Online Health Chat with Dr. Megan Tarr and Dr. Massarat Zutshi
October 24, 2011
Cleveland_Clinic_Host: Millions of women suffer from a wide range of urinary and bowel problems: Urinary incontinence and loss of bowel control, constipation, hemorrhoids, discomfort or pain, just to name a few. Many people often don’t seek help because they are too embarrassed or aren’t sure where to turn. The good news, however, is effective treatments are available.
Cleveland Clinic OB/GYN specialist Megan Tarr, MD, and Cleveland Clinic colorectal surgeon, Massarat Zutshi, MD, will help you understand the causes of incontinence, prolapse, and other pelvic organ problems and the treatment options available to you.
Dr. Megan Tarr is joining the Women’s Health Institute at Cleveland Clinic in October and will be seeing patients at main campus, Hillcrest Hospital, and Marymount Hospital. She completed her fellowship in Female Pelvic Medicine and Reconstructive Surgery and a Masters in Clinical Research Methods at Loyola University in the Chicago area in 2011. Dr. Tarr’s interests in resident and medical student teaching were solidified during her years as an OB/GYN resident at the University of Chicago. She focused on teaching robotic and laparoscopic surgery, patient education, and the informed consent process pertaining to surgery for urinary incontinence.
Dr. Massarat Zutshi is a colorectal surgeon in the Digestive Disease Institute and sees patients at the Colorectal Center for Functional Bowel Disorders. Dr. Zutshi received her medical degree from Grant Medical College, University of Bombay, Bombay, India. She completed her fellowship at Cleveland Clinic. Her clinical and research interests include pelvic floor dysfunction, rectal prolapse, fecal incontinence, constipation, and anorectal disorders. Dr. Zutshi sees patients at main campus and Beachwood Family Health Center.
To make an appointment with Dr. Massarat Zutshi, or any of the specialists in the Digestive Disease Institute, please call 216.444.7000 or toll-free at 800.CCF.CARE, extension 47000.Visit us online at clevelandclinic.org/digestive.
To make an appointment with Dr. Megan Tarr, or any of the specialists in the Ob/Gyn and Women’s Health Institute, please call 4HER®Women's Health Line at 216.444.4HER or 216.444.6601, or call toll-free at 800.CCF.CARE, extension 46601. Visit us online at my.clevelandclinic.org/ob_gyn.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Megan Tarr and Dr. Massarat Zutshi. We are thrilled to have them here today for this chat. Let’s begin with some of your questions.
Grannyscott: I am an 82-year-old woman who tries to walk for health reasons several days a week. I prefer to walk in the morning, especially when it is hot. I wait until an hour or so after breakfast, after I have had at least a couple of normal bowel movements and feel emptied. However, it frequently happens that about half an hour after I start out and am a mile or so from home, I experience leakage of loose bowel [contents], which is impossible to control. I arrive back home uncomfortable and embarrassed! What is causing this and what can I do about it? I take extra fiber. If I wait until afternoon I don't have the same problem.
Dr__Massarat_Zutshi: It is difficult to say what kind of stool you are having based on your report. Fiber will help in bulking the stool, but too much fiber may give you frequent bowel movements. You can try a synthetic fiber such as Citrucel® or Benefiber® in graded amounts and add an antidiarrheal like Imodium® (loperamide) as soon as you wake up in the morning to see if this will help you. If it continues, please see your physician.
Grannyscott: I did see a gastroenterologist, who told me to take Metamucil® only, not Benefiber® or any other kind, to control my uncontrollable urge to evacuate, specifically when I am walking in the morning.
Dr__Massarat_Zutshi: If you are already taking a fiber supplement, you could still try the Imodium®. Metamucil® has psyllium, which tends to give more bowel movements and more gas. Benefiber®, on the other hand, is a synthetic compound with fewer of those symptoms. If medical management has not helped you, then you should see a colorectal surgeon.
holly_903: I have been suffering from loss of bowel control. I am too embarrassed to seek treatment and don’t know if anything can be done. Do you have any suggestions for me?.
