Female Urology & Urogynecology

Are There Racial Differences Among Those That Have Overactive Bladder?

2012-01-25T20:29:00.001-08:00

A very common condition, Overactive Bladder (OAB) is asyndrome that consists of abnormal urinary urgency (uncontrollable or painful),with or without urge incontinence (leaking with the urge prior to getting tothe bathroom), urinary frequency, and often nocturia (waking up with the urgeto 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 largetrials, none looked at whether there are racial differences when it comes towho develops OAB.

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

White and Hispanic men and women perceived worse bladdercondition than black and Asian men and women. Women experienced greater impactthan men.

Black men were most affected by OAB compared to Hispanic,Asian or white men, while for women there was no racial difference. Among womenof 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 currentsmoker, 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 andBMI.

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

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

Does Pelvic Radiation for Cancer Affect Female Sexuality?

2012-01-01T19:31:00.000-08:00

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

Ionizing radiation destroys cancer cells due to their morerapid proliferation compared to normal tissue, but radiation can lead toanatomic changes resulting in bowel and bladder symptoms, pelvic pain, loss ofhair to irradiated skin, vaginal narrowing, vaginal dryness, higher infection riskand pain with intercourse, vaginal bleeding and premature menopause. At thesame time, women will often feel isolated, or develop anxiety and depressionfrom their diagnosis and throughout or after treatment.

A large study recently reviewed the common complaints andchanges that women reported as a result of pelvic radiation for uterine, rectalor anal cancer. Women reported more fatigue, lack of strength, vaginaldischarge, diarrhea, skin redness and psychological stress. Of all the sexualdysfunctions, sexual desire was affected more than other sexual domains such asarousal, orgasm, etc. The most common reason for avoiding sex was limitationfrom the cancer diagnosis and treatment itself, reported by 66% of women. Sexualfunction was not a function of overall radiation dose received.

Interestingly, 25% of the female patients reported thattheir doctors questioned them about their sexual function, while 17% reportedthat 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 theoverall health concerns.

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

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

How Does Diabetes Affect the Bladder?

2011-12-13T20:56:00.001-08:00

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

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

Nerve dysfunction- this is a typeof neuropathy, where sensation is lost, meaning, the urge to void is notperceived until the bladder is overfilled, or the nerves that control bladder contractionare weakened leading to less urine expulsion and more retained. This leads tochronic stretch and loss of elasticity. Bladder capacity can increase slowly,like a sinking boat, “taking on water”, till the bladder loses its ability potentiallyto contract. Mini-strokes or major strokes, brought on by diabetes canexacerbate bladder dysfunction, as the stroke may affect also perception of afull bladder till too late when incontinence may occur, or with sever stroke,bladder retention occurs outright.

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

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

Diabetics are already moresusceptible to developing infections, and elevated bladder urine residualssimply increases this risk. Interestingly, certain types of E coli bacteriaadhere more readily to the urothelium of diabetic patients.

So, what is diabetic patient todo? Tight sugar control minimizes the deleterious effects on blood vessels andall organs including the bladder. Timed bathroom trips and “double urinating”,can help empty a bladder that is weak. Fluid management helps prevent overproduction of urine that may stress the bladder. Consistent hygiene around thegenitals helps to reduce the chance of infection. Medications are availablethat help reduce the tone of the urethra to help bladder emptying, and self catheterizationcan be used to empty bladders without any function. In addition, Interstimsacral neuomodulation can be attempted in bladders with poor contractilefunction as well.

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

2011-11-02T13:38:00.000-07:00

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

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

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

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

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

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

2011-10-06T13:02:00.001-07:00

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

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

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

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

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

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

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

FDA and Mesh complications in vaginal surgery

2011-08-11T16:51:00.000-07:00

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

From their recent letter to the physician community:

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

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

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

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

FDA Pelvic Organ Prolapse Mesh Report; The Rest of the Story

2011-08-08T11:06:00.000-07:00

The following is an article by Sherrie Palm, who oversees an advocacy group for women called Association of Pelvic Organ Prolapse Support, and in response to the FDA's recent bulletin on mesh used in vaginal surgery I am posting her article here and the FDA's report.

Her website is: http://pelvicorganprolapsesupport.org

The FDA's bulletin can be found at: http://www.fda.gov/downloads/MedicalDevices/Safety/AlertsandNotices/UCM262760.pdf

