Incontinence, Pelvic Organ Prolapse and Sexual Dysfunction
June 19, 2008
Courtenay Moore, MD
Cleveland_Clinic_Host: Welcome everyone, and thank you Dr. Moore, for being with us to discuss Women's Pelvic Health. We look forward to an interesting chat today. Let's begin with one of the questions!
Speaker_-_Dr__Courtenay_Moore: Incontinence, Pelvic Organ Prolapse and Sexual Dysfunction are often difficult topics to discuss yet extremely important. I am looking forward to discussing these subjects.
bertl: What can be done for someone who needs to go to the b/r before they get in the car – right after they get out of car? And upon feeling the urge – can't hold it for more than 2-5 min? Will medication help?
Speaker_-_Dr__Courtenay_Moore: Urinary urgency can be treated with timed voiding, pelvic floor physical therapy and medications.
ttl: I have minor stress incontinence and whenever I read about the exercises I should do to improve things, it seems overwhelming – as much as 30 minutes a day. Is a small amount better than none? Is there a minimum time commitment a day? A week?
Speaker_-_Dr__Courtenay_Moore: Like any exercise program, the more you do it, the more benefits you will see. We recommend that you do Kegel exercises a minimum of 3X's per day, 10 sets each time.
ttl: I try to do Kegel exercises to help with mild stress incontinence but a few things I've read suggest as much as 20 minutes or more a day. Although I'd like to avoid surgery, it's hard to make that commitment. Is less still helpful? Is there a minimum?
Speaker_-_Dr__Courtenay_Moore: It depends on how much it bothers you. If you are benefiting from it – 20 minutes a day will help you avoid surgery. The other option is collagen, which is short term.
oldbat: I am experiencing urinary leakage with sneezing, etc. I thought since I was never pregnant, this would be something I would avoid. Are there other reasons for stress incontinence besides multiple births?
Speaker_-_Dr__Courtenay_Moore: Yes. There is a genetic as well as racial predisposition. Caucasian women are more likely to develop it than African American or Asian women. It can also result from chronic straining due to constipation and from strenuous physical activity.
patterj: Is there always incontinence after a birth or only after multiple births, or does it not always occur?
Speaker_-_Dr__Courtenay_Moore: Women can have post partum incontinence which can resolve, but it can also occur in women who have never given birth.
sung: What meds are available to treat incontinence?
Speaker_-_Dr__Courtenay_Moore: There are no FDA approved medications for stress incontinence. There are however several medications for urge incontinence or overactive bladder. These medications include Detrol, Ditropan, Enablex, Vesicare, Sanctura and Oxytrol.
ShaundaJenkins_2: Is there a surgical procedure that can completely resolve incontinence and if so, what are the side effects?
Speaker_-_Dr__Courtenay_Moore: Good question. First, incontinence is divided into 3 types: stress, urge and mixed incontinence. Stress incontinence is the involuntary leakage of urine on effort or exertion, or on sneezing or coughing. Urge involuntary is the loss of urine associated with a sudden, strong desire to void (urgency) or on exertion, coughing, sneezing. All three can initially be treated with physical therapy. While there are medications for urge incontinence there are no FDA approved medications for stress incontinence. Stress incontinence is treated surgically. There are several options, the most common however being the midurethral sling. This is an outpatient surgery which takes approximately 45 minutes. The success rates are in the 90-95% range. Very few people have complications- which include bleeding, infection or making the sling too tight so that you have difficulty urinating. If this happens the sling has to be removed.
knewit: Please explain collagen injection for stress incontinence. How is it done? Where is the injection placed and what frequency do they need to be done?
Speaker_-_Dr__Courtenay_Moore: Collagen is a bulking agent that is placed in the urethra. There are two approaches: transurethral and periurethral. The collagen is injected in the urethra near the bladder neck. Frequency varies in patients – but it may need to be performed every 6-12 months. Patients also need to have a collagen skin test to make sure they are not allergic to it prior to having the procedure done.
newtonm: Do you recommend patients consider Medtronic’s implants for incontinence? Is it an actual implant or just an electrical nerve stimulator?
Speaker_-_Dr__Courtenay_Moore: This device is actually used for patients with refractory overactive bladder and idiopathic urinary retention, not stress incontinence.
MICDS: I am a 50 year old runner who 98% of the time has no problem with stress incontinence. Every couple of months, out of the blue in the middle of a run I start to leak or will cough and pour. I have ridden the Kegel elevator up and down for years doing Kegels regularly. Is there anything I can do short of a procedure? My gyno says it will get worse as peri menopause continues. My blood work shows still pre-menopausal. I am not wild about wearing a pad all the time when it happens so infrequently, but I have no warning. Thank you.
Speaker_-_Dr__Courtenay_Moore: If it happens mainly when you are running, some patients will actually wear a tampon which mimics the sling surgery by supporting the urethra to prevent the stress incontinence. After the run it is removed. Try this and see if it helps.
bj: When I insert a tampon I have less leakage. Is it ok to do this when I go hiking ?
