Online Health Chat with Dr. Raymond Rackley
January 20, 2011
Cleveland_Clinic_Host: Millions of women experience involuntary loss of urine, called urinary incontinence. Some women may lose a few drops of urine while running or coughing. Others may feel a strong urge to urinate just before losing a large amount of urine. Many women experience both symptoms. Incontinence can be slightly bothersome or totally debilitating. It keeps some women from enjoying many activities with their families and friends. Urine loss can also occur during sexual activity, causing tremendous emotional distress.
Pelvic organ prolapse is a very common condition, affecting roughly half of women who have had children by vaginal delivery. It occurs when one or more of the organs in the pelvis (bladder, uterus, rectum, or small or large bowel) drops down due to a weakened or stretched pelvic floor muscle and/or loss of vaginal support. This downward descent may result in protrusion of the vagina, uterus, or both.
Cleveland Clinic’s Glickman Urological Center for Female Pelvic Medicine and Reconstructive Surgery is a state-of-the-art, specialized center offering a multidisciplinary team approach for women with urological conditions. The center provides individualized treatment with the latest procedures targeted at comprehensive evaluation and management of disorders, such as urinary incontinence and pelvic organ prolapse.
Dr. Raymond Rackley joined the Cleveland Clinic staff in 1995 and is a member of the Glickman Urological & Kidney Institute. His specialty interests include cystocele, female genitourinary reconstruction, female pelvic organ prolapse, female urinary incontinence, fistula, diverticula, rectocele, and male urinary incontinence. Dr. Rackley is Professor of Surgery at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University and Staff in the Center for Pelvic Health and Reconstructive Surgery within the Glickman Urological & Kidney Institute.
If you would like to make an appointment with Dr. Rackley or any of our other urologists in the Glickman Urological & Kidney Institute, please call 800.223.2273 or request an appointment online by visiting www.clevelandclinic.org/appointments.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Raymond Rackley, M.D. We are thrilled to have him here today for this chat. Let’s begin with the questions.
Taz87_: What is a pessary?
Dr__Raymond_Rackley: A pessary is similar to a synthetic tampon - placed in the vagina - that blocks the dropping or bulging of the pelvic organs through the opening of the vagina.
Taz87_: Does a pessary stay in place 24/7 and who places it?
Dr__Raymond_Rackley: A pessary is used 24/7, but may be self-removed if the vagina is needed for other uses. Pessaries are typically managed by gynecologists or nurse practitioners/physician assistants.
Tax87_: I have been told that use of a pessary will not prevent the progression of the pelvic floor disorder. Subsequently, surgery will be necessary at some time in the future. Is this accurate?
Dr__Raymond_Rackley: This depends on your level of activity and concern for certain quality of life issues. Let me qualify. Some women will experience excellent, life-long results with a pessary. Some women will find it bothersome and feel it interferes too much with physical activity or sexual intercourse.
Generally, most active women who have tried a pessary will typically desire not to use it as permanent therapy. However, there are some women with significant medical illnesses that cannot undergo even a simple outpatient procedure to eliminate the need for a pessary.
almond: I've been told that I should wait until I am at least 70 before considering surgery to correct my issues, because the surgery won't last all that long - 10 years if I am lucky. Are there any better treatments coming along?
Dr__Raymond_Rackley: If you are referring to a surgical treatment for incontinence or prolapse, this information is incorrect. In fact, waiting to correct older tissues may be more difficult. It is however, an electively timed procedure, typically chosen to improve the quality of life that can be performed on any age group.
HBS926: I've heard horror stories about women having problems with the synthetic mesh used in many sling procedures. How common are mesh problems?
Dr__Raymond_Rackley: The synthetic mesh use in slings is now considered the gold standard. Complications rates are less than 3 percent. The secret to success is to find a surgeon who has done a high volume of procedures and who can manage complications when they do occur.
Tranquil: Complications like what?
Dr__Raymond_Rackley: All pelvic surgeries have a limited list of complications: failure, bleeding, and infection in the short- and long-term. These typically occur in less than1 percent to 3 percent of women. In regard to the sling surgery, it is like the story of the 3 bears: If the sling is placed too loose, it fails to treat the symptoms; if it is just right, everybody is happy; if it is too tight, you are miserable. If it is too tight, which can occur in 3 percent to 10 percent of ALL women who undergo this form of surgery, it may resolve spontaneously over 1 to 3 months, or it may need to be adjusted or revised with a second outpatient surgery.
HBS926: Is the Monarc sling an outpatient procedure? How long is the recovery time?
Dr__Raymond_Rackley: All sling procedures are typically outpatient. At Cleveland Clinic, the patient will go home the same day without a catheter, and can perform daily activities, such as climbing stairs. They can drive a car the next day, as long as they are not taking narcotic pain medications. For the first two weeks, lifting is restricted to objects weighing no more than a gallon of milk. Exercise is restricted for four weeks. Generally, patients are allowed to resume normal duties after four weeks post-op.
