Monday, December 21, 2009

Vaginal massage during pregnancy may avoid episiotomy

A previous post on this blog discussed performing Kegel muscle exercises late in pregnancy and into the first 12 post-partum months to help reduce the development of urinary incontinence. This in encouraging especially for first time mothers wishing to decrease the “side effects” to the pelvic floor as a result of their first vaginal birth. In addition, a recent review of the literature, researchers found that massage of the perineum and lower vagina can reduce the chance of needing an episiotomy at the time of birth.

An episiotomy is a surgical incision either usually ay the 6 o’clock or 5/7 o’clock position during the birth process in order to facilitate delivery of the baby’s head in order to preempt/prevent an uncontrolled tear of the same place during the birth, if it appears that the head may too big. It is not always needed and is controversial whether an “intentional tear” preempts a tear that may or may not have occurred. Both are repaired regardless, after the birth.

Massage of the perineum and lower vagina during the last four to five weeks for four minutes appears to help the vaginal area expand and help avoid an episiotomy.

Monday, November 23, 2009

Pain with Sex

Dyspareunia is a sexual dysfunction where pain is experienced during, before, or after sex. It often leads to disruption of normal sexual activity and relationships problems. It can be a localized pain or general discomfort.

What else can it occur with? Often, Dyspareunia can be seen with chronic pelvic pain, IBS, urinary urgency, bowel urgency, or tampon discomfort. Only when symptoms are severe enough do we women seek medical treatment, but the actual number of women who experience it is unknown. It can be brought on by physical or psychological events.
Psychological causes can include: Sexual abuse during childhood, feelings of shame or guilt towards sex, and fear of intercourse or pain from first intercourse.

In addition, dyspareunia can be classified as being either superficial or deep, and whether it occurs all the time, or just with certain partners or situations.

What are common causes of superficial pain during sexual intercourse?

Vulvar pain (vulvodynia) may be described as a burning sensation or pain with penetration. It can be lifelong or develop with age. Some common causes are menopause, vulvar infection, lichen sclerosis and idiopathatic reasons.

Vaginismus is rare but is the involuntary spasm of the entryway muscles of the vagina from psychological stress.

What are some of the causes of deep pain during sexual intercourse?

Chronic Pelvic Pain (CPP) which can be pain of the pelvic floor muscles or related to Painful Bladder Syndrome/Interstitial Cystitis.

Endometriosis- common symptoms include abnormal menstrual bleeding, pelvic pain, premenstrual spotting, and sometimes infertility.

Pelvic Inflammatory Disease (PID) if chronic. Pelvic scarring can cause the uterus to become fixed in place and lead to deep pain during sex.

Perineal Trauma from Chiildbirth occurs quite commonly and is often thought to be related to episiotomy. Approximately 90% of woman will have perineal pain after childbirth (which is expected), however, the painful sexual may not resolve for 4-6 months after vaginal delivery. This is not necessarily a sexual dysfunction as much as it is normal tissue recovery. Resumption of sex too soon after childbirth may not be giving the vaginal tissues enough healing time. However, resumption of sex after childbirth depends heavily on: the mode of childbirth (vaginal vs. C-section), the severity of perineal tearing, maternal age, breastfeeding status and cultural issues. Women with 3rd or 4th degree tears were much five times likely to resume sex when compared to women with no tearing. Moreover, approximately ¼ of new mothers report loss of sensation and inability to achieve orgasm at 6 months post partum.

The doctor’s approach to dyspareunia should be thoroughly investigative since most women will not present with this specific complaint. Rather, dyspareunia may be present with other pelvic health conditions and direct question can lead to diagnosis. A physical exam of the abdomen and vagina with careful palpation both without and with a speculum, and often bimanual exam will yield the most information.

How Can Dyspareunia be Treated?

Psychological Assessment if appropriate

Medical treatment depends on the cause of pain. Often, lubricants or topical estrogen can improve dryness. Changing sexual positions may help as well. Vaginal massage or painful trigger points can sometimes help CPP. Pelvic floor relaxation with stretching, yoga or warm baths can aide in this as well. Antibiotic therapy can be given to treat PID. Pain meds or anti-inflammatories can help with CPP. Vulvodynia and CPP can sometimes be addressed with anti-depressants or local topical numbing creams. Vaginismus often responds to a combination of behavior and psychological retraining, and vaginal dilators.

Surgical treatment also depends on the cause of pain. Endometriosis is often diagnosed and treated with laparoscopy. Benign cysts, tumors and cutting adhesions can be performed but are uncommon findings. Treating superficial vulvar skin conditions may require biopsy or cutting scar tissue that can develop from childbirth.

Thursday, November 12, 2009

"Designer Vagina"

Cosmetic vaginal surgery has become increasingly popular, and I have posted blog comments on it in the past. It can include labiaplasty (reducing large inner lips), or vaginoplasty (tightening the vagina).

Sometimes there are true medical indications, such as pain with sex, or tight clothes/biking riding from large inner lips, or a loose vagina that may draw in air or lack sensation during sex. Others may seek it for lesser reasons, such as aesthetics, or perceived (real or false) imperfections in their genitals. Psychological reasons may exist as well.

Here is an interesting brief article from the BBC which reports on this phenomenon.

Monday, November 9, 2009

Is Diabetes and Urinary Incontinence Related?

Diabetes Mellitus, the condition where the body is resistant to insulin, leading to elevated blood sugars, is a common condition that can lead to many detrimental health issues such as heart disease and stroke. Often, if diabetes is poorly controlled, patients will notice they have more urine, and urinate more frequently. The extra sugar in the blood spills into the urine through the kidneys and draws more water into the urine, increasing urinary volume.

This is a somewhat oversimplified look at diabetes, but diabetes can lead to muscle and nerve deterioration of the pelvic organs as well. This I will discuss further below.

Ask yourself, what can happen if you’re constantly making more urinate and have to void every hour? Well, drip, drip, gush sometimes. Controlling diabetes is one very simple and reversible way to treat urinary incontinence.

The number of people with diabetes is rising worldwide, which itself is contributed by increasing obesity rates and an aging population. As an aside, obesity and aging are themselves correlated to urinary incontinence rates as well. I posted a blog entry not too long ago, that weight reduction by 18 lbs showed a significant reduction in urinary incontinence. Aging, simply put, is unavoidable and many women will experience urinary incontinence, whether stress related (exercise-induced) or urge related (overactive bladder), and often times both together.
Women with urinary incontinence are known to experience social or sexual isolation, whether from friends, lovers, or even self-imposed. This adds to psychosocial stress and diminished quality of life. It is important when evaluating diabetes to include all co-morbid conditions that can be associated with it, when eye, kidney, heart or bladder related.

It is believed that the same damage that diabetes causes to small blood vessels and nerves that leads to poor circulation and numbness, also occurs with the bladder and urethral sphincter. I’m sure most of us have a relative with diabetes with “bad feet”. They can’t feel their toes, or they have bad circulation with foot, pain, or non-healing ulcers. Similarly, poor blood flow and nerve injury can lead to incontinence. Bladder muscle injury and bladder nerve injury can lead to overactive bladder. A “numb” bladder may not sense it’s full till it’s “too late”, leading to urge incontinence. Bladder muscle can lose its elasticity and not fill all the way, leading to frequent urges. Poor muscle function may lead to incomplete bladder emptying (that is not perceived due to nerve injury), leading to the constant sense of urge. Incomplete bladder emptying and bad sugar control are ripe conditions for recurrent urinary tract infections.

Poor muscle function or nerve injury of the urethral sphincter can lead to stress incontinence, but diabetes can lead to obesity which itself is a risk for stress incontinence anyway.
A recent large study from Turkey compared groups of women with and without diabetes and found a 2.5 fold increased risk of urinary incontinence with diabetes. Age and BMI were also weakly related to incontinence as well. Among diabetics, 41% had urinary incontinence, while only 22% of non-diabetics had urinary incontinence. This is an astounding set of figures. Other researchers suggest that nearly 50% of severe incontinence could be avoided by preventing diabetes. Where does this lead us? Lifestyle changes, diet regimen and exercise are all important interventions. Since diabetes is an independent risk factor for urinary incontinence, all diabetics should be questioned about it for overall health promotion.

Thursday, October 29, 2009

Can Marijuana Potentially Treat Overactive Bladder?

First, a disclaimer. This blog post does not endorse the use of marijuana as it is illegal; however I recently read several studies of interest on this topic.

THC, tretrahydrocannabinol, is the major active ingredient in the marijuana and well known for inducing euphoria and relaxation, as well as sedation and drowsiness. It has been used for treating nerve pain, or neuropathic pain, cancer pain and even convulsions seen with multiple sclerosis.