Speaker_-_Dr__Courtenay_Moore: Absolutely. If a tampon is helpful, definitely use it during any type of exercise.
bj: I live in the Seattle area and would like to have a recommendation for a urologist here. Otherwise I can travel to Cleveland, if possible.
Speaker_-_Dr__Courtenay_Moore: Dr. Kathleen Kobashi at Virginia Mason is fellowship-trained in female urology.
vickyd: Are there surgical options for incontinence? How affective are they? What is the recovery period?
Speaker_-_Dr__Courtenay_Moore: Once again this is a good question. Let me repeat – first off, incontinence is divided into 3 types: stress, urge and mixed incontinence.Stress incontinence is the involuntary leakage of urine on effort or exertion, or on sneezing or coughing. Urge involuntary is the loss of urine associated with a sudden, strong desire to void (urgency) or on exertion, coughing, sneezing.All three can initially be treated with physical therapy. While there are medications for urge incontinence there are no FDA approved medications for stress incontinence. Stress incontinence is treated surgically. There are several options, the most common however being the midurethral sling. This is an outpatient surgery which takes approximately 45 minutes. The success rates are in the 90-95% range. Very few people have complications- which include bleeding, infection or making the sling too tight so that you have difficulty urinating. If this happens the sling has to be removed.
madden08: Would Pilates or Yoga be more beneficial in controlling stress incontinence than walking on a treadmill, using an elliptical machine, stairmaster, or stationary bicycle?
Speaker_-_Dr__Courtenay_Moore: Recent studies suggest that core training not only engages the abdominal muscles, but also the pelvic floor muscles and can be preventative for stress incontinence.
kellys: Which doctor do I go to first if I want to begin treating my incontinence? My family doctor or an urologist? A doctor from the Glickman Institute?
Speaker_-_Dr__Courtenay_Moore: This depends. If you have overactive bladder, this can be treated medically by your primary care doctor. If you have stress incontinence that does not improve with Kegel exercises, you should see a urologist.
Pelvic Organ Prolapse
bernieb: I am 63, active, healthy and in shape but after my hysterectomy for a prolapsed uterus I became totally incontinent. Had cystoscopy and urodynamics tests and was told that my bladder was now repositioned and also that my urethra muscles were weak. I had a bladder neck suspension done in 1994 for a slight incontinence and I was completely dry until this recent surgery. Why would this happen and what are my options for correcting this?
Speaker_-_Dr__Courtenay_Moore: You need to be evaluated by a urologist to rule out vesicovaginal or ureterovaginal fistula since you report total incontinence.
memo1: I have uterus prolapse; what are the odds of having to have a bladder lift? Has this procedure been improved? A friend who had to have a bladder lift a few years ago wished that she had not had the surgery.
Speaker_-_Dr__Courtenay_Moore: A bladder lift is done when the bladder is prolapsed, not the uterus. There have been several new techniques developed to repair a cystocele (dropped or fallen bladder).
dangerd: I have been diagnosed with a moderate cystocele and rectocele. How do I decide about surgery? Can my gynecologist do this or do I need to ask for referral to a Urogynecologist? What procedure is generally recommended for this combination of problems? I am 51 and am not yet in menopause.
Speaker_-_Dr__Courtenay_Moore: When deciding about surgery for prolapse it comes down to quality of life. Does the prolapse bother you enough for you to want intervention? Is it affecting your life or activities? Prolapse can be treated conservatively with a pessary or surgically. I would recommend that you see a urogynecologist or a urologist like myself that specializes in female reconstructive surgery. The type of surgical procedure recommended depends on several things: Do you have a uterus? Do you also have vault prolapse? Do you have concomitant incontinence?
susan: I have had a preliminary diagnosis of prolapsed uterus, cystocele and rectocele. A urodynamic evaluation has been done and, next month my urogynecologist will do an in-office analysis of my vagina, urethra and rectum before planning surgery. Is this the path you would take? Also, if I have to have all of that "fixed", what type of recovery time should I anticipate?
Speaker_-_Dr__Courtenay_Moore: Yes – you need urodynamics to rule out occult stress incontinence. Recovery is dependent on the type of surgery that is actually performed. Vaginal procedures have a shorter recovery period than abdominal surgeries. Also if a hysterectomy is performed, the recovery period will be longer.
susan: I also have been treated for urethral stricture, which, has strangely "gone away" since my bladder dropped. The urogynecologist I am seeing says that is due to the cystocele. Do you concur?
Speaker_-_Dr__Courtenay_Moore: Urethral strictures are very uncommon in women. A cystocele will have no effect on a urethral stricture.
sgray: What are current treatments for urethral stricture? I have suffered over eight years of quarterly dilations with no improvement. Eliminating caffeine, improving diet and exercise has helped, but I find the use of dilation to be barbaric.