FDA Pelvic Organ Prolapse Mesh Report; The Rest of the Story
By Sherrie Palm

When the FDA speaks, everyone panics. On July 13, 2011, the FDA released a safety communication on
the dangers of transvaginal mesh procedures for treatment of pelvic organ prolapse. The purpose of the
FDA is to protect and promote health; they are our watchdog agency. However what often happens with
reports of this nature is individuals seldom read the entire article and only the yikes factors shouted by
the media are grabbed. It is unfortunate that when most women read this article, what they will read is
“all mesh is bad”. That is simply not the case. Women truly need to know the “rest of the story”.
All surgical procedures have a risk factor whether utilizing mesh or not. Statistically the surgical
complication risk factor of POP mesh repair is considerably lower than with other surgeries. The FDA
report states 1503 adverse event reports were filed between 2008 and 2010 with approximately 75,000
transvaginal procedures per year-a ratio of 1%. Risk factor in case reports of hernia mesh repair are
approximately 7%, risk factors of complications in breast augmentation surgery are 25%, facelift
procedure complications come in at 12%. Realistically for those experiencing surgical complications, the
cold stats don’t have nearly as much significance as the pain and dysfunction experienced; there is no
doubt that individuals who experience complications from any surgery wish they’d never had the
procedure done. We need to clear the air a bit so women considering a surgical procedure to treat
pelvic organ prolapse will investigate multiple avenues when considering their treatment choices
including mesh procedures that can provide long-term benefit.
The reality of pelvic organ prolapse treatment is quite complex; there are 5 types of POP and it’s
possible to have any combination of these types. According to an AUGS article (American
Urogynecologic Society), research provided by Dr. Jennifer Wu indicated that 28.1 million women in the
US alone will have pelvic floor disorders in 2010; 3.3 million of them are women with pelvic organ
prolapse. This is a global women’s health pandemic; with vaginal childbirth and menopause as the 2
leading causes, POP encompasses the largest demographic of any women’s health issue.
There are multiple POP treatments available, both surgical and non-surgical. Surgically the choices are
numerous and will vary by the type of POP that needs to be addressed as well as the preference of the
physician performing the surgery. Our bodies are very individual in how they react to surgical
procedures; each woman's scenario is unique. It is important that women do their homework; we
position ourselves ahead of the curve by consulting with a urogynecologist, the specialist trained in the
intricacies of the female pelvic structure. Most difficulties arise when surgeons who are not specialists in
the field of pelvic organ prolapse attempt these complex procedures that are best left to the experts.
Improper technique utilized in attachment of mesh really muddies the waters and leads to
complications such as those addressed in the FDA article.
Typically women in an earlier stage of prolapse will consider treatment options prior to jumping to the
surgical page but for women in more advanced stages of POP, surgery is most often the treatment of
choice. It was for me. Surgical treatment for 3 types of POP at an advanced stage meant I had to
consider and discuss mesh placement. I felt the mesh procedures my urogynecologist wanted to
proceed with were the best choice for me; we discussed it in great detail. I’m extremely active; I felt my
risk factor for additional surgery was reduced by utilizing a synthetic product that was stronger than my
own menopausal tissues. As a woman in her mid 50’s, I wanted my POP repair to be a one-time event. I
did my homework and made sure I not only found a urogynecologist, I also did a background check to
make sure her reputation was good and asked a ton of questions prior to surgery.
As is typical with health scares, there are multiple layers to consider. As a women's pelvic floor health
advocate who guides women regarding POP treatment and surgery on a daily basis, I feel it is vital that
we give women ALL available information. It puts women at a disadvantage when they only get one side
of the story to health concerns. No mesh may mean additional surgery in your future; when discussing
your surgical choices for a POP procedure, make sure to discuss both sides of the coin for mesh use vs.
the potential for additional surgery down the road if mesh is not utilized. Like most health procedures
that get a bad rap, mesh use for pelvic organ prolapse surgery should be carefully analyzed from many
angles b/4 being dismissed. New procedures are developed for POP repair every year; currently
minimally invasive robotic surgery has added a new page to the POP surgical agenda.
Ideally treatment of POP truly should be a partnership between multiple layers of healthcare
professionals with primary care physicians and gynecologists screening and diagnosing pelvic organ
prolapse and urogynecologists and physical therapists providing surgical guidance and treatments.
According to the AUGS website, there are approximately 1200 urogynecologists/urologists in practice
with another 100 physicians currently undergoing fellowship training in female pelvic medicine and
reconstructive surgery. To find a urogynecologist in your area, you can access a link to the AUGS
provider page on the APOPS website at
http://pelvicorganprolapsesupport.org/health_care_connections/urogynecologists-uscanada
It is up to each of us along with our healthcare providers to determine which treatment modem suits us
best; it's not as simple as whether surgery or treatments are the best option or even whether or not
mesh should be utilized. What it boils down to is choosing the best path for you as an individualexploring
all options prior to making a treatment/surgical decision is vital. We all need to be our own
best health advocates and then share what we learn with others
NO ONE CAN HELP US AS MUCH AS WE CAN HELP OURSELVES

Complications of TVT vs TVT-O slings; Which is Better or Worse, or Are They the Same?

2011-07-18T12:18:00.001-07:00

Modern slings for the treatment of stress urinary incontinence took a huge technological step forward after the TVT was invented and debuted in 1996. The “tension free vaginal tape” (TVT) is a narrow mesh sling that goes under the urethra and supports it during exercise, running, coughing, laughing, etc, in order to prevent leakage of urine during these activities.
Over the years there have been many variations of the TVT, and many companies have copied the method of placing this sling, and have also developed new methods for placing slings. Variations develop because of some dissatisfaction with the original concept. So in 2001, the TVT-O was developed. It is placed sideways through the pelvis, instead of behind the pubic bone. Is this difference relevant?

Many studies comparing these 2 methods have been performed and the latest one reviewed 1081 patients from Russia. Group 1 consisted of women undergoing the TVT, while Group 2 underwent the TVTO. All the entry criteria for the women were equal between the two groups, except that Group women had a slightly higher BMI.

Both sling approaches have equal efficacy in treating stress urinary incontinence as has been shown in many prior studies as well as in this study, but this study was specifically looking at complication details.
In the women who received a TVT there were higher rates of hematomas (large bleeding) (9.1% vs 1.5%), and bladder injury (5.4% vs 0.6%), vs the TVTO, while the women who received the TVTO had a higher rate of injuring the vagina (3.8% vs 0) compared to TVT. If the injuries are recognized during the surgery by the astute surgeon, then they can be dealt with immediately.
Importantly, the risk of urinary dysfunction (trouble with too strong an urge, or weak stream, or not emptying the bladder) were higher in the TVT group. This is not news and is expected given prior research, but the chance of developing NEW urge incontinence and NEW overactive bladder were at least 3-4 times higher in the TVT group.

Ultimately, the best method to treat stress incontinence is based on the patient’s condition, pre-operative assessment, and which surgery is most successful in your surgeon’s hands. Make sure to ask your surgeon which slings they have done and would they feel comfortable handling complications should they occur.

New Office Location and Practice

2011-07-18T11:16:00.000-07:00

On August 1, 2011, I will be moving practices and opening a new office location. I will be leaving Center for Urological Services where I have been practicing Urology for 6 years, and will be joining, proudly, Arizona State Urological Institiute. They have one office in Gilbert, AZ however I will be opening their new and 2nd office in Ahwatukee located at:

4530 E Ray Rd, Suite 178
Phoenix (Ahwatukee), AZ 85044

phone 480-394-0200
fax 480-394-0202

Our new website (which will soon be updated) is www.asui.org

I will continue to treat all aspects of Adult Urology, for both men and women, but will continue to specialize in women's urological issues.

After Hysterectomy, Which Women Are at Risk for Developing Stress Incontinence?

2011-06-21T13:56:00.000-07:00

Approximately 30% of women report having some form of urinary incontinence, but only those the most troubled by it, or those where fluid restriction and Kegels fail to help will be considered candidate for correcting it with a sling. We also know that many things predispose to the development of stress incontinence, among them: menopause, birth trauma, hysterectomy, and chronic straining (from high impact exercise, coughing, constipation).

But, in those women undergoing a hysterectomy how likely is it that the patient will develop stress incontinence? The majority don’t, but for those who do, it can be disheartening, embarrassing and restrictive on their quality of life.
The hysterectomy (removal of only the uterus, NOT the ovaries) operation itself leads to unavoidable damage to supportive structures of the bladder and urethra, as well as affecting the nerve supply to these structures. Can we separate the risk factors for developing stress incontinence from the risk of the hysterectomy by itself, since many women undergoing hysterectomy have some of the risk factors for stress incontinence already.

I must compliment a very ingenious and simple methodology for calculating this risk factor to Dutch researchers who devised a simple equation to predict of a woman is more likely or not going to experience stress incontinence after her surgery.
They surveyed 234 women after three years from their hysterectomy and collected data. Bothersome stress incontinence developed in 22% of the women by three years. Among the women, abdominal hysterectomy was performed in 3 times as many, vs vaginal hysterectomy.