AJA, Ajulemic acid, is the synthetic equivalent to THC, and is a strong pain reliever an anti-inflammatory but does not have the mind altering effects the THC has. In lab studies, it mimics many of the same properties as the popular anti-inflammatories known as NSAIDs, such a motrin or naproxen. In studies on neuropathic pain and volunteers, AJA did not cause dependency after withdrawal at the end of a one-week treatment period.

So, how would AJA potentially treat overactive bladder? A recent study on rats showed that AJA was able to suppress normal bladder activity and urinary frequency induced by bladder irritants. The researchers believe that AJA blocks the outgoing pain signal from the bladder by one of the receptors it and THC can bind to in the bladder. In the experiment, two different bladder irritants were administered to rats. Bladder pressure and contractions were measured. After injection of AJA, the bladder muscle contraction intervals and bladder pressures were blocked reversing the effect of the irritants.

So what does this mean? AJA is a promising compound that can have potentially broad application in treating the pain and overactivity symptoms that occur in many bladder conditions such as overactive bladder, interstitial cystitis, and perhaps even the bladder pain after surgery or urinary tract infections. One wonders if it many also be effective in not only treating the pain or symptoms after they occur but also given before to prevent them as well. Hmm….

Saturday, October 17, 2009

Are Women with Pelvic Organ Prolapse at Risk for Other Hernias Elsewhere in Their Bodies?

This is such as interesting question, because when I see patients who present with a cystocele, vaginal vault prolapse or rectocele, I will often help describe it as a “bladder hernia” or “rectum hernia”. In essence it is, since a hernia is a defect in muscle or fascia (connective tissue) that when sufficiently weak will allow another organ usually to push out or through. We think classically of a male groin hernia, after lifting a heavy box. The fascia in the groin will tear or become weak, allowing the small intestine to push through creating pain and a bulge.

The same can be said of pelvic organ prolapse. Muscle weakness and fascia injury from hysterectomy, childbirth or age/menopause develop and will allow the pelvic organs to push down on the various vaginal walls creating a bulge. The more severe the hernia/prolapse, the more bulge/pain and symptoms are created, whether urinary, defecatory, or with sex.
The next question is: if hernias are more common in women with POP (pelvic organ prolapse), where in the body should we look out for it, and why is this happening in the first place?

A recently published study addresses at least the first question, but a lot of research in the past 5 years has addressed the second question. Researchers in Israel performed quite a simple chart review of 60 patients they had treated surgically for POP and compared them to 60 controls. They found that the total prevalence of hernias in the POP group was significantly higher vs. those without POP. Nearly 32% in the POP had hernias elsewhere in the body vs. only 5% in controls. This was a huge difference! Women with POP were more likely to have hiatal hernias (16.6% vs. 1.6%), as well as inguinal (groin) hernias (15% vs. 3.3%). [Hiatial hernias can lead to gastric reflux).

Collagen is the substance of connective tissue in the body and there are many collagen types. Some are stronger than others. There is mounting evidence that certain proteins which degrade collagen faster or at higher levels in women with POP. These proteins are often regulated by estrogen which can affect the balance of destruction of old collagen and production of new collagen. Add childbirth, menopause, and hysterectomy and you’ve got a “golden recipe” for POP (and stress incontinence). This logically suggests that weaker collagen is not just a pelvic problem but a problem of collagen throughout the body wherever collagen is relied upon to confer strength to an organ or tissue.

Of course most women do not undergo surgery for POP or incontinence, in fact just over 10% do over the course of their lifetime. However, POP and incontinence do run in families and now we are finding out why. So now you ask your mother, aunt or grandmother if they have pelvic floor problems to see what your risk factors are, but also ask them about other hernias as well.

Monday, October 12, 2009

What Else Can Lead to Pelvic Organ Prolapse Besides Childbirth?

It is widely known and accepted that even just one vaginal birth is the most common risk factor for pelvic organ prolapse (POP) such as cystocele, rectocele, uterine prolapse and urinary incontinence. There are some women who can develop POP even in the absence of vaginal birth. POP is usually blamed on torn or stretched connective tissue (fascia) that invests/supports the pelvic floor muscles (levator ani), in addition to injury to nerves r blood supply to the organs in question. Are there other concomitant conditions that may call attention to the risk of developing POP?

Interestingly, and per common sense, POP conditions and urinary incontinence often co-exist in women. A huge study from Kaiser in 2008 surveyed more than 4000 women, with a mean age of 56, to see what kind of pelvic floor disorders they have. The prevalence is as follows:

Stress Incontinence 15%
Overactive Bladder 13%
Pelvic Organ Prolapse 6%
Anal Incontinence 25%

Not surprisingly, 48-80% of women with one disorder reported having at least another disorder. 60% of women had at least something.
An even larger population based study of women from Stockholm of 8000 recently reported their findings of the non-obstetric risks for developing POP. They are:

History of conditions suggesting connective tissue defects (hernia, varicose veins, hemmorhoids)
Family history of POP
Heavy lifting at work

Saturday, October 3, 2009

Vaccine for Urinary Tract Infections?

For several decades, scientists have been attempting to develop a vaccine for the common UTI. The only problem is, that UTIs are caused by more than one type of bacteria and there are many risk factors for developing UTIs. UITs affect more than 50% of women at least once in their lives. This leads to a lot of medical costs, lost work days and emergency room visits.

Escherchia coli (E. coli) is the most common pathogen leading to UTIs. There are many types of E coli that exist. Certain bacteria express certain proteins that act as anchors that allow them to easily attach to urogenital mucosa and creep into the urethra and bladder. Recently, researchers at Univ. Michigan developed a vaccine against E coli using certain iron receptors on the bacteria against which the patient’s immune system can react. The vaccine is administered in the nose and is currently in phase 1 trials.

Friday, September 25, 2009

Interstitial Cystitis can mimic other common female pelvic conditions

Interstitial Cystitis (IC) is a chronic pain syndrome of the bladder that is often now included within Painful Bladder Syndrome (PBS). IC is noted for symptoms of pelvic pain, urgency, frequency, nocturia in the absence of bacterial infection.
Some surveys show that it may be present in up to 2% of all women. The chronic nature of the symptoms can be debilitating and have a profound negative impact on quality of life.

What causes IC is not well understood, but it may be secondary to defective bladder lining that then allows acid/other toxins to permeate into the bladder wall and lead to pain. Pain nerves are stimulated but perhaps maintain an “on” state where pain is perceived in the absence of the bad stimulus.

After a bladder infection is cleared with antibiotics, the pain and symptoms resolve. In IC the nerves that send pain signals may continue to be active despite the fact that no toxin/bacteria are present any longer.

So what can common diagnoses can IC mimic? In other words, most or all of the following conditions are often diagnosed first, while IC becomes a diagnosis of exclusion once these common problems have been ruled out.

Recurrent UTIs- a simple culture can verify the presence of bacteria, but if recurrent UTIs really occur, a search for why bacteria persist or recurs must be sought after.

Endometriosis- this could lead to pelvic pain and bladder symptoms, as well as pain with sex. Pain with endometriosis will mimic the menstrual cycle and laparoscopy with a gynecologist can make the diagnosis.

Chronic Pelvic Pain- this is usually defined as pain for at least 6 months with unclear etiology. It can be from the back, buttocks, abdominal wall muscles, and the pain leads to functional impairment. Common causes are: adhesions, pelvic inflammatory disease, ovarian pain, radiation pain, and so on…)

Vulvodynia- this is pain emanating from the opening of the vagina in the absence of any clear pathology. The vulva and the bladder share nerve endings and are derived from similar structures in development and there is likely some crossover in perception of symptoms. Often IC and vulvodynia will be diagnosis together in about half of all IC cases.

Overactive Bladder (OAB)- This is a common constellation of symptoms of urgency, frequency, and urge incontinence, with or without nocturia. It does not involve chronic pain. Often, OAB can be managed with fluid/diet/caffeine control, and of more severe, medication.

Bladder cancer- This usually presents with blood in the urine. It’s higher risk in those over 50, or smokers. Gross blood in the urine should always be evaluated, but microscopic blood in this age and risk group should also be evaluated. Bladder cancer usually doesn’t cause pain, but can lead to OAB-type bladder symptoms.

Friday, September 18, 2009

Persistent Gential Arousal Disorder

Recently I saw a patient with an interesting and peculiar complaint: she felt constant clitoral arousal that lead to pressure that she could not relieve. It was leading to anxiety and disrupting her life and activities. Even after achieving orgasm from masturbation, she would still sense the clitoris to be stimulated.

It was fortuitous that I read about this condition about 3 months before I saw the patient in the office. It is a little known condition that was first described in 2001. It is a problem of genital arousal not sexual arousal. Patients will experience tingling, pressure, irritation, congestion, throbbing, pain or vaginal contractions. Only sometimes can sexual intercourse or masturbating alleviate the sensation. In a recent Dutch study, there appears to be a correlation between PGAD, overactive bladder and anxiety.

