Urogynecology Services at the Bladder Control Center 287 Main Street Plaza, Lewiston 207 795-2121 www.cmmc.org 287 Main Street Plaza, Lewiston 207 795-2121 www.cmmc.org
Table of Contents What is a Urogynecologist?........................... 2 How do I find a Urogynecologist?...................... 3 Urinary Incontinence................................ 4 Pelvic Organ Prolapse................................ 8 Sexuality and the Pelvic Floor......................... 12 Fecal Incontinence.................................. 17 What causes fecal incontinence? Anything that damages the anal sphincter, or the other muscles, nerves or connective tissue of the pelvis can cause uncontrolled loss of stool. Examples include: Hemorrhoids and anal fissures Irritable bowel syndrome Injury to the pelvic floor as a result of childbirth Previous pelvic surgery and resulting scarring Parkinson s Disease or other diseases of the nervous system Accidental injuries What can be done to help with this problem? There are several approaches that are used to decrease or stop uncontrolled loss of stool. What works best for any one person depends on the cause of her problem. Frequently used treatments include: Pelvic floor rehabilitation- including exercises, physical therapy, biofeedback, can strengthen and tone muscles. This can help compensate for damage that has been done Management of stool consistency- used to keep the stool soft but formed, a combination of fiber, exercise, fluids, and constipating medications like Immodium, can limit fecal loss Surgery- can repair damaged muscles of the anal sphincter. How do I know what will work for me? Generally, you must see a physician who has special training in the diagnosis and treatment of bowel incontinence. Urogynecologists, colorectal surgeons and gastroenterologists are all appropriate specialists. The evaluation to decide what types of treatment might work best includes a physical exam, and special tests designed to understand how the muscles and nerves in your bowel area are working. These tests may include a special radiology procedure called a defecating proctogram, anal ultrasound [Done at the Women s Health Center] or a test of rectal and anal function called anal manometry. Most patients report that the tests are sometimes embarrassing, but not uncomfortable and more importantly, that the information they provide can be critical to helping your doctors understand and treat the causes of your problem. 18
Overview Fecal Incontinence Normally bowel movements (stools) are stored in the rectum until the bowel sends a message to the brain that it is full, and the person finds a convenient bathroom. This voluntary control is provided by a ring of muscular tissue called the anal sphincter which surrounds the anal opening and lower rectum. This sphincter works together with other muscles, nerves and connective tissue that support the pelvic floor. Sometimes, through damage to any of these tissues, voluntary control is lost, allowing leakage of stool or gas. Fecal incontinence means difficulty controlling your bowel movements. This includes involuntary loss of solid or liquid stool and inability to control bowel gas. The loss may occur in association with a strong urge to defecate, or there may be no warning or sensation that an accident is occurring. Stool loss may occur during intercourse. Another common problem is smearing of stool on the undergarments after or in between bowel movements. Still another is seepage of anal secretions and mucus. Fecal incontinence in women is a more wide spread problem than previously thought. As many as 10% of women over age 65 who are not living in nursing homes report troublesome loss of bowel control. Many younger women are also troubled by fecal incontinence. There could hardly be a more devastating problem to have to live with than the fear of losing control of your bowels. Yet, we know that most women with this problem do not bring it up with their doctors and often do not seek treatment even when they do. We also know that most primary care physicians do not routinely inquire about problems with stool loss. It is important to know that while not everyone can be cured, most women with fecal incontinence can be helped substantially - often without surgery. What is a Urogynecologist? A Urogynecologist is an Obstetrician/Gynecologist who has specialized in the care of women with Pelvic Floor Dysfunction. The Pelvic Floor is the muscles, ligaments, connective tissue, and nerves that help support and control the rectum, uterus, vagina, and bladder. The pelvic floor can be damaged by childbirth, repeated heavy lifting, chronic disease or surgery. Some problems due to Pelvic Floor Dysfunction and their symptoms are: Incontinence: Loss of bladder or bowel control, leakage of urine or stool. Prolapse: Descent of pelvic organs; a bulge and/or pressure; dropped uterus, bladder, vagina or rectum. Emptying Disorders: difficulty urinating or moving bowels. Pelvic (or Bladder) Pain: Discomfort, burning or other uncomfortable pelvic symptoms, including bladder or urethral pain. Overactive Bladder: Frequent need to void, bladder