Sunday, November 4, 2012

Vaginal Laxity (Looseness): What does the Woman's Doctor Think?

Stretching of the vagina and its opening (introitus) can occur from vaginal delivery or from pelvic organ prolapse (dropping of the bladder, uterus, rectum), however it may also be a natural process. It is thought that looseness or stretching may contribute to diminished sexual satisfaction from loss of sensation, and affect body image. It is not clear how many women may experience this condition, but 83% of urogynecologists from a recent survey described vaginal laxity as underreported by their patients. These physicians felt that laxity may be a bothersome condition to patients that may impact on “happiness and sexual function”. It is the most obvious physical change that physicians felt women experienced after childbirth.

Some studies conflict about where repair of pelvic organ prolapse improves sexual function. If prolapsing organs are uncomfortable or affect urination or bowel movements, these conditions will be repaired regardless if the woman is sexually active or not. Since prolapse also usually affects an older population of women who may already be less sexually active due to their own libido, health or their partner’s health, it is difficult to sometimes judge whether prolapse surgery improves sexual function. “Vaginoplasty” is the tightening surgery, often done for cosmetic reasons  or with the intention of improving sexual function, but studies measuring whether this actually improves sexual function are poorly designed so a true answer  is elusive.

Conversely, it is also known that with age, hysterectomy and reconstructive surgery for prolapse the length of the vagina shortens. Dyspareunia, or pain with sex, can occur from either being “too tight”, from having a narrow introitus, or from reduced vaginal length. Vaginal dilators can be used to stretch the introital opening after scarring/narrowing develops with age, radiation, and surgery.

So, does the woman’s doctor (urologist or urogynecologist) feel comfortable talking about sexual health to their patients? The vast majority of those surveyed (>90%) feel comfortable discussing sexual health, but often feel than time pressure in the office may limit the depth of the conversation. 83% felt that vaginal looseness was an underreported concern among patients, 57% believed that vaginal laxity directly affects the quality of life of relationship happiness, while only 31% felt that vaginal looseness was an issue driven by the male partners of patients. 4% responded that vaginal laxity was an industry invented condition. Some of the concerns cited about sexual impact were: less confidence, perceived inability to please partner, altered sensation and less satisfaction.

The prime location of looseness was cited as being the introitus, and the most frequently recommended treatments were Kegel muscle exercises and pelvic floor physical therapy, though physical therapy was noted to be more effective. Only 54% of doctors recommended surgery to correct looseness, yet it was felt to be a more effective therapy.

Overall, vaginal laxity is not well studied and may affect sexual quality of life. Yet, there is a keen interest in addressing it, but there is inconclusive evidence to date that any one therapy works well or is the best option. There is debate and scant data, and this means, more study is definitely needed.

Sunday, September 16, 2012

Obstructed Sling: Can’t Pee From Your Sling? How to Prevent it and What to Do If This is Your Problem.

Sling surgery may be the perfect combination of mixing the art and science of medicine. Urinary incontinence, for which sling surgery is indicated, is a well-known quality of life problem that millions of women in the US and worldwide experience. When stress urinary incontinence is bothersome enough and conservative measures have failed, a sling is indicated to correct it. There are many surgical procedures for stress incontinence, but the sling has become the standard of care, and the mesh sling has become the most performed and the standard of care in the US and worldwide as well.

Balancing dryness after a sling with the ability to void urine is of paramount importance. One would not want to reasonably trade being constantly wet with being dry but unable to pee. Therefore a work up before sling surgery is necessary. Urodynamics should always be performed to determine what the preoperative bladder function is in order to properly determine whether and which type of sling should be performed. The two archetype slings are the retropubic “TVT”, and the transobturator “TVTO”, but there are many iterations of these original types that are equally successful. The minislings, such as the Miniarc as one example, are not well studies and fall under the recent 522 FDA requirement for further studies.

Sling obstruction essentially means, that even if placed correctly, the female patient cannot void. This does not mean 1 or two days, or even 7 days, but obstruction is considered if the patient still needs a catheter for at least 28 days. The rate of retention can be as high as 10% with this definition. What’s important to determine is when the inability to void began after surgery. It can present with obvious symptoms: straining, weak stream, sense of incomplete emptying, bladder cramps/spasms, urinary frequency, burning with urination and UTIs. Obstruction can even occur after many years and symptoms and a work up are needed to properly determine this.

