Prolapse & Incontinence: Ask an Expert
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 condition?
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 or incontinence?
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 www.clevelandclinic.org/appointments.
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This chat occurred on 9/23/2011
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