What’s amazing, even before getting to the equation, is that 22% (!!!!!) of women by just years after surgery, developed bothersome stress incontinence. That is a lot of women.

What the researchers found is that 3 variables helped to predict the risk for stress incontinence (SUI). They are: BMI, age, and surgical route. Women with higher BMI simply have more pelvic pressure due to their higher weight that can affect the support of the urethra. Secondly, the YOUNGER the women was the more likely she was at risk for developing SUI. One would think the converse would be true, since with menopause, the risk for SUI increases. But here, if the woman is younger, she has longer to develop SUI in her lifetime where it would also be more bothersome if more physically active, versus an older woman who may have made it to an older age prior to hysterectomy with having developed SUI, and if not very active, may not experience SUI as bothersome or at all. Vaginal approach may put special strain on the bladder during dissection that is not seen with an abdominal approach. On the other hand, vaginal hysterectomy is preferred for those with dropped uteruses, who already are predisposed by virtue of this condition to developing SUI.

RISK FOR SUI score= 32 + BMI –age + (7.5 x route of surgery), where abdominal route =0, vaginal = 1.

For example, a 40 year old woman with a BMI of 25 scheduled for have an abdominal hysterectomy would have a risk score of 17. This would equate to a 23% chance of SUI at 3 yrs according to the graph developed by the researchers. If the surgery were done vaginally, the risk score would be 32 +25 – 40 + 7.5= 24.5, which would translate to a 40% risk, according to the graph developed by the researchers.

This fascinating predictive model finds its biggest utility in counseling women prior to their hysterectomy, what their risk of SU I may be. All women prior to hysterectomy should at least know that SUI is a risk, but now we can estimate just how much a risk it may be. With this knowledge in hand, those women at higher risk for SUI can be advised to begin Kegel muscle exercises more dutifully to mitigate development of SUI. Of course this represents only one researcher’s data, and to be truly accurate must be validated and repeated, but it holds potential.

Giggle Incontinence (Leaking with Laughing): It’s Not So Funny If It’s Happening to You

2011-05-26T13:04:00.000-07:00

Giggle Incontinence was first reported in 1959 in children. Unlike adult women who leak urine with laughing, due to stress incontinence, in children the reason for GI is not entirely known. It has been proposed that perhaps it’s due to an overactive bladder, or some release of pelvic muscle control with extreme emotional discharge.

How Does It Happen?

Think of total loss of muscle control when an extreme emotion overtakes you: fear is good example. Under heavy emotional stress, control of the urethral sphincter or a spontaneous bladder contraction can occur leading to full on urination. Is it a brain reaction or a bladder reaction? It is not clear, but in a small subset of female children, extreme laughter can lead to full on urination and bladder emptying, not simply a little squirt of pee with a heavy laugh like mom.
Some industrious researchers in Korea set out to study GU in teenage girls, and tried to see what was happening to the bladder during urination before and after treatment. Past treatments for GI included overactive bladder medications.

They treated 9 teenage girls between the ages of 12 and 19 who had pure giggle incontinence with methylphenidate (Ritalin) for 1 year. All had resolution of their symptoms, and none suffered side effects of the medication. They noted high urethral pressures after treatment, and it took approximately 7 months to see full resolution.

What is the significance of such a study? It may be useful in children with ADD/ADHD who may be considered for Ritalin treatment. Treating children with medication is a complex and individualized issue. In the absence of ADD/ADHD and if GI is severe and debilitating or embarrassing for the patient, there is an available option, and this study adds to available evidence already.

What Makes Women Satisfied with Their Sling Surgery for Urinary Incontinence?

2011-05-16T14:01:00.000-07:00

Stress urinary incontinence is a significant bother to women beginning in their 30s all the way into their 80s, as more and more women remain physically and sexually active into their later years. It can be very restricting in terms of odor, embarrassment, as well as interfere with exercise, and even sex. Approximately 30% of women in their 40-60s will report some urinary incontinence.

After fluid restrictions and Kegels fail to improve stress urinary incontinence, the most common and most successful procedure to correct it is the sling. There are a variety of sling types and different methods of placement. Slings have supplemented and replaced the older open surgical methods, and have become the technique of choice for surgeons as well as requested by many patients in consultation (often after their friends have had successful procedures). Tissue slings harvested from the patient’s own tissue used to be the most common way 15 yrs ago, but these days, mesh slings dominate the most common types of slings placed.

We know that the success rate of modern mesh slings is approximately 90% in the longest term studies (11 yrs follow up), and so you would say, “that’s great”. But, is being dry the only thing that makes the woman satisfied after such a surgery, and, are there things that would predict lower levels of satisfaction after the surgery? This quality of life question is very important.

A recent study published from researchers in Minnesota asked and answered this very question. The purpose of the study was to ass which pre-operative and post operative variables correlated with patient satisfaction after sling surgery for stress urinary incontinence. They used extremely stringent criteria for grading how satisfied the patients were after surgery, on a scale from 1 to 5, 5 being “completely satisfied”, and 4 being “somewhat satisfied”, while 1 was “completely dissatisfied”.

A total of 367 women returned surveys of 428 total women who underwent either a mesh sling or a sling from tissue harvested from their own body. At a median follow up period of 2.9 years, 61% answered that they were “completely satisfied”. Broken down, 65% of the mesh sling patients were completely satisfied, while 48.3% of the tissue sling patients were completely satisfied. Women with the mesh sling were twice as likely to be satisfied with their surgical outcome.

What pre-operative characteristics predicted less satisfaction? These would be higher age, higher BMI and having had a tissue sling performed. Of the patients completely satisfied, 90% said it was because they had resolution of their incontinence. For those who were less than satisfied, it was mainly for reasons of incomplete resolution of the incontinence, or development of a stronger urge to urinate, urge incontinence, or even the inability to empty the bladder. Some of these urinary symptoms predated the surgery, and others developed after the surgery.

Despite a high chance of success, no surgery is perfect. It can help many women regain their prior “normal” lives, but even if the sling works to prevent stress incontinence, patients should know that adverse effects on urination can occur. Interestingly, the women who received the mesh slings were more satisfied that those who received their own tissue for a sling. This is likely due to the extra bikini line incision that is required for harvesting tissue which is not required for mesh slings.

Radio Interview on Toginet

2011-04-20T20:24:00.000-07:00

Julianna Lyddon, who is an Intuitive Therapist, with a masters degree in marriage and family counseling, and who works and resides here in the metro Phoenix area, hosts a one hour weekly show, on Toginet radio. I had the pleasure of being interviewed by her on her show about, yes, female urinary incontinence.

Please find the show at the following link:

http://toginet.com/shows/connectwithjulianna

then look to the right side column for a link to my show interview from April 15, 2011

Is Being a Yoga Instructor a Risk for Having Urinary Incontinence?

