Bladder and Pelvic Health

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1 A Woman s Guide to Bladder and Pelvic Health Symptoms Tests Conditions Treatments Dayton Center Englewood Center Huber Heights Center Trotwood Satellite

2 Table of Contents About Bladder and Pelvic Health Making a Diagnosis Common Conditions Treatment Options Glossary This side view of a normal female pelvis shows the bladder, uterus and rectum in place and well supported. When pelvic organs slip out of place due to weakened pelvic muscles, the result can be discomfort, pain and embarrassing incontinence. -William J. Rush, MD Bladder and pelvic health is an increasingly important issue for women.

3 About Bladder and Pelvic Health A Message from William J. Rush, MD Since its inception more than ten years ago, Lifestages Samaritan Centers For Women has been dedicated to offering the highest quality healthcare and to setting the regional standard for recognizing and responding to women s unique health challenges. We know that bladder and pelvic health is becoming an increasingly important issue for women. Over a lifetime, three out of four women report some degree of urinary leakage and one out of three may experience pelvic organ slippage (prolapse). As common as these conditions are, women often don t talk about them even to their doctors. Eventually, however, their situation becomes unmanageable interfering with daily life, damaging self-esteem and causing physical pain. Recognizing bladder and pelvic health as a growing issue among women, Lifestages and its long-time partner Good Samaritan Hospital established the Women s Center For Bladder & Pelvic Health. The center, which combines the expertise of Lifestages medical team with the resources of a full-service hospital, makes it easy for women to seek care in a supportive, professional, comfortable setting. We offer our patients: Physicians, nurses and technicians with advanced training in women s bladder and pelvic health A multidisciplinary approach including physical therapy and nutrition counseling The latest diagnostic technology Multiple treatment options No woman should suffer needlessly with bladder or pelvic health problems or be embarrassed to seek help. It is our hope to end the taboo that has surrounded these conditions and to bring relief and peace of mind to many women who otherwise might suffer in silence. -- William J. Rush, MD Director Women s Center for Bladder and Pelvic Health 1

4 Making a Diagnosis Your initial visit to the Women s Center For Bladder & Pelvic Health will include a review of your medical history and medications, a physical examination, and a conversation with your physician about your symptoms. Depending on what is learned during this visit, your physician may order further testing such as a urodynamic study, a cystoscopy or both proceeded by a one-tothree-day bladder diary. Bladder Diary Activity During Leak Your physician will give you a form to use to Kegel Excercises complete a bladder diary for one or three days. You Kegel Exercises Strengthen Pelvic Muscles will record all fluid intake If you and need additional output help identifying (including and exercising your pelvic muscles, we have a physical therapist who is trained leakage) for the to evaluate prescribed your muscle time strength and period, help you learn including how to perform Kegel exercises. Ask your physician for what you were doing information. when leakage occurred and Find Your Pelvic Muscles whether or not you felt an Try urge to stop your to urinary urinate. stream. If you succeed, you have r day three of a three-day diary. The three days you choose e in a row; however, each day must be a full 24 hours during nient for you to measure every void. when you wake up in the morning and continue for 24 hours. entry each time you void, leak or have anything to drink. ml measurements) using the hat. If you are not at home, use ale to measure the amount of urine voided: 1=small, 2=medium, take in ounces. 6. When recording a leak, use the following scale: 1=drops/damp, 2=wet/soaked, 3=bladder emptied. Indicate your activity during the leak and if you had an urge to void (yes or no; strong or not). Was There An Urge? cut along this line for one-day only diary identified the right muscles to exercise. Exercising the muscles around the rectum will also strengthen those around the vagina and under the bladder. Squeeze the muscles that would prevent gas from escaping from your rectum. Do not tighten your stomach and back muscles or squeeze your legs together as you isolate and contract your pelvic muscles. Kegel Exercise Routine Begin your routine lying down. As you get stronger, you can exercise while sitting or standing. Pull in and hold a pelvic muscle squeeze for 5 seconds; relax for 5 seconds. Do 10 sets of repetitions three times a day. Increase your hold by 1 second each week until you are contracting for 10 seconds. Rest and breathe between contractions. Bladder Diary One- to Three-Days Source: American Urogynecologic Society 2 Dayton Center 2200 Philadelphia Dr Ste 101 Dayton, OH Englewood Center 9000 North Main St Ste 232 Dayton, OH Huber Heights Center 6251 Good Samaritan Way Ste 130 Huber Heights, OH Trotwood Satellite 3038 North Olive Road Trotwood, OH

