Online Health Chat with Dr. Howard Goldman
September 23, 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,
small or large bowel) drops down due to a weakened or stretched pelvic floor
muscle and/or a loss of vaginal support. This downward descent may result in
protrusion of the vagina, uterus or both.
Cleveland Clinic’s 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.
Howard B. Goldman, MD, is a board-certified urologist
who is fellowship-trained in the subspecialty of female urology and voiding
dysfunction. He was in charge of female urology at University Hospitals of
Cleveland from 1998 to 2004. He is currently a staff member of the Section of
Female Pelvic Medicine and Reconstructive Surgery at Cleveland Clinic and on the
faculty of Case Western Reserve University School of Medicine. He has a joint
appointment in the departments of Regional Urology and Gynecology.
He is actively involved in the training of fellows and
residents, and has been co-director of the National Urology Resident
Preceptorship Program in female pelvic medicine and reconstructive surgery, held
annually at Cleveland Clinic. He has also given numerous invited lectures on
applied genitourinary anatomy and recently created an American Urologic
Association-sponsored DVD on this topic.
If you would like to make an appointment with Dr.
Goldman or any of the urologists in the Glickman Urological & Kidney Institute,
please call 1.800.223.2273, ext 45600, or request an appointment online by
visiting www.clevelandclinic.org/appointments. Thank you!
Cleveland_Clinic_Host: Welcome to our Online
Health Chat with Howard B. Goldman, MD. We are thrilled to have him here today
for this chat. Let’s begin with some of your questions.
Causes and Stages
47n: What causes prolapsed bladder? Is it only in
women who have given birth?
Dr__Howard_Goldman: There are multiple factors
that may lead to a prolapsed bladder. Vaginal delivery, the very act of being in
labor, prior hysterectomy, smoking, coughing a lot, and genetics are just a few
of the risk factors.
47n: What is a dropped bladder? I believe it is called
prolapsed bladder. How is it treated?
Dr__Howard_Goldman: It is a weakness in the walls of
the front of the vagina that allows the bladder to drop. If asymptomatic, leave
it alone. If bothersome, it can be treated with a device placed in the vagina to
hold it up (a pessary) or with surgery.
luciana: You mentioned that prior hysterectomy can
cause prolapsed bladder. That bums me out because I thought it was just from
childbirth. So can you explain why the prior hysterectomy might cause this
Dr__Howard_Goldman: Nerves and muscles in that area are damaged when you cut an organ out.
nh: Would a polyp in the urethra cause incontinence of urine? Can they be malignant?
Dr__Howard_Goldman: Typically not. You should be checked by urologist.
tutu: Does diet have anything to do with prolapse or incontinence?
Dr__Howard_Goldman: Prolapse – It is unlikely.
Incontinence – Certain acidic foods, such as caffeine and alcohol, can aggravate
the bladder and may contribute in some cases to overactive bladder.
nh: My husband complains that he cannot penetrate
obstruction? What is this, cervix or bladder?
Dr__Howard_Goldman: Typically, prolapse will not prevent penetration. That is more likely due to vaginismus. See your physician for an evaluation.
mommo: My 17-year-old daughter has started
experiencing some incontinence. I intend to bring it up at her next doctor's
visit. What causes incontinence in young adults and should I be more concerned than I am?
Dr__Howard_Goldman: There are a number of potential causes, none of them particularly serious. Discuss with your physician.
kray: Can you please explain the stages 1-4 for prolapse of vaginal walls (cystocele and rectocele) and uterine prolapse? It would help me to understand it better (what I read and what people tell me).
Dr__Howard_Goldman: Sorry. That is really difficult to do in this format. You need drawings etc., but I’ll give you a rough idea.
- Stage 1 - normal
- Stage 2 - starting to protrude
- Stage 3 - coming all way out of vagina
- Stage 4 - whole vagina inside out
Sally: I have urinary incontinence. How can I tell
which option to try since I just 'leak'?