Dr__Massarat_Zutshi: There are multiple treatment options for your symptoms. You should be evaluated by your local gastroenterologist or colorectal surgeon.
thegardener: I have a history of IBS (irritable bowel syndrome) for 40 years that is more under control now. In the past year, I have had four episodes of FI (fecal incontinence), all with watery stool. I also have an uncontrollable, extreme gas issue that keeps my social life at a standstill. I have had Kegel exercise class and do them regularly. I have had three episiotomies with three deliveries. The rectal doctor wants to implant an interstimulation device in my spine or inject silicone (??) in my sphincter muscle. I only seem to have the FI issue with loose/watery stool, but I ALWAYS have urgency with bowel movements, and it has limited all social interaction, causing much anxiety and stress. What are my options here? I am the kind of gal who wants the least invasive procedure done. I am 66 years old.
Dr__Massarat_Zutshi: IBS-related symptoms are best controlled with control of bowel habits, which can be directed by a registered dietitian and a gastroenterologist. The dietitian can help with guiding you regarding foods to avoid, and the gastroenterologist can help with symptomatic control with medications. As you have had only four episodes of fecal incontinence in the last year, with loose stools, it would be helpful to address this first. Urgency is harder to control but may be controlled with antidiarrheals and probiotics. InterStim is an option if your symptoms deteriorate.
umom31: I have two children (both delivered vaginally). The last birth required the use of forceps and now I have a mild rectocele and have difficulty with incontinence (mostly urine, sometimes stool). What types of treatment are available to help with this?
Dr__Megan_Tarr: The mild rectocele and the fecal incontinence may or may not be related. I would advise that you seek consultation from a pelvic reconstructive surgeon. Many times, fecal incontinence can improve with dietary manipulations and medications. Fixing the rectocele may help reduce the stool trapping and reduce the sensation that a bulge is present.
Dr__Massarat_Zutshi: Here is some additional information that may be helpful to you. You can see an urogynecologist to address your symptoms of urinary incontinence. This will need to be assessed and treated, as rectoceles usually do not cause urinary incontinence. Fecal incontinence can also be treated by that specialist if both symptoms are occurring together.
Elliemay: I have about 1 minute from the time I feel I am going to have a bowel movement. If I don't get to the bathroom, it is coming out. Can you fix this? I'm 63.
Dr__Massarat_Zutshi: We need to know much more about your symptoms regarding the number of bowel movements a day, consistency, and whether you have had any work-up done. You are recommended to see a gastroenterologist to have your problem evaluated.
bongo33: I have a loose bowel movement every morning about half an hour after I wake up. I have to be careful and stay near the bathroom at this time, because once I feel it, I have to get to the bathroom quickly, or will start leaking. How can I stop this from happening?
Dr__Massarat_Zutshi: Is this a recent occurrence? Have you had a colonoscopy to evaluate your colon? If the answer to both questions is yes, then you can try taking an Imodium® tablet at night to see if this changes your symptoms. If they persist, then you should see your primary care physician or a gastroenterologist.
ballyhoo: When I go to the bathroom, I almost always have to urinate again within about 10 minutes. Does this mean I am not fully emptying my bladder the first time? What can I do about this? It is very annoying; especially when I am going somewhere, have a meeting at work, etc.
Dr__Megan_Tarr: Urinary urgency without incontinence is often best approached with the use of vaginal pelvic floor physical therapy and behavioral therapy. Many times, women with urinary urgency feel that they are not completely emptying their bladder. After it is assured that a woman is completely emptying her bladder, it is important to assess how much she is drinking during the day and to make sure that she does not have a urinary tract infection. With proper training through physical therapy, women can often gradually prolong their intervals between voiding, as some of this becomes a behavioral issue.
Cat666: Do you have any suggestions to help a woman empty her bladder completely when urinating?
Dr__Megan_Tarr: In order to answer this question, I would have to know why you feel that your bladder is not emptying completely. If it is due to a past incontinence surgery, you may find that sitting backwards on a toilet or attempting to relax your pelvic floor muscles while urinating may be helpful. Sometimes, a specialized pelvic floor physical therapist can teach you how to train your pelvic floor muscles to relax more completely during voiding. Alternatively, if you have pelvic organ prolapse, you can simply reduce the prolapse bulge with your fingers and more fully empty your bladder.
betty_boop: I am 52 and prone to urinary tract infections. What can I do decrease/stop getting them?
Dr__Megan_Tarr: When women have recurrent urinary tract infections, it is very important to obtain urine specimens for culture at each doctor visit. This tells us if the urinary infection is cleared with antibiotic treatment or if it is a persistent infection with the same/different organisms. After reviewing the causative organism, some physicians will initiate women on daily suppressive antibiotic therapy for several months at a time. It is also important to make sure that the woman is emptying her bladder well. In addition, foreign bodies in the urinary tract, such as stones or mesh from a past pelvic surgery can also harbor microbes and result in recurrent urinary tract infections.
fifi: How are stress incontinence and overactive bladder different?
