Urogynecology

Urogynecology or urogynaecology is a surgical sub-specialty of urology and gynecology.

History
In 1893, Howard Kelly, a gynecologist and pioneering urogynecologist, invented an air cystoscope which was simply a handheld, hollow tube with a glass partition. When the American Surgical Society, later the American College of Surgeons, met in Baltimore in 1900, a contest was held between Howard Kelly and Hugh Hampton Young, who is often considered the father of modern urology. Using his air cystoscope, Kelly inserted ureteral catheters in a female patient in just 3 minutes. Young equaled this time in a male patient. So began the friendly competitive rivalry between gynecologists and urologists in the area of female urology and urogynecology. This friendly competition continued for decades. In modern times, the mutual interest of obstetricians, gynecologists, and urologists in pelvic floor problems in women has led to a more collaborative effort.

Education and training
Gynecologists who practice this sub-specialty are called urogynecologists and urologists who practice this sub-specialty are called female urologists. In the United States, urogynecologists have completed medical school and at least a four-year residency in obstetrics and gynecology and female urologists have completed medical school and at least a five-year residency in urology. However, many specialists also complete fellowship training after residency that can range from 1-3 years in length. These physicians become specialists with additional training and experience in the evaluation and treatment of conditions that affect the female pelvic organs, and the muscles and connective tissue that support the organs. The additional training focuses on the surgical and non-surgical treatment of non-cancerous gynecologic problems.

The subspecialty of Female Pelvic Medicine and Reconstructive Surgery obtained approval for board certification from the American Board of Medical Specialties in 2012, and in June 2013 practitioners will be taking the board certification exam in the subspecialty for the first time, meaning that there are very few board certified urogynecologists. Board certified urogynecologists' titles are followed by 'FPMRS' (Female Pelvic Medicine and Reconstructive Surgery) to reflect their status. Some practitioners have completed a board-accredited fellowship in Urogynecology and Reconstructive Pelvic Surgery after completing a residency in Obstetrics and Gynecology or Urology. The first fellowship received accreditation in 1996. As of January 2010, there were 30 fellowship programs approved by both the American Board of Obstetrics and Gynecology and the American Board of Urology. Additionally, qualified candidates may seek board certification for Female Pelvic Medicine and Reconstructive Surgery through the American Osteopathic Board of Obstetrics and Gynecology (AOBOG). These fellowships are three-years for obstetrician-gynecologists and two-years for urologists. Thus, the combined duration of training for female pelvic medicine and reconstructive surgery is seven years after medical school for both urologists and gynecologists. The International Urogynecology Journal publishes a listing of world-wide training programs.

Scope of practice
Urogynecology involves the diagnosis and treatment of urinary incontinence and female pelvic floor disorders. Incontinence and pelvic floor problems are remarkably common but many women are reluctant to receive help because of the stigma associated with these conditions. "There is no more distressing lesion than urinary incontinence-A constant dribbling of the repulsive urine soaking the clothes which cling wet and cold to the thighs, making the patient offensive to herself and her family and ostracizing her from society" Although countless women are bothered by a loss of bladder control, bowel symptoms, and pelvic discomfort they are often not aware that these problems have a name much less how common they really are. Pelvic floor conditions are more common than hypertension, depression, or diabetes. One in three adult women have hypertension; one in twenty adult women have depression; one in ten adult women have diabetes; and, more than one in two adult women suffer from pelvic floor dysfunction.

Some conditions treated in urogynecology practice include:
 * Cystocele
 * Enterocele
 * Female genital prolapse
 * Fecal incontinence
 * Urinary incontinence
 * Interstitial cystitis
 * Lichen planus
 * Lichen sclerosus
 * Müllerian agenesis
 * Overactive bladder
 * Painful intercourse
 * Pelvic organ prolapse
 * Rectocele
 * Rectovaginal fistula
 * Recurrent urinary tract infections
 * Urinary incontinence
 * Urinary retention
 * Vaginal agenesis
 * Vaginal septum
 * Vesicocutaneous fistula
 * Vesicouterine fistula
 * Vesicovaginal fistula
 * Voiding difficulties

Diagnostic tests and procedures performed include:
 * Cystourethroscopy
 * Urodynamic testing
 * Ultrasound

Specialty treatments available include:
 * Abdominal reconstruction
 * Behavioral modification
 * Biofeedback
 * Botulinum toxin injection
 * Dietary modification
 * Fascial grafts
 * Laparoscopic reconstruction
 * Medications
 * Pelvic floor re-education
 * Pessary (for prolapse and incontinence)
 * Pubovaginal slings
 * Relaxation techniques
 * Robotic reconstruction
 * Sacral nerve stimulation
 * Urethral injections
 * Urethral reconstruction
 * Urge suppression drills
 * Vaginal reconstruction