Botox for Overactive Bladder and Incontinence

Botox for Incontinence

JUNE 24, 2014

A new use for Botox: incontinence in women

It’s a nuisance that can drag a woman back to her potty-training days: accidentally peeing in her pants. Urinary incontinence rears its ugly head in two basic forms. If urine leaks out when you cough, sneeze, laugh or jog, that’s stress incontinence. If you have to go so badly or frequently that you often don’t make to the bathroom, that is urge incontinence.

It’s a nuisance that can drag a woman back to her potty-training days: accidentally peeing in her pants. Urinary incontinence rears its ugly head in two basic forms. If urine leaks out when you cough, sneeze, laugh or jog, that’s stress incontinence. If you have to go so badly or frequently that you often don’t make to the bathroom, that is urge incontinence.

And it’s the kind of dirty laundry most women don’t like to air in a doctor’s office.

“There is a component of embarrassment. There is a component of social acceptance that it is OK to pee on yourself as you get older. It’s not something you normally bring up in conversation,” said Dr. Carlos Medina, associate professor of obstetrics and gynecology and director of the Division of Female Pelvic Medicine and Reconstructive Surgery at UHealth, University of Miami Health System.

Though women in their late 40s to 60s typically seek medical help for incontinence, Medina said he is seeing a trend toward younger women.

“You have women saying ‘I want to go to the gym. I want to enjoy life. I want to wear normal clothes again. I don’t want to be embarrassed,’” he said.

To diagnose the problem, patients are asked to keep a three-day voiding diary to document how much they drink, how many times they use the bathroom, and if they leaked urine at any point, said Dr. Yvonne Koch, a urologist and assistant professor of urology at the Columbia University Division of Urology at Mount Sinai Medical Center. A thorough history is taken, and typically a urodynamics test, an interactive test which tells how the bladder is working, or a cystoscopy, which uses a camera to make sure there is not an anatomic problem, she said.

Treatment depends on the type of incontinence.

Stress incontinence

For stress incontinence, women can try pelvic floor muscle training, also known as Kegel exercises, at home, Medina said. If a patient is overweight, then losing weight also may help. “Those are the two home remedies,” he said.

“I would avoid buying all sorts of gadgets that promise to improve the pelvic floor because they don’t really work,” Medina said. “The exercises are what have been proven to work.”

Another option is a pessary, a ring that a woman can insert in the vagina. The ring presses at the level of the bladder neck to help avoid incontinence episodes, he said.

Some women find improvement by wearing a tampon, depending on the degree of leakage. Every woman has a different degree, Medina said.

Surgery, considered the most effective treatment for stress incontinence, is an option for those who have not found relief from Kegels or physiotherapy to help identify pelvic floor muscles and proper exercise techniques, he said.

Many surgeries for incontinence provide support for a sagging urethra with a sling of strong material that acts as a “hammock.” Though there are various options for sling material, the position of the sling, its purpose and how it is placed, “the gold standard worldwide is mid-urethral slings,” Medina said. Placed at the middle portion of the urethra, they “provide a backstop,” he said.

Other procedures include urethra bulking, which use injections to build up the urethra to help stop urine leakage.

Medina said the most common surgical treatment in his practice is the mid-urethral sling. He performs about a dozen a month. Risks include urinary obstruction, difficulty urinating or recurring urinary tract infections. The success rate is about 81 percent.

“It is like being born again. Some of these women have never been able to wear white pants. Some have never been able to jump or cough without worrying if they were going to pee on themselves,” he said. “I’ve had marathon runners who could run again. I’ve had very athletic people who could go to the gym again. It is totally life changing.”

Urge incontinence

Women who suffer from urge incontinence sometimes have trouble working or shy away from socializing because they often can’t make it to the bathroom on time.

The American Urologic Association sets the protocol for treatment for urge incontinence. Anticholinergic medicines in tablet form, which help relax the bladder, are generally tried first, Koch said. There are seven or eight on the market, and patients should try at least two for a four-week period, she said.

If the tablets don’t help, or you can’t tolerate them, Botox is one mode of treatment. Just as it relaxes facial muscles, it can relax bladder muscles, Koch said.

