Monday, November 8, 2010

Do slings work in women over 80 years of age with urinary incontinence?

Does age matter when it comes to treating women with slings for urinary incontinence? Will the sling work the same way, are there added complications for older women? What are the risk factors that lead to sling failure?

These are just some of questions recently addressed by some researchers from Australia when they went back to look at 1,225 patients of theirs that had undergone midurethral sling surgery over the course of approximately 8 years. Various types of slings such as TVT, SPARC, Monarc and TVT-O were used. Of the group, 96 women were 80 years and older with an average age of 85, while their younger cohort’s average age was 58 years. Interestingly, the older women averaged more childbirth, used more pads per day to catch urine leakage, and were also found to have worse urinary incontinence when tested pre-operatively.

For the entire group of women, the overall success rate was 85%, with the elderly women averaging 81% cure and the younger group average 85%, which were statistically equivalent. Importantly, the elderly group was more likely to fail their first attempt to void after surgery vs. the younger group, 37% vs. 9%, but the elderly women were ultimately as successful in finally voiding when compared to the younger women.

What were some risk factors for possible sling failure, whether young or old?

BMI >25

Mixed urinary incontinence (both Stress Incontinence and Urge Incontinence)

Previous anti-incontinence surgery

Diabetes

Severe sphincter dysfunction

Vaginal prolapse surgery done at the same time

The rate of complications overall were similar between the two groups, although hospitalization was longer in the elderly group as one may expect, if other medical issues are present. The rate of developing new urinary urgency was also similar.

Elderly patients may be more complex and may have other medical conditions, or have more severe urinary incontinence, however despite this, they appear to tolerate sling surgery well, which is minimally invasive and can benefit from it, if appropriate and desired.

Monday, October 11, 2010

Is Squatting When Urinating Bad for Women?

It’s not uncommon to hear from patients that in public restrooms they will squat or hover above the toilet during urination in order to avoid contact with the toilet seat for hygiene reasons. This may still be better than holding it in all day and becoming uncomfortable and then only urinating once at home. Nevertheless, there are different postures that women adopt when urinating, whether sitting, hovering above the toilet (“semi-squatting”), or actually crouching/squatting on the toilet seat itself. In certain cultures in Asia, women are accustomed to squatting over a floor drain in public restrooms. In the West women will sit of course, but evidence shows that the best overall posture is sitting on the toilet edge, legs separated but supported, leaning forward a little, to help open and relax the pelvic floor.

If women hover above the toilet or do not relax completely to urinate, does this affect their ability to empty the bladder? Is it detrimental to not sit to urinate?

A group of 45 university students was asked to participate in a survey of how they posture themselves during urination, as well as measuring residual urine and urine flow rate. They were also asked why they do this. What was found?

When voiding in the semi-squatting posture (hovering), women had a longer delay time to initiate voiding than in either the sitting or crouching (squatting on the toilet seat) posture. This is likely explained due to better relaxation of the pelvic floor which occurs with sitting. Forward bending helps to relax the pelvic floor, especially with the legs supported, and thighs spread apart. It was found that sitting allowed a smoother void pattern than either semi-squatting or crouching, but residual urine volume and maximum flow rate were no different among the three postures in these young women.

In order to squat or hover over a toilet, women have to contract their gluteus maximus and adductor femoris muscles, which when the latter is contracted, has been associated with failure of the pelvic floor to relax, impeding urination.

Crouching or squatting on the toilet seat itself may seem like it would open the pelvis more, but if the woman is unsure of her balance and therefore not relaxed, voiding will not be as smooth. With older women, or those after child birth, bladder function may be diminished and may lead to residual urine or lower flow rates.

Women’s reasons for adopting non-sitting postures in this survey were:

Toilet seat not clean- 97.8%

Space limited- 82.2%

Toilet height – 66.7%

Of the 45 participants, 40 (88.9%) preferred to not sit in public restrooms, even though 80% felt that it would be more comfortable, and very few felt comfortable when squatting or hovering. Among the women who did not sit to void, 39.5% reported that they began using such postures since junior high school. It may be therefore be interesting to consider a brief mention of the “right way” to urinate to young girls by their mothers, or even during health class at school.

Wednesday, September 15, 2010

Do Women Develop Bladder Cancer, and what are the Risks?

Like men, women can develop cancer of the bladder. The most common type is called urothelial carcinoma, previously known as transitional cell carcinoma. It is the 8th most common cancer in women, and of all new bladder cancer diagnoses a year, women make up 20% of them. It has been either under-diagnosed, under –appreciated or under-suspected in women because the usual presenting sign of bladder cancer, blood in the urine, can often be assumed to be a urinary tract infection, which women experience commonly, and thus not suspected.

Bladder cancer is most often non-invasive at diagnosis, but requires periodic bladder endoscopy, xrays and bladder treatments to reduce the risk of recurrence which can be high. In about 15% of cases, bladder cancer is diagnosed as being “muscle-invasive”, which in healthy patients is best treated by complete bladder removal. This requires either reconstructing a “new bladder”, or having a urinary ostomy to drain urine. Chemo and radiation are sometimes necessary when bladder cancer is invasive.

Risks for bladder cancer are toxins, most commonly smoking, environmental exposure to arsenic, and certain “aromatic amines”, or chemicals used in the coloring/dye industry, which are less common these days. Theories exist that certain nutrients, when excreted in the urine, and after contacting the bladder lining on a chronic basis, can lead to tumor formation. However, a recent report published in Cancer investigated whether eating meat contributes to bladder cancer, via potential carcinogenic compounds found in meat, related to cooking and processing. Prior evidence connecting meat and carcinogenesis has been inconsistent.