2011-04-20T20:06:00.000-07:00

We all know that yoga is a te4rrific way to stay in shape, become fit, and get a good cardio work out. Most full time yoga-holics are in shape, and certainly this is true for yoga instructors. But like most women, yoga instrcutors are no different, especially in experiencing urinary incontinence.

A recent study from Norway evaluated hundreds of yoga instructors, most were women, by no surprise. Six hundred and eighty five women, with a mean age of 32.7 years answered a specially designed questionnaire. Interesting results were found.

26.3% of all the female instructors experienced urinary incontinence, with about 21% reporting that it occured about once a week, while 3% reported that it occured about 2-3 times a week. Only 1.7% reported that it occured more than once a day.

About 24% reported that the leakge was mild to moderate, but 15% reported leakage of urine during physical activity, and about 11% reproted incontinence during coughing and sneezing.

So what does this prove?

It means that physically fit women are more in tune with their bodies and may pay more attention to urine leakage that can occur which may be embarrassing or restrict activities, such as urine loss. Yet it may also more likely occur and be reported by women who actually were physically fit, and thus perhaps bother them more. A more sedintary woman may not experience urinary incontinence as much due to relative inactivity, or may not realize that she would pontenetially have it since she is not necessarily exercising regularly. Of course, if severe enough, urinary incontinence can occur no mater your body size.

Yoga positions themselves do not lead to urinary incontinence, but I wouldn't be surprised if certain positions put stress on the pelvis and bladder leading to leaking during yoga. The common life events that are risk factors for developing urinary incontinence are childbirth, aging, menopause, hysterectomy, and chronic straining (such as with high impact aerobics, chronic cough or constipation).

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

2010-11-08T11:14:00.000-08:00

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.

Is Squatting When Urinating Bad for Women?

2010-10-11T11:01:00.000-07:00

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.

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

2010-09-15T13:17:00.000-07:00

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.

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

2010-09-02T15:55:00.000-07:00

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).

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

2010-08-08T07:01:00.000-07:00

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

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

2010-07-02T08:56:00.000-07:00

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!

Female Sexual Dysfunction and Hypothyroidism

2010-06-20T23:13:00.000-07:00

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.

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

2010-06-01T21:00:00.000-07:00

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?

Naturopathic Treatments of Urinary Incontinence

2010-05-03T11:51:00.000-07:00

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.”

Can Bladder Prolapse Recur after Surgery- and Why

2010-04-21T06:27:00.000-07:00

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.

Overactive Bladder? Smear the Cream!

2010-03-26T09:11:00.000-07:00

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%.

Flibanserin: A Sex Pill for Woman?

2010-03-11T05:37:00.000-08:00

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.

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

2010-03-01T12:06:00.000-08:00

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.

Are There Racial Differences in Pelvic Organ Prolapse?

2010-02-17T04:41:00.000-08:00

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.

Kidney Stones & Pregnancy

2010-02-07T20:26:00.001-08:00

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/

Does Yoga Improve Female Sexuality?

2010-02-04T13:10:00.000-08:00

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.

Does obesity in adolescent girls lead to urinary incontinence?

2010-01-29T07:16:00.000-08:00

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.

Can Yogurt Help Vaginal Health?

2010-01-21T05:10:00.000-08:00

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.

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

2010-01-15T07:22:00.000-08:00

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.

Can Certain Foods Kill Your Sex Drive?

2010-01-04T12:37:00.000-08:00

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.

Vaginal massage during pregnancy may avoid episiotomy

2009-12-21T07:57:00.000-08:00

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

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

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

Pain with Sex

2009-11-23T13:02:00.000-08:00

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

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

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

What are common causes of superficial pain during sexual intercourse?

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

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

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

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

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

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

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

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

How Can Dyspareunia be Treated?

Psychological Assessment if appropriate

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

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

"Designer Vagina"

2009-11-12T14:52:00.000-08:00

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

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

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

http://news.bbc.co.uk/2/hi/health/8352711.stm

Is Diabetes and Urinary Incontinence Related?

2009-11-09T11:21:00.000-08:00

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

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

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

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

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

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

Can Marijuana Potentially Treat Overactive Bladder?

2009-10-29T11:09:00.000-07:00

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

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

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

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

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

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

2009-10-17T15:01:00.000-07:00

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

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

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

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

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

What Else Can Lead to Pelvic Organ Prolapse Besides Childbirth?

2009-10-12T21:51:00.000-07:00

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

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

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

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

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

Vaccine for Urinary Tract Infections?

2009-10-03T15:46:00.000-07:00

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

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

Interstitial Cystitis can mimic other common female pelvic conditions

2009-09-25T11:23:00.000-07:00

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

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

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

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

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

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

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

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

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

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

Persistent Gential Arousal Disorder

2009-09-18T12:59:00.000-07:00

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

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

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

What are considered to be the triggers for PGAD?
Sexual stimulation
Masturbation
Stress
Anxiety
Loss
Menses

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

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

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

What Causes the First UTI a Woman Develops?

2009-09-01T12:37:00.001-07:00

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

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

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

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

Vaginal Wind: An Embarrassing Event

2009-08-19T09:01:00.000-07:00

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

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

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

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

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

Vaginal Health for Post-Menopausal Women PART 2

2009-08-13T12:40:00.000-07:00

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

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

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

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

Vaginal Health in Post-Menopausal Women: Part 1

2009-08-10T19:49:00.000-07:00

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

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

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

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

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

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

2009-08-01T16:14:00.000-07:00

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

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

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

Sex and Urinary Incontinence

2009-07-31T09:54:00.000-07:00

Does this happen to you?

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

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

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

http://www.femalepatient.com/html/arc/sig/uroG/articles/034_08_032.asp

Competitive Cycling May Reduce Genital Sensation in Women

2009-07-27T09:07:00.000-07:00

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

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

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

Free Seminar on Mesh Complications After Pelvic Floor Repair

2009-07-14T13:43:00.000-07:00

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

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

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

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

Vibrator Use Common and Linked to Sexual Health

2009-07-10T05:30:00.000-07:00

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

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

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

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

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

FU&U on Facebook

2009-07-01T09:17:00.001-07:00

I have begun a Facebook page on Female Urology & Urogynecology. Colleagues in these fields are encouraged to join!

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

2009-07-01T09:14:00.000-07:00

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

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

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

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

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

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

Painful Bladder Syndrome

2009-06-22T15:50:00.000-07:00

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

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

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

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

Vaginal Mesh Erosion: Part 2

2009-06-01T09:03:00.000-07:00

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

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

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

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

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

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

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

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

Stem Cells in Urology?

