Book Launch! Female Urinary Incontinence

I am proud to announce the launch and availability of my new book on Female Urinary Incontinence. It is immediately available at www.BladderBook.com

It is informative, concise, well illustrated, and not too heavy with medical jargon. It will inform and improve your life if you experience Urinary Incontinence, no matter how long you've had it or what causes it to occur.

In 10 minutes you can change your life dramatically and regain lost confidence.

It is only available at www.BladderBook.com  You will find it is shorter (60 pages), less expensive, and as comprehesive as any comparable book at Amazon or B&N. And it fits conveniently in your purse or pocket.

To preview the chapters go to www.BladderBook.com. We can ship to all 50 states, and worldwide.

Are There Racial Differences Among Those That Have Overactive Bladder?

A very common condition, Overactive Bladder (OAB) is a syndrome that consists of abnormal urinary urgency (uncontrollable or painful), with or without urge incontinence (leaking with the urge prior to getting to the bathroom), urinary frequency, and often nocturia (waking up with the urge to void urine), when no other bladder disorder is present (such as infection, tumors, etc). The prevalence of OAB in Europe and the US ranges between 11-16% of the adult population, with similar rates between men and women. Of the large trials, none looked at whether there are racial differences when it comes to who develops OAB.

An enormous internet based survey was conducted in the US among over 62,000 participants from the US, UK and Sweden. Over 36,000 responded and a random sample of 20,000 men and women were chosen. There were very interesting findings:

White and Hispanic men and women perceived worse bladder condition than black and Asian men and women. Women experienced greater impact than men.

Black men were most affected by OAB compared to Hispanic, Asian or white men, while for women there was no racial difference. Among women of all races the prevalence of OAB was between 27-46%, the lowest were Asians, the highest were black women.

Significant predictors for developing OAB in women were:

History of bedwetting as a child, high BMI, being a current smoker, history of recurrent UTIs, uterine prolapse, hysterectomy, arthritis, depression, hypertension, IBS, previously given birth, and sleep disorder.

For men, predictors of OAB were also arthritis, hypertension, diabetes, heart disease, prostatitis, prostate cancer, IBS and BMI.

Many of the health conditions that are predictors of OAB are shared between men and women, and these are usually age related changes, where an aging bladder itself as well as underlying vascular disease can contribute to OAB symptoms. Pelvic floor surgery or weakness is a risk factor in women for OAB as well.

Though race is not predictive among women for who may develop OAB, it is a common condition that can affect quality of life and can be exacerbated by lifestyle habits and poor health.

Does Pelvic Radiation for Cancer Affect Female Sexuality?

Sexuality is a complex synthesis of the physical, psychological, and social interaction. Cancers that develop in the pelvis, such as uterine, cervical, anal or rectal cancer may require surgery, radiation or both. How does radiation affect women and their sexuality? Often, sexuality is neglected after treatment, or considered secondary in terms of importance related to overall survival. But in women who survive, can they resume sexual activity, and how are they affected by radiation to the pelvis? Survival rates for cancers are increasing and as such, more attention is then paid to quality of life.

Ionizing radiation destroys cancer cells due to their more rapid proliferation compared to normal tissue, but radiation can lead to anatomic changes resulting in bowel and bladder symptoms, pelvic pain, loss of hair to irradiated skin, vaginal narrowing, vaginal dryness, higher infection risk and pain with intercourse, vaginal bleeding and premature menopause. At the same time, women will often feel isolated, or develop anxiety and depression from their diagnosis and throughout or after treatment.

A large study recently reviewed the common complaints and changes that women reported as a result of pelvic radiation for uterine, rectal or anal cancer. Women reported more fatigue, lack of strength, vaginal discharge, diarrhea, skin redness and psychological stress. Of all the sexual dysfunctions, sexual desire was affected more than other sexual domains such as arousal, orgasm, etc. The most common reason for avoiding sex was limitation from the cancer diagnosis and treatment itself, reported by 66% of women. Sexual function was not a function of overall radiation dose received.

Interestingly, 25% of the female patients reported that their doctors questioned them about their sexual function, while 17% reported that they were the ones who prompted the doctor with questions about sexuality. These topics may sometimes be perceived as trivial and may be dismissed in light of the overall health concerns.

No less important is the quality of the relationship the woman has with her spouse/partner, who may withdraw for fear of the cancer itself, or fear causing harm to their loved one, or fear of the unknown if sexuality is explored. Overtime, the stress on the body, whether physical or psychological can increase, thereby worsening sexuality with time as well. In the end, intimacy may be avoided in order to avoid anxiety that may be provoked with sexual activity.

Reviewing such a topic with women who are dealing with cancer may be encouraging and inspire hope and strength throughout treatment.