Nitrates and nitrites, found in meat, are hypothesized to promote carcinogenesis. They are used to preserve color and flavor. They are converted to compounds that have been shown to induce tumors in many different organs, including the bladder.

Following over 300,000 men and women over a 7 year period between the ages of 50 and 71, of whom a fraction developed bladder cancer, food questionnaires were answered as a part of a very large Diet and Health Study.

What was found?

There was a borderline, statistically significant increased risk of bladder cancer only for those who were the highest consumers of red meat, mainly from processed red meat and not unprocessed. No association was seen with beef, bacon, hamburger, sausage, or steak. Overall, there was only an association with dietary nitrites in those that were the highest consumers. The researchers conclude that this study provides some limited evidence for an association between dietary nitrites and bladder cancer. This underscores the common sense approach to eating, which is, all things in moderation, but it’s no reason to skip the BBQs.

Thursday, September 2, 2010

Phytoestrogens: What are they, and are they safe for women?

Phytoestrogens are a group of naturally occurring, plant-derived compounds that have either a weak estrogenic, or anti-estrogenic effect. They are often called “dietary estrogens”, and are used widely by women to treat the symptoms of menopause. Their popularity has increased after several large women’s health trials alluded to health risks in women taking hormone replacement therapy for menopausal symptoms.

Phytoestrogens can be divided into three groups:

Flavinoids, such as genistein, naringenin, and kaempferol

Coumestans, such as coumestrol

Lignans, such as enterodiol, and enterolactone.

The most widely known and studied phytoestrogens are the isoflavones found in red clover and soy: genistein, formononentin, biochanin, and daidzein.

Urologists have known, rather assumed, that diets high in soy, such as in Asia, have a protective effect on men against development of prostate cancer. However, in women there has been conflicting evidence. Some studies show a protective effect against breast cancer, while some in vitro studies differ on whether they hinder or potentiate tumor cell growth. Some phytoestrogens are weakly estrogenic and bind the estrogen receptor, but are approximately 1000 times weaker than estradiol. Other phytoestrogens exhibit a blocking effect on the estrogen receptor. The isoflavones in soy show mainly an agonist effect, namely, a weak estrogen effect.
Does this mean that soy compounds can lead to “side effects” such as endometrial hyperplasia or cancer- this of course is not known.

More intrigue: Genistein antagonizes the inhibitory effect of tamoxifen on breast cancer cell growth in vivo. This raises more questions than answers.

Recently, a group of researchers from Austria set out to clarify the safely profile of phytoestrogens by analyzing all known studies published in English. 174 randomized controlled trials comparing phytoestrogens to placebo were identified, however in 82, no side effects were discussed. Mean treatment duration was short at approximately 6 months.

Various categories of side effects were studied: GI, Gyn, urinary, neurological, musculoskeletal, etc. The most common side effects seen among the women were GI complaints, such as: nausea, vomiting, heartburn, gastric irritation or pain. Women older than 55 yr old had a higher rate of these GI symptoms. Studies in US and Europe were less likely to report GI side effects. The length of the study, such as 6 months vs. 24 months did not lead to a higher incidence of side effects. Actually, fewer side effects were observed the longer women were taking phytoestrogens. Other side effects noted were muscle pain and sleepiness.

Of potential gynecological side effects, the side effects of vaginal spotting, nipple discharge, breast pain/enlargement, breast cancer, endometrial hyperplasia, and pelvic pain were reviewed. One study showed a higher rate of endometrial hyperplasia with atypia after 5 years of phytoestrogen supplementation. However there was no observed increased risk of endometrial cancer or breast cancer in any individual study or meta-analysis. There was no indication of other side effects that can occur with hormone replacement such as stroke, blood clots, heart attack and breast cancer.

The authors were cautious but did conclude that based on the available data, phytoestrogens can be used over a 2 year period. They did not however comment on their efficacy in controlled menopausal symptoms. Overall, only GI upset was seen to be the category of significant side effects, while over a 2 yr period, no endometrial or breast cancer was observed. This comprehensive review that these researchers took highlights the recurrent theme when treating oneself with medication or “natural products” when it involves hormone manipulation: that we may not know the true long term (>5 yrs) effect, they may be safe in the short term, there is sometimes conflicting data, and they should be taken in moderation. Just because compounds occur in nature doesn’t confer on them an automatic sense of “safety” or “health”. And certainly, eating a soy burger may have less fat than a regular burger, but only eating soy burgers is not going to make you live to 100 (without hot flashes).

Sunday, August 8, 2010

Are You a Woman With Low Libido/Sexual Desire and Want Some Help?

A lack of Sexual Desire that causes distress is defined as one of the Female Sexual Dysfunctions (FSD), specifically, Hypoactive Sexual Desire Disorder (HSDD). In other words, the lack of have sexual desire is what is distressing for the woman. For example, if a woman is in a relationship, and the husband is ill, and there is no desire/interest for sex due to the circumstances, then this scenerio is not HSDD. However, if a woman would like to have sex, but simply does not feel the urge/desire but wants to and cannot, and this lead to stress in her relationship, then this scenerio is HSDD.

If you are a woman who is distressed by her lack of sexual desire and this leads to distress or stress in your relationship, you may qualify to voluntarily enroll in one of two Phase III studies through my office. I have the honor of being recently selected by research coordinators in Phoenix, working with BioSante Pharmaceuticals, to help enroll women, whether they are my patients or not, into one of two trials studying LIBIGEL, which is a testosterone gel.

The study of testosterone gel is the Bloom Study, which is comprehensive in order to not only see if testosterone gel can boost a woman's sexual desire, but ensuring safety as well.

To see if you qualify to enroll, scroll to the bottom for a contact and link.

From BioSante's website:

"LIBIGEL is a gel formulation of testosterone designed to quickly absorb through the skin after a once-daily application on the upper arm, delivering tesotsterone to the blood stream evenly over time and in a non-invasive and painless manner.