Urodynamics are needed to access a variety of things in terms of bladder and urethral function. Of paramount importance is how strong (or weak) is the bladder contraction. Even if placed well, if the bladder contraction is weak, then the patient may not void well and the sling will act to obstruct the flow. A normal bladder contraction is required to overcome the normal resistance of the urethra and all the more so if a sling is present.   Women who void by Valsalva (or straining), and do no not necessarily relax to void, are at risk for retention after a sling as well. The sling will simply do what it is designed to do- block urine from coming out when a woman strains, whether it is during aerobics or straining to void.

Retropubic slings, whether mesh or autologous tissue, tend to hug the urethra more snugly and have a tendency to lead to retention and obstructive symptoms. This generally does not occur with transobsturator sling, as this type of sling is configured more splayed out. Both types have equal efficacy in curing stress incontinence. Retropubic slings may be favored if incontinence is more severe, or if a prior sling failed, yet, an important judgment call is deciding between being 95% dry with a transobturator sling even if the incontinence is severe, versus begin “105%” dry with a retropubic sling, which may make the patient dry but is now causing obstruction. “Dry” does not always mean “perfect”.  If may be better to leak rarely with a sling, than have constant trouble with emptying.

A weaker flow rate on Urodynamics, higher residual bladder urine before surgery, or older patients (>75 yrs), many also be at risk for post sling obstruction.  Alternatively, if a sling erodes into the urethra or extrudes into the vagina, sling obstruction symptoms will likely occur. In addition, if a bladder prolapse is not identified or fixed at the time of sling surgery, or if one develops later, the sling will effectively kink off the urethra at the point where the bladder drops. It will be difficult to empty the bladder in these cases as well. If the sling is not positioned well, either too close to the urethral opening or too far back off the urethra or if it migrates after placement, the sling can obstruct as well. These constitute the discoverable pre- and intra-operative factors that are the science of sling surgery.

Physician factor is equally important. There is really no standardized way of preventing obstruction. Each physician performs tensioning as he/she sees fit based on the sling type, body habitus, degree of incontinence and urodynamic factors. Retropubic tissue slings are most difficult to “eyeball”, and can obstruct right away or tighten and obstruct over time. This type of arbitrary tensioning of slings underscores the physician’s experience in performing slings. The more a physician has done, and the more slings the physician may also have re-done, whether his own or from another physician, the better the physician is at setting sling tension. That is the art of sling surgery without a doubt. As the old saying goes “caveat emptor”, let the buyer beware. Seek out a physician that is experienced in incontinence diagnosis and treatment.

A thorough pelvic exam, cystoscopy and urodynamics after the sling are required to evaluate and determine the correct treatment plan. Sometimes biofeedback or pelvic floor retraining may be all that is required if no obstruction is suspected or diagnosed. Sling transection, removal, or incision and release of the urethra is often needed if obstruction is diagnosed, and often will remedy the problem. However, this must be balanced with the risk of recurrence incontinence. Some patients may opt to self-catheterize versus risking being wet again after sling release. If diagnosed early enough, the sling maynot need to be removed, but rather can be loosened.

Tuesday, August 14, 2012

Urinary Tract Complications/Injury after Laparoscopic Hysterectomy

Gynecologic surgery is performed for many reasons, such as cervical, uterine or ovarian cancer, abnormal or severe menstrual bleeding, ovarian cysts, pelvic pain, large fibroids and endometriosis. Urological or urinary tract injury can be a serious complication of these surgeries and can lead to significant morbidity, loss of work time and permanent injury or need for corrective surgery. Laparoscopic surgery is a great advance and is used in gynecology as well as other specialties and affords great benefit to the patient such as: less post-operative pain, quicker recovery, shorter hospital stay, better cosmetic results, and quicker return to work. However it can be technically challenging, and may not be appropriate for all gynecological surgery. Such complications can even occur in the most experienced hands. The key to treatment is early appreciation, identification, and correction of injuries to minimize long term problems.

What are some of the most common complications that can occur?