How Does Diabetes Affect the Bladder?

Diabetes is a staggering health burden. There are approximately 26 million Americans with diabetes, and about 79 million who are “prediabetic”. Bladder dysfunction in those with diabetes has been reported in 80% of diabetic individuals. By comparison, neuropathy occurs in about 60% of diabetics, and kidney dysfunction in 50% of diabetics. The effect of diabetes on the bladder can be wide ranging: from underactive bladder (with retained urine that can lead to UTIs), to Overactive Bladder, to urinary incontinence.

Damage from diabetes can occur on various levels: nerve dysfunction, muscle dysfunction, and urothelial (lining of the bladder) dysfunction.

Nerve dysfunction- this is a type of neuropathy, where sensation is lost, meaning, the urge to void is not perceived until the bladder is overfilled, or the nerves that control bladder contraction are weakened leading to less urine expulsion and more retained. This leads to chronic stretch and loss of elasticity. Bladder capacity can increase slowly, like a sinking boat, “taking on water”, till the bladder loses its ability potentially to contract. Mini-strokes or major strokes, brought on by diabetes can exacerbate bladder dysfunction, as the stroke may affect also perception of a full bladder till too late when incontinence may occur, or with sever stroke, bladder retention occurs outright.

Muscle dysfunction- This may be related to neuropathy as described above. Direct damage from diabetes to bladder muscle does not occur, unlike direct nerve damage to axons leading to neuropathy, by impaired nerve signals lead to muscle weakness, poor contraction, poor emptying, chronic stretch, loss of elasticity, thinning of the muscles. The urethra, or bladder opening, can be directed affected, by impaired relaxation/opening when voiding should occur, leading to elevated urinary residual levels. Impaired contraction combined with impaired sensation and perception can lead to urgency, frequency, retained urine, UTIs and incontinence.

Urothelial dysfunction- The inner bladder lining in contact directly with urine is not simply a barrier, but also acts a signaling way station as well between deeper surfaces. Rat models show that in diabetes, the urothelium thickens, releasing certain chemicals that can contribute to overactive bladder symptoms. This bladder overactivity has been reported in 48% of diabetics, and is the most common finding on urodynamics testing, followed by poor muscle contraction in 30%, and poor compliance in 15%.

Diabetics are already more susceptible to developing infections, and elevated bladder urine residuals simply increases this risk. Interestingly, certain types of E coli bacteria adhere more readily to the urothelium of diabetic patients.

So, what is diabetic patient to do? Tight sugar control minimizes the deleterious effects on blood vessels and all organs including the bladder. Timed bathroom trips and “double urinating”, can help empty a bladder that is weak. Fluid management helps prevent over production of urine that may stress the bladder. Consistent hygiene around the genitals helps to reduce the chance of infection. Medications are available that help reduce the tone of the urethra to help bladder emptying, and self catheterization can be used to empty bladders without any function. In addition, Interstim sacral neuomodulation can be attempted in bladders with poor contractile function as well.

Is Advanced Maternal Age a Risk Factor for Stress Urinary Incontinence- What is the Medical Evidence?

It is well known that birth trauma ( pregnancy and vaginal birth) and age are two of the well known and common risk factors for developing stress urinary incontinence (SUI) (leaking urine with coughing, sneezing, laughing, lifting, exercise and sex). But, is delivering a child when a woman is “older” an additional risk factor for developing SUI? And, what is considered “older”? Is it 30, 35, 40, or over 45?

The injury that occurs during pregnancy and birth is both stretch and compression injury to the supportive ligaments of the bladder and urethra and the nerves that control the urethra. A prolonged labor or large baby head can worsen the birth trauma that occurs, but bear in mind that not all women who deliver ultimately develop SUI. In fact most don’t, but if a woman does deliver when older, are the tissues of the pelvis “less resilient” and more subject to long term changes that lead to SUI?

Further, if a woman develops SUI during pregnancy, the majority will recover within a few months to a year after delivery. Partial recovery or no recovery is a predictor for development of SUI within the next decade.
Though common sense would dictate “yes” to the question of “advanced maternal age”, some researchers recently looked at the medical literature to glean the answer from papers that review risk factors for SUI.

The results were mixed, but skewed heavily towards older age. In fact, of the papers, 15 showed that advance age was a risk, while 3 papers did not. Most of the papers did show a risk for women older than 35 yrs old, while some showed a risk from women older than 40-45 yrs. Interestingly, there were a few that showed risks for SUI for mothers of young age, less than 22.

Other risk factors noted include high BMI (>30), incontinence early on in pregnancy, and pre-pregnancy SUI. As the studies mount, further weight to the existing evidence will confirm our current theories and even uncover further risks. For women planning pregnancy, reducing risk factors such as high BMI and family planning for the best age to deliver can be very relevant issues.