She typically treats four to five patients a month with Botox. In the 15-minute procedure, a tiny camera called a cystoscope is inserted into the bladder through the urethra. A small needle on the cystoscope injects the Botox into the bladder wall, calming it down and increasing its storage capacity.

“It relaxes the bladder muscles, which gives people time to get to the bathroom,” Koch said. “We’re not making the body retain fluid…you’re going to pee. We just want you to have time to get to the bathroom so you don’t have an accident.”

On average, Botox is administered every six to nine months. Complications are rare, but can include urinary tract infection. Patients are screened for infection prior to the procedure and are given antibiotics as a precautionary measure.

There is a 92 percent success rate, Koch said. About eight percent will experience retention of fluid, where the bladder is relaxed so much that the patient is unable to urinate, and must temporarily use a catheter.

“Most people are so desperate to get relief, that they have no problem doing the procedure,” she said. “Most people do fine.”

Another mode of treatment is sacral neuromodulation, which uses a device similar to a pacemaker for the bladder. “We’re trying to change the impulses to the bladder, so you can control when you go to the bathroom,” Dr. Koch said.

In the procedure, a small wire and a device the size of two quarters is implanted in the buttock area, right underneath the skin. It is performed under a local anesthetic.

The procedure is done in two phases. In the trial phase a small wire is inserted through the back. The wire is connected to a programmable unit the size of a cigarette box. Settings are adjusted over one to two weeks, and if the patient feels relief, the next phase – implantation – takes place, Koch said. The risks are bleeding and infection, so preventative antibiotics are given, and patients on blood thinners have to be off of them for two weeks prior to the procedure.

Patients need to follow-up annually with their doctor. The device’s battery needs to be changed about every five years in a minor procedure, she said.

About 90 percent of patients who go through the trial phase get the implantation, and about 90 percent of patients are happy with the device, Koch said. She does about four procedures a month.

“This is something that really affects their quality of life. Some people go to the bathroom every 15 minutes. They can’t work. They can’t sleep. They’re exhausted. They can’t sit through a movie. They don’t want to go on trips,” she said. “The benefits outweigh the risks.”

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4K Score Test and Prostate Cancer Diagnosis

4Kscore for prosate cancer diagnosis
4Kscore for prosate cancer diagnosis

Miami urologists David Robbins MD and Amery Wirtshafter MD utilize the OPKO Lab 4K score for the detection of high grade prostate cancer and to assist in avoiding unnecessary prostate biopsies.


The US Preventative Task Force has downgraded PSA as a screening test for prostate cancer diagnosis.  While contemporary urologists realize that over treatment of low grade and clinically indolent prostate cancers (i.e. gleason 6 low volume disease) has contributed to this recommendation, virtually all clinical urologists know that abandoning screening will lead to delayed and lack of treatment for the 30-40% of men who undergo prostate biopsy and are diagnosed with high grade and aggressive prostate cancers (i.e. gleason ?7) who will eventually go on to develop metastatic disease and die from prostate cancer.

The appropriate response to over treatment of low grade disease is not to avoid prostate biopsy all together and condemn those who would benefit from treatment, but rather the responsible response is to biopsy more selectively.

The 4Kscore by OPKO labs is a tool that allows us to accomplish this goal.  The 4Kscore can be used prior to biopsy in men who have an elevated PSA or abnormal DRE or men with a prior negative prostate biopsy considering a repeat biopsy.   The 4K score uses both clinical data as well as a blood test assessing 4 Kallikrein protein biomarkers including total PSA, free PSA, intact PSA and human kallikrein-related peptidase 2 in an algorithm to predict a patient’s risk for high grade prostate cancer (gleason ?7).  Numerous US and international controlled trials have demonstrated that the 4K test is useful in determining which patients are at risk for high grade prostate cancer while selecting for those with an elevated PSA who do not require biopsy.

At Urological Consultants of Florida we offer the 4Kscore test to help us differentiate which of our patients are at risk for high grade prostate cancers versus those who we could safely follow and avoid prostate biopsy.

For those who would benefit from prostate biopsy based on clinical perimeters and 4Kscore we can further target aggressive prostate cancer with an MRI US Fusion Targeted Prosate Biopsy.



