Stress incontinence is urinary leakage associated with “physical stress” or activity that is exercise, coughing, sneezing, changing position, jumping, running or the like.  It is related often to childbirth injury and tends to get worse over time for many reasons.  Gravity is the first issue.  Since we walk on 2 legs, our pelvic organs are just above our vagina.  If there is a disruption in the support structures of the vagina and uterus from childbirth we then have prolapse or “falling” of the bladder, uterus and possibly rectum.  This results in urinary loss, difficulty with bowel movements at times and sometimes an uncomfortable bulge at the vaginal opening. Although this bulge can be alarming, it is rarely dangerous.  If we were like man’s best friend, the dog, we would not have prolapse because animals that walk on four legs have a vagina that is horizontal and not affected by gravity.

The urinary leakage is also caused by the hormonal changes of menopause.  Less estrogen can result in weakening of the support structures and more urinary leakage.  And aging is a factor as well.

So when do you consider surgery?  If there is minimal or no prolapse, the TVT Sling procedures are outpatient procedures with minimal pain and short recovery times.  Most women are back to work in a week and pain medication is required for only a day or two.  There are no external stitches, just a few dissolving stitches in the vagina and most activities are manageable in a short time.  There is a limitation on strenuous exercise and heavy lifting for 2 months and no swimming or intercourse for 1 month.

When I counsel women I find that most put up with symptoms of urinary leakage far too long. When they get this corrected they invariable ask, “why did I wait this long? I didn’t have to suffer with pads and embarrassment as long as I did”.  Many younger patients note that their symptoms get worse with each subsequent delivery.

If you are finished having children, if you are limiting your activities because of your bladder, if you are wearing more than 1 mini-pad per day, if you are not playing sports, hiking, playing tennis or golf because you can’t find a bathroom every 30 minutes, it is time to consider surgery for stress incontinence.

The success rate of these nylon-like slings is 90% and the slings are permanent.  They act as a hammock to support the urethra (the tube that empties the bladder) when there is a cough, sneeze, or when exercise tightens the abdominal muscles.

Some women have heard that mesh is dangerous, and in large quantities this may be so, BUT these mesh ribbon slings have been implanted in women in the USA for the past 15 years and in Europe for another 5 years prior to that. There is a very long experience with them. I have been implanting them since they were first introduced in this country and have a 15 year experience with them.  They are very safe.

So, if you are bothered by your bladder, consider surgically correcting the incontinence (if it is stress incontinence).  You do not have to live with it, there is no benefit to putting off treatment, it is not likely it will be necessary to treat it again.  You can reclaim your life now, feel better, and be more active with yourself and your family.

This is usually due to damage to the pelvic floor caused by the birth itself.  I have discussed how this happens elsewhere on my website.  This damage is reparable, the looseness can be fixed, and the vagina will function better sexually, and be more comfortable the rest of the time if there was any sense of pressure or bulge at the opening.

When these pelvic floor defects or herniations are repaired, along with tightening the appropriate muscles, this is called a pelvic floor reconstruction.  This is the medical term for cystocele and rectocele repair, or anterior and posterior repair.  “Vaginal rejuvenation” is a marketing term, used to sell procedures to women.  I am not a great fan of “selling” anything to women but I do believe we have the right and the responsibility to understand our bodies and how they work and what makes them function optimally.

If you are suffering from vaginal laxity or looseness, the first thing to do is Kegel exercises. Very often tightening and strengthening the pelvic floor muscles will increase sexual satisfaction for you and your partner. (See prior blog about vaginal tightening and pelvic floor exercises).  If you cannot figure it out alone, try either biofeedback or a session with a specialized pelvic floor physical therapist to instruct you.  If this is not the answer, it is time to consult a qualified pelvic floor surgeon: a urogynecologist who can properly evaluate and treat this surgically.

The surgery is done vaginally, can be done without mesh for most natural results, and is minimally uncomfortable.  It is either an outpatient procedure or possibly 1 night in the hospital and patients typically return to most activities in 1 – 2 weeks. It can be done in conjunction with a minimally invasive sling for incontinence if that is also a problem.

Since this is a medical condition, this is covered by most insurance.  Not to be confused with labioplasty, which is plastic surgery to make the vulvar lips smaller.  Labioplasty is a cosmetic procedure and is not usually covered by insurance, nor is it necessary for sexual function or satisfaction.