2009-05-23T12:12:00.000-07:00

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

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

There are many sources of stem cells:

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

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

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

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

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

Mesh Complications and Vaginal Surgery: Part 1

2009-05-09T12:07:00.000-07:00

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

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

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

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

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

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

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

Blood in the Urine: Hematuria

2009-04-21T17:03:00.000-07:00

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

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

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

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

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

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

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

Weight Loss Can Reduce Incontinence in Women

2009-04-14T06:23:00.000-07:00

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

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

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

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

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

Is Your Bladder Getting in the Way in the Bedroom?

2009-04-11T12:10:00.000-07:00

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

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

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

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

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

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

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

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

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

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

Ad in Perfectifiy

2009-04-11T11:53:00.000-07:00

This is a very nice ad that was recently published in the April issue of Perfectify magazine. It is a woman's health magazine that is based in the East Valley here in Phoenix.

Perfectify willl be co-sponsoring a Women's Health Expo at University of Phoenix Stadium, on April 25-26.

You can find free copies of Perfectify around the valley, including at CVS.

Is Your Bladder Preventing Intimacy?

2009-04-07T06:39:00.000-07:00

I recently had an article published in Perfectify Magazine on womens' bladders and intimacy.

Basically, is your bladder getting in the way in the bedroom? Do you leak urine or is your bladder dropping leading to pressure and pain?

Well read about it here. http://www.perfectifymedia.com/mag/Main.php?MagID=1&MagNo=8

Follow the link to Perfectify magazine, and go to the April 2009 issue. Then go to Page 10 in the issue to find the article.

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

2009-03-25T06:04:00.001-07:00

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

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

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

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

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

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

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

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

Kegel Muscle Exercises aka Pelvic Floor Muscle Training

2009-03-22T21:26:00.000-07:00

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

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

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

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

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

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

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

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

Urinary Tract Infections- More

2009-03-10T11:54:00.000-07:00

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

http://www.sunlakesofarizona.com/blog/category/health-2/

Free Upcoming Events on Female Pelvic Health

2009-03-09T15:42:00.000-07:00

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

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

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

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

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

2009-03-09T14:33:00.000-07:00

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

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

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

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

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

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

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

Slings: what are the risks, benefits and recovery?

2009-03-06T23:51:00.000-08:00

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

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

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

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

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

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

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

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

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

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

Despite the fact that TVT and other slings are placed in the vagina under the urethra, it has an overall beneficial effect on female sexual dysfunction when it is related to incontinence. Women may be embarrassed to have sex if they fear a urine leak or odor, and will avoid it or have decreased pleasure. Surgical correction of SUI with TVT has been shown to improve sexual function domains such as desire, arousal, lubrication, orgasm, satisfaction, and pain. As a result of the surgery, women report reacquiring self confidence and greater sexual interest after resolution of sex-related incontinence. The consensus in the literature concludes that there is a positive, not negative, impact on female sexual health.

Most women are motivated to cure SUI and will often first perform Kegel muscle exercises and restrict fluids, or urinate frequently to keep the bladder empty and avoid a leak. These can be successful strategies but are tedious and frustrating to many. Once these conservative options have been exhausted, evaluation for a sling can be performed.

Urinary Incontinence Treatment Options

2009-02-21T15:46:00.000-08:00

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

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

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

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

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

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

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

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

Doctors who Blog

2009-02-18T09:38:00.000-08:00

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

See the interivew here:

http://www.azfamily.com/video/index.html?nvid=333055&shu=1

Television Interview on Female Incontinence

2009-02-14T05:54:00.000-08:00

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

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

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

mms://cocsv01.chandleraz.gov/Chandler_In_Focus_Urological_Health

Female Urinary Incontinence

2009-02-13T08:28:00.001-08:00

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

http://www.empowher.com/news/herarticle/2009/02/13/what-urinary-incontinence

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

107.9 KMLE
101.5 Free Zone
94.5 KOOL

Cosmetic Vaginal Surgery?

2009-02-03T11:55:00.000-08:00

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

Cosmetic vaginal surgery is know by many names:

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

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

Vaginal tightening or vaginoplasty and labial reduction or labiaplasty.

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

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

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

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

Pelvic Organ Prolapse

2009-01-03T08:58:00.000-08:00

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

Please read it here:

http://www.sunlakesofarizona.com/blog/2009/01/female-urology-prolapse-and-voiding-dysfunction/#more-106

How Pelvic Organ Prolapse Affects Women's Sexuality

2008-12-16T21:24:00.000-08:00

I will be giving a talk on January 24, 2009 at Banner Desert Medical Center on this topic. It will review the types of pelvic floor disorders collectively termed "prolapse", and how these afftect female sexuality. It will review what prolapse is, how it occurs, in whom it occurs, how it affects women's intimacy and what can be done about it.

It is sponsored by the Spirit of Women's health series. The fee for whole morning, including two other talks, on boosting immunity and dietary supplements, is $5.

Follow the link here for more info and directions:

http://events.empowher.com/ev/164453

Call (602) 230-CARE to register, or call the Spirit office for more information at (480) 512-6205.

Urethral Diverticulum

2008-12-15T04:47:00.000-08:00

Urethral Prolapse

2008-12-12T10:50:00.000-08:00

It's not quite the same as pelvic prolapse. Pelvic prolapse is the abnormal descent of female pelvic organs into the vagina, or out the vaginal opening. This would include cystocele for the bladder, rectocele for the rectum, enterocele for the small intestine, vault prolapse for the vaginal apex after hysterctomy, or procidentia for uterine descent. It is an abnormal herniation of these organs due to intra-abdominal pressure pushing down on these organs as a result of poor pelvic floor support.

A urethral prolapse, also known as a urethral caruncle, is the mucosal lining of the urethra that protrudes and is visible at the urethral opening. It is not caused by pelvic floor weakness, rather, in women, it is caused by menopause and the low estrogen staus of the vagina and urethra. The prolpase will appear like a small red pimple on the urethral meatus (opening). It is usually of no significance, but its presence indicates hypo-estrogenization.

Uncommonly, it can bleed or cause blood spotting in the urine or cause pain if it gets large. If large, it can cause deflection of the urinary stream. If it doesn't bother the woman, then nothing has to be done. If the vagina is dry already, consideration can be given to applying local estrogen cream to help the prolapse retract and improve the vaginal health. If the urethral prolapse is spotting blood or painful, estrogen cream should be applied. Only when estrogen cream has not worked or if large and painful does the prolapse need to be removed in the operating room.

A urethral prolapse is NOT a polyp of the urethra. Most polyps of the urethra are benign and can be removed surgically. Tumors of the female urethra are rare entities, but present as polyps and are removed as well.

New blog article on Urinary Incontinence

2008-11-14T11:02:00.001-08:00

I am now the Urology Health contributor for the Sun Times Online Magazine, which is the online newsletter and blog for the greater Sun Lakes community in Phoenix.