MRI Ultrasound Fusion Targeted Prostate Biopsy

MRI US fusion prostate biopsy is rapidly becoming the standard of care for prostate cancer tissue diagnosis.  I was asked by ADI to write a testimonial for their product that allows them to provide mobile services for MRI US fusion prostate biopsy.
“My name is David Robbins and I am a board certified urologist and partner at Urological Consultants of Florida in North Miami, Florida.  I have been excited to get involved with MRI-ultrasound fusion targeted prostate biopsies since I first began to learn about it nearly ten years ago as a resident at NYU Medical Center where much of the research was conducted regarding the validity of this advanced technology.  A traditional 12 core prostate biopsy randomly samples the prostate with the hopes of a chance encounter with prostate cancer tissue.  In a small sized prostate or one with more advanced and diffuse disease, prostate cancer will usually be discovered with a traditional 12 core ultrasound guided biopsy, however when the prostate is large  or if the disease is focal or anterior in the prostate, it will often be missed in a random 12 core sampling.  Current MRI imaging techniques allow for precise localization of hot spots in the prostate consistent with cancer in patients with an elevated or rising PSA.  MRI-ultrasound fusion targeted prostate biopsy techniques allow me to specifically target hot spots seen on MRI while using real time ultrasound imaging making it more likely for me to diagnose prostate cancer which may have otherwise been missed on a traditional biopsy.  Unfortunately, until recently, this technology was limited to only a select few academic centers with the funding to purchase the costly hardware needed to implement MRI-ultrasound fusion.  Thankfully, in my practice I have been lucky enough to be associated with ADI, the only mobile provider with access to this advanced technology, allowing me to be able to offer my patients this advanced and improved biopsy technique that was previously available in only a few centers.  Now, I am proud to be able to offer my patients MRI-ultrasound targeted prostate biopsy which is a valuable and cutting edge tool for prostate cancer detection that is rapidly becoming the standard of care. “


Moving To 12411 Biscayne Blvd

We are moving April 28th to:

12411 Biscayne Boulevard

North Miami, Florida 33181

On behalf of Dr. Robbins, Dr. Wirtshafter and the staff at Urological Consultants of Florida we are proud to welcome you to our new location.  Please excuse any difficulties we may have during our moving process especially with regard to our phone and fax systems as well as our internet site.

We will get things ironed out as soon as possible.  Our phone numbers will remain the same and should be fully functional soon.

We appreciate your understanding.

GreenLight Laser Miami

GreenLight Laser Surgery in Miami, Florida

David Robbins is Miami’s premiere urologist performing GreenLight Laser surgery for enlarged prostate and BPH.  Dr. Robbins is a consultant for American Medical Systems, the parent company of the GreenLight Laser technology.  As a consultant, for AMS, Dr. Robbins leads local and regional workshops teaching other urologists both the science behind the GreenLight Laser technology and surgical techniques for both beginner and advanced GreenLight Laser users.

Dr. Robbins began using GreenLight Laser technology for treating BPH or enlarged prostate more than 10 years ago using the XPS 120 Watt System.  When AMS first introduced the 180 Watt GreenLight Laser XPS system Dr. Robbins was one of the first urologists in the Miami region to use the technology.  The 180Watt XPS system was a monumental upgrade from the 120 Watt HPS system because of the increased laser surface area and power, improved laser fiber efficiency and breakthrough coagulation technology.  These major improvements in technology  allowed advanced users such as Dr. Robbins to be able to treat patients with prostate sizes much greater than 100 grams or patients with enlarged median lobes without compromise in patient safety.  In fact, the vast majority of patients are able to go home the same day as their procedure with minimal blood loss and catheterization times of 1-2 days.

In the hands of an advanced GreenLight Laser surgeon such as Dr. Robbins, GreenLight Laser technology has significant advantages over alternative more invasive procedures such as open or robotic suprapubic prostatectomy and Transurethral resection of the prostate (TURP).  Addition, whereas other minimally invasive procedures such as Button vaporization can only treat smaller prostate glands with efficacy, GreenLight Laser XPS can be used to treat larger and more complex prostates and can even be used for patients who need to remain on blood thinner medications during surgery.

In the Miami region and South Florida, Dr. Robbins is highly regarded as an advanced GreenLight laser user.

Contact us for further information or to schedule an appointment. 