Dr__Howard_Goldman: See your doctor. Generally, if you
leak because you can’t get to the bathroom on time, the options are behavioral
treatment -- pelvic floor exercises -- and medication. If you leak with
coughing, sneezing, and other exertion, the options are more likely to be exercises or surgery.
MerryQuiteContrary: How do you treat stress or exertional incontinence? Does it require surgery?
Dr__Howard_Goldman: It can be treated with pelvic floor exercises or surgery. Try exercise first. Surgeries for this are now done as an outpatient with very good success rates.
tryin: In your opinion, does acupuncture help with prolapse or incontinence?
Dr__Howard_Goldman: It is hard to imagine it would
help prolapse. We are using a similar technique with a lot of success using a
needle in the ankle near the tibial nerve. We send a mild electric current
through the needle to modulate the bladder nerves for overactive bladder.
blunt1: I had the sling – with some success. Recently,
I had Botox® injected into the bladder, now I’m unable to void. What
will be the approximate time for the need to self-catheterize? Does
self-catheterization damage the urethra?
Dr__Howard_Goldman: Urinary retention typically resolves in a few weeks (six to seven). Catheterization should not damage the urethra.
mel: Why are more women not treated for incontinence?
Dr__Howard_Goldman: Many women find this an
embarrassing topic and are afraid to bring it up. Furthermore, many do not
realize that effective treatments exist. In addition, unfortunately, many
physicians are not fully aware of the range of treatments.
See your urologist, or in particular, a urologist with a subspecialty in female urology/female pelvic health/incontinence.
katie: My doctor has recommended using a pessary to
help with my prolapse. What are the pros and cons of this device? I am 38 and am
considering trying to have one more child within the next year or so.
Dr__Howard_Goldman: Pessaries can be very effective,
but some women do not like the idea of having something in the vagina and some
find it uncomfortable. Some types can interfere with sexual activity.
pray_for_me: When do you recommend patients consider
Medtronic’s implants for incontinence? If there is definite incontinence after a
birth or just poor response to doula?
Dr__Howard_Goldman: Typically, we consider the implantable neuromodulation devices if a patient has failed exercises and
medication for overactive bladder.
sunnyside: I have read and heard of problems with the
mesh-type surgery for prolapse and incontinence. What are the downsides and how
common are such problems? Thank you.
Dr__Howard_Goldman: The FDA recently met to review all
of this. Bottom line – the current mesh used for slings is fine. Mesh used for
prolapse, however, has encountered issues with complications. Much of that is
thought to be technical: surgeon experience, technique, etc., as opposed just to
mesh use. Thus, it is important to choose your doctor wisely and make sure he or
she has a lot of experience in this area. The FDA will likely ask for further
studies of these products.
2151957: What is involved with a sling procedure? How
long does it take? How long do I need to take off from work?
Dr__Howard_Goldman: It depends on your surgeon. With
our patients, the procedure takes 20 to 30 minutes and is generally done under
IV sedation and local anesthesia. Patients go home about two hours after surgery
and, depending on their occupation, can go back to work the next day or, if
involved with a lot of heavy lifting, can go back two to three weeks later.
brgtta: Prolapse and incontinence, can one surgery take care of both?
Dr__Howard_Goldman: It depends on the type of
incontinence. If someone has stress incontinence, a sling can be placed at the
time of surgery for prolapse. In some patients with urge incontinence, the
problem will disappear after prolapse repair.
hohoho: How long is the recovery for prolapse surgery?
Dr__Howard_Goldman: It completely depends on the type
of surgery performed.
Addy: I've been seeing TV commercials about the use of mesh. Do
Cleveland Clinic doctors use mesh?
Dr__Howard_Goldman: Some do and some don't.
bogg: How long would a sling last? Does it ever need to be replaced?
Dr__Howard_Goldman: Studies have followed patients for
about 12 years so far, and about 90 percent continue to do well at that point.
Thus, most – hopefully -- will not need it done again. However, in 5 percent to
10 percent, it may not work initially and have to be redone. In some other
patients, over time, their bodies may change and the sling will stop working.