The concept behind the LIBIGEL development program is intriguing- to develop a product to treat women who siffer from female sexual dysfunction for which there is no clinically tested, FDA approved product, and do this with a drug that will be shown to be safe and effective, and affordable both to develop and for women to use. The LIBIGEL development program has been designed to show that LIBIGEL can safely improve women's sexual desire and the frequency of satisfying sexual events and decrease personal distress assocaited with low sexual desire in women with HSDD. LIBIGEL could be the first FDA approved product to treat HSDD in menopausal women.

Though gnerally characterized as a male hormone, testosterone also is present in women and its deficiency has found to decrease libido or sex drive. In addition to increasing sexual desire and activity, and decreasing sexual distress, studies have shown that testosterone therapy can increase bone density, raise energy levels andimprove mood. The goal of testosterone treatment in women complaining of HSDD is to increase the serum testosterone towards the normal range."

I am conducting two studies as a sub-Investigator for LIBIGEL:

Women who have HSDD and are menospausal from surgery (ovaries removed)

Women who have HSDD and are naturally menospausal.

Please contact Meaghan Carpenter, Site Director for Connect Clinical Research Center at:

480-917-5800
or
meaghan.carpenter@connectcrc.com

to see if you qualify.

BioSante's website is:

www.biosantepharma.com/Libigel.php

A recent report on LIBIGEL showing cardiac and breast safety and thus getting aproval to continue with research: www.medicalnewstoday.com/articles/168220.php

Friday, July 2, 2010

Urinary Incontinence and Vaginal/Perineal Skin Irritation- Is this Common, And If So, What Can You Do About It?

The urethra in women lies just beneath the clitoris, and above the vaginal opening. Urinary incontinence, the involuntary loss of urine, can occur with activities such as exercise, sex, coughing, sneezing, and laughing, and can also occur with uncontrolled urge to urinate/overactive bladder. Sometimes it can be just a drop or two, requiring no more than a change of underwear, but in some women, it can be significant, leading to use of liners or pads. The pads, whether dry or wet with urine, can themselves irritate sensitive vaginal and perineal (the area between the vagina and anus) skin. Simple urine contact with vaginal and perineal skin, when chronic, can lead to dermatitis, skin irritation and infection.

How does this happen?

The opening of the vagina, the labia majora, and perineum can become red and inflamed. Women will complain of a “burning sensation down there”. I encounter this complaint frequently in my female patient population. This non-specific description can often be misunderstood for burning with urination (= urinary tract infection), leading to a reflexive prescription of antibiotics. If vaginal dermatitis exists, direct urine contact on these areas will lead to a burning sensation, that is, a burning sensation AFTER urination. The physician should be careful to elicit the correct problem here: is there burning WITH urination/dysuria (which may be a UTI), or is there vaginal skin burning? The treatments of course are much different.

Think of baby’s red bottom which after prolonged contact with a wet diaper, becomes irritated and very painful. This is how I describe this problem to my patients, as it’s a common scenario all mothers have dealt with. Balmex and Desitin to the rescue, usually. However, in adults, the treatment goal is not only to soothe and heal the skin, but to stop the incontinence and urine contact in the first place.

Constant moisture to the skin alters the skin’s pH and natural protective barrier, allowing this barrier to breakdown, becoming more permeable to bacteria. Despite best hygiene efforts in women, the perineum and vagina are areas where fecal bacteria can live, and most of the time, cause no problems. When the skin barrier is compromised, these bacteria can invade the skin leading to secondary infections. This then leads to frequent itching and wiping of this area, often vigorously, further causing local trauma to the delicate skin.

The skin can become red, swollen, crusty, develop scales or pimples, and cracks. This can occur around the anus, the perineum, and around the vagina/labia. If left untreated or ignored, bleeding and painful ulcers can develop. Staph and yeast infections can easily thrive in this environment. For those taking care of elderly family members, this may be an overlooked area either due to patient or caretaker embarrassment to either report it, or to examine this area on a routine basis. Moreover, if stool contamination occurs or if stool hygiene is poor, it clearly makes a bad situation worse.

Good skin care is always important, but again, treating the underlying urinary incontinence is more important. Pain and irritation of the perineum and vagina can become significant daily issues. It may impact very heavily on self-image, sexual relationships, overall health image, and exercise and care routines. Pad usage can in many cases exacerbate the already irritated skin by constant contact especially if not changed promptly.

Not to be neglected, the irritation can spread to the inner thighs, buttocks and lower abdominal skin folds.

What do you do then?

A thorough exam is necessary to evaluate all the “hidden areas” most people cannot reach or cannot directly see. Often anti-fungals and antibiotics are necessary to help eradicate infections. Topical barriers such as pastes or lotions help shield the skin from urine and/or stool contact. Pastes are better when diarrhea is involved.

Gentle skin cleaning is important. After each incontinence episode, the skin should be cleaned, the pad changed, and a barrier applied, if needed. Hand soap should be avoided because it can dry out the skin. Cleansers can be either liquid, foam, oil-based or towelettes. Mineral oil, and lanolin can replace the natural skin oils lost from urine contact, skin irritation and frequent wiping.

Skin barriers that contain lanolin, zinc oxide, petroleum, and dimethicone can all block the skin from moisture and irritants. Ointments are oil-based and can last longer than creams, which are water based. If any barrier stings the skin on contact, it should be avoided. Absorptive pads and undergarments that draw moisture away from the skin are preferred, not ones that trap the urine against the skin.

Lastly, treat the incontinence!