It turns out, the young cervix of the teen-age girl is uncommonly receptive to the HPV virus and some Pap smear changes are not uncommon.  It also turns out that the vast majority of these heal by themselves without medical intervention, evaluation or treatment.  Interfering with this natural process by doing Pap smears, biopsies and all sorts of treatment was simply an over reaction, unnecessary worry, and expense.  The new recommendations are to start Pap smears at age 21 but to perform STI (sexually transmitted infection) screening with the annual exam on all sexually active teens.  Condoms are recommended even with hormonal contraception, such as the pill or the ring, to prevent STIs.

HPV (human papilloma virus) immunization is recommended with either of 2 available immunizations, Gardisil or Cervarix.  These are shots to the arm in a series of 3 over 6 months that give immunity HPV 16 and 18, which cause 80% of the cervical cancer due to HPV.  Gardisil also protects against 80% of the venereal wart causing viruses (HPV 6 and 11).

There is NO live virus in either preparation and one cannot get HPV from the vaccine.  It is very safe; I have administered it to friends and family.  The immunization is the most effective when given before sexual activity begins as once there is exposure, the vaccine may be too late for some girls.  This is why it is recommended in early adolescents, starting at age 11.  Although no one likes shots, and there is some expense involved, it is less worry, less pain and less costly than having one significant Pap smear abnormality evaluated and treated and well worth the minimal aggravation of the immunization series.

It is important that immunized women over 21 continue to get annual cervical screening.

Males can also be immunized with these same vaccines. This is a new area of public health interest as it will also reduce the rate of cervical cancer as well as penile cancer, which is less common, but males are the carriers of the HPV virus to their partners.

As my grandmother always said:  “An ounce of prevention is worth a pound of cure.”  It was good advice then and remains good advice now.

While learning and performing these exercises can strengthen the muscles of the pelvic floor that form a hammock supporting our uterus and bladder and rectum, conscious control over these muscles can enhance the sexual experience for you and your partner.  Tightening these muscles during intercourse narrows the functional vaginal diameter and makes it feel “tighter”.  This increases the friction and sensation and can increase pleasure for both partners.  There is more control over timing and intensity of orgasm.

But can you learn to do this on your own?  Certainly many women can!  Try to tighten the muscles that control the expulsion of gas, the rectal sphincter muscles. Usually all the vaginal muscles will contract with these.  Continue to work these muscles holding the contraction for at least 3 seconds, relaxing for 3 seconds then repeating at least 10 reps sitting, standing, and reclining, a few times a day.

If you cannot figure it out yourself, a physical therapist, nurse practitioner, or gynecologist will be able to help.

Some women ask about items that might be helpful, like vaginal weights.  Some women find these helpful just to identify the muscles if you cannot figure it our alone but they are not usually necessary.

Give this a try. It can’t hurt as we say, and it might just light the spark you have been looking for.

I usually speak for the first 30 minutes about physiological, medical, and drug issues that can affect our sex life.  These issues include medical conditions such as diabetes, arthritis, and many others that can impact our sense of wellbeing as well as our self image.  We discuss the impact of many medicines we take that affect both libido and sexual response.  Most of us are aware that certain SSRI antidepressants ( such as Prozac and Zoloft), tranquilizers such as Valium, and even some blood pressure medications can impede libido, but did you know that taking oral hormones, even birth control pills can impede libido, too?  Turns out that when some women take oral estrogens they make more sex hormone binding globulin (SHBG) in their liver.  This binds to the normally small amount of testosterone made in the ovaries and reduces libido.  Our total testosterone level may be unchanged but the “free” testosterone which is biologically active, is significantly reduced at times and this is felt as reduced interest in sex.

It is also good to know that many women do not spontaneously experience “libidinous” interest in sexual activity until they become physically involved in it. What this indicates, is that there is a leap of faith here.  If you are happily involved with someone emotionally and are not feeling enough of that spark, try to push through and the spark will become ignited in most cases.  This can be a self fulfilling prophesy, more activity leads to more interest and more pleasure. There is a bit of inertia that you need to overcome.

There is a great payoff as well.  As we increase our sexual activity we increase our sense of well being, we secrete more oxytocin, a hormone that makes us feel more intimate and close, calm, and happy.  This in turn, increases our desire to continue to be sexually intimate.  And as we say,  One thing leads to another…

And did you know that so much of female sexual response is in our very complicated brain that we need to nurture our sexual interest with guided imagery, fantasy, readings, visual images, pictures, sounds and smells?  Women respond better when they pay attention throughout the day to the triggers of sensuality and sexuality. We need to see ourselves as sexual beings in everything we do, from how we dress, to how we approach our partners on non-sexual situations.  A kiss on the lips, contact in the manner of a hug, eye contact, all lead to better sex.  Even doing house work together increases sexual interest!! (Tell that to your partner; tell them you read it here).  Most of all remember what my friend Stella says, “Sex does not start in the bedroom, it ends there!”