5 Three out of four women report some degree of urinary leakage. Urodynamic Testing A certified technician will conduct a series of tests to evaluate how your bladder and urethra are functioning including how well your bladder fills with, stores and empties urine (cystometry), the rate of urine flow (uroflowmetry) and how well your urethra closes (urethral pressure study). The technician will also assess the strength and function of the muscles that control urination (electromyography and pressure flow study). Urodynamic testing is performed in a private exam room in the Lifestages office. No sedation or medication is required. The tests take about 45 minutes. Your physician will interpret the results. Drink two glasses of water one hour prior to your appointment so that your bladder is comfortably full and arrive about 15 minutes prior to your test. The technician will help you position yourself in a special chair and will drape you for comfort and privacy. You will be asked to empty your bladder; a collection device will measure the volume of urine. The technician will insert thin, flexible catheters into your urethra and vagina and will fill your bladder with water through one of the catheters. She will ask you to tell her when you feel the urge to urinate. She may ask you to cough or strain. If leaking occurs, the sensors in the catheters will record the pressure at the point where the leakage occurs. Finally, you will empty your bladder with the catheters in place to measure pressure. The technician will then remove both catheters. You will have a follow-up appointment within the next week at which time your Lifestages physician will review your results with you and develop your plan of care. 3

6 Cystoscopy Your physician performs a cystoscopy to examine the inside of your bladder and urethra. The procedure is performed in a private exam room in the Lifestages office. No sedation or medication is required. A nurse will help you position yourself in a special chair and will drape you for comfort and privacy. She will cleanse the opening to the urethra and insert a small amount of numbing gel. When your physician enters the room, you will be ready for the procedure. He/she will insert a small, lighted camera through your urethra and into your bladder. You will be able to see images taken by the camera on a television screen and your physician will explain what you see. When the procedure is over about five minutes you will be given privacy to dress and then will meet your Lifestages physician in a consultation room to review your results and develop your plan of care. You will receive medication to relieve any bladder discomfort and to help prevent infection. What to Do at Home After Urodynamic Testing or a Cystoscopy Some women may need to take it easy for the rest of the day; others may proceed with activity as tolerated. Drink plenty of water to flush out your bladder. Avoid alcohol, caffeine and carbonation for 24 hours. Take your medication for bladder discomfort and to prevent infection. Soak in a warm tub in the unlikely event of pelvic discomfort. Some patients have some mild urinary discomfort during the first 24 hours after a cystoscopy. If these symptoms persist beyond 24 hours or if you have any of the following symptoms of a urinary tract infection, please call the Lifestages office at : Fever or chills Blood in urine Painful urination Low back pain Frequent or urgent urination Difficulty emptying the bladder 4

7 Common Conditions Pelvic Organ Prolapse As muscles are weakened with normal aging and childbirth, pelvic organs may slip or protrude into the vagina. Pelvic organ prolapse also may be caused by obesity, chronic cough and chronic constipation with straining. Pelvic Organ Prolapse Symptoms Pressure in the vagina or pelvis Feeling very full in the lower belly Decreased pain or pressure when lying down A lump at the opening of the vagina Feeling a pull or stretch in the groin or lower back Recurrent urinary tract infections Incontinence or a need to urinate frequently Painful intercourse Bowel-related problems such as constipation Cystocele The bladder drops into the vagina. Rectocele The rectum bulges into the vagina. Uterine Prolapse The uterus drops into the vagina. 5