Sunday, June 20, 2010

Female Sexual Dysfunction and Hypothyroidism

The thyroid gland’s importance in the body is essentially related to its regulation of many aspects of the body’s functions. Dysfunction of the thyroid, either overactive or underactive, is a common problem experienced by many women. Low thyroid, or hypothyroidism, can occur after removing the thyroid, simply low functioning of the thyroid, or autoimmune diseases such as Hashimoto’s thyroiditis.

Low thyroid function can affect mood, metabolism, weight, heart rate, brain function, hair, and ovulation. It is therefore a stretch to hypothesize if hypothyroidism affects sexuality? In other words, is hypothyroidism linked to female sexual dysfunction (FSD)?

TSH (Thyroid stimulating hormone) is the common blood test used to screening for hypothyroidism. When TSH levels are abnormally high, this suggests low circulating thyroid hormone from an underactive thyroid. TSH production from the pituitary gland will increase to try to “rev up” the sluggish thyroid gland if it’s underactive in order to push it to produce more thyroid hormone. Usually, TSH above 5 is considered “high/abnormal”, but it’s important to note that if the patient “feels normal” and has a slightly elevated TSH, then thyroid hormone replacement may not necessarily be warranted. Conversely, if the TSH is within the “normal range” (less than 5), but the patient appears sluggish or "clinically hypothyroid", then thyroid hormone replacment may be warranted. This goes to the point of "treating the patient, no the number".

A study was recently published looking at four groups of women, comparing their thyroid status, to see if it links to female sexual dysfunction. The four groups were:

Women who were clinically hypothyroid

Women with a TSH less than 10, but overtly hypothyroid

Women with a TSH greater than 10 but not overtly hypothyroid

Control group of women with "normal thyroid"


FSD was diagnosed in 56% of women who were clinically hypothyroid, and 54.6% of women with a TSH greater than 10. By contrast, the control group of women, and the group of women with a TSH less than 10 reported 15% and 14.6% FSD, respectively. In addition, prolactin levels were also found to be higher in the clinically hypothyroid group, as well as the group with a TSH greater than 10, but no so in the other two groups of women. Other hormone levels, such as estradiol, free testosterone, FSH, and LH were all normal across the board.

As a sidebar, Prolactin is a pituitary hormone that is linked to lower sexual function as well. Lactating women post-pregnancy will have elevated prolactin levels, a “protective mechanism” to allow nurturing of the infant and avoidance of early sexual interest that may be a distraction during this time.

The importance of this study, which was quite simple and straightforward in design and results, should help us remember to screen for female sexual dysfunction in women with hypothyroidism. It may be simply overlooked when busy physicians are concerned with fixing one problem, to not neglect secondary conditions which may co-exist.

Tuesday, June 1, 2010

Cystocele (Bladder Lift) Surgery: Success Rates after First Surgery vs. Recurrent Surgery

Who has a more successful outcome from her bladder lift surgery? Is it the woman who is undergoing it for the first time, or is it the woman who is undergoing it for the second time? Reason would dictate that if a woman needs a corrective surgery for the second time because the first failed, the likelihood of success the second time would be lower. In addition, are there underlying risk factors that lead to bladder drop (cystocele) in the first place that may lead to recurrent bladder drop no matter how many times the surgery is done? If this is the case, is there anything that can be done to prevent or at least reduce recurrence rates to lower repeated surgeries?

To demonstrate this dilemma, a recent paper from Cleveland Clinic-Florida was published looking at the success rates of cystocele repair in women undergoing it for the first time, vs. those undergoing it for the second time. The “in-between-the lines” question to be asked from reading this research is how to try to prevent women from having a recurrence after theirfirst surgery so there is potentially no subsequent surgery.

The results from the study are a bit depressing. After one year, the group of women undergoing surgery for the second time (group I) and the group of women undergoing surgery for the first time (group II), had the following success rates at 1 yr:

Group I: 18/23 or 78.2% (“second timers”)

Group II: 17/21 or 81% (“first timers”)

You may say to yourself, these groups are nearly the same, without significant difference. That’s good, right? The real story here is why are 20% of women developing recurrence in either group just 1 year after reconstructive bladder surgery?

Now let’s evaluate their results at two years:

Group I (“second timers”) 9/21 (2 lost to follow up) or 42.8%

Group II (“first timers”) 15/21 or 71.4%

What are we to make of these worsening results?

These results are actually in line and consistent with published data about how bladder surgery commonly fails within the first 1-4 years post-operatively. In fact, failure rates are actually between 40-70%.

The authors of the study (rightly) conclude that if a woman has recurrence of her bladder drop and requires another surgery, then just “fixing it” again using the same technique that failed the first time will not give good results. A different technique would be required and is logical to prevent a second recurrence.

In addition, the real question is what can be done at the time of the first surgery in order to lower recurrence and avoid a second surgery in the first place?

These seem like obvious questions to be asked, but in terms of surgical success rates, the obvious needs to be often pointed out. What looks good at one year, may not be good at 2 years, and so forth. In addition, when we look back on surgical data and outcomes, we may only able to draw a conclusion retrospectively that we could not draw looking forward, prospectively. Our knowledge base grows as different procedures are developed and patient outcomes are followed over time. The ideal are the ones with the least risk going in, and good outcomes post-operatively. As any worker in the health care field can attest, there is no ideal, and failures always exist, even for well done cases.

The bladder is the most common site of recurrence of all vaginal/pelvic floor defects, whether it’s the bladder operated on, or another pelvic organ. This has to do with its position in the pelvis, where it’s most subject to repetitive force/pressure.

Developing an enduring repair is the “holy grail” of pelvic floor surgery, and many things have been introduced, such as tissue or mesh grafts, to strengthen these surgeries. These have been shown to have lower failure rates, but many factors go into proper use of these materials in patients, and come with their own inherent risks. These would include:

Is the intended surgery appropriate for the patient?