Here is the link to my recent article:

http://www.sunlakesofarizona.com/blog/category/health-2/

Recurrent Urinary Tract Infections- PART II

2008-11-10T20:48:00.000-08:00

What can you do to stop infections? It depends on many things as noted in the previous post on UTI causes.

Often, constipation, diarrhea, IBS can lead to infections. High bacterial counts in constipated women, or constant soiling of the perineum by diarrhea can increase the risk for vaginal contamination by fecal flora. Constant wiping leads to broken skin and local skin infections can occur that lead to chapped and red vaginal skin/labila skin that resembles baby rash. The vagina will burn, become red and warm and very uncomfortable. Urine contact on this type of skin only makes the burning worse. Women will say "it hurts to pee", but what they really mean is the that stream doesn't burn (dysuria), but that the urine contract on the vaginal skin burns them. This can also be true for women who have urinary incontinence where the the constast wetness of the labia from leaking urine leads to baby rash.

Good hygiene seems obvious but maybe hard to control. Frequently sweating, from working out or hot climates can increase the local bacterial counts. Urinating before and after sex and bathing after sex is always a good idea if infections are noted to occur 1-2 days after sex. Use of sexual instruments or anal sex followed by vaginal sex seems an obvious culprit. Using lubrication during vaginal sex helps to prevent small cuts/brakes in the vaginal skin allowing bacteria to enter.

Tampons keep blood and bacteria in the vagina. Switching to pads sometimes does the trick.

Certain foods and medications can raise the pH of the urine or vagina. Acidification of the vagina or urine can be done by avoiding over-douching, or taking urinary acidifiers that can be found OTC.

Vaginal estrogen is a common medication in post-menopausal women, not only to help rejuvinate the vaginal tissue for sex and lubrication, but also preventing UTIs.

These are just some of the tricks that can be tried. There are many other reasons recurrent infections can occur.

Updated Website

2008-10-21T07:02:00.000-07:00

Our practice recently completed updating our website: www.urodoc.net

It contains a host of information on a variety of different urological conditions, both male and female. In addition, my article from MD News magazine can be found under my profile.

Physician Blogging and Patient Privacy

2008-09-29T10:19:00.000-07:00

This is an excellent topic, timely and important. Physician blogging is an excellent and free way for medical information to flow from physicians to the public and/or current/future patients. However, patient privacy is paramount, and as the disclaimer atop this site indicates, this site is for medical information only. It is not for diagnosis or specific medical advice. Comments can be placed and are welcomed and I am always eager to respond, yet any personal issue can be taken care of, or discussed during a private appointment.

Please read this article on physician blogging and privacy:
http://www.aishealth.com/Bnow/hbd092208.html

Our new updated website is nearing finalization and will have some more information on it.

Nevertheless, my office is located at:

Center for Urological Services, P.C.
4545 E. Chandler Blvd, Suite 300
Phoenix (ahwatukee), AZ 85048
480-961-2323
480-961-2325 fax
www.urodoc.net

MD News Magazine

2008-09-03T19:59:00.000-07:00

I was recently interviewed by MD News magazine which profiled me and my practice. Here is the cover shot.

The text of article will be uploaded soon.

The title of the article is "The Woman's Urologist- Finding a Niche between Urology and Gynecology"

Video at AZExpoCenters.com

2008-08-17T21:34:00.000-07:00

See a video of me describing my practice at:

http://www.azexpocenters.com/azexpocenters/health/Karlovsky/index.html

Article On Urinary Incontinence

2008-08-17T21:28:00.000-07:00

I recently had another article published by AZCentral.com/The Arizona Republic in their "Ask The Expert" column. This time it was on Urinary Incontinence.

Read it here:
http://www.azcentral.com/community/gilbert/citizen/articles/2008/08/07/20080807mr-askexpert0808two.html

Why Do I Keep Getting Infections?

2008-08-07T14:22:00.000-07:00

Female urinary tract infections (UTIs) can occur for a variety of reasons. Firstly, it must be determined if the symptoms the woman is experiencing is truly a UTI ir is it something else mimicking a UTI.

Symptoms of UTIs commonly include:

dysuria (burning w/ urination)
pressure suprapubically or bladder ache
urgency
frequency
urge incontinence
bad urine odor or color
blood in the urine
body aches/chills
back pain
low grade temperature

Some of the frequent "fake outs" mimicking UTIs are:

Overactive bladder
Interstitial Cystitis
Bladder or Kidney stone
Resolved UTI with persistent symptoms
Pelvic Inflammatory Disease
Endometriosis
Enlarged uterus with fibroids pushing on the bladder
Bladder polyp
STD's (urethritis)
Urethral Diverticulum

Sometimes, when women complain of recurrent UTIs, it may be that the originial UTI was undertreated with antibiotics (not long enough), or the antibiotic was not strong enough, or perhaps there are other underlying issues predisposing to UTIs (neurogenic bladder, incomplete bladder emptying, pelvic floor dysfunction, kidney stones, kidney or bladder anomalies).

What are common reasons women develop UTIs?

First sexual intercourse
Sexual intercourse in general
Decreased hormone status (post-menopausal, post-hysterectomy)
Constipation
Diarrhea
Incomplete Bladder Emptying
High urine pH
Tampons

Up Next: What do you do about it.

WOMEN'S HEALTH FORUM- AUGUST 16, 2008

2008-07-29T12:02:00.000-07:00

I am participating in and helping to organize a very large and comprehensive Women's Health Event that will take place at Banner Desert Medical Center. There will be a panel of speakers on all topics related to women's health: Me (the urologist), several gynecologists, and a general surgeon. Some of the topics will be:

Breast health
Endometriosis
Fibroids
Ovarian cysts
Heavy bleeding
Pelvic pain
Urinary Incontinence
Pelvic Organ Prolapse

Cost: $5. It is free for Spirit of Women members. It will take place from 9am to 12pm. Refreshements will be served and it is sponsored by many industry supporters. It is a phyisican-organized (not industry) event.

Banner Desert Medical Center is located in Mesa at Southern Ave and Dobson Rd. Take the Southern Ave exit from the 101 highway and go east 1 mile.

Call ahead for seating reservations: 602-230-2273

See you there!

"You're Injecting It Where???"

2008-07-12T14:34:00.000-07:00

What happens if a woman has Stress Incontinence and cannot have a sling done? Perhaps there is a history of radiation, multiple failed prior operations, or of the bladder contraction is too weak as noted on urodynamics, then there is another choice.

By the time they come to see me, most female patients want something done about their stress incontinence, since it's bothersome enough to be inhibiting life or lifestyle. Slings are quite minimally invasive with a high success rate and short recivery time, but if they are not indicated. . .