The most common organ to be injured is the bladder. It is a floppy, hollow organ that lies on top of the vagina and must be separated from it during hysterectomy. The bladder can be inadvertently entered leading to a “hole” that requires closure. This injury is often recognized right away and can be easily closed in most cases, but it does require a bladder catheter to drain the bladder and allowing healing for at least a week.

The ureters are delicate thin tubes carrying urine from the kidneys to the bladder. Unfortunately, often these can be missed, misidentified and injured inadvertently during hysterectomy or ovary removal. They run beneath important arteries to the uterus. They can be cut, incorporated in sutures, or injured by heat/cautery. Often ureter injury in not appreciated right away and most commonly presents as pain, or obstructed kidney function, fever, flank pain or a combination of these several days after surgery. If the injury is recognized at the time of gynecological surgery the ureter can be repaired, but if the injury is noted later then the ureter or kidney on the affected side will require drainage with a tube or stent to allow for surgical inflammation to resolve over time and then delay repair the ureter till a later time.

Sometimes, and more rarely, if the bladder or ureter are injured by heat or incorporated into suturing of the vagina during surgery, a fistula can develop a week or so after surgery. The abnormal fistulous connection between the bladder/ureter and vagina will present sometimes with pain, blood in the urine and fever, but will most often present with fluid leaking from the vagina; this fluid being urine. A thorough exam of the vagina, bladder exam with x-ray and scope, and ureters with x-ray as well, all must be undertaken to determine where and how many injury points exist. Repair of the damaged ureter or bladder is then undertaken.

It is prudent and important for the female patient to ask her gynecologist prior to surgery which surgical approach is better or safer- this will depend on the problem at hand, how experienced the doctor is and what type of patient characteristics may predispose to injury.

An open incision for surgery may take longer to heal but if large fibroids are present or severe endometriosis exists, it may be safer. If the cervix is cancerous but not bulky, a laparoscopic surgery may do just fine. Laparoscopic surgery requires a special skill set and is itself a minor risk for urological injury. Large patient body size/high BMI, prior C-section, multiple fibroids, pelvic adhesions and severe endometriosis are considered risks during laparoscopic surgery. That is not to say that these injuries cannot occur if the surgery is done “open”, as they certainly can and unfortunately do occur from time to time.

The best defense is a good offense. Select the appropriate surgeon, review the best method of surgery based on the disease and patient limitations. And, don’t be afraid to ask how many cases a surgeon has done.

Saturday, July 14, 2012

After Your Sling, Check Your Bladder Function Prior to Leaving the Hospital. Avoid a Late Night ER Visit.

I have noticed a number of comments on the blog related to women who have had sling surgery and then leave the hospital afterwards without having voided yet, only to end up in the emergency room later that night unable to urinate, requiring then a catheter to be placed.

This is one of my pet peeves in regards to sling surgery, or any pelvic surgery. General anesthesia, spinal anesthesia, or any urological, gynecological, or pelvic surgery can and should be expected to have an effect on the bladder and one's ability to void after surgery. Though a minor surgery, sling surgery requires dissection around the urethra, and it may be difficult for some women to void afterwards. This should be expected and is not abnormal. The bladder is quite sensitive to surgery/anethesia and will recover function quite easily afterwards, but there are times when it simply is "on the fritz" and will not work. This takes forethought, time and patience to see through.

Though sling surgery is championed by many to be quick and easy, "routine", "minimally invasive", the perception that nothing can go wrong, is, wrong.

I routinely send the patient from the operating room to recovery with a catheter and guaze packing in the vagina. After the effect of anesthesia wears off about an hour or so later, I will have my recovery room nurses remove both, and then give the patient time to try to void over the next hour or so. Waking up with a catheter will give the sensation of needing to void, but it is better, in my opinion, than waking up with a full bladder and then unable to void. I have my patients void after surgery prior to leaving the hospital and will check their "residual urine" with a bladder scanner to be sure there is little leftover. This lets me know that the bladder is functional and an ER visit will be unlikely later that night.

If bladder function is known to be not so good going into surgery, I do not expect the bladder to function promptly right away, and I will therefore send the patients home with a catheter for a day or so. This may sound uncomforable, but the catheter is better than having the pain or bloat of a bladder that won't empty. Having it in overnight will also help sleep since it eliminates the need to wake up for the bathroom.