Most successful ones stay successful.
rahman: In light of all the FDA attention on mesh, are
other methods being used for cystocele repair? (Plication-only)
Dr__Howard_Goldman: Yes, plication has always been and
will continue to be used. Transvaginal mesh will likely continue to be used as
well. Other techniques are available as well.
nyst: Do they still do sling procedures like they did
in the 80s or is it different now?
Dr__Howard_Goldman: They do but the majority is
different. Prior to 1997, most slings used tissue harvested from the patients
belly or thigh. Now, most slings use synthetic mesh and avoid the issues of
harvesting tissue, and thus surgery is less morbid, quicker, less painful, and more reproducible.
kts: Is it better to wait as long as possible before
having surgery for prolapse or does it not make a difference?
Dr__Howard_Goldman: Get it taken care of when it is bothersome to you.
crocker: How common is it for women to have to have
more than one surgery to repair a dropped bladder?
Dr__Howard_Goldman: Currently, depending on the data
that is reviewed, it appears that from 5 percent to 30 percent of women who have
had surgery for prolapse will need it redone.
holly: Can you please tell me about the Genityte procedure?
Dr__Howard_Goldman: There is no good data that this
does anything. In fact the physician who does it is not a urologist or
gynecologist. It looks pretty bogus to me -- just my opinion.
too_much: How do you know if you are doing a Kegel exercise right?
Dr__Howard_Goldman: You should be contracting the
muscles in the area of the vagina and pelvic floor, not the abdominal muscles.
If you are not sure, it’s best to visit a physical therapist to review.
cromwell: Do you have any recommendations on exercise with prolapse?
Dr__Howard_Goldman: Exercise is good for overall
heath. Activities that involve heavy lifting - weight lifting, etc. - can aggravate prolapse.
art2: Are there exercises to strengthen the abdominal
core and pelvic muscles for patients who have arthritic hips and/or backs?
Dr__Howard_Goldman: Yes. See your physical therapist.
nh: Internet sources indicate that other forms of
exercise are better than Kegels and want to send a DVD of exercise to correct
inadequate pelvic floor structure.
Dr__Howard_Goldman: There was a recent article published noting the poor quality of information in this area on the Internet. Don't believe everything you read.
joker: Would Pilates or Yoga be more beneficial in
controlling stress incontinence than walking on a treadmill or using an
elliptical machine, Stairmaster, or stationary bicycle?
Dr__Howard_Goldman: I’m not aware that either of those options has been shown to help stress incontinence. You need to do pelvic floor exercises/Kegels.
JStrong: What are your thoughts on the Kegel machines? Are they worth it?
Dr__Howard_Goldman: I have seen the commercial late at night when I could not sleep, but I really have no more information or knowledge of whether it is helpful or not.
nh: Would attending a class on Kegels by a nurse educator or PT
after delivery pay off for women’s health?
jolly_good: Can you discuss the use of hormones to
help strengthen the vaginal wall and urethra in the hopes of preventing prolapse
Dr__Howard_Goldman: There is a lot of debate about
this. Generally, oral hormone replacement therapy has not been found to help in
this area. However, local vaginal application of hormonal creams may help
prevent UTI's (urinary tract infections), vaginal irritation, and sometimes
overactive bladder symptoms.
carrie: Your opinion about use of Ditropan®?
Will it get less effective when frequently used?
Dr__Howard_Goldman: Ditropan® (oxybutynin) is effective for overactive bladder. Its limiting factor is that some people have side effects from it, which is why many of the newer medications were developed. It should not get less effective with use, but if the problem gets worse, it may become less effective.
Queenie74: I've heard of Botox® being used for incontinence. Is this true?
Dr__Howard_Goldman: Yes – Botox® (onabotulinumtoxinA)
injections into the bladder were recently approved by the FDA for use in
patients with neurologic disease that cause overactive bladder. Studies are
currently being done in typical patients with overactive bladder.
juggler: I’ve been using Estrace® (estradiol)
for three to four years and have noticed no difference in my pelvic area, yet my
urologist said he noticed a difference. What should I see as the result of using this medicine?