I am 46 years old. History of fibroids. Married with three teenage children. Husband does not want any more children. I do, but don’t have the energy for another small one. I am in moderate constant pain from the fibroids. It’s like walking around with a dull ache inside my abdomen. I also have painful ovulations. My doctor told me today that a hysterectomy is my only alternative as I already had fibroid surgery five years ago. Are there any other options for me? A hysterectomy seems so final. Thanks!

Ann

ANSWER:

Thank you for your question. It is often stated that after a myomectomy the only choice is hysterectomy, but this is not the case. I have on several occasions performed a second or even a third myomectomy for patients either eager to get pregnant, possibly ambivalent about getting pregnant, or just wanting to keep the uterus they came into this world with intact. There are studies showing that myomectomy is not surgically riskier than hysterectomy, is not associated with greater blood loss than hysterectomy, and only in very rare instances can result in very good outcomes. There are rare cases of fibromatosis (where the uterus has over 100 tiny fibroids) that are not very successful, but this condition is not common. Since fibroids are benign and since they stop growing at menopause and actually shrink, I would recommend another myomectomy to any woman not ready or interested in hysterectomy. The benefits of hysterectomy are that no further fibroids can grow, there will be no further menstrual bleeding at all, and estrogen replacement if desired will not need to be balanced with progesterone. Still, if uterine preservation is necessary or desirable, myomectomy is the way to go.

There are other options for fibroids if bleeding is the problem such as resectoscope myomectomy and ablation but this will not treat the pain. There are drugs that put you into temporary menopause and stop the growth and bleeding of fibroids, but not always the pain.

If you cannot find a doctor to take care of this near you, we have many patients who come for care here in Santa Monica from all over the country. Best of luck in your quest.

Amy Rosenman, MD

Coincidentally I attended a discussion of mesh with the director of Urogynecology at UCLA.  I had the privilege of training him as a resident and fellow.  He reviewed the literature on vaginal mesh repairs and concluded that the patient must be openly consented for all the possible complications we are now aware of.  He agreed that it takes at least 3 years on the market for new materials to be properly evaluated for long term safety.  We are now at the 3 plus year mark and we are learning that the placement of vaginal mesh has some complications.  I have decided that I will not use these mesh kits for repairs the first time, that I may only use them if a previous repair has failed requiring re-operation.  This is just a small sub-group of patients.

In my experience I have seen several women who had this mesh placed elsewhere and then had complications.  They were uncomfortable and in many cases I had to remove part or most of the mesh.  It is quite difficult to remove all the mesh because it grows into the surrounding tissue.  These women were uncomfortable with either pelvic pain, discharge and bleeding or all of these symptoms.  Each of them said if they had understood the risks they would not have proceeded with the mesh.  For the first (or a primary) repair it is usually advisable to use the native tissue and perform the least invasive surgery possible.  In my hands that is a transvaginal hysteropexy or colpopexy ( uterine or vaginal suspension through the vagina) or a laparoscopic vaginal suspension if the woman has already had a hysterectomy.  These procedures have good success, in the 80% range, and if there is a recurrence, it rarely requires another surgery, and if it does, we may have more information about mesh repairs by then.

At this time I will reserve my judgement and stick to native tissue repairs in most circumstances especially since the FDA (Federal Drug Administration) which regulates medical and surgical devices issued a warning about vaginal mesh last November 2008 pointing out that there are more mesh related complications than originally expected.  Most of these are mesh exposures in the vagina and pain with intercourse.  The erosion rate was in the 10 – 13% range.  I agree with the above patient, I would rather have prolapse, or try a procedure without those particular risks, even if it had slightly more recurrences.

There is a relatively new device on the market called a Colpexin which is ideal for younger women.  It is a spherical firm ball that is used to give added support to the pelvic organs by placing it in the vagina.  Kegel exercises are performed with it in place and it increases the effectiveness of the Kegels with a mild biofeedback letting you know to contract the correct pelvic floor muscles.  It can be fit by a urogynecologist in the office and costs under $150 for the device.

If you plan to have children, definitive surgical repair should be put off until you are finished with pregnancies.  When this is not possible and surgical repair is a necessity, cesarean birth is usually recommended to avoid disruption of the previously repaired area.

There are some risk factors to prolapse at any age:  childbirth trauma is top of the list but after this are heredity, vocations that increase pelvic pressure (like parachuting), use of steroids that weaken tissue, other medical conditions that weaken tissue.