In my patient’s case, as is described for PGAD, the patient felt genital/clitoral arousal the entire day; it was unwanted and intrusive to her life; it was triggered by non-sexual activity (she had a UTI that preceded it); it lead to distress; it was not associated with a psychological condition. Because of the problem, her anxiety level is raised which leads to a vicious cycle of worsening the condition.

What are considered to be the triggers for PGAD?
Sexual stimulation

What can exacerbate the condition?
Pressure against the genitals
Visual arousal
Vibration (car, motor)
Stimulation by partner
Genitals becoming too hot
Riding a bicycle/horse

There is no specific treatment since the cause remains vague. Psychosocial support and defining the condition helps to create some knowledge that such a condition exists. Intercourse or orgasm may bring some temporary relief. Ice or topical anesthetics can help reduce swelling and sensation. Pelvic massage or stretching exercises may help. Mood stabilizing medication is empiric and may or may not help, especially if there is underlying anxiety or depression. Anxiety-reducing coping skills and activities can lead to distraction and may be useful.

Thus far, topical anesthetics have brought my patient some relief.

Tuesday, September 1, 2009

What Causes the First UTI a Woman Develops?

Like most women suspect, often the first UTI a woman will have is related to sexual activity. In bygone days, it was called “honeymoon cystitis”, referring to a bladder infection the developed after have sex on the honeymoon. Recently researchers in Florida characterized the presentation and risk factors of the first UTI women experience.

181 women who visited the university health clinic in Gainsville, Florida for their first UTI were observed and compared to controls. Urinary urgency and frequency were the two predominant presenting symptoms in these young women. The average age was 21 years. Sexual activity was the most important risk factor for their first UTI, with vaginal intercourse and number of sex partners within the prior two weeks. Interestingly, tampon use vs. pads during menstruation and direction of wiping was not strongly correlated to first UTI. (These are two hygiene practices I ask about in my female patients who have recurrent UTIs, though).

There was found a strong correlation to coffee and tea consumption, and a weak correlation to alcohol consumption. E coli was the most common bacteria isolated in cultures, followed by Ureaplasma. E coli happens to be the most common bacteria causing all UTIs.

The ultimate conclusion of the researchers was that certain lifestyle choices are the items that pose the risk for development of the first UTI.

Wednesday, August 19, 2009

Vaginal Wind: An Embarrassing Event

Some women have experienced passage of air or wind from the vagina that can create an audible noise, and may be embarrassing. It can happening during sporting activities, sexual intercourse or sometimes just from squatting.

Pelvic floor weakness, usually from childbirth, is the main culprit here. Air can get drawn or sucked into the vagina during any of the above mentioned activities, especially if the vaginal opening is wider or looser than what it had been previously. After the air is drawn in it becomes trapped in the upper vagina behind one of the vaginal walls that may be loose, such as from a mildly dropped bladder. Then during repositioning of the body, the air is pushed out the vagina creating a noise and sensation.

Pelvic floor muscle weakness is common. Many women already perform Kegel muscle exercises to help decrease the severity and incidence of urinary incontinence/leakage they experience. Similar pelvic floor muscle retraining can re-strengthen this part of the body. In addition, squeezing the thighs closed against a beach ball, or pushing the thighs out against resistance at the gym, also helps the pelvic floor.

Weighted vaginal cones are different sized smooth cones that are placed in the vagina around which the woman squeezes in order to retain the cone. You begin with larger sizes and work your way down.

Sometimes placing a large tampon in the vagina while working out, simply blocks movement of air. It may also support the urethra just enough to prevent urinary incontinence as well during a workout, and trap urine within it prevent wetting of underwear or workout clothes.
Significant pelvic floor weakness can be surgically corrected if significant. When the bladder, top of the vagina or rectum push into the vagina, causing pressure, or even push out the vagina, then it’s time to have a formal examination.

Thursday, August 13, 2009

Vaginal Health for Post-Menopausal Women PART 2

Loss of Estrogen with menopause can also lead to urinary incontinence and bladder symptoms. The two most common types of urinary incontinence are Stress Urinary Incontinence (SUI), and Urge Urinary Incontinence (UUI). Atrophy itself doesn’t directly lead to incontinence, but atrophy does increase the likelihood of development and both types of leakage are more symptomatic in the woman with atrophy. Other contributing factors to incontinence include: birth trauma, previous surgery such as hysterectomy, radiation, obesity, repetitive straining (constipation, heavy exercise), medication use, and age.

Review of the medical literature has shown that Estrogen replacement (topical preferred), is beneficial in treating atrophy, particularly symptoms of dryness, itching, burning, pain with intercourse, recurrent UTIs, and urinary urgency and frequency.

The usual dose is 1 gm inserted into the vagina at bedtime between 2-3 times per week. Usually there is a run-in period for 1-2 weeks when first beginning when it is inserted every night or every other night. Of course, any history of breast cancer, cervical or endometrial cancer is clearly contraindicated. Sometimes even vaginal estrogen topical cream can lead to transient flushing, breast tenderness or other symptoms when first starting up. The overall absorption of estrogen into the bloodstream after topical application is inconsequential, and circulating blood levels of Estrogen are unchanged even after 6 months of typical use (1 gram topical every other night). Occasionally it can lead to a burning sensation itself in the vagina, and thus it is not for everyone.

Generally, about 2-12 weeks are needed for resolution of symptoms, however, some women find that once therapy is initiated, it should be continued as long as it is tolerated or desired. Symptoms usually return about 4-6 weeks after it is discontinued. Topical Estrogen alone DOES NOT treat stress or urge incontinence, but Estrogen in conjunction with other therapies can improve urge incontinence. Usually, stress incontinence is best treated by a sling procedure once Kegel muscles exercises have failed, or if severe. Lastly, Estrogen therapy is not effective in treating pelvic organ prolapse, such as a dropped bladder (cystocele).

Monday, August 10, 2009

Vaginal Health in Post-Menopausal Women: Part 1

What is it about menopause that leads to deterioration of vaginal health? Most answers revolve around Estrogen levels getting lower but how does the latter lead to the former?

The environment of the vagina has normal bacterial flora, just like the mouth or intestines, that serve certain good purposes. These normal vaginal bacteria keep the tissue healthy and protect against infection. Lactobacilli are the normal bacteria in the vagina. They produce lactic acid which keeps the vagina slightly acidic, preventing bacteria around the anus or other parts of the body from “invading”. However, Lactobacili require a healthy vagina high in Estrogen to thicken the vaginal lining to allow these to survive.

Atrophy, or thinning of tissue, occurs with loss of Estrogen following menopause. The degree of atrophy depends on multiple factors which helps explain a wide variety of symptoms. Up to 50% of menopausal women experience symptoms of genital atrophy, and with women living longer and healthy, vaginal atrophy symptoms can lead to dramatic effects on quality of life.

What are some symptoms of atrophy?
Vaginal: burning, watery discharge, dryness, uncomfortable intercourse, itching.
Bladder: recurrent UTIs, frequency, urgency, burning with urination, waking at night frequently to urinate.

Bacteria can exist in the bladder in 20% of 70 year old women, and increases up to 50% by age 80. Close to 10% of women over the age of 60 will suffer from recurrent UTIs, which is defined as more than 2 UTIs per year. Once Estrogen levels drop, Lactobacilli fail to grow in the vagina, leading to a loss of acidity, which then allows harmful bacteria to propagate in the vagina and lead to infections.

Saturday, August 1, 2009

Pessaries- What are they and when do you use them?

Until surgical methods matured, Pessaries were the only form of treating pelvic organ prolapse (POP), such as cystocele, rectocele, uterine prolapse and stress incontinence. A pessary is classically a round ring that is placed into the vagina to reduce the prolapse. It derives from the Greek word pesos, meaning stone. Modern Pessaries can take many shapes: rings, cubes, horns, rings with knobs, and semi-circle forms. Since the lifetime risk for a woman in the US for undergoing POP surgery is 11%, pessary is often discussed as one of the non-invasive treatment options either for mild-moderate prolapse or in women who may not be good surgical candidates.

Pessaries must be properly fit to the woman’s pelvis and must be comfortable. Often, 2 or 3 fittings are necessary in order to see which size is appropriate. Not many practitioners are skilled in fitting Pessaries, but usually, a GYN nurse practitioner is the most common health care professional who does the fittings.

Care must taken when using a pessary. Women who have them inserted must be comfortable removing and placing them by themselves. They must be removed before intercourse. Local estrogen cream is necessary to keep the vaginal tissue from becoming irritated from the pessary. It can be left in during the day and removed at night. Side effects include: discharge, odor, vaginal skin irritation with bleeding, spontaneous expulsion, obstructive urination, and discomfort. Rare cases of vaginal erosion or ulceration can occur if women forget they have a pessary in place. If the woman cannot herself remove it, she must at least visit her practitioner on a frequent basis to have it removed and cleaned.