pressure, urgency, urgency incontinence or difficulty holding back a full bladder. When Should I See a Urogynecologist? Although your primary care physician or Ob/Gyn may have knowledge about these problems, a Urogynecologist can offer additional expertise. You should see or be referred to a Urogynecologist when you have problems of prolapse, and/or troublesome incontinence or when your primary doctor recommends consultation. Other problems for which you or your doctor might think about consulting a urogynecologist include: problems with emptying the bladder or rectum, pelvic pain, and the need for special expertise in vaginal or pelvic surgery. What Treatment Options are Available from a Urogynecologist? A Urogynecologist can recommend a variety of therapies to cure or relieve symptoms of prolapse, urinary or fecal incontinence, or other pelvic floor dysfunction symptoms. He or she may advise surgical or non-surgical therapy depending on your wishes, the severity of your 17 2
condition and your general health. Non-surgical options include medications, pelvic exercises, behavioral and/or dietary modifications and vaginal devices (also called pessaries). Biofeedback and Electric Stimulation are two newer treatment modalities that your Urogynecolgist may recommend. Safe and effective surgical procedures are also utilized by the Urogynecologist to treat incontinence and prolapse. He or she will discuss all of the options that are available to treat your specific problem(s) before you are asked to make a treatment decision. How Do I Find a Urogynecologist? If you believe that a Urogynecologist is the right specialist for you, ask your Primary Care Physician for a referral or contact CMMC hospital s referral center or the Bladder Control Center at 795-2121 or 1-877-836-3900. It is not a normal part of a woman s aging process to develop uncomfortable, troublesome symptoms of incontinence or prolapse. Women need not learn to live with it. Effective help is available through the services of a Urogynecologist. Helpful Hints to a Better Sex Life Here are bits of information our patients with incontinence have told us helped them improve their sex lives: This is the most important and obvious be sure you have an understanding partner. Talk to your partner about your situation. Whether you are incontinent or not, a supportive and caring lover is what you need. Make sure you have the partner you deserve or help your partner become one. Seek professional counseling if necessary. Always empty your bladder before intercourse. This should help avoid leaking and help you maximize your enjoyment. Try to avoid fluids just before intercourse. This doesn t mean you need to be dehydrated or dry-mouthed, but avoiding that cup of coffee or cola may make a big difference. If you think you might need them, use towels, disposable pads, or rubberized sheets to keep the bed dry and fresh. Planning ahead may minimize any anxiety you have. Be calm if you leak. Urine is a sterile fluid, and a little leakage is just not that important. A sense of humor might help defuse the situation, while anger or frustration may only increase your anxiety or that of your partner. Sometimes our bodies seem to be loaded with booby traps for potential embarrassment. That s the way we humans are. Do Kegel exercises regularly. Toned muscles often decrease or eliminate leaking, and they can increase pleasure for both partners. Experiment with your partner to find the most comfortable positions for you both. 3 16
How Can You Talk with Your Partner about Incontinence? Both women and men with incontinence may suffer from feelings of isolation. Embarrassment and fear of humiliation often keep them from talking to their partners about the subject. Usually the fear is worse than the reality. Unnecessary tension and emotional distancing hurts both people in a relationship. We know that good communication between lovers helps to make sex more joyful, under any circumstance. If you have incontinence, talking to your partner about it may be the most important thing you can do. Good communication will lead to greater affection and trust. Talking about any kind of problem is usually easier in a long-term, intimate relationship, but even in a new relationship, getting things out in the open often brings relief. If you have incontinence with intercourse, discussing this with your partner before having sex might help you both. Many women, although embarrassed at first, are surprised at how easily the conversation goes. Oftentimes mentioning that there might be a bit of dribbling is all that is needed. Some men worry about getting a bladder infection from an incontinent partner. Although loss of urine may feel unclean, urine is entirely sterile. Your partner can be reassured that no risk of transmitting infection exists. Others worry needlessly about hurting a woman with a prolapse when all that is needed is to push the prolapse back and use a lubricant. The bottom line is very clear. Incontinence does not need to get in the way of sexuality. Will Sex Be Better If You Have Surgery? To answer this, a recent American study questioned a group