Verde luz láser Programa Internacional de Miami

Haga clic aquí para obtener más información sobre Cirugía cabo Verde luz láser para la HPB y nuestro programa internacional de láser de luz verde.

Urólogos Miami David Robbins, MD y Amery Wirtshafter, MD son reconocidos a nivel mundial por su experiencia con el uso de la tecnología de luz láser verde XPS para tratar incluso los casos más complejos de la HPB o agrandamiento de la próstata. En consultores urológicas de Florida reconocemos los claros beneficios de la cirugía láser verde de luz como una opción mínimamente invasiva para el tratamiento de la HBP. Nuestra vasta experiencia con la cirugía láser verde luz nos ha dado la oportunidad de probar nuestro conjunto de habilidades únicas para ayudar a los pacientes de todo el mundo. Hemos tratado a pacientes que sufren de BPH molestos (próstata agrandada) síntomas de destinos internacionales como Colombia, El Salvador, Nicaragua, Panamá, Uruguay, Trinidad, Jamaica, Puerto Rico, Brazil, Argentina, Peru, Venezuela, Chile, Ecuador, Bolivia, Paraguay, Guyana, Suriname, French Guiana, Mexico, Honduras, Guatemala, Belize and Costa Rica y las Bahamas.

En Urología Consultores de la Florida, nuestro Miami urólogos, David Robbins MD y Amery Wirtshafter MD están disponibles para ayudarle a resolver su HPB (próstata agrandada) se queja relacionada incluyendo despertarse en la noche para orinar, flujo urinario lenta, urgencia urinaria, incontinencia urinaria, infecciones del tracto urinario, cálculos en la vejiga, vaciado incompleto, retención urinaria e incluso hidronefrosis.

Como resultado de su compromiso a largo plazo de la cirugía láser verde de luz, los urólogos Dr. Robbins Miami y el Dr. Wirtshafter tienen una estrecha relación con American Medical Systems de la compañía propietaria de la tecnología láser verde luz. Hay pocos urólogos mundo de ancho con un fuerte compromiso y la experiencia con la cirugía láser verde de luz para la HPB.

Haga clic aquí para obtener más información sobre Cirugía cabo Verde luz láser para la HPB y nuestro programa internacional de láser de luz verde.

Ten natural treatments for erectile dysfunction

This article was published online on 9/2014.

Many patients in my Miami offices ask me about natural treatments for erectile dysfunction.  Although I do think that some of these treatments hold some merit, I feel strongly that for patients with more advanced erectile dysfunction prescription strength medications both oral and injectable as well as penile implant surgery are powerful options helping patients regain normal sexual function.  I do encourage patients to explore the natural options well highlighted below.

David Robbins, MD

Erectile dysfunction is also known as impotence. It is a sexual condition in which men are unable to sustain or achieve an erection – but what can you do to fix it?

Men aged 18+ and up can experience some form of ED, due to fatigue, stress, personal issues, and bad habits like smoking or drinking too much alcohol. Men should see their physician if this problem lasts more than a few weeks or months.

Just over half of all men experience erectile dysfunction (ED) and at age 40 plus, about 40% experience light to moderate ED and by age 70, men will experience 70% chance of erectile dysfunction. There are varying standard treatments that include pumps, prescribed drugs, implants, and surgery. However, the scientific community has discovered that natural options are effective at improving symptoms of ED. Let’s look at a list of 10 natural treatments for ED:

1. Red Ginseng – Also, known as the “panax” ginseng by the scientific community, red ginseng is called the herbal Viagra. Continued clinical studies have shown that a dose of red ginseng, ranging from 600 to 1,000 mg, at three times a day, was very effective in improved sex drive and male libido.

2. DHEA – DHEA is known as dehydroepiandrosterone, which is a natural hormone created by human adrenal glands. DHEA is made into a safe and natural supplement, made from wild yam and soy extracts. DHEA is a vital hormone because it can be converted to both estrogen and testosterone in the body. Studies have shown that men, who experience ED symptoms, have shown to be low in DHEA. Clinical trials showed effective responses with a study of men who were experiencing ED symptoms. They were given 50 mg of DHEA supplements for six months and they were able to achieve and keep an erection.