Friday, July 31, 2009

Sex and Urinary Incontinence

Does this happen to you?

Many women experience the embarrassing sensation of leaking some urine during sex- some with penetration and some with orgasm.

It can be very distressing and lead to sex avoidance and impact negatively in qualtiy of life.

See my article recently published in The Female Patient. Download it. It's free.

Monday, July 27, 2009

Competitive Cycling May Reduce Genital Sensation in Women

Researchers in the Department of Obstetrics, Gynecology & Reproductive Sciences at Yale School of Medicine and The Albert Einstein //College of Medicine report that women who are into regular bicycling experienced reduced genital sensation and were more likely to complain of pain in the genitals. The researchers undertook a comparative study between 48 women competitive cyclists and 22 women runners.

With the help of non-invasive techniques, they studied the possible implication of bicycling on genital sensation and sexual health. Participants in the study were women bicyclists who consistently rode an average of at least 10 miles per week, four weeks per month. Women who ran at least one mile daily or five miles weekly were chosen as a control group because they represent an active group of women who were not exposed to direct pressure in the perineal region. “We found that competitive women cyclists have a decrease in genital sensation. However, there were no negative effects on sexual function and quality of life in our young, healthy pre-menopausal study participants,” said lead author Marsha K. Guess, M.D., assistant professor of obstetrics and gynecology at Yale.

About 13 million American women bicycle regularly, according to statistics cited in the article. While health benefits of bicycling are many, the activity has also been linked to injuries and fatalities due to motor vehicle collisions, neck and back pain, and chafing, folliculitis, and other ailments that affect both sexes. Past studies, including one authored by National Institute for Occupational Safety and Health co-investigator Steve Schrader, have found an association between bicycling and erectile dysfunction and genital numbness in men. “This is the first study to evaluate the effects of prolonged or frequent bicycling on neurological and sexual function in women,” said Guess. “While seated on a bicycle, the external genital nerve and artery are directly compressed. It is possible that chronic compression of the female genital area may lead to compromised blood flow and nerve injury due to disruption of the blood-nerve barrier.”

Tuesday, July 14, 2009

Free Seminar on Mesh Complications After Pelvic Floor Repair

I will be giving a Grand Rounds presentation at Banner Desert Medical Center, in Mesa, AZ on July 23, 2009, in the Rosati Education Center, Ocotillo Amphitheatre.

It will be on Mesh Complications of Pelvic Floor Repair. It is for physicians and nurses, but for anyone who is interested as well.

Registration and Lunch are at 12pm, and the program begins at 12:30pm

To register, call Wendy Tee at 480-512-3852

Friday, July 10, 2009

Vibrator Use Common and Linked to Sexual Health

A recent nationwide sampling of women conducted by Indiana University revealed that 53% of women have used vibrators during sex. Despite longstanding assumptions, this was the first large survey on such matters. It affirms what many therapists and doctors have known for years.

The study was conducted on over 2,000 women between the ages of 18-60 years. There were some other interesting findings with the study:

52.5% of women have used a vibrator, with about 25% having used it in the past month.

Vibrator use was more likely if the woman had a gynecological exam within the past year, or had done a genital self-exam within the last month, reflecting an awareness and interest in maintaining sexual health.

71.5% reported have no side effects from the vibrator. Most side effects reported were rare and short in duration.

Wednesday, July 1, 2009

Pelvic Floor Muscle Retraining Can Reduce Urinary Incontinence in Late Pregnancy and Post Partum Women in the first 12 months

Urinary Incontinence (UI) is a common female pelvic health problem and physical therapy is the most commonly recommended first line therapy for it. About 1/3 of women have UI. It is usually recommended for Mixed UI (Stress and Urge) and less commonly for Urge Incontinence alone. Pelvic Floor Muscle (PFM) retraining is usually done over 5 -12 sessions in order to adequately localize the correct muscles to train and reinforce therapy and adherence.

There are no adverse effects of doing PFM retraining. Overall, it is most beneficial when individually taught to the individual woman who is immediate post-natal but at high risk for incontinence (urinary or fecal), such as after instrument delivery, vaginal delivery after a large baby, or a third degree perineal tear.

If women perform PFM training during pregnancy or just after birth what are the findings:

In women without UI who have never given birth yet, or those with only one birth, PFM reduce UI in late pregnancy (34 weeks or more pregnant), immediate post partum (up to 12 weeks), and even up to 3-6 months after birth.

In women with UI at baseline, PFM retraining did lower UI in late pregnancy but did not show lasting effects into the post partum period.

So for all you soon-to-be new moms or those with only one child who do NOT have UI, start doing those Kegels about 2 months before the baby is due to help cut down on UI after birth.

Monday, June 22, 2009

Painful Bladder Syndrome

The term Painful Bladder Syndrome (PBS) has become the new “catch-all” diagnosis for women who experience pain with their bladder, and has become interchangeable and/or incorporated with the diagnosis of Interstitial Cystitis (IC). IC is a pain syndrome of the bladder that must fit a tight research definition, as is often considered in women presenting with pelvic pain or a painful bladder. PBS, on the other hand, is defined simply as the complaint of suprapubic pain during bladder filling, in addition to other symptoms of urinary urgency (day or night), when other bladders issues (such as infection) and other pelvic issues (endometriosis) have been ruled out.
PBS can be seen in teenagers as well as adults. As mentioned the main symptoms is pain during bladder filling that is relieved after voiding and can be cyclical, especially with menses. IC will often demonstrated transient relief or no relief after voiding, and is thought to be more pelvic pain in nature. PBS pain can also be experienced in the urethra or flank area (kidney), with urinary urgency, frequency or burning (dysuria).

Examination must rule out several other common problems as bladder and pelvic pain can overall with other GYN sources. Infection or irritation of the bladder with food or drink, are easy to discern with a culture and food diary. Incomplete bladder emptying can be assessed as well. Ovarian and tubal pain or pathology can be assessed on exam and/or ultrasound such as cysts, tumors or Pelvic inflammatory disease. Fibroids or painful menses are other common GYN to consider. Cystoscopy is always necessary if blood is present in the urine, and after other conditions have been eliminated from consideration.

Therapy is aimed at controlling symptoms to keep PBS “in-check”. Symptoms may wax and wane for years. Dietary manipulation to reduce acidic foods and caffeine are always helpful. Reducing urine acid content can also be done with TUMS. Relaxation of pelvic floor muscles can be achieved with stretching, yoga, warm baths, and sometime muscle relaxants. Constipation prevention helps eliminate pelvic pressure and reduce the chance for urinary tract infections.
Many medications have been tried for PBS or IC, none with smashing across the board success. Essentially, it comes down to trial and error, seeing which one works best. Some that have been used are: Elmiron, Atarax, Elavil, Tagament, overactive bladder medications, and muscle relaxants. Occasionally, instillation of medication in the bladder is effective such as lidocaine, Elmiron or DMSO. If IC is present and bladder ulcers are present, cautery of them is usually indicated.

When PBS and urinary symptoms (of urgency and frequency) are present together, InterStim bladder neuromodulation can be tried. InterStim is a bladder pacemaker-like device that can reduce the symptoms of overactive bladder (OAB) in about 75% of patients when medications for OAB fail or cannot be tolerated. There has been some secondary gain in several small trials showing reduced bladder pain with the use of InterStim when implanted for OAB.

Monday, June 1, 2009

Vaginal Mesh Erosion: Part 2

The most common and proven mesh for vaginal surgery is type I polypropylene. It is inert, soft, and has a wide weave to allow tissue ingrowth and acceptance into body tissues. All others are inferior. Many comprehensive reviews of mesh are available and have been published, including my review article in Urology in 2005. We know that mesh reinforced repairs significantly reduce recurrence rates for bladder lift surgery, but is it safe, should it be used, and what complications can occur and how can they be minimized?

Surgeon experience and patient selection are of paramount importance. A doctor who has done 10 mesh cases a year is likely not going to be as proficient as one who does 100 a year, nor as comfortable taking care of complications when they arise. This is common sense. Is the patient’s health and body appropriate for mesh placement: this answer is often easily answered with good clinical judgment based on a history and physical, but there are issues than can exist that may weigh in on a decision, such as: overall health, diabetes, prior radiation or surgeries, immune disorders, etc.

Nothwithstanding mesh properties than either enable it to be incorporated into tissue or not, surgical technique alone can lead to complications. Bladder injury, bleeding, bowel perforation, wrong suture selection are uncommon but significant surgical issues than occur even in the best of hands. That is just how statistics fall out. 99 consecutive cases may go smoothly, but the 100th will have a complication. That is the nature of surgery and human error. That is the whole reason for informed patient consent. Complications can happen to anybody and they must be addressed promptly. Patients should not be embarrassed to question the doctor or bring to light an issue, and doctors should not think themselves perfect. Honesty is the best policy, and the sooner a complication is realized, the sooner it can be addressed.