Is the intended graft (tissue or mesh) appropriate for the patient?

Is the surgeon knowledgeable about the material and experienced in its use?

Can the surgeon deal with any complications that may arise?

Are there patient factors that increase risk of recurrence after surgery?

Monday, May 3, 2010

Naturopathic Treatments of Urinary Incontinence

Modern medicine can often and effectively address female urinary incontinence issues, with either a combination of behavior modification, medication or surgery, or alone as strategies. Most will have some degree of success, but the proper diagnosis must be made and proper treatment executed.

The rise in popularity of naturopathic treatments for a variety of common health conditions puts the proper pressure on western medicine to revaluate what we offer patients, and presents us sometimes with new options.

Urinary incontinence (UI) in women can usually manifest as stress incontinence (urine lost during activities or straining), or urge incontinence (urine lost with an uncontrollable urge). Kegel muscle exercises are the standard fist line treatment that can help either type of UI, by either improving muscle tone of the urethra/pelvic floor, or improving the “holding power” of the pelvic floor to inhibit the bladder when the urge comes on.

It is well studied the loss of estrogen with menopause or ovary removal leads to thinning and weakness o f the vagina and pelvic floor, but estrogen replacement with pills or creams is not for everyone. Moreover, estrogen replacement does not improve stress incontinence, and may only improve somewhat urge incontinence. Natural estrogen replacement however is something many women will want to do, and I don’t mean taking bio-identical hormones. Phytoestrogens are plant estrogens that are naturally occurring and have estrogen-like effects and may reduce some of the menopausal symptoms women experience. They are found in soy and soy products (soy nuts, soy milk, tofu). Soy isoflavones which are the components of soy that have the effect can be purchased in capsule form, as well as creams that can be applied to dry vaginal tissue.
Overconsumption of water, or consumption of diuretic medication can overwhelm the bladder and lead to incontinence. Moderation or alteration of these can help. Diuretics are usually given to control blood pressure, so changing to a non-diuretic blood pressure med is something to discuss with your prescribing physician. Contrarily, adequate water consumption is necessary to create a natural dieresis of toxins out of the bladder.

Bladder irritability from acidic foods, caffeine and alcohol can lead to incontinence in some cases. Evaluating your diet and eliminating certain problem foods can improve bladder health. A blander diet is often used by people who suffer from Painful Bladder Syndrome(PBS)/Interstitial Cystitis(IC), and can found on their national website. It is a good place to start. Eating whole, unrefined and fresh foods can eliminate additives that can irritate as well.

Natural anti-inflammatories are available but the science behind them vis-à-vis the bladder can be “thin”. Bromelain, flaxseed, and Vitamins C and E are common recommendations.
Herbal medicines are taken by many but little is truly known about them, and few are tested in studies. Many have properties that are anecdotal, and the business of herbal medicine is huge.

Therefore a health “dose” of suspicion is required when evaluating these prior to spending the money, but here is a list of herbals I found online and their claims.

“The following herbs may be used to soothe and heal the urinary tract:

Buchu (Barosma betulina) – A soothing diuretic and antiseptic for the urinary system.
Cleavers (Galium aparine) – A traditional urinary tonic.
Corn silk (Zea Mays) – Has soothing and diuretic properties.
Horsetail (Equisetum arvense) – An astringent and mild diuretic with tissue-healing properties.
Marshmallow root (Althea officinalis) – Has soothing, demulcent properties. It is best taken as a cold infusion; soak the herb in cold water for several hours, strain, and drink.
Usnea (Usnea barbata) – Has soothing and antiseptic properties.”

Wednesday, April 21, 2010

Can Bladder Prolapse Recur after Surgery- and Why

I have many female patients who see me after their bladder has been previously “lifted” surgically, that is, fixing a dropped bladder, and we find that it has dropped again. Many female patients are apprehensive about evening fixing their dropped/prolapsed bladder for the first time because they’ve heard from their friends/sister/others that it’ll drop again. Even others are proud to say in the exam room, that they’ve had their bladder “tucked up” 3 times and they need it done again because they feel it dropping once more.

Well, we all know that a cystocele is a dropped/prolapsed bladder that can occur in any woman, but there are risk factors for it occurring in the first place. Are these risk factors also important in leading to a recurrence even after surgery? Is fixing it a second time any better than the first? Is there a way to improve on surgical outcomes so we are not endlessly and repeatedly re-operating on everyone? Are these improvements worth it?

These are the questions I frequently ask myself, and patients ask me, as I constantly reassess pelvic floor technology. We must always strive to improve on our current technology in order to achieve better outcomes and less patient morbidity.

So, some common risk factors for cystocele, and for that manner, any vaginal prolapse are:
Pregnancy
Childbirth
Obesity,
Age
Menopause
Hysterectomy
Chronic stress on the pelvis (chronic cough from smoking, asthma, bronchitis, constipation, high impact exercise)
Family/genetics

But why do these lead to prolapse?

One well accepted theory is that the first step in the alteration of the pelvic floor is damage to the support muscles, the levator ani, that act to support the pelvic organs. If they become lax or loose or stretched, it leads to a widening of the “genital hiatus”, the opening essentially of the pelvis downward. The pelvic organs (bladder, rectum, uterus) sit on, and are supported by the levator muscles and the connective tissue fascia the covers them. When the muscles are strretched or weakened by childbirth, pelvic surgery, or other risk factors list above, this in turn leads to undue tension on all the connective tissue support structures (fascia, ligaments) that then tear, break, and stretch. This ultimately allows the bladder to push down on the vaginal wall, and try to push out the vagina leading to a bulge. The same mechanism of prolapse can also occur to the cervix/uterus, the vault/top of the vagina after hysterectomy, or rectum.