of women before and after surgery to repair a prolapse or incontinence. About half of these women were sexually active. Before surgery, 82% of the sexually active women reported being happy with their sex lives, and after surgery, 89% of the women felt happy with their sexual relationship. However, the study brought out a number of interesting findings. For one, the frequency of intercourse did not change following surgery. And two, while only 8% of the women had pain with intercourse before surgery, 19% noted pain with intercourse after surgery. About one quarter of the women who had a repair of a bulging rectum (rectocele) developed pain with intercourse. About one third of the women who had repair of a rectocele and a bladder suspension had painful intercourse. Overview Urinary Incontinence Involuntary loss of urine is reportedly experienced by upwards of 95% of women in their reproductive and post-menopausal years. This, however, does not mean that this overwhelming majority has urinary incontinence. To qualify as urinary incontinence (UI), the involuntary loss of urine must have a negative impact on the quality of the individual s life, particularly for hygienic and/or social standpoints. As such, the only person who can ultimately determine the presence of UI is the woman herself. If you or someone you know is affected by loss of bladder control, you are not alone. An estimated 15-20 million people in the United States have bladder control problems. This condition affects men and women, although it is nearly twice as common in women. The prevalence of this condition does increase with age. 15 to 30 percent of adults greater than 60 years of age have UI. However, this condition should not be considered a normal result of aging. Urinary incontinence is often caused by specific changes in body function due to related or unrelated diseases and/or usage of medications that affect function of the urinary tract (e.g., diuretics or water pills, anti-hypertensives or blood pressure pills ). More often than not, incontinence is more of an annoyance than a sign of a life-threatening condition. Despite the high prevalence, most people with UI are reluctant to seek help. They might be embarrassed to acknowledge that they have a problem, even to themselves. Or, they might have broached the issue with family members, acquaintances, and/or friends who were discouraging or suggested that no truly useful remedies exist. Thus, many sufferers resort to dealing with the progressively worsening leakage by using the many absorbent products available, including pads and/or diapers. This resignation often results in emotional and psychological vulnerability, including depression and social isolation. It also typically results in diaper rash. There is absolutely no reason for this to happen. The good news is that 80-90% of cases can be treated successfully. Although complete cure may not be attainable in all cases, substantial improvement can be expected in the vast majority. So, if you or someone you know suffers from this condition, BE PROACTIVE. Get evaluated and review treatment options appropriate to your condition. The more you know, the more confident you will be in choosing the direction of treatment. 15 4
Types of urinary incontinence Stress Incontinence Urine leakage occurs with increases in abdominal pressure (hence, mechanical stress ). Leakage may occur during physical activities that increase abdominal pressure (for instance: sneezing, coughing, boisterous laughing, and straining when performing exercises like abdominal crunches, or lifting objects). Many of the above-described activities lead to increased pressure within the abdominal cavity. This, in turn, increases the pressure within the bladder, which behaves like a balloon filled with liquid. The rise in bladder pressure has a tendency to force the urethra open and urine loss ensues. The amount of urine loss associated with SUI is usually small, ranging from mild seepage to drops to a large squirt. Urge Incontinence Often referred to as overactive bladder. Inability to hold urine long enough to reach restroom. If you suddenly lose urine at the wrong time and place, you may have urge incontinence. This is usually associated with feeling the need or urge to urinate. Because this urge cannot be stopped, this type of incontinence is called urge incontinence. The most common cause of urge incontinence is a spasm or contraction of the bladder muscle, which squeezes at the wrong time, earlier than it normally would and cause leaks. This loss of urine often begins before we reach the toilet. The wetness can be any amount from dribbling up to soaking our clothes. Urge incontinence is the leakage that can occur when you put your hands under running water, when you hear running water, after drinking a small quantity of liquids, or when you rush home and put your key in the lock of your door and experience a bladder contraction and leakage. Mixed Incontinence Refers to the presence of both stress and urge incontinence. Overflow Incontinence Leakage or spill-over of urine when the quantity of urine exceeds the bladder s capacity to hold