The most common place vaginally placed mesh can cause a complication is exposure in the vagina. The incision line may not heal well or promptly and mesh will be seen or felt during sex. It can give the sense of pulling or tightness, or cause infection, discharge, blood, or pain. An exam will readily make the diagnosis. Mesh exposure is not a new phenomenon and it well described. Rated can vary between 6-38%. The amount of mesh placed, how it is placed, the quality of vaginal tissue, type of suture used, dissection technique, patient activity during recovery, infection of the mesh, bleeding are all factors related to mesh exposure. Often, local excision, time and estrogen cream will fix this.

A fistula is a very rare complication of any surgery, including mesh surgery anywhere in the body, and the vagina is no different. It is so rare that it is often not clear if it’s related to the presence of mesh or an undetected injury at the time of surgery.

Pain with sex: Dyspareunia. This can occur with bladder drop and is itself an indication for surgery, but dyspareunia is a well known complication of vaginal surgery even without mesh. Overtightening the vagina will lead to pain with penetration. Pain from mesh can occur if it folds or doesn’t lay flat, is too tight or conforms the wrong way around the vagina. Many studies exist on pain or resolution of pain after vaginal surgery with slings (TVT) or bladder lifts. The overall consensus in the literature is that mesh slings improve sexual function and not worsen it. Restoring vaginal anatomy with or without mesh reduces pain with sex, yet there are studies that show a low but significant number of women who have dyspareunia after mesh repair. Some cases are mixed with other vaginal surgeries and so the true incidence is unknown. A detailed sexual history pre-operatively is important in determining the likelihood of this being a factor.

Mesh materials and patient’s bodies change over time. Most biological meshes do not last and lead to recurrence. Synthetic meshes can shrink over time after being scared in. Menopause, weight gain or loss can affect the quality of mesh repair as well.

The FDA released an alert in October 2008 to physicians and patients about potential mesh complications for transvaginal surgery. Most reconstructive surgeons were well aware of these issues and so this was nothing new necessarily, however it highlights the need for public awareness. Although excellent long term data for TVT exists (10-13 yrs), we have at best 5 year data for mesh and bladder repair. Refinement in technique, surgeon experience, product selection and patient appropriateness are all equal factors in successful management of pelvic organ prolapse.

Saturday, May 23, 2009

Stem Cells in Urology?

There is hot debate about stem cell use, their ethics and potential for curing diseases. Although promising, the application to disease states should not be overblown. We may all feel bad for Christopher Reeve, but injecting him with stem cells is simply not going to make him miraculously walk. Some cold water needs to be thrown on the loudest proponents, since common sense dictates that all advancements in science don’t always happen out of sheer will and hope. Like all medical experiments, we ask the question: will it work and is it safe, and this applies equally to stem cells.

Stem cells are regarded as the ideal resource for tissue regeneration, outside of formal organ transplantation. Stem cells have the following properties: they self-renew, they can form any cell type in the body, and they can multiply into clonal populations.

There are many sources of stem cells:

Adult stem cells exist in adult tissues throughout the body such as bone marrow, brain, muscle, and GI tract. Research with these cells has progressed slowly because they are difficult to maintain in culture. Their advantage is that they will not provoke an immune response such as rejection.

Embryonic stem cells are obtained from the inner cells of the blastocyst, an early stage in human embryonic development formed 5 days after fertilization of the egg by the sperm. The ethical and political controversy dates back to 1998 when human embryonic stem cells were first isolated from donated human embryos. Although they can differentiate into any cell type (except placenta), their growth is not well controlled and can provoke an immune reaction.

Amniotic fluid and placental stem cells can be obtained from amniotic fluid, can self-renew and can differentiate into all types of cells. They are less studied but have properties between adult and embryonic stem cells, and importantly, unlike embryonic stem cells, they do not form teratomas, a type of tumor.

Stem cells for urinary incontinence is a potentially exciting application. The external sphincter can become weak and allow urine to leak past it with coughing, sneezing, laughing and exercise. Age, menopause and childbirth are common risk factors for stress incontinence. Several groups in the US and Germany have performed animal studies showing improvement in sphincter function. There are small series of human trials showing some improvement as well. Upper arm muscle biopsies from female patients are taken, and the muscle cells and connective tissue cells are grown in culture and then injected into the urethra of the same women. One early study showed a 60% cure rate and a 28% improvement rate. Another small series of 8 patients showed some modest improvement at 12 months after injection, and several needed repeat injections.

Onset of improvement was between 3 and 8 months after the injections were performed.
Despite these early modest findings, stem cells are a promising avenue for medical treatment if/when some of the ethical considerations are settled.

Saturday, May 9, 2009

Mesh Complications and Vaginal Surgery: Part 1

In all realms of medicine, advancement in patient care is a learning process, with the ultimate goal being better patient care. New technologies abound, and scientists and physicians are often at the cutting edge to adapt these technologies to patients through experiments in the labs and trials in the real world. However, new technology comes with responsibility and proper patient counseling prior to any procedure helps to define the risks and benefits of all surgeries, including those involved in mesh repair of hernia throughout the body.

Mesh is a common and safe synthetic product that can be surgically placed in many areas throughout the body to reinforce a hernia or defect that occurs over time or as a result of injury. The classic example is a groin or inguinal hernia in a man. It is painful and can occur in 10% of men, usually after repetitive straining. A mesh patch or plug is placed through a small incision and reinforces the weak tissue and significantly reduces recurrence rates. It has been widely adopted by general surgeons over the last 2 decades.

Repairing or lifting dropped pelvic organs have been common surgeries in women. The most common is the bladder (cystocele), but the uterus, small intestine or rectum can also drop and push out the vagina. It can be painful and lead to urinary and defecatory problems, pain with sex, and other issues. Many surgeries have been devised to “lift” the bladder, but unfortunately, recurrence rates for cystocele repair is quite high, approximately 30% at 4 years. It is the most common organ to drop after hysterectomy. Naturally, mesh has been considered to reinforce these repairs to reduce recurrence rates and prevent an unnecessary second and even third operation.

Many types of mesh exist, and not all mesh are created equal, nor appropriate for the vagina. Some mesh are synthetic and others are biological, from human or animal. The ultimate questions when approaching a patient with pelvic floor weakness, such as stress incontinence or bladder drop, are: Is surgery indicated, what type of surgery is indicated, what are the alternatives, how is the surgery to be done, and what are the complications that go along with it, is the surgeon comfortable and highly trained to perform it, and is the patient’s condition appropriate in order to place mesh?

There has been an explosion and revolution in women’s pelvic health in the last decade and many mesh products are available to the physician to choose from to fix incontinence and dropped organs. Subjects that older women were embarrassed to discuss are now out in the open, and since women are living longer and healthier with more active lifestyles, there is a demand for sustaining and improving quality of life in regards to the bladder. Incontinence affects a woman’s self esteem, and is restricting. Women often will stay at home in order to avoiding embarrassing odor or accidents in public, will not socialize and avoid sex. It’s a common an underreported problem with less than half of women even bringing it up for discussion with their family doctor.

The TVT (tension-free vaginal tape) mainstreamed mesh into common use for correcting stress incontinence. It has been on the market since 1996 with millions done worldwide. It is relatively easy to place, is minimally invasive, has a short recovery period and a low complication rate, and high success rate. Most urologists and gynecologists now use some type of TVT copycat to treat stress incontinence.

The question is then asked, can mesh for bladder repair, or other pelvic organs do the same thing?

Tuesday, April 21, 2009

Blood in the Urine: Hematuria

Blood in the urine is never normal, but it can be present for benign and not-so-benign reasons. "Microscopic hematuria" is when blood is only seen on a urine test (urinalysis), or "gross hematuria" where actual blood or clots are seen in the urine.

There are many urinary tract issues that can lead to both, but essentially, blood in the urine can come from the kidney, ureter, bladder or urethra. Often menstural blood, or if urine contacts labial skin/hair on the way out prior to hitting the cup, can both lead to false positives.

Common benign reasons for blood in the urine are: urinary tract infection (active or resolving), kidney or bladder stones, foreign objects in the urinary tract (stitches or mesh that have eroded into the bladder), urinary tract deformities from birth, interstitial cystitis, estrogenic changes to the bladder base (common and benign) and benign polyps. Sometimes medications can lead to blood "leak" into the urine- often these are blood thinners such as warfarin (coumadin), aspirin, plavix or pain medications such as prolonged motrin, Celebrex and the like.

More serious conditions that lead to blood in the urine can be tumors of the kidney, ureter or bladder. Of all the urinary organs, the bladder is the most common place to find tumors. Biopsy confirms the findings.