When the bladder cannot empty after surgery and goes into retention, it stretches, and this transient stretch injury needs to recover prior to normal voiding. Simply removing the catheter one day later after a retention episode is not enough time. Leaving the catheter in the bladder for 3-7 days ensures good bladder recovery and minimizes the need for further repeat catheterization. If the catheter is removed too soon after it has been stretched, the bladder will simply not work well, and patients will experience pain and small volume voids with urge and spasms. Repeated catheterizations increase infection risk.

If you are considering sling surgery or other urologic/gynecologic surgery, simply ask your urologist/gynecologist to do a bladder scan on you in recovery prior to leaving. An ounce of prevention...

Monday, June 4, 2012

Ever have a Foley (Bladder) catheter and develop an infection? You are not alone.

A urinary bladder catheter, more commonly called a Foley catheter after its inventor, is frequently necessary and required when undergoing bladder or other urology procedures, or when after surgery the bladder is not expected to function right way. Often patients go home with the Foley to a leg bag and it can be managed easily, though it can be annoying. Often when debilitation occurs such as after stroke or long term immobility, the Foley is left in the bladder long term, months or even years and needs to be changed at least monthly to avoid bladder infections.

Despite good hygiene and Foley changes, bladder infections can still occur. However more often than infection, bacteria can colonize the catheter and urine, but remain asymptomatic and not lead to overt infection. These are not infections per se.

Foley catheters should be inspected on a periodic basis, can be taken into the shower and cleaned with soap (not with alcohol), and the urethra and skin around the urethra must be cared for as it can develop irritation and discharge.  The catheter can stir up blood in the urine which is expected but is usually minor and resolves with water consumption. Individuals who take blood thinners (aspirin, Plavix, warfarin, pradaxa) are going to be at higher risk of bleeding in the urine with a chronic catheter in the bladder, which leads to irritation (which resolves after it is removed).

Foley trauma is equally an issue. The catheter drains and is usually connected to a legbag or long bedside bag. If the catheter pulls inadvertently, or gets tugged on, it will be painful, may stop draining or stir up blood and then stop draining as well. This is especially an issue in those requiring catheters for longer periods of time. When the catheter is left in too long the tip can become encrusted with stone deposit making it difficult to remove or traumatic upon removal. Sometimes if the urethra is narrow or the anatomy is difficult the Foley may not pass in easily and trauma can occur to the urethra which then will lead to bleeding, infection or both. These types of problems require overseeing by urologists, yet unfortunately, if issues occur over the weekend this leads to emergency room visits.

Taking antibiotics for infections is often required, and sometimes the catheter leads to infections itself, but constant or repeated antibiotic usage when catheters are present will lead to bacterial resistance to antibiotics. Antibiotics are like torpedoes, they need to be aimed precisely and used only when absolutely necessarily. Overuse can also lead to diarrhea, yeast infection, and other side effects.

Wednesday, May 9, 2012

Yogurt and Bee Honey in the Vagina Can Help Yeast Infections?

You’re saying: What? Why would anyone do that, and does it help?

We know that the vagina contains many bacteria to begin with, and are necessary to maintain its health. Many women find that after taking antibiotics for some other reason, they develop a yeast infection. Why? The antibiotics you may take for a UTI or strep throat, will also kill the “good bacteria” in the vagina, allowing overgrowth of Candida (yeast), which then has to be treated itself. Over 250 species of bacteria have been identified.  The most common and important are species of Lactobacilli that produce chemicals that lowers the pH of the vagina (making it more acidic) and not a good place for other unwanted microbes to grow. Several good examples are Candida, yeast, that is normally present in and around the vaginal/anal area, but can overgrow and leading to symptoms such as white discharge, redness, swelling, and odor, and BV (bacterial vaginosis), which can also lead to discharge, odor and irritation. Both need to be treated to restore the normal balance of “good vs bad” in the vagina.

BV is a common infection among reproductive age women and has been associated with increased risk of PID (pelvic inflammatory disease) and STD transmission. Candida can occur when estrogen levels are higher such as during pregnancy. Diabetes, immune suppression, and oral contraceptives can also predispose for Candida.

Oral anti-fungals are the most common remedy for yeast, such as fluconazole, and topical medications can also be used in the vagina, especially during pregnancy, where oral drugs for this should be avoided.

