in women may be caused by cigarette smoke. People who quit smoking have a gradual decline in risk.
- Chemical exposure at work — About one in four bladder cancer cases is caused by exposure to cancer-causing chemicals (carcinogens) on the job. Dye workers, rubber workers, aluminum workers, leather workers, truck drivers and pesticide applicators are at the highest risk.
- Radiation and chemotherapy — Women who received radiation therapy to treat cervical cancer have an increased risk of developing transitional cell bladder cancer. Some people who have received the chemotherapy drug cyclophosphamide (Cytoxan) are also at increased risk.
- Bladder infection — A long-term (chronic) bladder infection or irritation may lead to squamous cell bladder cancer. Bladder infections do not increase the risk of transitional cell cancers.
- Parasite infection — Infection with the schistosomiasis parasite has been linked to bladder cancer.
- Abdominal CT scan
- Cystoscopy (examining the inside of the bladder with a camera)
- Bladder biopsy (usually performed during cystoscopy)
- Intravenous pyelogram — IVP
- Urine cytology
If the cancer has spread into the bladder wall or outside the bladder, treatment may include:
- Cystectomy with urinary diversion — In men, the bladder and prostate are identified, dissected and removed. In women, the bladder, uterus, fallopian tubes, ovaries and anterior portion of the vagina are identified, dissected and removed. Surrounding lymph nodes are removed to assess the extent or spread of the cancer.
- Chemotherapy — a systemic treatment in which drug is given throughout the entire body. It’s designed to kill cancer cells. Typically, it is administered intravenously (through a vein).
- Radiation therapy with chemotherapy — Radiation uses high-energy x-rays to destroy cancer cells. The addition of systemic chemotherapy makes cancer cells more vulnerable to the killing effects of radiation. Radiation therapy is also used to relieve symptoms of advanced bladder.
This cancer is the most common malignancy in men between ages 15 to 35 years, although the occurrence is still very low. Only about 0.2% of American men will develop testicular cancer during their life time. Fortunately, it is also one of the most curable cancers due to early diagnosis and effective treatments.
Early detection is important, so we recommend a monthly self-examination. This is best performed in a warm shower. Please let us know of any suspicious areas.
- A lump or enlargement in either testicle
- A heavy feeling in the scrotum
- A dull ache in the abdomen or groin
- A sudden collection of fluid in the scrotum
- Pain or discomfort in a testicle or the scrotum
- Enlarged or tender breasts
- Unexplained fatigue or a general feeling of not being well
- An undescended testicle (cryptorchidism) — Testes usually descend into the scrotum before birth. Men who have a testicle that never descended are at greater risk of testicular cancer than men whose testicles descended normally. The risk remains even if the testicle has been surgically treated.
- Abnormal testicle development — Conditions that cause testicles to develop abnormally, such as Klinefelter's syndrome
- Family history
- Age — Testicular cancer affects teens and younger men, particularly between ages 15 and 34. However, it can occur at any age.
- Race — More common in white men than in black men
- Blood test