Dr__Howard_Goldman: Typically, you should have less vaginal irritation. In some women, it may help with overactive bladder, but in some it won't.
jrs: Please explain collagen injection, how are they
done, how often is it in the pelvic floor muscles?
Dr__Howard_Goldman: For some patients with stress
incontinence - cough, sneeze, etc. - a material is injected into the urethral
lining to help it close off better. The nice thing is that it can usually be
done in the office. It is not as effective as surgery for stress incontinence.
Collagen is no longer produced so other materials are used.
Virginia: Is there any way to avoid incontinence as you age?
- Maintain overall good health.
- Do pelvic floor exercises.
- Don't smoke.
- Avoid unnecessary pelvic surgery.
jolie: Can a person be 'taught' to cough a certain way so that it has less of an effect on prolapse/incontinence? Cold season is coming and I had a terrible time of it last year. I read a snippet online that this can be done.
Dr__Howard_Goldman: They can be taught to contract the pelvic floor at the time they cough or sneeze. It is sometimes called the "knack."
mary_jo: What new research is being done concerning the treatment of prolapse?
Dr__Howard_Goldman: Much research is being done in
what causes prolapse. A lot of research is being done on newer techniques, such
as using mesh. Research is also being done on better ways of diagnosing prolapse
and rejuvenating the pelvic floor.
gracie: Are stem cells utilized for incontinence?
Dr__Howard_Goldman: There is currently much research
in this area. The idea is to take stem cells and inject them into the urethra to
help the sphincter muscle regrow or to let chemicals secreted by the stem cells
help the sphincter repair itself.
nh: Who is doing stem cells to urethra?
Dr__Howard_Goldman: It is only being done at select
academic medical centers as part of research protocols.
julie: What can be done for women who have had a mild
stroke or who have MS, with regard to incontinence?
Dr__Howard_Goldman: A lot. They typically have urge
incontinence and that can respond to medication, exercise, or neuromodulation.
QQB: Would you have any concerns for a person who
wants to get a tummy tuck but has prolapse?
Dr__Howard_Goldman: Interesting question. There is some thought that some people have weakened body tissues in general and are more prone to hernias in general. We have seen cases where a prolapse is fixed and a groin hernia appears and vice versa. We have not seen this specifically with a tummy tuck.
go_on: Do you ever connect allergy to ingested food or
drink and increased frequency of urination?
Dr__Howard_Goldman: Some people find that acidic and some other types of liquids/foods make them void more often. Try eliminating one at a time and see if it helps.
stg456: One week after a spinal, I experienced slight
incontinence with coughing. If a nerve was injured/affected, what can be done?
Years later, I now have frequent urinary and leakage beginning.
Dr__Howard_Goldman: If your current problem is related to a spinal issue, what you are experiencing is very common. There are plenty of treatment options. See your urologist
hands_up: Are decaffeinated coffee and tea to be avoided to prevent urgency and frequency?
Dr__Howard_Goldman: The bigger issues are the caffeinated beverages and alcohol.
sing_2_me: I have recurrent urinary tract infections (UTIs)
that I believe are due to doing water exercises for knee/hip joint replacements.
I seem to contract UTIs too often. I choose pools carefully and those that are
well maintained. I have had bladder prolapse surgery repair but continue to have
UTI's. I practice good hygiene -- I know how to "wipe" etc., -- but still have
UTI's every one to two months. I tend to have adverse effects to sulfa and
quinolone medications. What else can I do?
Dr__Howard_Goldman: I doubt the water exercises are
causing your UTIs. See a urologist who is knowledgeable in this area.
Cleveland_Clinic_Host: I'm sorry to say that our time with Howard B. Goldman, MD, is now over. Thank you again for taking the time to answer our questions about prolapse and incontinence.
Dr__Howard_Goldman: Thank for all of your questions. Unfortunately we are out of time.
For further information you can do a "pubmed" search of me and see the various articles we have published in this area.
If you would like to make an appointment with Dr. Goldman or any of the urologists in the Glickman Urological & Kidney Institute, please call 1.800.223.2273, ext 45600, or request an appointment online by visiting
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This chat occurred on 9/23/2011
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