Smoking and exposure to certain chemical agents used in heavy manufacturing of dyes, paint, leatherstripping can lead to urinary tract tumors.

False positives can also happen with food dyes, pyridium, beets, and certain antibiotics.

Gross blood in the urine or persistent microscopic blood should be investigated.

Tuesday, April 14, 2009

Weight Loss Can Reduce Incontinence in Women

It is now common knowledge that weight loss decreases the risk of developing type 2 diabetes, high blood pressure, high cholesterol, and enhances mood and quality of life. Obesity is known to be a risk factor for developing urinary incontinence.

Recent research has shown that weight loss in obese women significantly reduces the incidence of stress incontinence. Even though weight loss may be difficult, losing weight by whatever mechanism or program will lead to results.

This very interesting 6 month trial from San Francisco was performed in obese women between the ages of 42 and 64. A reduced-calorie diet and exercise program was followed by half the women, while the other half were only given reading material on weight loss. The women in the structured program had a mean weight loss of 8% (17 lbs), vs. those women who were not, who lost 1.6% of their weight (3.5 lbs).

The women in the weight loss group had a greater decrease in frequency of stress incontinence compared to the control group: 58% vs. 38%, as well as a decrease in all incontinence episodes: 47% vs. 28%. The women in the weight loss group at the end of the study perceived their incontinence had become less of a problem and had a higher satisfaction rate with this change in their incontinence.

Now, this study may also hold true for women who are overweight but not "obese". In general, less overall weight does mean good over health. Those women who are probably within 20 lbs of their expected weight for their height and age and who have stress incontinence, likely have stress incontinence due to other reasons. These include: vaginal birth, genetic predisposition, chronic straining (cough, heavy exercise), menopause or hysterectomy.

Saturday, April 11, 2009

Is Your Bladder Getting in the Way in the Bedroom?

The title is a little different, but the theme is the same. This is nearly the same article that I recently published in the April 2009 edition of Perfectify:

Women’s bodies are very resilient, but many women notice changes to their bodies below the belt after major life events. Because women are living healthier and longer lives, the chances of having a problem with your bladder, and how it affects the activities in your life is expected to only become more bothersome over time.

Problems with bladder control are quite common in women of all ages, but starting in the 30s and 40s, many women notice that going to the bathroom or accidental urine loss becomes embarrassing and restricting. Despite being healthy or physical fit, the muscles and connective tissue supporting the bladder, vagina, uterus and rectum can become weak or stretched and declare itself in a variety of ways.

Urinary incontinence (UI) is the involuntary loss of urine in any situation. It can be stress-induced, meaning, urine loss during exercise, running, jumping, laughing coughing and even sex. This is known as Stress Urinary Incontinence (SUI). Very often, the sense of needing to go to the bathroom never goes away and you may feel like you have to know where every bathroom is no matter where you go, otherwise there will be trouble. The constant sense of urge, frequency and leaking before you can even pull your pants down is known as Overactive Bladder (OAB), and can coexist with SUI in many women.

Giving birth is an exciting life-changing event, yet even one vaginal childbirth increases a woman’s risk of bladder and other pelvic floor problems. Having a C-section does not seem to be protective over time. The aging process, menopause, repetitive straining such as with a chronic cough, constipation, obesity, and surgery such as a hysterectomy, are other common predisposing factors. In fact, the lifetime risk for an American woman to need surgery for problems related to pelvic floor weakness is 11%. Urinary incontinence affects 13 million adults in the US, 85% of them being women. Often women with urinary incontinence are reported to be depressed and/or embarrassed about their appearance and odor. Consequently, social interaction with friends and family, activities with the kids, and sexual activity is often avoided.

Sexual complaints are very common in women with pelvic floor weakness. Besides urine leakage with sex (which we’ll explore further below), a dropped bladder (cystocele) also impacts sexuality. Women with urine leakage, in general or during sex, have less libido, have vaginal dryness and irritation, lack of sexual excitement and lack of orgasm. Coital incontinence (urine leakage with sex), is noted to be a big cause of sexual inactivity. Intuitively, a dropped bladder or uterus can cause pelvic pressure and pain with sex and lead to avoiding intimacy as well.
Coital Incontinence (CI) has been reported to occur in 10-24% of sexually active women with pelvic floor weakness yet is probably under-reported. It can occur with a sexual partner or with masturbation. Women will rarely bring it up on their own or even after direct questioning by their family doctor.

There are two types of CI: urine leak with penetration, and urine leak with orgasm. Urine leak with penetration is caused by a weak urethra or bladder sphincter, the same cause of urine leak with exercise or laughing. Urine leak with orgasm is seen in women with severe OAB symptoms. Urine loss from penetration is more common than with orgasm. Leakage can occur even if a woman tries to empty her bladder before becoming intimate. Diagnosing CI should be included in the overall diagnosis and evaluation of any female pelvic health issue, since many often coexist.

An important question to be asked is: Does treating CI or bladder drop help improve a woman’s sexual experience? Many treatments for UI, whether it be from Stress Incontinence or OAB, are available, as well as repairing a dropped bladder or loose vagina. They range from conservative treatments, to medicine, to minimally invasive procedures. Often, pelvic floor muscle retraining, or Kegel exercises, can tone up a weak sphincter, help retrain an OAB, or tighten up the vagina just enough to make sex more pleasurable. They’re easy to perform but must be continuously done. Some common OAB medications have been shown to help orgasm-induced urine leakage. Common side effects of these meds are dry mouth and constipation. Minimally invasive surgery, such as slings, are placed in less than a ½ hour, have high success rates, low complication rates, and relatively short recovery times. These will often treat penetration-induced leakage. Bladder lift and vaginal tightening can be performed to help reduce dropped pelvic organs and reduce a wide vagina opening.

Correcting urinary incontinence has been shown to greatly reduce CI, and as a result, women report improvement in all sexual domains: desire, arousal, lubrication, orgasm, satisfaction and pain. Resolving CI leads to greater self-confidence and greater sexual interest. Bladder lift leads to less vaginal bulge sensation, and less pain with sex.

My goal in treating women with CI and other pelvic health problems is a comprehensive and tailored approach in addressing all potential concerns. The only thing holding you back is the courage to regain those life activities that may have been lost from embarrassment and avoidance.

Wednesday, March 25, 2009

Cranberry Juice: Does It Really Help Prevent Urinary Tract Infections (UTIs)?

This is a very common question I get from my female patients, both young and old. Many seem convinced that cranberry juice or pills can stop a urinary tract infection (UTI) in its tracks when they feel it coming on, or take cranberry to prevent them. Well…they may not be wrong.

After many years of grandma’s advice, in 1994 a study was done on elderly women who consumed 300 ml of cranberry juice for three months and showed less bacterial counts in the urine.This is where the whole cranberry-UTI link picked up some steam. But there is more...

I used to tell patients that cranberry juice or pills can improve the acidity of the urine, and acid is a natural defense against bacteria. Common sense would dictate that more acid is better, and cranberries are a good source. Correct? Cranberry juice however may contain a lot of sugar, and it may require drinking A LOT of it to get the effect. This isn't necessarily good for diabetics or those watching their weight. Cranberry pills may be helpful, but how many should you take to get the desired effect?

Not too long ago, a well designed study showed a trend, but no significant improvement in preventing UTIs with cranberry, and cranberry products, however, have not been shown to significantly reduce acidity. So now what?

Cranberry is seen as a natural element people can take, in order to prevent overconsuming antibiotics. Antibiotics help, but they must be tailored to the infection, and be given at the right dose, for enough period of time to prevent recurrence, persistence or development of resistance by the bacteria. However, there are women who are most susceptible to bacterial adherence, and certain bacteria are more likely to stick to the body surfaces than others.
So, what’s so special about cranberries?

In raw cranberries there are at least six chemical compounds that can interfere with bacterial adherence to the body. These compounds modify the surface properties of the bacteria to make them less sticky to the lining of the bladder. When someone consumes cranberries, the bacteria itself are actually altered by the cranberry products that dwell in the urine, changing how the bacteria express certain proteins on their surfaces leading it to cling less effectively to the bladder. This is how cranberries reduce infection. If the bacteria are less sticky, then the bladder is more capable of washing out the bugs with good urine flow. Drinking more fluids helps to create a better flow.

Interestingly, once the bacteria are removed from exposure to cranberries, they regain their “old ways” and their adhesive properties return. A recent study showed that just 6 hours of exposure to cranberry products resulted in an 84% decrease in bacterial attachment to bladder cells. Continuous exposure resulted in the continued inability of the bacteria to attach!

Now everybody go out and get some Ocean Spray!!!