it. Functional Incontinence Leakage (usually resulting from one or more causes) due to factors impairing reaching the restroom in time because of physical conditions (e.g., arthritis) 5 Unfortunately, the researchers did not ask these women why they were more satisfied with their sex lives even though more of them had painful intercourse. Another study performed in Sweden may shed some light. This study found that one third of women noted an increased interest in sex after incontinence surgery, and one half of their male partners were more interested in sex. It could be that knowing the repair for the prolapse or incontinence had been addressed was enough to make the couples feel better about sex. What Can You Do If Intercourse is Painful? One way to reduce discomfort during intercourse is to use a lubricant. Ask the pharmacist to recommend a good lubricant or try a few to see which one works well for you. Try to avoid using Vaseline or hand lotion, as these tend to dry out quickly. If vaginal dryness is a longstanding problem, consider asking your doctor about vaginal estrogen. Estrogen makes the vagina more elastic and increases natural lubrication. Local forms of estrogen, available as creams, estrogen-containing silastic rings or small pills inserted into the vagina can improve vaginal health without any significant absorption of the estrogen into the bloodstream and the body. If You Have Interstitial Cystitis, Can Anything Help Make Sex More Comfortable? For a woman with IC, finding out what works for her and her partner can involve some trial and error. In general, women tell us that sexual positions where the pressure is off the bladder are the most comfortable. Many report the most comfortable positions are lying on their side or rear entry. Again, the best idea is to experiment until you find what works for you. Some couples substitute oral sex if intercourse is too painful. Using a vibrator to stimulate only the clitoris without involving the vagina may also give pleasure. Keeping a heating pad on the pelvic area before sex brings blood to the area and may help facilitate orgasm. A cold pack applied on the pelvic area after sex keeps inflammation and discomfort down. 14
incontinence. Stress incontinence often happens at predictable times, most often right at the beginning of intercourse when penetration alters the angle of the bladder and urethra. Urinating just before having sex will usually prevent this problem. Urge incontinence, the result of an overactive bladder, causes more distress because it is unpredictable and unavoidable. Women with urge incontinence often lose urine during an orgasm, which may be particularly upsetting. Also, the amount of urine leaked because of an overactive bladder is usually greater than with stress incontinence. One study found that almost 70% of women with urgency or urge incontinence had unsatisfying sexual relations while only 20% of women with stress incontinence had this complaint. Can Prolapse Cause Problems with Sex? Prolapse does not usually cause problems with sex. If prolapse results in bulging of the bladder or rectum into the vagina, the bulge can be easily pushed back into place before intercourse, and most women with prolapse say they don t notice it during intercourse. Also, if you have a prolapse, you should know that intercourse will not cause any harm to whatever is bulging: your bladder, vagina, uterus or rectum. It is common for women to notice that the prolapse is much less apparent when they are lying down, a likely position during sex, allows the prolapse to move out of the way. However, if the prolapse is severe, the vagina may be exposed to the drying effect of the air and intercourse may be irritating and uncomfortable. In that situation, a lubricant can be very helpful. Does Incontinence Make You Less Attractive? Incontinence can undeniably complicate life in an unpleasant way. Many women modify what they wear and how they live as a result. Some tell us they feel less feminine and less independent. Their wardrobe is suddenly limited to only dark clothing in order to hide any possible leaks. They avoid situations where they won t have easy access to a bathroom. Some women so dread of embarrassing themselves that they only feel comfortable at home and don t even leave the house. They may also be concerned about odor and may fear that nobody will want to sit next to them at social events. The social and physical isolation that incontinence sometimes brings is unnecessary. Treatment is available. 