Interestingly, bee honey has been shown in several studies to have antimicrobial effects, against yeast and in wounds. It was reported to be “prescribed” as a liquid broth or as vaginal tablets for treating yeast. It has a high acidity and levels of hydrogen peroxide may account for its effect.

Yogurt is rich in Lactobacilli which has been demonstrated to inhibit growth of Candida yeast when inserted into the vagina during active yeast. Given all this, some researchers in Egypt decided to create a mixture of bee honey and yogurt believing that together their anti-fungal properties would enhance the killing and treatment of Candida infections in pregnant women who develop Candidal infections, in order to avoid oral meds. These food products were readily available and inexpensive to the researchers and patients. The admixture contained a small third part of distilled water to lessen the thickness and stickiness of the paste.

Two groups of women were then recruited, all pregnant, both with vaginal Candida, however one group was treated with vaginal anti-fungal meds, while the other was given this bee honey/yogurt mixture. Cultures were taken before and after. The average age of the women in both groups was about 35 years old. Symptoms of yeast infection were similar between the two groups.  So what were the results?

Both groups tolerated their treatments well. The bee honey/yogurt group experienced less vaginal irritation compared to the vaginal medicine group. Both groups had high cure rates, but the bee honey/yogurt group reported an 88% clinical cure rate, while the conventional group reported a 72% clinical cure rate. However, after treatment, the vaginal medicine group showed a better negative culture rate than the bee honey/yogurt group. Soiling of clothes was higher in the bee honey/yogurt group: 17% vs 11%, as one may expect.

The bee honey/yogurt group was shown to also have an effect on other pathologic bacteria that were present, such as Staph and Strep. In addition, it may have lowered the itching and other symptoms better due to some anti-inflammatory properties.
This study was a simple and novel trial in a group of women with positive results. It adds to our knowledge for those interested in complimentary medicine, but should not be taken as a substitute for conventional treatment. Perhaps both types of remedies can be used together to maximize the intended treatment against yeast, while the mixture can be used as a supplement to sooth local symptoms.

Monday, April 2, 2012

Does Vitamin B12 level Affect Stress Urinary Incontinence?

It is a fascinating question because very little is known about how diet affects Stress Urinary Incontinence. Most doctors will counsel patients about diet adjustment when urge incontinence is the issue, such as lowering caffeine or other stimulants in your diet to lower the irritability of the bladder, or avoiding spicy or acidic foods if there is a question of Painful Bladder Syndrome (sometimes called Interstitial Cystitis). But not much is said in regards to dietary influences on Stress Urinary Incontinence. Conservative measures to help SUI include fluid restriction and Kegels. When this fails, and if SUI is bothersome enough, sling surgery is the most successful surgical intervention.

The risk factors for SUI are well known and include vaginal childbirth, age, repetitive straining (constipation, chronic cough, heavy jumping exercises), as well as menopause and hysterectomy. We also know that there are connective tissue differences in collagen between women who have urinary incontinence and vaginal prolapse and those who don’t. Studies over the last 10 years have slowly mapped out certain enzymes and proteins that degrade and turnover collagen more readily in the pelvic floor of women with urinary incontinence and prolapse. This lends weight to the notion that these bladder conditions are genetic and run in families. It’s often true that my patients who have urinary incontinence and/or prolapse will say that their mother, grandmother, or aunt also had “these problems” as well.

Recently, a study from Istanbul addressed the question as to whether there are dietary influences on SUI. Vitamin B12 was selected for study because of its integral role in connective tissue production of collagen. Since collagen is the main connective tissue in the body (and there are several forms of it), the researchers wanted to see, quite simply, if there was a correlate between Vitamin B12 levels and symptoms of stress incontinence. More simply, is Vitamin B12 deficiency seen in women with stress incontinence, whereas is it normal in those without SUI?

 This is a huge connection if one exists. Why? One assumption is, if B12 is lacking does this outright lead to stress incontinence? If this is true, does B12 replenishment correct SUI, or prevent/lessen SUI in the face of other risk factors? Can SUI be completely prevented by keeping B12 levels high? (Likely not given all the other potential life cycle risk factors).  Perhaps the connection is not as direct. Perhaps in some women there is a genetic predisposition to not absorbing B12 well in the gut, and this is the weak link which may predispose to SUI. Perhaps diet preferences based on fads or religious beliefs lead to less B12 intake. Moreover, there are many factors which affect collagen synthesis and degradation, not just B12 levels, yet this question has never been raised.