Placing an injection of a bulking material into the urethra is another valid treatment for stres incontinence. Think of it like bulking up someone's facial lips with collagen: they become fuller. So too, the urethra. The product that has been around the longest is Collagen, but it suffers the same fate in the urethra as the lips: the body reabsorbs it rather quickly, usually within 3-6 months, where less than 20% of patients still notice any improvement by 12 months.

Because it is painful, injections are performed under anesthesia. No incisions are made. A cystoscope is placed into the urethra and thorugh a long but ver small needle, the material is injected under the urthral lining.

This is the before image of a female urethra looking through a scope.

This the after image once the collagen is injected under the urethral lining causing it bulk up and occlude the opening.

Other various materials have been designed inorder to improve on the durability of collagen. The ideal agent is biocompatible, cost effective, is not rejected by the body or migrates within the body, is minimally invasive and of course effective.

Durasphere is gel carrier with carbon beads that is injected. Overall effectiveness is not much better. Once injected, the gel is reabsorbed so that bulking volume is lost, and the carbon beads can, though rarely, migrate.

Another agent, Coaptite, is a gel based material, composed of microscopic spherical particles made of calcium hydroxylapatite. It has the consistency of toothpaste and is injected the same way.

At twelve months, about 80% of women are either still dry or "much improved", and fails in about 10%.

The procedure usually takes about 15-20 minutes and its out-patient. Usually between only 2-4 cc of material is needed to acheive an effect. The effect is noted right away.

Most women will experience a little blood in the urine for about 24hrs. Buring with urination is also common for 24hrs. Infection and urinary retention are possible but uncommon.

I have used all three agents and have found the best success with Coaptite. Even in patients with NO bladder contraction on urodynamics, I have had NO patients with prolonged urinary retention (>1week), who have had to self-catheterize themselves after urinating to ensure adequate bladder emptying. I have patients who are more than 2 years out from injection with durable results.

It is not superior to sling in treating Stress Incontinence but it is a nice alternative. One other interesting thing about it is that the procedure can be repeated if incontinence recurs.

New Video of Dr. Karlovsky describing InterStim therapy

2008-06-07T08:14:00.000-07:00

Recently, Banner Health posted a video of me describing InterStim for the treatment of Overactive Bladder.

http://www.bannerhealth.com/Services/Health+And+Wellness/Ask+the+Expert/Womens+Health/_Female+Urinary+Incontinence+Video.htm

InterStim is appropriate and indicated for those patients that have failed medications for OAB or cannot tolerate them, in addition to urinary retention not due to obstruction (such as after hysterectomy that leads to a weakened bladder).

Test stimulation is done in hte office and takes about 30 minutes.
Assessment of the device takes 1 week. If patients noted a >50% improvement in urinary frequency, urgency or urge incontinence, then the patient can qualify for permanent implantation.

The permanent implant device is a small, round, smooth battery that resembles a pacemaker, about the size of a half dollar. It is placed under sedation and local anesthesia as an outpatient procedure, and takes less than an hour. It is placed under the skin in the right upper buttock.

Cystocele Images

2008-05-05T09:10:00.000-07:00

This is good image of a cystocele seen from the side.

Below is an image of a cystocele seen from the front. It appears to be a grade II.

Cystoceles are graded on a scale of I-IV.

Grade I: Mild bulge with straining only

Grade II: Bulge noticable at rest but not protruding out

Grade III: Bulge is at the vaginal opening

Grade IV: Bulge protruding past the opening.

"Is My Bladder Dropping?"

2008-05-05T08:42:00.000-07:00

This is a common question that is asked by many women if they have any urinary incontinence problems.

Urinary incontinence can occur simply on its own as Stress Incontinence (urine lost with excerise or any other activity), or Urge Incontinence (urine lost with uncontrollable urge, Overactive Bladder). Your bladder may be in the normal anatomic position and you may still experience incontinence. This is a totally separate issue, "the leaky faucet" problem, that itself can be treated: see blogs posted below.

"Cystocele" is the term used when the bladder drops from its normal anatomic position. It can occur with incontinence, or on its own. Essentially, the support structures under and next to the bladder become weakened and allow the bladder to push down into the vagina. This leads to a bulge a woman can feel or even see. Many women say they feel they're "sitting on ball", or see something protruding from the vagina. This is more pronounced at the end of the day. If it's uncomfortable, some women will try to push it back in.

Higher grade cystoceles that cause pain, discomfort, or bulge outward and protrude past the vaginal opening should be surgically corrected. Often, many cystoceles are mild and only occur with straining and may not warrant any treatment at all.

Sometimes cystoceles can mask stress incontinence if the urine becomes trapped in the vagina by a kinked urethra, or even have trouble evacuating the bladder leading to a constant sense of urgency and incomplete emptying. Infrequently, this can lead to UTIs.

The most often sited reasons for cystocele formation are: menopause, childbirth, chronic cough conditions (asthma, smoking), and genetic. Sometimes cystoceles occur by themsleves or inconjunction with other organs that protrude from the female pelvis: rectocele (rectum protruding), vaginal vault prolapse, procidentia (uterine prolpase).

Next topic: How do we treat cystoceles?

Post operative Retention & Urodynamics

2008-04-19T16:08:00.000-07:00

One of the less common complications after sling surgery is "post-op retention", essentially, not being able to urinate right away, or rarely, for a awhile.

Hence the use of urodynamics pre-operatively. Urodynamics is like a "stress-test" for the bladder. Instead of getting on a treadmill and running to check your heart, during urodynamics, the patient sits on a commode and the voiding cycle is tested. It usually takes about 20 minutes.

A pediatric catheter is placed into the bladder and another one the same size is placed in the rectum (yes!, but not very far). Also, some patch electrodes are placed on the groin. The bladder catheter serves to fill the bladder and detect bladder pressure during urination, and the rectal catheter assists with the calculation. The patch electrodes help discern if during urination there is adequate sphincter opening or not.

During the test, the patient is asked to cough or strain to provoke a leak to test the "leak pressure".

During bladder filling, the capactiy and compliance of the bladder are gauged.

All in all, its an excellent road map for the urologist trying to determine pre-op parameters in order to help predict outcomes after surgery, or even if surgery should not be done in the first place.

I find it to very useful, and reliable since we have seasoned techs (female) who perform the tests daily.

Getting back to post-op retention. . . As long as the patient has an adequate bladder contraction and voids reflexively (the "normal way") without straining to get the urine out, then post-op retention is unlikely. Factors that can contribute to it include:

Poor bladder functionality/contraction
Strain pattern void
Anesthesia
Post op pain
Other simultaneous procedures performed: cystocele repair, vault prolapse repair, hysterectomy
Overtightening the sling
Age > 70 (in my practice)- this doesn't mean these women can't void- but they may need a urinary catheter for a few days to a week or perform self-cath for about he same time until the bladder "wakes up"

Long-term urinary retention after a sling is very uncommon these days. Current mid-urethral slings are placed "tension free"- (hence the acronym TVT= tension free tape) have very low long term retention rates. It also greatly depends on who's doing the sling surgery- to make it "just right"- not too tight or not too loose. Since modern day slings are not stitched or anchored to fascia or bone, retention is uncommon.