Dr__Megan_Tarr: Stress incontinence refers to urine leakage that occurs with an elevation of intra-abdominal pressure (during coughing, sneezing, lifting, or laughing). Urge incontinence is urine leakage that occurs after one feels an "urge" to urinate. Many women have symptoms of both. As urogynecologists, we like to differentiate them because they are treated differently.
plg555: At what point should I seek the advice of my doctor? I am 50 and have to wear pads every day due to urinary leakage. I am annoyed with the problem!
Dr__Megan_Tarr: Although urinary incontinence is more common as women age, it should not be considered a "normal" part of aging. Feel free to seek a consultation for this issue at any time in your life. If it is bothersome to you, please seek treatment.
grammarhodes: Does atrial fibrillation contribute to frequent urination? Will slowing the heart rate reduce the urges?
Dr__Megan_Tarr: This is a bit of a complex question. The atrial fibrillation may be causing the heart to excrete atrial natriuretic peptide (which often occurs in sleep apnea), which will ultimately cause the kidneys to excrete more urine. This may then cause you to urinate more frequently, due to the increased urine production. There are many complex hemodynamic changes that occur with cardiac function and the medications used to treat cardiac issues, so it is not certain that treatment of the atrial fibrillation will improve your urinary symptoms.
jollop: I have three children that were born naturally. I now have some incontinence, but mostly very frequent urination. I have been told that pregnancy can cause this. How is this? I know that therapy can help with the incontinence, but can it also help with the frequent urination?
Dr__Megan_Tarr: Urinary urgency is best helped with pelvic floor physical therapy. These specialized therapists do myofascial release (just like when you have a back massage) and help retrain the muscles to both relax and contract when you need them to do so. We believe that urinary urgency is often due to spasm of the pelvic floor muscles, and your brain cannot discern this spasm from urinary urgency.
bpaula: My husband for the last two weeks feels like he has to have a bowel movement, and when he does, it’s bloody and with mucus in it. Sometimes his bowels move and sometimes they don’t. It’s the red blood not the black. Wondering what could be causing this? He has a little discomfort in his abdomen but no other symptoms.
Dr__Massarat_Zutshi: Your husband needs to be seen by a gastroenterologist or a colorectal surgeon. If he has not had a colonoscopy, he will need to do that also.
mater: I have bright red blood after a bowel movement. Should I be concerned?
Dr__Massarat_Zutshi: You did not mention how old you are. Symptomatic bright red bleeding can be from the lower part of your large intestine. If it is not assessed with an exam or a colonoscopy, it should be addressed.
hear_me: I’ve been suffering from chronic constipation for years, despite eating a diet that is high in fiber. Is there anything that can help with this?
Dr__Massarat_Zutshi: Fiber does not help every patient who has constipation. You can try a minimum fiber diet that you can find on the Internet and increase the amount of water you are drinking. You can also see a gastroenterologist who can suggest medication if the above does not help you.
gyro: When I get constipated, I don’t like to take a laxative, as I am a very busy mother of three and don’t have the convenience of being able to run to the bathroom on a moment’s notice. What can I do to help with the constipation that is more ‘gentle’ than a laxative?
Dr__Massarat_Zutshi: It depends on what you define as constipation. If you are having fewer bowel movements then what you expect in a day, then start with a high fiber diet. Also, increase your water intake and decrease sodas and artificial sweeteners. You can add a fiber supplement such as Citrucel® or Benefiber® in a powder form a few times a day. Exercise also helps. If this does not help your symptoms, then you should consult a gastroenterologist.
cardigan: My son only has a bowel movement about twice a week. He is 15 years old. Is this normal? Also, if he does have to go and he is not at home, he will ‘hold it’ until he gets home. Can this hurt him in any way?
Dr__Massarat_Zutshi: Having a bowel movement every three days is quite normal as long as it is not incapacitating him or he is not inconvenienced by it. You can try adding a fiber supplement in a powder form on a daily basis, and make sure he is drinking plenty of water daily and see if this improves his symptoms. 'Holding it' will not hurt him, but will diminish the urge in the long run.
under_ground: I have a bowel movement about two to three times a day, especially after eating food not cooked at home. Is this normal or should I be worried? Could it be my diet?