Time From First Sex to First Sexually Transmitted Disease: What Age Women/Girls Are at Risk, and What to Do About It

The time of first sexual activity in young women has always been a subject of debate as it relates to complex social and ethically issues but also for serious health issues. This has been highlighted recently by the debate over the cervical cancer vaccines, Gardasil and Cervarix, as it raises the issue about if/when to vaccine girls/women against a serious form of cancer that is contracted as an sexually transmitted disease (STD) or sexually transmitted infection (SDI).

Screening for STDs in young women/teenage girls is appropriate given sexual behavior in younger women and the high level of morbidity/complications that can occur from untreated STDs, such as pelvic inflammatory disease (PID), ectopic pregnancy, infertility, premature births, and increased risk of contracting HIV.

A group of researchers from Indiana recently tried to determine the age at first sexually intercourse among girls aged 14 to 17, the time interval from the first sexual intercourse to first STD, and the time between infections. The most common infections that were screened for were Chlamydia, Gonorrhea, and Trichomonas.

The goals of the study were to try to establish when it would be appropriate to begin screening sexually active girls once they begin having sex, and then what is the appropriate screening interval to be sure they do not have a 2nd/3rd, etc infection.

A group of 386 girls were studied and followed. They were mostly urban and black ethnicity (89%). The follow up period for the study was 2 yr, and the average number of sexual partners was 3.

The age at first sexual intercourse was on average 14 years old. By age 15, 25% of the girls acquired their first STD, most often Chlamydia, although the median interval between first sex and first STD was 2 yrs. Other infections, as noted were gonorrhea and trichomonas. The time between the 1st and then 2nd infection was on average between 3-6 months, often with the same organism. This concerning fact points to the either the prevalence of STDs among the teenage boys infecting these girls, or the fact that the boys may or may not be treated and may be reinfecting their same sex partners. Interestingly, the younger the girl, the longer it took to screen her from her first sexual encounter, for example, for girls age 10 or 11 who were sexually active, they were not screened for 3-5 years later, while for girls ages 13 or 14, they were usually screened within 1-2 yrs after their first sexual encounter.

What can we learn from such a study? May girls become sexually active while still teenagers, and young teens or pre-teens, and early age of sexual intercourse is correlated with a higher risk of STDs. Multiple sex partners and an urban population increases the risk for STDs, but the finding allows doctors, health advocates, teachers, parents and teens to understand that among the many potential pitfalls with early age sexual activity, also comes the risk and reinfection of STDs. Since often Chlamydia and gonorrhea may not lead to symptoms in girls, untreated infection can lead to serious gynecologic and fertility health concerns, as well as promoting transmitting infection to other sex partners.
If screening for STDs were to be adopted in girls within 1 yr or less from when the begin engaging in sex, it would benefit them by catching them often before they acquire an STD, and can be appoint of education for sex education and prevention.

FDA and Mesh complications in vaginal surgery

In response to the FDA's recent bulletin on complications related to mesh used to correct vaginal prolapse, the Prolapse Surgeons Network release a thorough report on the evidence for the use of mesh in correcting prolapse.


From their recent letter to the physician community:

"We are of the strong opinion that the recent FDA UPDATE fails to convey an accurate perspective to the public, to the press and unfortunately, even to the legal community. We believe that even surgeons who use mesh for prolapse in a limited fashion would concur that this is less a matter for the FDA and more for the medical community to work on and determine surgeon training requirements and patient selection. We believe that the framework for improving safety should center around comprehensive efforts between specialty societies, hospital systems and thought leaders to improve and formalize surgical training guidelines, credentialing criteria, and outcomes monitoring , rather than being mandated by the FDA unilaterally. As with any surgical procedure, proper training and adequate volume will minimize the risk of complications.


Moreover, we feel that several key conclusions in the UPDATE are not consistent with the scientific literature pertaining to vaginal mesh and are inconsistent with the clinical realities we encounter as surgeons caring for women with severe prolapse. Both the abdominal and vaginal mesh options are indeed accompanied by unique risks and benefits that need to be candidly and thoroughly discussed; but the FDA and public must also understand the broader perspective that every prolapse option involves risks and benefits. Debating the most favorable risk-benefit is a decision best steered by a discussion between a patient and properly trained surgeon guided by best practice guidelines that we agree upon."


To read the evidence please follow the link below or paste into your browser.

https://docs.google.com/viewer?a=v&pid=explorer&chrome=true&srcid=0B1tkV5dMf-zIZTc0ODNlNDYtODllYS00MGVjLWEwYmQtMDc5ODUwNTM4NDJi&hl=en_US&pli=1