Sunday, March 22, 2009

Kegel Muscle Exercises aka Pelvic Floor Muscle Training

“If you don’t you use it, you lose it” principle also applies to the muscles in the pelvis. Age, menopause and childbirth can cause weakness and looseness to the pelvic floor muscles known as the levator ani. They wrap around the anus, urethra and vagina in the female pelvis and support the organs in the pelvis: the bladder, vagina/uterus and rectum. When pelvic muscles and their connective tissue covering (fascia) weaken or tear, women may experience urine leak when coughing, sneezing, laughing or exercising (stress incontinence), or have the sense that the bladder or other pelvic organs are dropping or pushing into the vagina. Overactive bladder symptoms can also occur with a dropped bladder, such as urgency , frequency and urine leak (the “I gotta go and I can’t hold it any longer” feeling). Importantly, weak pelvic floor muscles can give a woman the feeling of vaginal looseness, and decreased sensation and/or satisfaction during sex.

Strengthening the pelvic floor muscles (PFM) by performing Kegel exercises helps to improve the tone, essentially, of these muscles. Imagine trying to stop the flow of urine during urination, or holding in poop, well, these are the sphincter muscles that can be strengthened by Kegel exercises. The main challenge is figuring out for yourself how to isolate and squeeze these muscles. But once you have, it’s easy.

Repetitive exercises can reduce stress incontinence, help with mild bladder drop, and improve tightness and sensation during sex and orgasm.

One should always begin by emptying the bladder, then relax. Tighten the PFMs and hold it for a count of 10 seconds. You should feel a sensation of lifting around the vagina or pulling around the rectum. Another way to do PFMs is to tighten and hold the PFMs tight for 10 seconds straight and then relax. Do this 10 times and repeat 3 times a day.

Try to do 10 sets of PFMs in the morning, 10 in the afternoon, and 15 at night. Or you can do it for 10 minutes 3 times a day. In the beginning, you may not be able to hold the contraction for the complete 10 count or do 10 full repetitions. However, you will slowly build to this over time. The muscles may start to tire after 6 or 8 contractions or sets. Take a break then and do some later on.

These exercises can be practiced anywhere and anytime. Most women seem to prefer doing them in bed while lying down or while sitting. Women can also try to do them during sex. Tighten the muscles to grip your partner’s penis or finger and then relax. Your partner should be able to feel the increase in pressure.

Never use your stomach muscles, legs or buttock muscles. Rest your hand on your abdomen during PFMs to see if you tense up here. Eventually, they will become effortless and part of your lifestyle. You may do them while walking, before you sneeze, or on the way to the bathroom.
After 4-6 weeks of consistent daily exercise, most women will see results. Women will notice less accidents, and feel more confident. Sex may feel better as well. After 3 months the results will be even more noticeable.

Kegel muscle exercises are not harmful and most women find them easy and relaxing. If your stomach or back muscles feel tense, then you’re probably not doing PFMs the right way. Breathing during any exercise is important, including these. Headache or neck ache can be from holding one’s breath. Breathe easy like in Lamaze or yoga.

Tuesday, March 10, 2009

Urinary Tract Infections- More

I had my article on UTIs in women posted to the Sun Times Online:

Monday, March 9, 2009

Free Upcoming Events on Female Pelvic Health

The following is short list of free educational events given by me this month and next in the East Valley.

March 25, 2009, 2:30pm: Pelvic Floor Prolapse: United Methodist Church, Chandler, AZ

April 8, 2009, 1:30pm: Female Urinary Incontinence: Ahwatukee Women's Club, Ahwatukee, AZ

April 29, 2009, 6:00pm: Female Urinary Incontinence: Chandler Regional Hospital, Morrison Building, Chandler, AZ

More pelvic health topics

Please see my blog page at's website

“Why do I keep getting recurrent urinary tract infections, and how can I prevent them?”

This is a reprint of an article of mine on urinary tract infections (UTIs) that ran in a local paper several years ago. It's worth posting it again here:

Recurrent urinary tract infections (UTIs) are defined as two or more UTIs within a twelve month period. They are bacterial infections that typical involve the bladder. Classic symptoms include lower abdominal pain or ‘pressure’, urinary burning, urgency, and frequency. If the kidney is also involved, back pain and fever may be present as well. The majority of UTIs in women are uncomplicated and involve only the bladder. Complicated UTIs are those involve the kidney or occur in pregnancy, diabetics, transplant patients, frail elderly, in weakened immune systems, or with urinary tract structural or anatomic abnormalities.

Common risk factors include: sexual intercourse, diaphragm/spermicidal jelly containing nonoxynol-9, fecal soilage of the vagina/groin, constipation, tampon use, menopause, urinary catheter use, diabetes, urinary stones, incomplete bladder emptying, anatomic abnormalities such as obstruction or reflux, neurological diseases such as multiple sclerosis or spinal cord injury, incomplete antibiotic usage, bacterial resistance.

Other urogenital problems that may mimic symptoms of UTIs include: urinary stones, vaginal infections, urethral infections from sexually transmitted diseases (STDs), interstitial cystitis.

Medical workup may include: determining a pattern of infection (intercourse, menses), prior antibiotic usage/compliance, prior catheter use, gynecological history, physical exam, urine culture, x-rays or endoscopy of the bladder (cystoscopy) if warranted.

Potential treatment options include: Longer or different course of antibiotics, proper daily hygiene, post-intercourse voiding/showering or antibiotic use, alternative contraceptive use, panty liner instead of tampons, bladder retraining for inappropriate habits, low dose antibiotic suppression, self-start therapy, and correction of anatomic problems.

Follow-up may include: monitoring for symptom resolution, re-culturing urine if symptoms recur, identify other potential risk factors, perform x-rays or cystoscopy, re-evaluation every six months.

Friday, March 6, 2009

Slings: what are the risks, benefits and recovery?

Mid-urethral slings have become the most common method to treat stress urinary incontinence (SUI). They are typically placed in under 30 minutes in an outpatient setting and are popular with both physician and patients due to the high cure rate, relative ease of placement, low complication rate and quick recovery.

The prototype of modern day slings is the TVT (tension-free vaginal tape), and many similar ones exist on the market that are placed in a similar fashion, but ultimately perform the same function. TVT has been around for approximately 15 years and is used worldwide.
The sling is made of a thin strip of polypropylene mesh weave, a common and safe type of mesh used for surgery in a variety of body locations. The width is 1 cm and the length left in the body is usually between 6-8 inches long. There are various methods for placing slings, but ultimately, it must rest under the mid-urethra.

It is placed through a small incision in the vagina, usually under general anesthesia, and women can go home the same day without a urinary catheter after urinating in recovery. Vaginal stitches to close the skin dissolve, but the sling is permanent. It becomes incorporated into the body tissue. The body lays new collagen and scar within the sling and around it, and it becomes a new firm ligament under the urethra replacing the one that had become weak. The sling acts like a backboard and supports the urethra during straining maneuvers such as coughing, sneezing, laughing, jumping and exercise. It prevents it from descending, thereby preventing urine loss.

Slings are durable to about 10-15 years but longer term data does not exist simply because it hasn’t been around that long. It is less invasive than the next most popular procedure for SUI, the Burch colposuspension, which requires a bikini line abdominal incision and then the bladder neck is raised up and stitched close to the back part of the pubic bone. Despite equivalent cure rates, surgery time and recovery time is longer. It has generally fallen out of favor as a modern approach to curing SUI. If a woman is undergoing other pelvic surgery such as a hysterectomy or bladder lift (cystocele), a sling can be done concomitantly and adds only a few extra minutes to these procedures.

For those women who desire cosmetic vaginal surgery, sling surgery can be done as well at the same time.

The expected cure rate for slings is approximately 89-91% where the female patient is dry. There is about a 2% failure rate, and the rest can be considered improved. Improvement from soaking 6 pads a day to 2 thin liners is a success for severe cases of incontinence.
Durability is important and most (85%) will still be dry in the long term. There is an expected drop off (recurrence) rate which is inevitable given changes that occur to the body with age, menopause, weight loss or gain, etc. Women who are still considering another pregnancy should not undergo a sling till childbearing is complete.

Preoperative evaluation with a history, physical exam, urinalysis, and urodynamics help to make the appropriate decision as to whether: 1. A sling is appropriate and, 2. which type of sling to use. Other factors taken into consideration when deciding if/when/and how to place the sling include age, prior surgeries, body habitus, overall health, and other considerations. Bladder function, capacity, and sphincter function as determined by urodynamics helps to tailor the sling to the individual patient.

Common risks include: infection (low), bleeding (low), injury to bladder (low), mesh exposure in the vagina (low), and post operative urinary dysfunction. Vaginal spotting is expected for 1-2 weeks after the surgery.

Recovery is usually straightforward. Typically, being a “couch potato” for 72 hrs is recommended. Women can return to work thereafter (if non-physical). Exercise and exertion should be delayed about 2-3 weeks, but no pools, baths or sex for six weeks.
Slings will usually work right away even though most scarring isn’t complete for several months. In the first several weeks, occasionally the stream may seem a little slower than usual, or may split or deflect. These usually self correct after a few weeks.