13 Diagnosis An appropriate evaluation helps your physician or other health-care provider pinpoint the type(s) of urinary incontinence you might have. Before a physical examination and other tests, your doctor/provider will ask you a series of questions. Your responses will assist your doctor/provider in mapping out the tests that will be utilized. A thorough history will be taken, reviewing your past and more recent medical, surgical and Ob/Gyn history. You will be asked to list your medications. A 1-7 day voiding diary recording the amount and time of every void will need to be kept by you and reviewed by your provider. The physical examination will involve the following: Neurologic examination: basic testing of nerves supplying the legs and vaginal opening; the same nerves service the bladder and urethra. Pelvic examination: a typical GYN examination to identify pelvic floor defects, including those of the front (cystocele), back (rectocele) and top walls (uterine and/or vaginal prolapse) of the vagina. Urine specimen: obtained following voiding to determine how efficiently the bladder empties itself; a specimen is sent for bacterial culture (a urinary infection can cause or worsen urinary incontinence). Cystoscopy: the physician looks into the urethra and bladder with a small, illuminated telescope-like instrument to rule out stones, growths and foreign bodies (sutures from previous anti-incontinence surgery). [Done in the Bladder Control Center] Urodynamic studies: these are tests that measure pressures in the bladder and urethra simultaneously to tell how both components are working. They are done in the Bladder Control Center, take 30-45 minutes, and are not painful. Can Surgery Be Used to Treat Incontinence? Some women try medications and exercises for relief of incontinence but still are plagued by bothersome symptoms. For these women, surgery may provide much needed relief. Surgery is most effective when stress incontinence is a major component of the incontinence, and it may help if some urgency accompanies stress incontinence. It is not likely to be effective for pure urgency or urgency incontinence. 6
One of the goals of surgery for the treatment of incontinence is the restoration, by a number of proven techniques, of the bladder and urethra to their normal position. Most women who have given birth vaginally have some degree of loosening, stretching and even tearing of the supporting ligaments of the vagina, bladder and rectum. This weakening of the supporting ligaments usually begins unnoticed and without any symptoms and remains that way for the majority of women for their entire lives. But for some women, changes that occur as a result of the lengthening and stretching cause significant incontinence that interfere with their daily lives. Incontinence never jeopardizes a woman s health, but it does play havoc with a woman s ability to live and enjoy her life. For those women, surgery can restore a sense of basic good health and a return them to a life free of worry and wetness. What About Non-surgical Options To Treat Incontinence? Absorbent pads/diapers Kegel exercises: Pelvic floor muscles act as a hammock or sling to buttress support to the urethra and bladder during stress related activities; exercising these muscles improves the resting tone and strength of active contractions to help close the urethra when coughing or laughing; innumerable Kegel exercise regimens are used but all have one thing in common: they must be done on a regular basis and indefinitely for the recipient to derive noticeable benefit. Pessaries: These simple plastic shapes, worn in the vagina, were originally used only for pelvic organ prolapse. However, properly sized and incontinence modified pessaries can provide support beneath the urethra, compensating for the laxity of urethral support often found in women with urinary incontinence. Special devices: Urethral plugs and other devices may be available when the above strategies are unsuccessful. Urethral implant: Injection into the urethra of sterilized collagen is directed by a telescope-like device (urethroscope) to decrease the size of the gaping neck of the bladder. This creates a washer-like effect that assists in closing the urethra during coughing or straining. Unfortunately, more than one injection is usual. 7 Overview Sexuality and the Pelvic Floor The good news is that a recent study tells us women with incontinence or prolapse report the same amount of sexual activity, comfort, and enjoyment with sex as women without incontinence. There s more: 80% of the women with either prolapse or incontinence felt their partners were also satisfied with their sexual relationship. Naturally the woman s feeling about her partner and the relationship has a lot to do with whether she is satisfied sexually or otherwise. But the incontinence and the prolapse turned out to be less important than expected. Incontinent or not, many women stay sexually active well into their seventies and eighties. However, the same study stated that women with the most severe prolapse or most frequent incontinence did report that their physical condition interfered with their sex lives. As a result, these women were more distressed about their medical situations and were less content. While the women with less severe incontinence did not have a significant problem with sexual satisfaction, those with severe problems found it was a detriment to their sex lives. Can Young Women Have Incontinence During Sex? Surprisingly, young women actually have incontinence during intercourse more than older women. A study performed in Israel found that while only 3% of women over age 65 reported incontinence with sexual activity, 29% of women under age 60 had this problem. And, as might be expected, this incontinence caused these women some anxiety. While almost all the women in this study were in stable marriages, 43% of them felt anxiety because of the incontinence during intercourse. Although there is no comparable study for single women, more than likely the absence of a stable relationship only makes things worse. Can Incontinence Cause a Problem with Sex? Incontinence makes some women feel unclean and, consequently, undesirable. They may consequently avoid sex or feel less pleasure and freedom when they do have sex. The type of incontinence a woman has can greatly affect how much it troubles her. Women with stress incontinence usually have fewer problems with sex than women with urgency 12