HBS926: If a patient opts to have a sling procedure and has minimal uterine prolapse, is a hysterectomy really necessary?
Dr__Raymond_Rackley: Hysterectomy is never truly indicated outside of a cancer operation.
peanut: Is surgical mesh used to construct the sling to correct a low bladder?
Dr__Raymond_Rackley: Your surgeon may opt for this type of adjuvant repair, but it is typically not used in patients undergoing their first time repair which typically is successful in over 80-90% of cases.
This question is worthy of a discussion with your surgeon. Patients should ask their doctors if they plan to use the mesh, and if they are comfortable with handling the 2 percent to 8 percent chance of providing you an additional outpatient or overnight post-operative stay after revision surgery to correct this minor issue. It is not a big deal, as long as you know what to expect.
doodle: I have uterine prolapse and have experienced severe depression since the birth of my last child in 1977, so I have not had surgery because I am afraid of my depression returning. Is there anything new on the horizon, or is robotic surgery my best option? Also are any surgeries done without being put to sleep, such as surgery using a saddle block instead?
Dr__Raymond_Rackley: Surgery is not known to activate depression across many surgical fields of specialty.
In regard to the use of robotic surgery, there is a saying that ‘a fool with a tool is still a fool.’ It really does not matter what surgical approach is used to have success. The robot does not perform the surgery.
In regard to your specific question about anesthesia, a spinal block would necessitate a vaginal approach to your prolapse repair. Open or abdominal surgery, with or without the robot or other ‘tools of fools,’ would require a general anesthetic. Just as a disclaimer - I do perform laparoscopic repairs when indicated.
ernap: My OB/GYN noted at my last examination that I would eventually need surgery for a bladder prolapse. I am not incontinent, but suffer from frequent urination and sometimes feel that the bladder is protruding. What does surgery involve in terms of difficulty and time of recovery? I am 75 years old.
Dr__Raymond_Rackley: I suspect that even if you live to 126 years of age - the oldest known recorded life span of a human - you may in fact never need surgery for your prolapse. The reason being is that you do not appear to be significantly bothered, and you do not have to manually replace the bladder up inside of the vagina. Many women have some degree of prolapse; however, the majority of these women never actually need to undergo surgical repair. Some prolapse is known to improve in some women, especially obese women with dramatic weight loss. My advice is to keep moving.
Anxious: I have been on many medicines for incontinence and have been catheterized for retainment. Are there any new medicines that are proving to work better?
Dr__Raymond_Rackley: Anxious - you have a very complex situation. Basically you have a failure to store and a failure to empty your bladder. There are medications, devices, and surgery to help you store. There are also devices such as catheters and stimulation devices (InterStim®) that may be useful to help you empty.
You need to see an experienced physician to help you select the proper balance of all of these choices. This would be impossible to work through in this type of internet chat forum. However, there are easy and great solutions to your complex situation. Be flexible and patient.
Anxious: I can't remember the name of the device that is inserted into the body to help control urine flow, but I understand it interferes with MRI, CT scan, etc. Is there a way to still use one of these devices if those tests are frequent for me?
Dr__Raymond_Rackley: The InterStim® is the device you are referring to. It is legally but not clinically a problem with MRI utilization. Most if not all radiologists require the removal of the device in total when an MRI is indicated. Thankfully, there are other forms of imaging - such as CT scans - that can be used in place of an MRI. This topic deserves full disclosure to you by the implanting InterStim® surgeon.
CG12010: I have a pelvic organ prolapse. Because of a kinked urethra I make it a point to empty my bladder. Can this condition be corrected without a hysterectomy? Is there a device that can align the organs without risk of infection or frequent follow-up examinations for efficacy? I have had this condition for more than 10 years. However, it has worsened in the last two years to the point that any strenuous activity causes urination problems and/or sensation of organ protrusion.
Dr__Raymond_Rackley: A kinked urethra can occur when the bladder drops due to pelvic organ prolapse. This happens because the urethra tends to be "fixed" or attached to the bone, but the bladder has lost its support and falls. Imagine it as similar to a water balloon being held over the table, but allowed to hang below the edge by supporting the balloon outlet. Thus, it would be very hard to urinate uphill.
The solution is to address the pelvic organ prolapse that does not require a hysterectomy. The prolapse can be addressed with a simple vaginal procedure or temporary/permanent use of a pessary.
peanut: I have a stage 3 cystocele and am waiting for my surgery date to arrive. This prolapse is causing my pelvic floor to become numb when just walking a short distance, like around the grocery store. It then becomes so sore that I cannot sit comfortably for a day or two. I find that all I can do is stand or sit for short periods or lie in bed all day. Why is this happening and is there anything I can do to get relief until the surgery?
Dr__Raymond_Rackley: Peanut, find some type of substitute such as petroleum jelly - and apply it to the prolapsed tissues that may be "hanging out." While lying down, manually push the prolapse back up inside. Then, with the prolapse inside, put on a tight pair of shorts or spandex. This will keep things comfortable for you to walk and be active until your surgical repair.
