Approximately ten million American adults, the majority of whom are women, have problems controlling their bladders. Over ten billion dollars a year are spent on medical care and absorbant products to manage these problems. Those facts should go a long way toward pointing out that if you have a problem with the loss of urine, you are very far from alone. We hope that knowing that you are not alone will encourage you to seek help. New techniques in the fields of urology and gynecology are enabling us to help more and more women with bladder problems. Sadly, despite the enormous number of women suffering from bladder problems and despite a variety of new treatments available, many women are still reluctant to seek treatment and relief.
SUSAN'S DIFFICULT DECISION
Susan came into my office seeking a third opinion. She is a 46-year-old attorney, employed full time and spends a good part of her day lugging heavy legal briefs all over town. She is also busy with her two children, playing competitive tennis, and exercising three times a week. She was suffering from stress incontinence and was not satisfied with the results of the non-surgical interventions she had tried. She was advised by one doctor to have a needle suspension because that's what he did on all his patients, and they all did well. Another doctor recommended an anterior repair because he'd been doing them for thirty years, and he liked the procedure.
Since Susan is young, healthy, and active, long term results were important to her, and she was willing to tolerate the longer recovery time and increased discomfort following an abdominal operation. She decided to have an laparoscopic bladder suspension, where the bladder neck would be stitched to the firm ligaments under the pubic bone. Susan was admitted to the hospital and had surgery the same day. She did so well that she was able to go home the following morning. Susan was driving in one week and back to work in two weeks. She has continued to do well during the several years since her surgery - a long dry stretch you might say!
The bladder has two jobs; storing and emptying urine. It functions in two phases. First, we expect the bladder to store our urine as it is produced by our kidneys. The bladder must give us quiet messages as it fills, and then it must loudly inform us that it is almost full, while still giving us plenty of time to find a bathroom. All this is accomplished while the bladder expands and collects urine painlessly. We then sit on a toilet and tell our pelvic muscles to relax, while our bladder muscle contracts and pushes the urine out the urethra and into the toilet...MISSION ACCOMPLISHED. When all works well, it becomes second nature to us. This is a complicated system that, for most of us, functions everyday with little conscious effort or consideration.
Incontinence is the inability to control when and where your bladder empties. We all learned to control our bladders as young children, and it then became second nature to us as adults. We come to depend on this control for confidence in social situations. We are not prepared to have to reconsider our bladder control again later in our lives. The good news is that with understanding and treatment you can once again make normal bladder function second nature.
Prolapse is the dropping of the uterus or the bulging of the bladder or rectum into the vagina. These changes may or may not be accompanied by incontinence. The problems and treatment of prolapse are described later.
Many people erroneously believe that loss of urine, called incontinence, is a normal part of aging. It is not. Although it is more common in women over age sixty, the majority of women, regardless of their age, are not incontinent. And, regardless of your age, we are able to evaluate and treat most of the causes of incontinence. You are never too old or too young to seek care for this troubling problem.
In order to find out how well the bladder is functioning, we must see if the muscle that makes up the wall of the bladder is doing what it is supposed to do. The test for this is known as urodynamics, or UDS for short. And, despite the name, this has nothing to do with jet planes or aerodynamics. UDS is done in the office and is painless. The muscular sac we call the bladder is supposed to relax and comfortably stretch out while it collects and stores urine made by the kidneys. Then, when you are ready to urinate, it is supposed to contract and force the stored urine out into the toilet. The urodynamic study allows us to measure the pressures in the bladder with a small tube painlessly placed in the bladder. In order to calculate the appropriate pressures, we must also know the pressure in your abdomen as measured by another catheter painlessly placed in either the vagina or the rectum. In addition, a specialized tampon is inserted into the vagina that can measure the strength of the pelvic muscles.
Although you may feel "wired for sound" during this exam, this test does not hurt at all, and we can get a wealth of information that can lead to a specific diagnosis for the cause of incontinence. Once we know the underlying cause, we can choose the best remedy.
The good news is that there are many options for the treatment of incontinence that include exercising, using a pessary, taking medication, and surgery. These are discussed fully in our book.
Yes. One of the goals of surgery for the treatment of incontinence is the restoration of the normal position of the bladder and urethra. There are many techniques available that can accomplish this. Most women who have given birth vaginally have some degree of prolapse. This begins unnoticed and asymptomatically in most women and remains that way for the majority. There are no health risks to this condition, so surgery is only necessary when you have discomfort or incontinence that can not be corrected by the simple techniques described earlier.
A bladder suspension technique may now be performed through the laparoscope. This is an appealing idea as it gets around the necessity of an abdominal incision and allows most patients to go home the day of surgery. It also results in a decrease in the pain and time needed for recovery. However, this operation is new and is still being evaluated from the point of view of long-term success rates. Studies are now being performed to compare the effectiveness over time of this new approach with the more traditional operations. It must also be noted that the laparoscopic procedure is technically difficult and requires specialized skills. I suggest that you discuss your doctor's personal preference regarding these operations and his or her experience in performing these surgeries.
This is a decision that takes into account many factors and is made in collaboration with your surgeon. Age and general physical condition are considered. Is surgery planned for prolapse and incontinence? What type of incontinence do you have? What is the severity of the incontinence? What level of activity is anticipated in your lifestyle?
If incontinence is a major problem, an abdominal bladder suspension is best. If prolapse is the primary problem, a repair of the weakenend tissues will need to be performed through the vagina, and a needle suspension of the bladder through the vagina may be the most appropriate operation. If the sphincter is scarred open, collagen injections may be the best answer. A careful history and physical examination, proper testing and an understanding of your problems and wishes are all important parts of this decision.
Experience counts. Ask questions. Make sure you are evaluated fully and properly. Inquire as to whether your doctor does urodynamics or works with someone who does. Make sure your treatment is tailored to your particular needs and that your doctor has a large repertoire of treatments and is choosing what is best for you. If surgery is necessary, make sure she or he performs these procedures successfully several times per month. Either a gynecologist, a urogynecologist, or both a gynecologist and urologist working together may be appropriate if they have the right experience. A urogynecologist is a doctor who completes the full training in gynecology and then gets further training in the evaluation and treatment of incontinence and pelvic prolapse. This is a developing field, and you want your care to be the best that is available.
There are many types and causes of incontinence and pelvic prolapse. Fortunately, there are also many solutions. Incontinence is not a normal part of aging, nor is it inevitable after childbirth. It is a medical condition with many possible treatments and cures. So throw away those diapers and pads and take an active part in your evaluation and treatment. Solving this problem will improve your life and get you out and and active again. Don't be afraid or embarrassed. It can only get better.
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Disclaimer: The ideas, procedures and suggestions contained on this web site are not intended as a substitute for consulting with your physician. All matters regarding your health require medical supervision.