Older slings, such as "bone-anchored slings" or pubo-fascial slings" are fixed to structures and require some degree of guesswork/finesse/luck/experience to place it just right.

In terms of TVT-type slings of the modern age, if the sling is SLIGHTLY to snug, women will notice a weakened stream, intermittent stream, incomplete emptying or urgency/frequency. New onset urgency after sling is less than 10%, and the majority do resolve within 3 months. Even a weak stream does improve after 2-12 weeks as the bladder accomodates to the sling.

What if it still too tight?
If after 3 months there are still problems, this can be confirmed by repeat urodynamics, and if the bladder is "obstructed", then the sling should be cut.

Does this compromise the effect of the sling and lead to recurrent incontinence? It can happen in 20-50% of women. The sling should be cut at the 6 o'clock position and allow lateral release of the sling. There should still enough scar laterally on both sides to keep the urethra supported.

It pays to go someone who does MANY.

Coming next. . . .Cystocele (Bladder Drop)

How Long is Recovery after a Sling?

2008-04-06T06:16:00.000-07:00

Sling procedures for Stress Urinary Incontinence usualy take about 20-30 minutes and are performed as an outpatient.

I councel patients to "take it easy" for 72 hours after the procedure. Most women can go back to work thereafter (as long as work is not very physically demanding usually)

I advise patients to not do any heavy exercise for 2-3 weeks (biking, aerobics, spinning, hiking) but walking is acceptable.

No sex, baths or pools for 6 weeks!

If any other vaginal prolaspe problem exists, these can be repaired at the same time. And most are outpatient as well.

A web review of an article I've published

2008-04-06T05:58:00.000-07:00

Here is a web review of an article I've published on mesh use in pelvic floor repair by a comprehensive urology website:

http://www.urotoday.com/index.php?option=com_content&task=view&id=2340&Itemid=48

It has also been sited as a reference in other publications also reviewing pelvic floor repair and mesh.

http://www.indianjurol.com/article.asp?issn=0970-1591;year=2007;volume=23;issue=2;spage=153;epage=160;aulast=Nazemi

http://www.co-urology.com/pt/re/courology/abstract.00042307-200607000-00007.htm;jsessionid=H4MLZBbnYzXvLqsXh711Sc1vTT3gGbnbfxkpbhJG00GWLGYGlRmd!132671813!181195628!8091!-1

Talk on Stress Urinary Incontinence

2008-03-28T12:53:00.000-07:00

I will be giving an informal 1 hour talk on female stress urinary incontinence on April 9th at 7pm. It is part of the Chandler Regional Hosiptal "Boomerang" series on various health topics. It is open to public.

It will take place at the Morrison Building on the campus of Chandler Regional Hospital, located at the corners of S. Dobson Rd and Frye Rd in Chandler.

HEALTH EXPO

2008-03-11T12:46:00.000-07:00

My practice is featured this month at the electronic Health Expo hosted by KKNT 960AM.

The site is http://www.azexpocenters.com/

Click on my link to watch a short video of me describing my practice and specialty.

In addition, I will also soon be featured at the Banner Health website in their Ask The Expert video speaking about Interstim and bladder neuromodulation. Update to follow.

What is Female Urology?

2008-03-11T11:50:00.000-07:00

This is a good question. For a long time prior to the entrance of women physicians into the field of Urology, a "Female Urologist" was a urologist who dealt with female urological problems, such as urinary incontinence, bladder prolapse, recurrent urianry tract infections, bladder pain, and voiding dysfunction. In some regard, the subspecialty of Female Urology is akin to Urogynecology. Similarities exist and there are some differences.

Urologists graduate from a usualy a 5 or 6 year surgical traininf program after medical school. Usually it is 1 or 2 years of general surgery training and then 4 years of Urology. In addition, after completion of residency, 1 or 2 years of fellowship training is undertaken in the subspeciaty of Female Urology. These programs focus mainly on incontinence, treating complications, complex urodynamic evaluation, prolapse repair with an emphasis on research and publication.

Gynecologists graduate from a 4 year training program. Those that wish to subspecialize under take a urogynecology fellowship that is typically 3 years. They also focus on incontinence, complications, and prolapse.

Fellowships differ widely depending on the interest and focus of the program director, whether urology or gynecology. Certain programs incorporate some technologies or techniques that others don't. Most of us attend the same academic meetings to keep up on the lastest advances and research.

In my practice I incorporate the use of mesh or grafts in order to bolster pelvic prolapse repair such as cystocele, vault repair or rectocele. Often when not used, cystocele will fail approximately 30% by 3 years. Conversely, despite the success of mesh, it can lead to nonhealing in 6-20% depending on the mesh, the surgery and the surgeon. Some pelvic surgeons will use such grafts but many don't. Surgeon comfort level is also important, that is, can the surgeon use such a product well.

Urologists have the advantage of dealing with the bladder from early in training. Treating bladder injury, dysfunction, removal or replacement are standard things learned in training. Gynecologists operate on the vagina and perform hysterectomies. Our two subspecialties crossover somewhere in the middle. In my fellowship I operated with a urogynecologist at least once a week.

Recurrent urinary tract infections, hematuria (blood in the urine), complex voiding dysfunction (as a result of radiation, surgery, or neurological injury), and non-obstructive urinary retention are best dealt with by a urologist who can repair/reconstruct the bladder, urethra, ureters, and remove such organs if required. All things considered, incontinence and prolapse treatment is often the most fun part of Female Urology, and is very often successful if done well by the well-trained pelvic surgeon.

Interstim III

2008-02-08T20:18:00.000-08:00

Interstim neuromodulation is a very viable option for refractory overactive bladder symptoms: urgency, frequency and urge incontinence, as well as urinary retention that is not from obstruction.

It just got easier!

Interstim can be placed as a test lead in the office, while awake of course (and with some local anesthesia) as temporary leads. Usualy two are placed, one into each S3 foramen. The lead are superthin and are taped to the skin for easy removal once the test week is over. The leads are connected to the pulse generator box the same way.

This method averts the Stage I procedure which is done in the operating room. If testing is succcessful with the office-placed leads, the patient can skip to Stage II, that is, implantation of the permanent lead and battery generator in the operating room.

It's been around 10 years. About 2/3-3/4 of patients will respond, and can have dramatic improvement in their quality of life because the bathroom is not the main thing they worry about.

More to come. . . Chronic constipation treated with InterStim???