Be generous with the lubrication around the vaginal area and thighs. Always remember, you will never hurt yourself pushing things back up inside, but this will be hard to do with dry vaginal tissue. You will be greatly relieved after your surgery.
Anxious: Is Botox still used? Can doctors in my small area use it?
Dr__Raymond_Rackley: Botox injections are clinically indicated for people with overactive bladder (OAB) that fail to respond to more traditional therapies. It is still an off-label indication for use in the bladder, but there is a large amount of supporting clinical data that merits its individual use on a physician-to-patient decision.
Listening: How effective are Kegels and other pelvic floor strengthening exercises?
Dr__Raymond_Rackley: Kegel exercises works great in acquiring a skill to contract your pelvic floor muscles when you develop the symptom of urgency related to overactive bladder (OAB). Unfortunately, many people believe that these exercises will 'cure' their OAB or leakage from stress incontinence (leakage with physical "shake and bake" movement.)
pdipanfilo: How are stress incontinence and overactive bladder different?
Dr__Raymond_Rackley: Stress incontinence is an involuntary loss of urine that happens when you are doing something physical, such as coughing, sneezing, laughing, exercising – even having sex. It occurs when the muscles that support the bladder and urethra – the pelvic floor muscles – have weakened. As a result, the circular muscle around the urethra cannot hold as tightly, so some urine leaks under the added pressure of coughing, sneezing, etc.
Overactive bladder (OAB) - sometimes called urge incontinence - is a sudden, strong feeling of having to urinate. With OAB, the muscles that surround the bladder contract spastically, which results in continuously high pressure within the bladder. This makes you feel like you always have a full bladder and need to urinate.
Listening: How effective is the Premarin cream?
Dr__Raymond_Rackley: Premarin Vaginal Cream® or Estrace Vaginal Cream® (topical estrogen-based vaginal cream or other similar vaginal based products) is indicated for the prevention of urinary tract infections in post-menopausal women and indicated for sexual dysfunction as well. If these two issues concern you, please speak to your urologist or gynecologist.
LJE: What types of diagnostic tests are needed to determine if someone has a 'dropped bladder' or other organ? Can it be done without an MRI? Thank you.
Dr__Raymond_Rackley: The old-fashioned physical exam is still the gold standard for determining pelvic organ prolapse or a dropped bladder. All radiological procedures are NOT indicated for primary and even secondary evaluations. There is some use of MRI as a research tool at academic centers but is not used in part of the surgical evaluation needed for considering management options.
leaprevail_1: At what point does the problem go from being a nuisance to a serious medical condition?
Dr__Raymond_Rackley: I assume you are referring to pelvic organ prolapse - so the absolute indications for repair include: the complete inability to empty the bladder or bowels resulting in urological and GI issues.
Taz87_: Does elective procedure mean that insurance will not cover it?
Dr__Raymond_Rackley: Elective refers to the timing or immediacy of when to perform the intervention. This term is not used to define a life-threatening condition and is in no way related to medical health insurance coverage.
Africawatcher: There seem to be differences of opinion whether hysterectomies are likely to exacerbate prolapse. I had one during a cancer staging and have experienced increased symptoms of prolapse. What is your view on the evidence?
Dr__Raymond_Rackley: Yes. Hysterectomies, especially done for oncology reasons, may compromise the support of the pelvic organs, not always though. One should be evaluated by a specialist who understands pelvic organ prolapse, and this is typically not a gynecological surgical oncologist.
Insider: I have "stress urinary incontinence, urinary frequency, pelvic organ prolapse Stage II, atrophic vaginitis, pelvic muscle wasting". "pessary, PT, possible TVH, USVVS, AR, sling in future" has been recommended. A possible hysterectomy was also recommended. Are all of these procedures really necessary?
Dr__Raymond_Rackley: Sounds like you met a walking encyclopedia as a surgeon. Why not just keep it simple and start out with some topical estrogen vaginal cream for six months and see how you do? At a minimum this would prepare any and all of your vaginal tissues for the surgeries you were recommended.
Most surgeons would pass on the opportunity to operate on Stage II prolapse and wait until it was more Stage II-III or Stage III. Most surgeons will not recommend a concomitant hysterectomy for any of the symptoms or findings that you have listed. It is difficult as a surgeon to take a good situation and to make it perfect enough that the patient actually is satisfied with the outcome over the risk of complications
Cleveland_Clinic_Host: I'm sorry to say that our time with Raymond Rackley, M.D. is now over. Thank you again Dr. Rackley for taking the time to answer our questions about Prolapse & Incontinence.
Dr__Raymond_Rackley: Thanks for such an interesting forum. We did not get to all of these questions today and appreciate such a great response. Please let us know if we should continue to have additional forums in the future. I will answer any questions that have come in and they will be posted to the transcript. Thank You!
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