The bladder is uniquely at risk for prolapse, because when the woman is standing, the upper 2/3 of the vagina is almost completely horizontal, or laying flat. (The lower 1/3 of the vagina, or the opening, is mostly vertical.) Because the upper 2/3’s is horizontal, any force/strain/pressure/stress brought to bear on the pelvis pushes directly down and primarly onto the bladder. Even normal physical activities put more strain on it than the other compartments of the vagina.

Repair of any vaginal prolapse must meet surgical indications, but, it must essentially re-establish/recreate proper anatomy. However, with all surgery, there are pitfalls, riska, and the chance for recurrence.

Is recurrence dependent on the sugeon's choice of what to do? YES. Is it dependent on the route to access the body? YES. Is it dependent on the patient's body and tissue quality? YES. Is it dependent on what the patient does in her free time/work/smoking status/level of obesity? YES.

There are clearly multiple reasons which interconnect that can lead to recurrent bladder prolapse. Therefore, what can be done to lower the risk? What technologies are out there? Are they good long term bets? Are there complications that go along with it? All good questions to be answered in my next post.

Friday, March 26, 2010

Overactive Bladder? Smear the Cream!

There are a variety of proven and efficacious medications available on the market that are approved for Overactive Bladder symptoms of urgency, frequency and urge incontinence. Most of the medications are well tolerated with typical side effects of dry mouth (approximately 25%) and constipation (approximately 10%), which are short-lived (last for a few weeks). Most are once-a-day pills.

Recently released is a gel that can simply be rubbed onto the skin (upper arm usually), once a day, to achieve to same desired results. It is oxybutynin in gel form. It is the “original” overactive bladde drug that comes now in oral generic form, but as a pill it lead to high side effect issues, not only dry mouth and constipation, but sleepiness, concentration issues or short term memory issues, especially in the elderly.

The gel is absorbed through the skin thereby bypassing the liver and therefore minimizes side effects. The study included 352 women. A recent phase III trial reported dry mouth rates of 7.4% and constipation rates of approximately 3%. Application site reaction (rash) was about 2%.

Thursday, March 11, 2010

Flibanserin: A Sex Pill for Woman?

Medications like Viagra, Levitra, and Cialis have revolutionized the male sexual health world, and brought the subject of sex “out of the closet”, for open discussion in the doctor’s office, but also in the media. Commercials for erections are everywhere. The “male pill” has certainly enabled many older men, or men with vascular conditions or injury to regain some sexual potency. Once it debuted in 1998, sex researchers were busily trying to adapt Viagra to women to see if it would help similarly. It does not. It can lead to engorgement of the clitoris, perhaps helping arousal, but it does not help achieve orgasm, increase desire, or decrease sexual pain.

In women, more often than not, desire must precede arousal (though the reverse is true), in order to become romantic. Many things can kill sexual desire: stress, fatigue, bad relationships, menopause, surgery, and many health conditions and the medications taken to treat them, whether physical or psychological. No less important, the loss of sexual desire must be bothersome. For example, if a woman has no sexual desire AND does want to have sex, then her low desire is NOT a problem. It must lead to distress in order to merit treatment of course. So is there help for improving women’s desire on the horizon? Is there a magic pill for women?

Actually, there are medications already on the market that improve sexual desire in women already. I will address testosterone supplementation, which is widely used to restore female libido, in a future post. It is effective and usually given in post-menopausal women, but must be monitored closely with blood tests, and there are risks with hormone replacement, and of course its use is still off-label in the US. Therefore, is there something coming down the pike to help low sexual desire in women?

This past November 2009 a huge pooled phase III study was presented at a sexual conference in Europe. Flibanserin, is still investigational, but may be approved by the FDA within a year or two. In multiple large studies conducted throughout the US and Europe, Flibanserin was shown, if taken once a bedtime, to significantly increased the number of satisfying sexual events and sexual desire, while significantly decreasing distress associated with Hypoactive Sexual Desire in pre-menopausal women. This is incredibly promising and has sex researchers very “excited” about it. It is a novel compound, unlike any other med out there and it is not a hormone.

Is it safe? Most adverse reactions to Flibanserin were mild to moderate. The dose that worked the best with tolerable side effects was 100 mg prior to bedtime. Most side effects were seen within the first 14 days. The pill therefore must be taken daily, as it was studied, in order to achieve its “desired” result of increased sexual desire. We do not know if it can be taken on an as needed basis, like Viagra. The most common side effects included: dizziness, nausea, fatigue, sleepiness and insomnia. They occurred in approximately 15% across all studies, and lead to discontinuation of treatment in those women.

So, how does it work? Flibanserin acts as an agonist and binds to the serotonin 5-HT1A receptor, and an antagonist at the 5 HT2A receptor, in certain brain regions. It acts as a neurotransmitter in the sexual response cycle, and is believed to restore the balance between inhibitory and excitatory factors leading to a better sexual response.

Monday, March 1, 2010

Stress Urinary Incontinence 1 year after Childbirth: Can anything predict it?

It is well known that just being pregnant, is an established risk factor for stress incontinence in women, whether young or middle-aged. Common theories include pelvic floor damage during pregnancy, labor and delivery, as well as chronic stress conditions like coughing, straining, hysterectomy, and genetic linkage.

An interesting question is whether urinary incontinence itself during pregnancy is a risk factor for urinary incontinence after pregnancy, whether immediate or long term. Persistence of urinary incontinence after pregnancy is linked to higher maternal BMI, and those who delivered heavier babies. Most of the studies that look at these risks include women with multiple births, and concluded, rightly, that these variables are causal in the development of urinary incontinence after birth. But what about new-onset stress incontinence during pregnancy- is this linked to higher rates of it after a woman’s first birth?