3.  L-arginine – This is a naturally occurring amino acid which makes nitric oxide, allowing blood vessels to relax and support sustained erections in men. Significant improvement in men experiencing ED was accomplished when they ingested about 5 grams of L-arginine supplement. Combined with a plant supplement called “pycnogenol” which is derived from tree bark, nearly complete ED was restored to about 80% after two months and to 92.5% after three months.

4. Acupuncture – Even though clinical studies are somewhat mixed, acupuncture methods have shown improved ED functions. This 2500 year old principle is designed to stimulate certain points on the body to modify the sensation of pain and to change bodily functions to treat ailments. Acupuncture releases endorphins, making men feel very relaxed and helping in their arousal emotions that stimulate the nervous system and blood vessels.

5. Zinc Supplements – Deficiencies of zinc in men are known to cause weak erections, causing hypogonadism in males. Zinc treatments can improve the body’s natural levels of testosterone in about 30 mg. per day.

6. Yohimbe – Before Viagra, there was the West African Yohimbe herb. Physicians have prescribed Yohimbe in men with erectile dysfunction.

7. Horny Goat Weed – Horny goat weed is a natural herb that has been used to treat various sexual problems in men, including erectile dysfunction, pain, fatigue, and low libido. This herb contains inhibitors that are similarly used to treat men for erectile dysfunctions.

8. Pomegranate Juice – Improvements in ED, has been proven in men who drank antioxidant rich pomegranate juice, which supplies blood to vital organs like the penis.

9. Muira Puama – In its original state, the muira puama is a flowering bush in the Brazilian Amazon jungles. Converted into a supplement, it has proven to improve erectile dysfunction and low libido conditions, as well as many other ailments. Its roots and bark have been used by the Amazonian indigenous people to treat many sexual dysfunctions because it increases a person’s testosterone levels. Modern trials and tests have also noticed ED improvement when men were given muira puama supplements.

10. Tongkat Ali – This is a Malaysian herb that has been used successfully in reproductive trials and studies. It helps to release luteinizing hormone cells and causes a chain reaction that increases testosterone levels and it blocks the action of harmful chemicals that block clogged arteries and blood flow to the penile area.


Men and women of all ages are seeking alternative treatments to help heal themselves and the medical community also concurs. Younger male statistics for erectile dysfunction is catching up to older male statistics. Thankfully, the medical community continues to research the value of natural methods and ingredients in providing treatment options to their patients. Natural herbs, exercises, and other treatments can safely be used, but under a physician’s guidance and common sense.

About the Author

Churchill Otieno (@ChurchillOtieno), holds a degree in Communications and Public Relations. He is an accomplished independent researcher, experienced, professional writer based in Chicago, IL past Nairobi, Kenya. He has been writing articles on health for more than two years with interest on bone, joint health, arthritis, osteoarthritis etc. He is truly passionate about lifestyle, beauty and fitness. He is also contributing articles for many other popular websites. His mission is to educate, empower and advocate people whose lives have changed due to certain illness. He also strive to support the families and caregivers as they learn how to advocate and care for the afflicted person.


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Vasalgel- An Alternative to Vasectomy

Vasalgel- An Alternative to Vasectomy

Vasalgel is a vasectomy alternative, currently still in its research stages that may be ready to hit the mainstream market by 2017.

Vasalgel is a polymer hydrogel that is injected into a man’s vas deferens.   The gel binds to the walls of the vas deferens and forms a “semi-solid plug” that prohibits sperm from passing through the channel into the semen during ejaculation.

The difference between Vasalgel and Vasectomy is that Vasalgel is reversible by injecting a reversal agent into the vas deferens to dissolve the Vasalgel plug.   This reversal procedure is certainly simpler than a vasectomy reversal surgery that is not covered by insurance and certainly not guaranteed to work.

For men electing for long-term sterility, Vasalgel needs to be reinjected every 10 years.

While the benefits of Vasalgel certainly sound interesting, long term studies and human trials have yet to take place. A study in baboons involved injecting three male baboons with Vasalgel and letting them interact with 10-15 female baboons 6 months later resulted in no pregnancies during the trial period.

Vasalgel certainly seems like an interesting alternative to vasectomy. However it should be noted that for men who are looking to achieve permanent sterility, vasectomy remains the gold standard. Vasectomy is a simple to perform office-based procedure with a long term efficacy greater than 99%.