8 Urinary Incontinence Usually, a woman can hold urine in her bladder until she is ready to go. It may seem like a simple thing to do, but actually requires a number of functioning systems strong pelvic muscles, a healthy bladder, a strong urethra that opens and closes properly, and brain and nerve control over the whole process. If one or more of these systems isn t working properly, an involuntary loss of urine urinary incontinence (UI) can occur. UI can be light or heavy, regular or occasional. It can interfere with activities of daily life, work and travel. The emotional impact of UI due to embarrassment and loss of self-esteem can be devastating. UI has several triggers: Stress incontinence is leaking associated with coughing, sneezing, jumping, heavy lifting and exercise. It can occur when the urethra is not well supported and cannot close properly, thus allowing urine to leak. This failure to completely shut off the flow of urine happens when muscles around the urethra are weak or when weak pelvic floor muscles allow the bladder and urethra to shift from their proper position. Physical changes resulting from pregnancy, childbirth, hysterectomy and menopause can contribute to stress incontinence. Urge incontinence involves a sudden strong urge to urinate caused by bladder spasms, followed by an uncontrolled loss of urine. People with urge incontinence may need to urinate often, especially during the night. Urge incontinence, also called overactive bladder, can worsen with anxiety. Urinary tract infections, bladder irritants, the slippage of pelvic organs (prolapse), bowel problems and some medications may cause urge incontinence. When stress incontinence and urge incontinence occur at the same time, the condition is called mixed incontinence. Overflow incontinence happens when the bladder fills normally but does not empty properly. In this case, urine flow is usually weak and may be a constant dribble. If the pelvic organs have slipped out of place (prolapse), they may be blocking the normal flow of urine. In some cases, however, the bladder muscle may not contract normally or there may be no sensation to empty the bladder. People with nerve damage from diabetes, stroke or spinal injuries sometimes suffer from overflow incontinence. Some prescription medications can cause this condition as well. Urinary Incontinence at a Glance You May Have This If You... Type of Incontinence... Stress Leak or lose urine during physical movement Urge Leak or lose urine at unexpected times Mixed Have both stress and urge incontinence Overflow Leak small amounts of urine unexpectedly 6

9 Painful Bladder Syndrome This chronic syndrome is also called interstitial cystitis. It is thought to be an inflammation of the bladder wall. The exact cause is unknown and the severity of symptoms can fluctuate and may even disappear for periods of time. Painful bladder syndrome is sometimes confused with overactive bladder because the patient may experience frequency and urgency. A woman with painful bladder syndrome, however, may have a greater need to empty her bladder repeatedly during the night than does a woman with overactive bladder. Painful Bladder Syndrome Symptoms Pain, pressure, discomfort or a burning sensation that may increase as bladder fills and is alleviated temporarily by urinating Lower abdominal pain that sometimes extends to the lower back Pain in the vagina, urethra and rectum A frequent need to urinate, especially at night One out of three women may experience pelvic organ prolapse. 7

10 Treatment Options Your physician will discuss treatment recommendations with you. These recommendations will depend on the nature of your condition, its severity, its underlying cause and your general health. The medical team at the Women s Center For Bladder & Pelvic Health are trained in all the latest treatments and take a minimally invasive approach whenever possible. May be used to treat: Pelvic organ prolapse Urinary incontinence Painful bladder syndrome (including urgency and frequency) 8 No woman should suffer needlessly with bladder or pelvic health problems.

11 Non-Surgical Medication and physical therapy are among the non-surgical treatments your physician might recommend. Some of these approaches may be combined with surgical repair. Medication Several medications are available to treat the symptoms of urge incontinence or overactive bladder. Low-dose topical estrogen may rejuvenate tissue in the vaginal and urethral area. Your physician may also prescribe anti-inflammatory drugs, antidepressants and antihistamines to relieve pain and other symptoms. In some cases, your physician may place medication directly into the bladder to help relieve symptoms. Nutrition Counseling Diet plays an integral role in bladder health. For example, avoiding irritants such as coffee, tea, citrus and carbonation and drinking the optimal amount of fluids are two important considerations. The center s registered dietitian will assess your diet and advise you on how to make healthy food choices. What you eat and drink can have an impact on the healthy functioning of your bladder. We help you identify your food sensitivities and develop a realistic eating plan that promotes bladder health. Shannon Lingg, RD, LD Registered Dietitian Women s Center For Bladder & Pelvic Health Bladder Retraining Urinating at regularly scheduled times may help re-establish bladder control. 9