A study from Spain observed woman during and after their first birth. Questionnaires and exams were performed. Pelvic floor strength was also measured at 6 months post partum. Nearly 400 women were seen in follow up after one year and assessed. The average age of the women was 31 years. Stress incontinence affected 40 (11.4%) of women 1 year after their first delivery. That is a huge number. Out of the total number of women, 4.3% had new onset stress incontinence, while 7.1% reported stress incontinence during pregnancy. When asked to break it down according to severity, 62.5% had “slight”, 32.5% had “moderate”, and 2.5% had severe.
Analysis revealed that women who had stress incontinence during pregnancy and who had vaginal delivery were more at risk for developing stress incontinence 1 year after first childbirth. This factor increased the risk more than 5 times. In addition, the strength of their pelvic floor was also lower on average at 6 months after delivery.

Taken altogether, this is just one more piece of evidence that suggests that women may want to adopt preventative strategies to lessen the risk of stress incontinence, or other consequences of pelvic floor damage by performing pelvic floor muscle training during pregnancy, before pregnancy, as well as perineal massage towards the end of term to prevent tearing during delivery. C-section after obstructed labor is not considered protective against urinary incontinence at 1 year post partum in other studies, and so the data suggest that merely being pregnant can be contributory to development of incontinence, not necessarily mode of delivery.

Wednesday, February 17, 2010

Are There Racial Differences in Pelvic Organ Prolapse?

Racial differences exist for certain diseases which are well known: diabetes, high blood pressure and prostate cancer may be more aggressive or more difficult to treat in American blacks. So researchers asked if racial differences exist as well in regards to pelvic organ prolapse.

Pelvic organ prolapse (POP) is very prevalent and can lead to many health-related issues. Certain risk factors are well known, such as childbirth, hysterectomy, menopause, and familial. A large population-based study conducted by Kaiser looked at over 2,200 middle aged and older women. Data was all self-reported by the women in the survey who then underwent an exam.

What were the findings?

Certain conditions were shown again to be associated with POP such as: prior hysterectomy, menopause, chronic cough from bronchitis/emphysema, and weekly urinary incontinence. Race/ethnicity was also found to be relevant. Even though degree of prolapse was similar across all race groups, White and Latina compared to Black women were associated with symptomatic prolapse. Latina women were most bothered with 41% reported moderate to extreme bother, with 20% of white women, 20% Asian women, and 17% of black women. Factors that were independently associated with the leading edge of the prolapse being at/beyond the hymen and stage of prolapse (objective prolapse) were white vs. black race, age, BMI and vaginal delivery, and diabetes.

Even though the degree of prolapse was the same across all groups, Latina and white women had more subjective complaints about their prolapse. The study authors suggest there may be cultural differences in attitudes towards the condition or in tendency to report it. To me this suggests that a thorough history and physical exam is always good medicine in order to properly diagnose pelvic health conditions.

Sunday, February 7, 2010

Kidney Stones & Pregnancy

On its own, a kidney stone attack is one of the most painful events described by patients. My female patients always declare that the pain from a kidney stone is worse than childbirth. When a kidney stone drops and causes pain during pregnancy, it presents a unique challange. Care for patient must be balanced with preventing harm to the fetus or premature labor. Often, conservative treatment is successful in charaponing the patient through her pregnancy, and sometimes the patient will pass the stone even prior to delivery. Other times, intervention is required.

To read more on it, please visit my latest article in online journal The Female Patient at:
http://www.femalepatient.com/

Thursday, February 4, 2010

Does Yoga Improve Female Sexuality?

Female Sexual Dysfunctions (FSD) are common and often do not get the attention necessary since the topic may be of embarrassment to the female patient or physician. FSD is usually categorized into 4 major groups: Low Sexual Desire, Low Arousal, Lack of Orgasm, and Pain and must cause distress to the woman. At the present time, there are limited medication treatments for FSD, and current therapies are generally limited to hormone replacement (estrogen or testosterone), local creams, herbals, couples counseling, and lifestyle changes. Any one of the FSDs can lead to low physical and emotional satisfaction.

A recent study looked at whether yoga has a positive effect on FSD, since it is becoming widely popular in Western societies. 22 different positions were evaluated. Some common ones were: Kapalbhati, Yog mutra, Halasan, Dhanurasan and Chakarasan. Yoga was advised to be performed for an hour twice a day, or as much as the participants could tolerate. Three repetitions of each pose was suggested. After yoga was completed differential relaxation with slow breathing and relaxing the muscles that were just stretched was performed.

All domains of FSD were improved: Desire, arousal, lubrication, orgasm, satisfaction and pain, with an overall improvement of nearly 20% of all these domains collectively. Overall, 72% of women reported improvement in satisfaction about their sexual life after yoga. Women over 45 years old noticed more improvement versus those under 45. The greatest improvement seen in women over 45 was in arousal and pain, and the least improvement was in desire. In women under 45 years old, the greatest improvement was in orgasm and satisfaction, and the least improvement was desire. Lubrication and pain also improved significantly in women older than 45 years.

What is it about yoga that has a positive effect on FSD?

Yoga is known to have beneficial effects on lumbar muscle tone, depression, high blood pressure, peripheral neuropathy, anxiety, joint disease, stress, labor pain, epilepsy, pain, addiction, infertility, psychosomatic disorders, obsessive-compulsive disorder and quality of life overall. In general, stress reduction appears to be a common thread, as well as improved blood flow from stretching. Although, it is not known exactly how long yoga must be performed in order to achieve improvement in FSD, but it can be said that improvements can be made in FSD over time. Considering the non-pharmacological nature of yoga, there is little reason to not try it if FSD exists.

Friday, January 29, 2010

Does obesity in adolescent girls lead to urinary incontinence?