Dr__Massarat_Zutshi: This could be because you have a sensitive gastrointestinal tract or have some food allergies. You can see a registered dietitian if it bothers you.
Patchworkdivas: I am 58 years old. In order to have a bowel movement I have to lean back and push, why?
Dr__Massarat_Zutshi: It is very hard to say why with such few details. If you are having a bowel movement every day, but evacuation is difficult, please see a pelvic floor specialist in your area who may be able to guide you with treatment for your symptoms.
minnie_mouse: Something is coming out of my bottom end after I have a bowel movement. What could this be? Can the problem be corrected?
Dr__Massarat_Zutshi: Based on your question, it could be many things. You need to be evaluated by your local colorectal surgeon who can advise you.
prancer: I've heard horror stories about women having problems with the synthetic mesh used in many sling procedures. How common are mesh problems?
Dr__Megan_Tarr: This is a very important topic in pelvic reconstructive surgery. The concern is mainly focusing on synthetic meshes that are placed vaginally for prolapse repair. The recent reports focus on the high rates of the mesh coming through the vaginal wall over time, resulting in pain with sex and vaginal discharge/bleeding. These particular uses of synthetic mesh should be differentiated from the midurethral tapes (or slings) that are used to treat stress incontinence. These have a much lower risk profile and are used as the first line of treatment for stress incontinence by most practitioners. In addition, vaginally placed mesh for prolapse repair should also be differentiated from abdominally placed meshes for prolapse repair.
barbk: 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?
Dr__Megan_Tarr: A simple office exam by a physician experienced in treating pelvic organ prolapse is usually sufficient to diagnose prolapse ("dropped bladder"). Oftentimes, we will do a standing exam, as the prolapse is largest when you are able to bear down with the assistance of gravity.
marymary: I have uterus prolapse; will I also need to have a bladder lift? If yes, is it common to have these procedures done at the same time?
Dr__Megan_Tarr: This question is best answered with an analogy. Think of the vagina as a sock suspended inside your pelvis by various support ligament. Prolapse occurs when there is a loss of support of the vagina. Consequently, there are several structures that prolapse simultaneously. Most commonly, the very top or apex of the vagina (or cervix in women with a uterus) loses support, and the front wall (where the bladder is located) and the back wall (where the rectum is located) follow. Consequently, many prolapse surgeries focus on fitting these multiple sites where pelvic floor support has been lost.
Cnythia: I have vaginal prolapse, no incontinence (yet). My OB/GYN is aware but seems unconcerned. I am 72. I have had it for about three years. Are there exercises that can help?
Dr__Megan_Tarr: Prolapse can be watched over time, as it may or may not progress. Non-surgical treatments usually involve a pessary. Pelvic floor physical therapy can help prolapse symptoms, especially if there is a mild degree of prolapse and one's doctor notes pelvic floor muscle tenderness upon exam.
rosie: I'm 38 years old and have had three children. After my last child was born, I had a lot of problems and was diagnosed with a grade 2 cystocele and rectocele. The rectocele is the most problematic. I have recently been diagnosed with a grade 2 uterine prolapse. The suggested treatment is a repair with a vaginal hysterectomy. I have my concerns with this. What other options do I have?
Dr__Megan_Tarr: I would not advise undergoing pelvic reconstructive surgery until you are sure that you are finished with childbearing. Many women who are not finished with childbearing use a pessary, which is a flexible support similar to a diaphragm inserted into the vagina. It can be left in place for several weeks at a time or removed a few times a week for intercourse and cleaning.
Surgical treatment options for pelvic organ prolapse include a variety of vaginal, minimally invasive (laparoscopic or robotic), or abdominal procedures. Some surgeons will preserve the uterus at the time of surgery and others will not.
dani_j: I have been suffering from a hemorrhoid that is bothersome, but I am able to deal with it. I am worried about getting treatment because I have heard that it is painful to get hemorrhoids treated. Are there any treatments that are easy and non-invasive to help me with my problem?
Dr__Massarat_Zutshi: You did not mention how old you are or if you have had a colonoscopy or if this is a proven hemorrhoid seen by a physician. Oftentimes, what patients perceive as a hemorrhoid could be very different.