12 Pessary A pessary is a silicone support device that is inserted into the vagina to support pelvic organs. Pessaries come in various shapes and sizes and, with regular inspection and cleaning, can be used for many years. If your physician recommends a pessary, it will be professionally fit to your body. Strengthening Pelvic Floor Muscles Strengthening your pelvic floor muscles may be all you need to relieve your symptoms. If you have a surgical procedure, strengthening the pelvic floor muscles will be an important part of your rehabilitation and critical to the long-term success of your surgery. Kegel Exercises. These exercises help strengthen pelvic floor muscles. Once the proper technique is learned, they can be done virtually any time and anywhere. You will be instructed on how to tighten and release your pelvic floor muscles (as if stopping the flow of urine). Kegel exercises are repeated several times a day. Techniques and procedures such as pelvic floor exercise, biofeedback and electrical stimulation are proven non-invasive ways to treat bladder problems. They help by strengthening the muscles surrounding the bladder and by improving bladder control. We work with you one-on-one to teach you these therapies. Wendy O Shea, PT Physical Therapist Women s Center For Bladder & Pelvic Health 10

13 Biofeedback. If you have trouble performing Kegel exercises properly, your physician may recommend biofeedback to help you identify your pelvic floor muscles. A small tampon-like sensor placed into the vagina or rectum will link you to a computer and screen. You will see an image showing the tightening and releasing of your pelvic muscles on the computer screen. By associating your action with the image, you will learn how to identify and control the proper muscles. Electrical Stimulation (E-Stim). Your physician may recommend E-Stim if neither Kegel exercises nor biofeedback work well for you. A mild, painless stimulus is delivered to the pelvic floor muscles through a small tampon-like sensor placed in the vagina or rectum. This stimulus causes the pelvic floor muscles to contract and become stronger. Surgical The type of surgery your physician recommends depends on your condition and the repair needed. Sometimes a patient will need more than one procedure during a single surgery. Cystocele Repair* This surgical repair, which is performed through an incision in the vagina, is used when the bladder has fallen into the vagina. Stitches are placed between the bladder and vagina to reposition the bladder and add support. Rectocele Repair* This surgical repair, also performed through the vagina, is used when the rectum is bulging into the vagina. Stitches placed between the vaginal wall and the rectum help reposition the rectum and add support. Cystocele or Rectocele Repair with Mesh* When the tissues supporting the bladder or rectum are too weak to repair, a specially designed supportive mesh, similar to a hammock, may be used to reinforce the repair. 11

14 Sling Procedure (TVT)* A special mesh material (tension-free vaginal tape) is attached to strong tissues and muscles within the pelvis and placed underneath the urethra to provide support and help it close properly. This outpatient procedure requires a small incision in the vagina and either just above the pubic area or near the creases of the thighs. Sling procedure with tensionfree vaginal tape. Sacral Nerve Modulation (InterStim) A small, pacemaker-like device, surgically implanted in the lower back, sends mild, painless stimulation to the sacral nerve, which controls the bladder and surrounding muscles. This stimulation may decrease or eliminate urgency and frequency symptoms, incontinence and urinary retention. (The patient uses a portable test device prior to surgery to ensure she will benefit from this therapy.) 12 * ETHICON, Inc. All images reproduced with permission.

15 Glossary Bladder a muscular sac in the lower abdomen where urine collects before being voided Catheter a small hollow tube used to drain urine from the bladder Cystoscope a small camera used to look inside the urethra and bladder Incontinence the inability to control the release of urine from the bladder Pelvic floor a group of muscles that provides support for the bladder, intestines and uterus Prolapse the falling down of an organ, such as the uterus or bladder, from its normal position Rectum the last section of the digestive tract, extending from the colon to the anus, where waste is stored before elimination from the body; located behind the vagina Urethra the tube through which urine is released from the bladder; located in front of the vagina Vagina a tube-shaped tract leading from the uterus to the vulva; located between the urethra and the rectum 13

16 or toll free Dayton Center 2200 Philadelphia Dr Ste 101 Dayton, OH Englewood Center 9000 North Main St Ste 232 Dayton, OH Huber Heights Center 6251 Good Samaritan Way Ste 130 Huber Heights, OH Trotwood Satellite Trotwood Family Physicians 3038 North Olive Road Trotwood, OH

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