We know, from the news and medical reports, that American kids are fat, and fatter than they have ever been. Whether due to video games or junk food, obesity in children and adolescents has doubled in the past three decades. A survey in 2004 on nutrition and health done in the USD showed that 17% of children and adolescents in the US are obese (BMI >95% percentile for age and sex). Unfortunately, obese children and adolescents suffer from the same health issues as obese adults: diabetes, high blood pressure, high lipids/cholesterol, sleep apnea, joint problems and psychological issues.

It is well known that obesity is a risk factor for urinary incontinence and that weight loss can significantly improve both stress and urge incontinence, and that diabetes has been correlated to urinary incontinence. Constipation and stool soiling is also more common in obese children, and constipation can also lead to urinary incontinence in both adults and children. Therefore the logical question is: are obesity girls (children and adolescents) at higher risk for urinary incontinence?

A recent study from Minnesota looked at this very question. 40 obese girls and 20 non-obese girls between the ages of 12 and 17 were recruited to answer a questionnaire. The kids were examined and weighed. Incontinence of urine was defined as leaking once or more per week. Questions regarding stress and urge incontinence were asked.

Among the obese girls, 12.5% reported incontinence at least about once a week. None of non-obese girls reported any incontinence meeting this definition. Infrequent leakage (less than once a month) with low volume occurred in both 45% of the obese and non-obese girls. The impact of incontinence was more severe in the obese girls in terms of degree of “bother”. Children with daytime wetting have been reported to have lower self-esteem. This is all the more relevant, as the authors state, that obese children and adolescents may be reluctant to report it, are embarrassed about it, and may not know there is treatment. On the basis of this, pediatricians, and other health care providers should gently ask their patients about such topics in order to offer assistance. First line remedies that are safe include weight loss (non-surgical), Kegel exercises, and even medications that aide bedwetters.

Thursday, January 21, 2010

Can Yogurt Help Vaginal Health?

The consensus seems to be Yes. Fermented milk products contain so-called “probiotic,” or “good” bacteria, including lactobacillus, acidophilus , and bifidobacterium , that compete with Candida in the vagina. Candida is a common yeast found in our colon and in women's vaginas. It can overgrow if healthy bacteria are killed (when taking antibiotics) and lead to a yeast infection. The probiotics found in yogurt are thought to counter the growth of Candida. That is considered a desirable effect.

In a Finnish study conducted of 320 women, researchers found that those who ate three or more servings per week of yogurt–or in some cases, cheeses made from fermented milk–had far fewer UTIs than those who didn’t eat yogurt or ate it only infrequently.
Several studies have found that to cause a significant reduction in the occurrence of yeast infections, people need to consume at least one serving of yogurt per day. In these studies, the yogurt contained acidophilus bacteria, which is generally noted on food labels as containing “live” or “active” cultures.

Half of all women will experience a yeast infection in their lifetime. Women who suffer from repeated infections may want to add yogurt to their regular diets, and have at least one serving daily. Because yeast feeds on sugar, most researchers recommend choosing low sugar or unsweetened yogurts.

P.S. once you have a yeast infection or UTI, you must take antibiotics to treat them- yogurt will do nothing for an active infection, but it can help prevent them.

Friday, January 15, 2010

Lateral episiotomy protects from obstetric anal sphincter rupture only with the first child

Tearing through the perineal tissue (from the vagina to anus) during labor is a serious complication of childbirth and even if repaired can lead to fecal incontinence. Some studies have shown that risk factors for anal sphincter rupture during delivery include vacuum assisted delivery, forceps delivery, high birth weight, and prolonged 2nd stage of delivery, and midline (straight downward) episiotomy. Some reports don’t see a difference between routine use of episiotomy and very restrictive use of it in terms of anal rupture.

A recent HUGE study of over 500,000 women from Finland looked at risk factors for anal rupture during delivery and whether episiotomy had any bearing on it. It was found that episiotomy decreased the likelihood of anal rupture only in women delivery their first child, but not for any subsequent delivery. The strongest risk factors for anal rupture in first time births was forceps delivery, birth weight over 4 kg (approximately 9 lbs), vacuum assisted delivery, and prolonged 2nd stage delivery), reinforcing previously held concepts, which were also risk factors for women delivering their second child or more. Episiotomy appeared to be protective only in vacuum assisted delivery in women delivering their first child, but nothing else. Ultimately, the study concludes that episiotomy should be used sparingly as it takes nearly 900 episiotomies to spare one anal rupture. Cutting sideways away from the anus appears to be protective only in first time deliveries using vaccum.

Monday, January 4, 2010

Can Certain Foods Kill Your Sex Drive?

Most of us know that oysters are commonly known as aphrodisiacs, whether in truth in myth, and yohimbine has been used as an aphrodisiac for hundreds of years, however, are there foods that can kill your libido? There may be truth to these, or merely myth as well, but some brief researching came up with the following short list:

Soy- Soy is well known to be heart healthy, and an ingredient in many foods, however, soy contains phytoestrogens, which may be good for the cardiovascular or inhibit prostate growth but it can throw the Testosterone/Estrogen ratio off, whether male or female. Estrogen may be the “female hormone”, but libido in men and women are driven by testosterone. Anything that upsets this imbalance may drive the libido down. What else can offset this ratio in women?- Oral contraceptives and oral hormone replacement therapy. Again, good for your heart, and may prevent a baby, but may be bad for sex drive.

Licorice- huge quantities of black licorice which contains glycyrrhizin has been shown in studies to lower testosterone in men and women. Red licorice usually does not contain glycyrrhizin.

Tonic water- Used as a home remedy for leg cramps because it contains quinine. (Quinine has also been used to treat malaria.) However quinine has been shown to lower testosterone levels and testosterone production in rat studies.