The researchers looked at 2 groups of women, both about 50 years old; the study group had stress urinary incontinence and the control group did not. B12 levels were then drawn from both groups. (How simple!) Under 200 pg/mL is considered deficient, while 200-350 is considered low-normal. The threshold for 300 pg/mL was used as the cut off, mimicking other prior B12 studies.

In the study group, the B12 level was 300.95 vs. the control group which had a B12 level of 598, a significant difference. When comparing the two groups, other characteristics such as BMI, folic acid level, and employment status were no different. In the study group of women with SUI, the mean number of years they had it was 7.4 yrs. In fact, women with B12 levels less than 200 pg/mL had SUI for longer. The prevalence of B12 deficiency was seen to be 66%, a rate higher than the general population.

In analyzing their data, the researchers refer to a prior study that suggested that zinc and B12 may be associated with SUI. These micronutrients are acquired in meat and dairy products. If women perceive “being healthy” by avoiding meat and dairy, are they really doing themselves a disservice? If proper nutrition calls for a balanced diet, then are “salad eaters” who work out in the gym to maintain weight control doing so at the expense of true health…? This is a larger question that cannot be addressed in this blog, however it does give one pause to consider the need for a balanced diet. Of course B12 shots can always be used to supplement low levels, yet that steals the satisfaction from the individual from enjoying some good foods.

The researchers of this current study did suggest that B12 deficiency may be a causative factor in developing stress urinary incontinence. Among the study group women, almost all were still premenopausal and so the “protective effect” of estrogen was still present. Diet is the main source of B12 and a poor diet may have contributed to SUI, over time. Middle age women, not young women were the ones demonstrating SUI, yet in this older age group other SUI risk factors may have also played a role such as birth history and age.  It is too big a leap to directly suggest that simply lack of B12 lead directly to SUI, but B12 is a critical nutrient that is required to maintain good overall health, not just of the connective tissue system, but is also needed for good bone marrow support and bone health. Low B12 leads to anemia and bone loss as well.

B12 may be considered a useful biomarker for poor overall nutrition in middle aged women, but only some doctors check it on routine exam. So, perhaps, if you have SUI, check your B12 level. It may help your overall health as well.

Monday, March 26, 2012

Bladder injury/perforation during TVT sling placement: Does route affect rate?

There are a myriad different sling types currently in the market place that can be placed a variety of different ways. All try to achieve the same desired result, that is, cure of stress urinary incontinence (SUI). The paradigm shift in treating SUI occurred in the mid to late 1990s with the introduction of the tension free vaginal tape (TVT). It made sling surgery and cure of SUI a shorter, highly reproducible and out-patient procedure. Sling surgery has been around for more than 100 years and was primarily considered the last resort surgery after other types of failed incontinence procedures, mainly using one’s own tissue, but the introduction of modern mesh slings has lead to wide spread adoption of the surgery and its high success rates are evident in hundreds of peer reviewed literature papers.

First, a brief word on mesh. Recently, the FDA has issued bulletins on mesh for vaginal surgery related to pelvic organ prolapse, most recently in July 2011. It did not call attention to mesh for sling surgery. Although mesh is mesh, the amount, technique, and final position of mesh for incontinence surgery is far different than for pelvic organ prolapse. Mesh for slings for incontinence surgery is considered the standard of care, in the US and worldwide, although there are still other types of incontinence surgeries available, including non-mesh slings, injections and abdominal surgeries (Burch, MMK), which are either less successful, more complex, or reserved for specific indications. All mesh are foreign and must heal and scar into the body. A well trained urologist or gynecologist will have the skills to perform a sling relatively quickly, with little complication, will have familiarity with several ways to place slings, and be willing to dealing with potential complications, though they are low.

Many different methods of placement of slings exist, and method of placement depends in large part on surgeon training, patient body habitus or prior surgeries. The classic TVT as first described is not as often performed any longer as much as it used to be in the US due to modifications and different ways to place slings, but there is always debate as to which is the best method, as it relates to reproducibility, success and complication rate.