There are women who experience leakage of urine with penetration during sex, and others who experience leakage of urine with orgasm. Several studies have shown that penetration-related leakage is treatable with TVT type slings. Orgasm-related leakage can be treated with overactive bladder medication, but one study did show TVT to help this as well. Urodynamic evaluation is important to verify the correct type of sex-related incontinence prior to treatment.

Despite the fact that TVT and other slings are placed in the vagina under the urethra, it has an overall beneficial effect on female sexual dysfunction when it is related to incontinence. Women may be embarrassed to have sex if they fear a urine leak or odor, and will avoid it or have decreased pleasure. Surgical correction of SUI with TVT has been shown to improve sexual function domains such as desire, arousal, lubrication, orgasm, satisfaction, and pain. As a result of the surgery, women report reacquiring self confidence and greater sexual interest after resolution of sex-related incontinence. The consensus in the literature concludes that there is a positive, not negative, impact on female sexual health.
Most women are motivated to cure SUI and will often first perform Kegel muscle exercises and restrict fluids, or urinate frequently to keep the bladder empty and avoid a leak. These can be successful strategies but are tedious and frustrating to many. Once these conservative options have been exhausted, evaluation for a sling can be performed.

Saturday, February 21, 2009

Urinary Incontinence Treatment Options

There are a variety of ways to treat or even completely control urinary incontinence, but it depends on the cause. While there are sometimes multiple factors in play that cause this condition, treatment options are limited by patient motivation, cognitive level, physical impairment, or anatomic abnormalities of the urinary tract. For most, conservative management is the first line strategy and often is quite successful in decreasing the severity of leakage.

Behavior modification and bladder retraining are among the first strategies employed. Timed voiding and double voiding are habits that are easy to adopt and can help empty residual or retained urine from the bladder. Taking inventory of how much and what kinds of fluids are consumed over the course of the day is important. Caffeine intake in the form of coffee, tea, soda, or bladder irritants such as vinegar in salad dressing, citrus or other foods, if eaten in large quantity can be an easy culprit for bladder misbehavior. Simply reducing water consumption will less the sense of urinary urgency, frequency and incontinence, either urge or stress provoked. Timing of fluid consumption is also simple to adjust, that is, minimize caffeine or water at least 3 hours prior to bedtime to less nighttime bathroom trips.

Timing of medication during the day, such as when to take a diuretic/ water pill for high blood pressure, can impact frequency of bathroom trips. Diuretics force more urine production by the kidneys to lower blood pressure, but the bladder must still store and expel it. Forcing more urine production in the afternoon may leave someone relatively “drier” prior to bedtime, and may also less nighttime bathroom trips.

Pelvic floor retraining in the form of Kegel muscle exercises can help to strengthen the urinary sphincter and pelvic floor muscles to curb leakage of urine when a sneeze comes on or the urge becomes great. Squeezing down on the sphincter before sneezing gets the body ready for the rise in pressure that may force urine past the sphincter. Repetitively practicing Kegel muscle exercises can curb incontinence a great deal, but these exercises must be performed daily.

There are some “reversible” causes of incontinence which are not the bladder’s fault, but when addressed can lessen urinary leakage. Urinary tract infection can cause pain and urinary loss and simply antibiotic prescription can easily remedy this. Untreated diabetes can promote urine production and overwhelm the bladder leading to incontinence. In the elderly or frail population, delirium or dementia often lead to incontinence because of lack of perception of the need “to go”. Poor mobility due to weak or injured legs or back will hinder someone simply from getting to the bathroom in time and lead to an incontinence episode. Severe constipation, urethral tissue thinning from lack of estrogen, and even simply depression, are all treatable and reversible causes of incontinence. Those caring for others with cognitive impairments can prompt them to void on a schedule and maintain easy access to toilets to minimize urinary incontinence.

Medications for overactive bladder are frequently used in conjunction with bladder retraining since together the combination will have an additive effect. All overactive bladder medications essentially will confer the same benefit in a majority of those who are prescribed them. They can lower the sense of urgency, frequency, and urge incontinence by about 2/3. All can lead to common side effects such as dry mouth, dry eyes, and constipation. Avoiding overuse of other medications, such as diuretics, certain antidepressants, antihistamines, and cough or cold preparations may also have a significant impact on lower urinary incontinence. There are no medications that are approved to treat stress incontinence.

If medications for overactive bladder lead to undesirable side effects or do not work, a bladder neurostimulator may be placed to help control symptoms. Similar to a pacemaker, the neurostimulator, InterStim, dampens the urge signals from the bladder allowing for a normal voiding pattern. It is placed in the buttock and approximately ¾ of individuals who are symptomatic with urgency, frequency and urge incontinence can be treated permanently this way. It is considered minimally invasive and placed as an outpatient.

For stress incontinence that occurs with coughing, sneezing, laughing and exercise, minimally invasive outpatient procedures such as slings or urethral injections are highly successful and can achieve dryness in the majority of those who have it. A “sling” is narrow strip of mesh that can be placed under the urethra and serves as a backboard of support under the urethra during activity or coughing. Patients can return to work in a relatively short period of time after a brief recovery period. A urethral injection adds bulk or “beefs up” the urethra by injecting a substance via a scope into the urethra itself. It is an acceptable alternative for those who are not sling candidates. Pre-operative bladder testing with urodynamics and a full history and physical are required to assess who is an appropriate surgical candidate.

Wednesday, February 18, 2009

Doctors who Blog

Yesterday I was interviewed by Natalie Flanzer at Channel 3 in Phoenix. She was interested in doctors who kept blogs.

See the interivew here:

Saturday, February 14, 2009

Television Interview on Female Incontinence

I was recently interviewed by Bob Caccamo, the Vice Mayor of Chandler, AZ on Chandler television, Channel 11.

I discussed female urinary incontinence and pelvic prolapse, among other topics.

Please see the interview here at the following link, paste it in your browser:


Friday, February 13, 2009

Female Urinary Incontinence

I recently had an article of mine published on the Google news feed at, a website for all female related health topics, and here is the the link:

In addition, for those women in the Phoenix metro area, I will be on the Dr. Dan Health Show this Sunday morning at 6 AM speaking about female urinary incontinence as well. My program can be heard on simulcast on the following radio stations:

107.9 KMLE
101.5 Free Zone
94.5 KOOL

Tuesday, February 3, 2009

Cosmetic Vaginal Surgery?

Hmmm....This is a somewhat popular and edgy topic to speak about, lately, espeically with cosmetic vaginal procedures being spotlighted on some cable tv shows.

Cosmetic vaginal surgery is know by many names:

Vaginal Rejuvination
“Designer Vagina”
“Down Under Makeover”
Vaginal Tightening

There are a lot of reasons someone may opt for this type of surgery. Actually, cosmetic vaginal surgery can be broken down into two main categories:

Vaginal tightening or vaginoplasty and labial reduction or labiaplasty.

Labiaplasty has slowly grown in popularity over the past decade. Women with long, fatty or hanging vaginal lips are candidates for labiaplasty. Essentially, the size of the labia are reduced to a narrow or slimmer size, depending on anatomy and patient desire. Some women have always had very noticeable labia, whereas others develop the problem after having children, or as they get older. Large labia can interfere and cause pain with sex, and can be uncomfortable with tight-fitting clothes. Labiaplasty is a form of vaginal rejuvenation. It can restore confidence as well as enhance sexual pleasure in some women.

Vaginplasty, ('vaginal tightening") is another female cosmetic surgery procedure that has risen in popularity as well. It involves tightening the vaginal muscles, and can be done in conjunction with labiaplasty. Women who have gone through multiple childbirths are often the best candidates for this procedure. Some women complain of a looseness of the vagina, with loss of sensation during sex, and decreased pleasure. Pelvic floor exercises, such as Kegels, do not address the sensation of a wide or loose vagina. Surgery for cystocele and rectocele (dropped bladder and dropped rectum) often include vaginal tightening, but vaginal tightening can be done on its own. The degree of tightness is improtant to quantify pre-op and can be done with dilators.

Patient expectations are important to gauge, and like any cosmetic surgery, can improve self-image, but it must be done for the right reasons.

Hymenoplasty, restoring the hymen, is performed most often on young women who want the surgery for religious or cultural reasons. The hymen is usually first torn with sexual intercourse, but can also tear with the use of tampons, masturbation or vigorous exercise/accidents/horsebacking riding. It is a very thin membrane of skin located in the lower 1/3 of the vagina.

Saturday, January 3, 2009

Pelvic Organ Prolapse

I recently posted a new blog entry at Sun Times Online on Pelvic Organ Prolapse.

Please read it here: