Innovations and Clinical Expertise in Female Voiding Dysfunction Management

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Female voiding dysfunction (FVD) is a common multifactorial condition typified by abnormally slow or incomplete voiding of urine from the bladder. A range of urodynamic mechanisms, nerve dysfunction and possible comorbidities and injuries are implicated as causes resulting in detrusor underactivity and bladder outlet obstruction.

Successful treatment is highly individualized and requires expertise across specialties, a multidisciplinary structure that drives innovation in Massachusetts General Hospital's model of FVD management.

"By nature and historically, we collaborate closely across specialties, rather than operating in silos where patients have to flounder among departments on their own," says Elise J. De, MD, urologic surgeon at Massachusetts General Hospital.

Dr. De is also the director of Neurourology Services at Spaulding Rehabilitation Network, and the director of Urology Training for the Female Pelvic Medicine and Reconstructive Surgery Fellowship. She specializes in FVD and other related conditions across the continuum of research, clinical applications and surgical solutions such as female pelvic reconstructive surgery.

Teams of Experts

Clinical presentation of FVD varies from mildly irritating hesitancy in passing urine, to a sensation of urgency, or at the most troubling extreme, severe urine retention that restricts social interaction and impairs quality of life. Both men and women can experience voiding dysfunction. While Dr. De's clinical practice focuses on helping to resolve symptoms in which patients have experienced prior treatment failure, her integrated practice occupies a unique clinical niche that interacts broadly with teams of experts. At Mass General, she collaborates with colleagues across multiple departments and disciplines to revolutionize urologic care.

Collaborative Care

In her practice, Dr. De addresses a range of female-specific conditions including incontinence, prolapse, fistula (often in the context of hysterectomy), urethral diverticulum and native tissue approach to pelvic organ prolapse and management of mesh complications. Successfully treating these conditions requires cooperation among subspecialists, from experts in infection and pain control, to neurogenic bladder complications resulting from spinal cord injury, Parkinson's disease, diabetes, stroke and others.

"Subspecialists should naturally work together because the organs are lying next to each other and there is a lot of cross-talk among organs," says Dr. De. "It makes sense to address them as a system for optimal outcomes."

To that end, Dr. De collaborates with Mass General's Center for Pelvic Floor Disorders, led by May M. Wakamatsu, MD, director of Female Pelvic Medicine and Reconstructive Surgery for Gynecology, and vice-chair of Obstetrics and Gynecology, and Liliana G. Bordeianou, MD, chief of the Colorectal Surgery Program. This collaboration enables the team to facilitate relaxation of the pelvic floor muscles—a common problem in patients with FVD.

"The fact that we can seamlessly integrate urogynecology, physical therapy and gastrointestinal medicine means we can individualize treatment for a given patient's condition," says Dr. De.

Innovating to Reroute Nerves

Nerve involvement is a typical feature of voiding dysfunction for both men and women. Collaboration between urology specialists with neurology experts in research, medical and surgical patient care is therefore a productive strategy for improving voiding dysfunction outcomes. It also involves researchers in basic science, physician education and physical rehabilitation.

For example, Dr. De's team is working on a project with Justin Brown, MD, neurosurgeon, and director of Mass General's Paralysis Center. Dr. De's major contribution to this collaboration is a novel animal model she created for pelvic floor dysfunction and its impact on bladder function. Together, they strive to improve function in patients who have experienced the loss of activity of sacral nerves during sacral chordotomy surgery. The goal is to reroute nerve stimulation to the vesical nervous plexus to innervate the bladder.

"This is an innovative application of a technique that involves well-established research in the animal model," says Dr. De.

From the standpoint of functional urologic care and patient quality of life, its implications are significant. She says, "the aim is to allow patients whose bladder is not contracting at all to void at will, and to eliminate the need for self-catheterizing."

Expanding Urology Education Globally

Dr. De regards innovating to improve clinical outcomes in terms of systems of care. Coupled with her collaborative spirit, this view drives her deep commitment to developing a global education program for multidisciplinary urologic specialty teams. She chairs the education committee of the International Continence Society (ICS), where she has helped build an online learning platform and curriculum, and developed clinical care algorithms with a global reach. She believes the potential impact for improving care through this ICS global educational model is powerful.

"For me, it just makes sense for people to get together and have a common platform to see what each other is doing in terms of innovation in practice and research," says Dr. De. "It makes our common purpose more effective."

Visit the Mass General Department of Urology

Learn more about voiding dysfunction treatment at Mass General