If it is a hemorrhoid that is internal and coming out, it can be treated in various ways which are relatively painless. However, if it is a large hemorrhoid with a skin component, then it needs excision, and this can be painful. You need to have it evaluated by a colorectal surgeon, who will be able to give you all of the options for treatment. Newer options include the hemorrhoidal arterial ligation technique, which uses a Doppler device.
plato: At what point to you consider surgical treatment of hemorrhoids?
Dr__Massarat_Zutshi: If your symptoms are bothering you or if you are bleeding consistently, then you should seek treatment.
Trouble: What is the best way to avoid getting hemorrhoids?
Dr__Massarat_Zutshi: Having regular, easy, bowel movements without straining. Take fiber and drink plenty of water on a daily basis.
crazyT: I have read about colonic hydrotherapy as a treatment for hemorrhoids. What exactly is it and does it work?
Dr__Massarat_Zutshi: Colonic hydrotherapy is not a treatment for hemorrhoids.
for_now: I have been having the sensation that there is a lump in my anus. It is not painful, just a feeling like there is something there. There has been no bleeding. This feeling started after a two-week bout of constipation. Could this be an internal hemorrhoid or could it be something else?
Dr__Massarat_Zutshi: Any lump in the anal area needs to be evaluated by a colorectal surgeon. It could be a hemorrhoid, but it also could be other pathologies that need evaluation.
nanna: I have some drainage from near my bottom end. It is not much but is bothersome. Do I need to see a doctor?
Dr__Megan_Tarr: Yes, this should be evaluated by a colorectal surgeon.
hardy_mum: I have stool coming out from my vagina. I also pass air from my vagina. Can this be rectified? I am embarrassed.
Dr__Massarat_Zutshi: You have a rectovaginal fistula, which is a connection between the rectum or colon and the vagina. You need to be evaluated by a colorectal surgeon, and this can be rectified.
becmarch: Myself and my children have been told we have the genes for celiac disease and are at high risk. I have had a biopsy that was negative, and our antibody tests were negative. However, we get sick when we eat gluten and symptoms go away when we stop. Have you seen this before? Can you have negative celiac antibody tests and still be symptomatic for celiac?
Dr__Massarat_Zutshi: Celiac disease is a specialty for gastroenterology. If you are already seeing one, maybe you can find someone who has more expertise in this subject. If you would like to come to Cleveland Clinic, we have several experts in this field. Please visit clevelandclinic.org and choose “Find a Doctor.” You can search by specialty to locate a gastroenterologist. There is a celiac disease webchat on December 13 that will be led by a registered dietitian.
Viv64: How do you choose between a gastroenterologist and a colorectal surgeon for bowel conditions?
Dr__Massarat_Zutshi: Symptoms related to motility (diarrhea, constipation, irritable bowel syndrome, etc.) are directed to a gastroenterologist. Symptoms related to rectal bleeding; fecal incontinence; anorectal conditions such as hemorrhoids, fissures, fistula, abscess, rectalvaginal fistula; or anything involving surgery or resulting from surgery are referred to colorectal surgeons.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Megan Tarr and Dr. Massarat Zutshi is now over. Thank you again, doctors, for taking the time to answer questions about urinary and bowel problems.
Dr__Megan_Tarr: I would like to thank all of you for participating in the webchat today. We discussed a variety of issues that affect the lives of many women. The American Urogynecologic Society (AUGS) has a helpful patient education website at: www.mypelvichealth.org.
I have appreciated being part of the discussion about your symptoms. If you live far away, you may take advantage of Cleveland Clinic's MyConsult, where you can send in all of your reports and have a physician evaluation sent back to you. Go to www.clevelandclinic.org to access the MyConsult.
To make an appointment with Dr. Massarat Zutshi, or any of the specialists in the Digestive Disease Institute, please call 216.444.7000 or toll-free at 800.CCF.CARE, extension 47000.Visit us online at clevelandclinic.org/digestive.
To make an appointment with Dr. Megan Tarr, or any of the specialists in the Ob/Gyn and Women’s Health Institute, please call 4HER® Women's Health Line at 216.444.4HER or 216.444.6601, or call toll-free at 800.CCF.CARE, extension 46601. Visit us online at my.clevelandclinic.org/ob_gyn.
A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.clevelandclinic.org/myConsult.
This chat occurred on 10.24.2011
This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. ©Copyright 1995-2011 The Cleveland Clinic Foundation. All rights reserved.