Urogynecology Training

Faculty Contact: Michael Fialkow, MD, MPH

Training in Female Pelvic Medicine and Reconstructive Surgery (aka Urogynecology) for the Obstetrics & Gynecology residents provides exposure to the depth and breadth of the field. The program started in 1992 when Dr. Gretchen Lentz joined the faculty after completing fellowship training in London. Shortly thereafter Dr. Jane Miller (Female Urology) joined the faculty initiating a nearly 20-year collaboration between Urogynecology and Urology. Dr. Michael Fialkow completed training as the 1st Urogynecolgy fellow in 2004, later joining the faculty as well. As one of the most established Urogynecology practices in the Northwest, patients of every type are referred from throughout the WWAMI region.

The far-reaching goal of the program is to improve the health care of women by training residents to be skilled at the comprehensive management of women with complex benign pelvic problems, lower urinary tract disorders and pelvic floor dysfunction. Drs. Lentz and Fialkow are active in clinical care, medical education, and research, including mentoring residents in research and for fellowship.

Outpatients are seen in the Female Urology and Urogynecology clinic in the UWMC Surgery Pavilion, which features operating rooms and clinics utilizing the most advanced technology available. The Surgery Pavilion is primarily designed for outpatient surgery and for surgery that requires the specialized technical equipment installed in the video-endoscopic rooms.

The Female Urology and Urogynecology Clinic has 9 rooms for patient visits, one of which can function as a procedure room for cystoscopy for example. In addition there is a procedure room for video-urodynamics, defecography, cystoscopy, trans-urethral injections as well as PNEs for Interstim trials.

The Urogynecolgy service is comprised of two OB Gyn residents (PGY 4, PGY 2) and supervised by two full-time Urogynecology faculty who directly supervise all clinical care and pelvic reconstructive surgeries in both the inpatient and outpatient settings.

Training goals by level:

The PGY-2 works 1:1 with Urogynecology faculty to evaluate new consults and perform office procedures. The PGY-4 also works side-by-side with an attending in the clinic to evaluate new consults, and performs office procedures and preoperative assessments. The PGY-4 is the primary surgeon in operative cases and directs the post-operative care. The PGY-4 also works 1:1 with Urogyneoclogy faculty to evaluate new consults, perform office procedures and preoperative assessments on complex cases.  The PGY-4 is the primary surgeon in urogynecologic operative cases and directs the pre/post-operative care. The PGY-4 also provides leadership for the PGY-1 on Benign Gynecology and works together with the PGY-4 on Benign Gynecology to cover surgical cases and manage the inpatient service.

The rotation includes a weekly education conference covering the objectives listed below as well as a pre-surgery conference. At the pre-surgery conference, the Urogynecology and Gynecology divisions jointly discuss all upcoming surgical cases in respect to indications, options, relevant testing or radiology findings of interest and appropriateness of the surgical plan.

Typical weekly schedule:

Monday 8-5 Surgery Pavilion Clinic
Tuesday 7-5 Surgery Pavilion Surgery
Wednesday 8-9

Surgery Pavilion
Grand Rounds
Morbidity & Mortality
Resident Didactics
Thursday 7-5
Surgery Pavilion
Optional Clinic
Friday 8-9
Surgery Pavilion

Educational Objectives

Anatomy: The resident should demonstrate an understanding of the normal anatomy, anatomic interrelationships and variations of the bony pelvis, pelvic girdle and pelvic floor musculature, nerve supply, vasculature, lymphatic drainage, connective tissue supports and the pelvic viscera including the bladder, ureters, urethra, vagina, uterus, rectum, sigmoid colon, and small bowel surrounding structures.

Physiology: The resident should demonstrate a working understanding of the normal function of the lower urinary tract during the filling and voiding phases, the factors responsible for anal continence, and the key elements involved in normal pelvic floor support.

Urinary Tract Dysfunction/Incontenence: The resident should be able to perform a complete history and physical examination to evaluate lower urinary tract symptoms and signs. Given a patient with a complaint of involuntary loss of urine, the resident should be able to confirm the symptom, diagnose its etiology, and recommend and provide appropriate treatment.

Stress Incontinence: The resident should understand the principles involved in the confirmation of the diagnosis of stress incontinence. S/he should know when referral for further evaluation is necessary and be able to perform appropriate management, either nonsurgical or surgical, once the diagnosis is established.

Urge Incontinence: The resident should know the etiology, signs, symptoms, diagnosis, and treatment of detrusor overactivity.

Voiding Abnormalities: The resident should be able to recognize and understand the management of urinary retention and overflow incontinence.

Urinary Tract Infection: The resident should be able to diagnose and treat acute, chronic, and recurrent infection of the urinary tract in both pregnant and non-pregnant women.

Urethral Disorders: The resident should demonstrate the ability to diagnose and manage conditions referable to the urethra, including urethral syndrome, infectious and noninfectious urethritis, atrophic urethritis, and urethral diverticulae.

Intraoperative Injuries: The resident should demonstrate an ability to prevent, identify, and manage urinary tract injuries which occur during pelvic surgery. S/he should show an understanding of appropriate surgical repair of these injuries, although he/she may not always be responsible for performing these repairs.

Urinary Tract Fistulae: The resident should demonstrate knowledge of the etiology, prevention, recognition, diagnosis, and management of fistulae involving the urinary tract.

Pelvic Organ Prolapse (POP) Pathophysiology: The resident should demonstrate an understanding of the prevalence, etiology, predisposing factors, and symptomatology associated with pelvic organ prolapse.

POP Diagnosis: The resident should be able to identify, stage the severity of, and discern the symptomatology associated with pelvic organ prolapse.

POP Treatment: The resident should be able to identify the patient requiring treatment and establish a plan of treatment for the patient with pelvic organ prolapse.

Fecal Incontinence: The resident should be able to demonstrate an understanding of the prevalence, etiology, predisposing factors, symptomatology, and management of fecal incontinence.

Average Annual Statistics for Typical Diagnoses & Procedures

Diagnostic Procedures:  
Multichannel Urodynamics 325
Cystoscopy 423
Anal Ultrasound 8
Non-Surgical Management:  
Pelvic Organ Prolapse 314
Stress Urinary Incontinence 103
Unstable Bladder 257
Other UI 345
Urinary Retention 71
Fecal Incontinence 36
Defactory Dysfunction 12
Chronic Pain 20
Irritative Bladder Conditions 37
Urinary Incontinence:  
Peri-Urethral Injections 23
Retropubic Procedures 15
Laparoscopic Procedures 11
"Slings" 76
Pelvic Organ Prolapse:  
Abdominal &/or Retropubic 13
Vaginal 133
Combined Abdomino-Vaginal 8
Other/Robotic 6
Other Complex Procedures:  
Fistula Repair 8
Urethral Diverticulum 4
Anal Sphincteroplasty 6