Speaker_-_Dr__Courtenay_Moore: Urethral dilations were very commonplace in the 1970s & most were done for recurrent UTIs and overactive bladder symptoms, not actually for urethral strictures. Urethral stricture disease is very uncommon in women. First off I would make sure that you actually have a stricture. What symptoms are you being treated for? Do the dilations help with your symptoms?
susan: The dilations helps a lot with the following symptoms: Aching kidneys, slow, tiny flow. I just think there must be a better way. Mysteriously, after the old doctor retired and a younger one did the last dilation that was very painful, the symptoms have not returned. I'm not complaining about that and if it fixed it, I'm fine, too.
Speaker_-_Dr__Courtenay_Moore: There is a very select patient population that urethral dilatations are appropriate for. If you feel that you are benefiting from them you can continue - or you could try Flomax which is a medication. Flomax is not FDA approved for women. It is considered an off label use in women.
susan: They are recommending a vaginal hysterectomy in concert with repair of the cystocele and rectocele. So, is that about an 8 week recovery time?
Speaker_-_Dr__Courtenay_Moore: Yes – it is a 6-8 week period for recovery.
gamy: How is sexual dysfunction diagnosed? Can it be cured? Is there anything like Viagra or Cialis for women?
Speaker_-_Dr__Courtenay_Moore: Sexual dysfunction is diagnosed in a variety of ways. There is not one single diagnostic test to determine this. We base a diagnosis on symptoms and validated questionnaires. Can it be cured? Yes. It often will require a multidisciplinary approach, involving both a physician and a psychologist. We actually treat women with Viagra and Cialis, but once again it is used off label and is not FDA approved for this purpose. Just to let you know, within the Glickman Urological and Kidney Institute at Cleveland Clinic is the Center for Female Pelvic Medicine and Reconstructive Surgery that specializes in female incontinence and prolapse. If you would like more information you can visit the website at www.clevelandclinic.org/urology . The appointment line is 1.800.223.2273 ext 45600.
missmollie: I had endometriosis in my 30’s and was treated with Danazol. I was never able to get pregnant. Could the pelvic pain I intermittently experience now be the endometriosis returning?
Speaker_-_Dr__Courtenay_Moore: Endometriosis can reoccur and cause pelvic pain if you are still menstruating. You should be evaluated by a gynecologist.
shirleyn: I had a pap smear in April of this year and was told that my uterus was inflamed or infected because of my body not producing estrogen because of my not having a period anymore so he prescribed a vaginal cream that I am very afraid to use because of the side affects. I need to know if there is an alternative, such as a hysterectomy.
Speaker_-_Dr__Courtenay_Moore: Topical estrogen – while it is an estrogen – does not have all the side effects that oral or systemic estrogen has. While systemic estrogen can have effects on lipid profile & blood clots, topical estrogen works mainly on the vagina. Initially for 2-3 weeks after starting topical estrogen you can have minimal systemic absorption, which may or may not be detectable by blood tests. After that period it only has an effect on the vagina. Hysterectomy may be an option depending on what exactly is going on with the uterus. Indications for hysterectomy include: fibroids, abnormal bleeding & cancer or precancerous cells.
jenny: My GYN doctor has repeatedly told me that I have a tipped uterus whenever she does a vaginal exam. What does this mean? Does this have any relation to urinary leakage when I sneeze – which is starting to happen with me?
Speaker_-_Dr__Courtenay_Moore: Tipped uterus is just a descriptive term for the position of the uterus. A tipped uterus should not have a relation to a urinary leakage.
womanofthenight: I’ve been using Estrace for 3-4 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 expensive medicine?
Speaker_-_Dr__Courtenay_Moore: Estrace changes the vaginal pH and helps prevent recurrent urinary tract infections in post-menopausal women. From a physical standpoint, it promotes blood flow & improves tissue quality. Basically it would make the tissue feel more "bumpy."
dianad: Hello Dr Moore, I am a 58 yr old female diabetic insulin dependant A1c is 5.9. My question is: I have repeated UTI infections with blood found in the urine. I finally went to a urologist; he will be doing a scope on my bladder in July. I am very concerned about by kidneys. I do not have protein in my urine!! Thank you in advance!
Speaker_-_Dr__Courtenay_Moore: Part of the workup for recurrent urinary tract infections is imaging the kidneys to rule out an upper tract source of the infections. I would recommend that you have a renal ultrasound.
alexis: 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 on the need to self-cath? Can self-catheterization damage the urethra?
Speaker_-_Dr__Courtenay_Moore: The effects of Botox are reversed in 6-8 months. Self-catheterization needs to be performed until you can void spontaneously. Damage to the urethra is rare when self-catheterization is performed properly.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Moore is over. Thank you again Dr. Moore, for taking the time to answer our questions today.
Speaker_-_Dr__Courtenay_Moore: This has been a great venue to receive questions of this type. Thank you.
Cleveland_Clinic_Host: If you would like more information regarding women's pelvic health or other women's health issues, please see www.clevelandclinic.org/womens_health/disorders.aspx. For general health information you may also wish to visit http://author.my.clevelandclinic.org/health/default.aspx.
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