Case in point. A recent paper was published looking at two groups of patients receiving a TVT for SUI, where the method of placement differed between groups. The first group consisted of vaginal passage of the needles (bottom- up) position, and the other group consisted of abdominal passage of the needles (top- down) position. Injury to the bladder is one of the known risk factors during sling surgery. The rate of injury we know goes down as experience goes up, and as knowledge of anatomy increases, and as proper patient selection is used. During adopting of new techniques, is there a method of placing slings that will reduce bladder injury risk in less experienced hands? That was the goal of the study.

The greater injury risk was with sling placement in a bottom up approach vs. a top down approach , 37.9% vs. 6.8%. The first 5 cases is where the most injuries occurred and then they became less likely over time. There were no other differences between the two groups when compared.

Part of the analysis of the study by the authors from St Louis was an attempt to train less experienced surgeons in a technique that will lead to less injury.  If after training, there are surgeons who do not perform this surgery frequently, then one can conclude that the top down approach for low volume operators is the safer approach. The anatomic landmarks are better identified with the top down approach.  If the low volume operator is not familiar with several sling techniques or if the patient is complex or had prior surgeries, then the patient may want to be referred to a more skilled surgeon.  The patient is also responsible for asking the right questions when discussing potential surgery and ask the doctor how many slings they have done, and what his/her complication and/or success rates are. The patient is not a passive bystander in her medical care, and should ask these important questions.

The importance of this study findings is obvious. Less bladder injury is always desired, as it leads to less bleeding, less bladder catheter time, and more patient satisfaction. It is also important to always check the bladder at the time of surgery with a scope regardless of type of sling performed. This takes just a minute but missing an injury can have serious consequences.

Friday, February 10, 2012

BOTOX for the Bladder

The most powerful natural toxin, botulinum toxin, was first approved by the FDA in 1989 for the treatment of eye muscle disorders. Its use has expanded to include application to various body systems such as GI, orthopedic, cosmetic, dermatology, and now urology as well.

For the past 10 years, research has focused on how to properly and appropriately apply botulinum toxin to the urinary tract. Most commonly known as BOTOX, the toxin acts to prevent the release of the neurotransmitter acetylcholine from the nerve ending onto the muscle. By preventing muscle contraction, BOTOX acts to paralyze the muscle being treated that is abnormally spastic, or abnormally overactive. Directed by injection into the abnormal muscle, only that muscle is "treated" with paralysis, thereby giving relief to the patient experiencing muscle disorder.

For urology, a very common bladder muscle disorder is overactive bladder. There are a variety of reasons the bladder can be overactive, spastic, or contract abnormally. Five months ago, the FDA approved the use of BOTOX treatment for bladder overactivity from neurological disorders. Any type of neuropathy that leads to bladder overactivity and incontinence of urine would qualify for treatment. These would include bladder incontinence from stroke, multiple sclerosis, back nerve injury, spinal cord injury, Parkinson's disease, and others, when medication and other measures fail to control incontinence. It is not approved for "plain old" overactive bladder, a common disorder of women from age, menopause, or hysterectomy. Treament is carried out by injecting BOTOX directly into the bladder muscle via a cystoscope, while looking in the bladder.

In multiple studies, BOTOX injection has been shown to be effective in curbing incontinence, and bladder overactivity in neurologically affected bladders. The effect can last typically for 6-9 months. Retreatment is possible and often equally effective. In the 5 largest published studies the following results can be summarized:

Leaking controlled in at least 73% of patients
Frequency of incontinence episodes decreased by 32-90%
Bladder capacity increased significantly
Duration of treatment averaged 6-9 months

Those who may not respond to treatment are those with shrunken, thickened or scarred bladders.

Side Effects?
The most common side effects of treatment were urinary tract infection, blood in the urine and incomplete bladder emptying. Rare side effects include generalized muscle weakness and insomnia, which were transient.

Tuesday, January 31, 2012

Book Launch! Female Urinary Incontinence

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

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

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

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

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

Wednesday, January 25, 2012

Are There Racial Differences Among Those That Have Overactive Bladder?

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

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

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

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

Significant predictors for developing OAB in women were:

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

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

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

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

Sunday, January 1, 2012

Does Pelvic Radiation for Cancer Affect Female Sexuality?

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

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

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

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

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

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