It is important to understand that there are several different surgical techniques which are effective depending on the exact nature of your problem. There is no single operation that is right for every patient. You and your urogynecologist must decide on the specific surgery together. If I don t seek treatment, what will happen? In general, prolapse does not have to be treated in any way if it not causing discomfort. In other words, prolapse treatments are designed to improve quality of life. Often times, a patient experiences symptoms of urinary or fecal incontinence as well as prolapse which can all be evaluated at once, and treated in a single surgery. So if the prolapse itself isn t causing decreased quality of life, it doesn t usually have to be treated. The one exception to that rule occurs with severe prolapse which can block the flow of urine and may even eventually result in kidney damage. That situation is rare. Your urogynecologist will be able to determine whether that is possible in your case. Overview Pelvic Organ Prolapse Pelvic organ prolapse is a condition that results from weakening, breaking and/or stretching of the connective tissue, muscles, and nerves that make up the pelvic floor. This weakening and stretching allows pelvic organs to drop, bulge, or prolapse into the vagina. Commonly, prolapse is related to the pressure and stretching involved in childbirth, but it can also be related to repetitive strenuous work, chronic coughing, smoking and less commonly, accidental injury, or to an inherited weakened tissue. Any prolapse can be thought of as a type of hernia. Hernias develop when the abdominal contents bulge through any weakened area in the abdominal or pelvic walls. People are often more familiar with hernias in the groin or at the navel. It is important to understand that the tissue weakness that allows a hernia is still present after any treatment, and you may need to make lifestyle changes if you want to prevent further problems. Loss of pelvic support can involve a variety of problems The bladder can bulge through the front wall of the vagina as in the pictures below. This is known as a Cystocele. Keep in mind that your bulge may not look exactly like the picture. It may be larger or smaller. This picture shows what a Cystocele looks like from the outside. The picture below shows what is happening on the inside. 11 8
The rectum can bulge through the back wall of the vagina. This is known as a Rectocele. Keep in mind that your bulge may not look exactly like the picture. It may be larger or smaller. 4) After a hysterectomy, the top of the vagina may fall down into or out of the entrance to the vagina. Behind this vaginal cuff can be bowels or intestines prolapsing through into the vagina. This is known as an Enterocele. Keep in mind that your bulge may not look exactly like the picture. It may be larger or smaller. This picture shows what a Rectocele looks like from the outside. The picture below shows what is going on on the inside The uterus can fall down into or out of the entrance to the vagina. This is known as Uterine Prolapse. Keep in mind that your bulge may not look exactly like the picture. It may be larger or smaller. This picture shows what Uterine Prolapse looks like from the outside. 9 The picture below shows what is going on on the inside What are my treatment options? After being diagnosed with pelvic organ prolapse of any type, a woman generally has three options: 1) Ignore it 2) Have surgery to fix the problem 3) Be fitted with a pessary. Deciding whether or not to have surgery for your prolapse problems is an individual decision. The success or failure of someone else s operation should never be the deciding factor for you. Every woman s situation is different. Work with your Urogynecologist to make a plan that works best for you. A lot depends on your individual problems, and more depends on your preferences. A woman should seek treatment whenever her symptoms have negative impact on her life you don t have to wait until your symptoms are really bad. Uncontrollable urine leakage, while common, is not a normal result of childbirth and aging. You do not just have to learn to live with it. Seeking medical help does not mean that you have to have surgery right away. Some women start with more conservative treatment like physical therapy, and go on to surgery only if their urine loss is not well controlled. 10