Online Health Chat with Sandip Vasavada, MD
Monday, July 14, 2014
Suffering from urinary incontinence or pelvic organ prolapse can be extremely debilitating, inconvenient, uncomfortable and emotionally stressful. Many women think it’s just part of getting older, but what they don’t realize is that you do not have to live with these conditions. Treatment options are available to help you regain control of your active life.
What is incontinence?
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, sudden 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 also can occur during sexual activity, causing tremendous emotional distress.
What is pelvic organ prolapse?
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.
About the Speaker
Sandip Vasavada, MD, serves as the medical director, Center for Female Urology and Reconstructive Pelvic Surgery at Cleveland Clinic within the Glickman Urological & Kidney Institute. Together with his colleagues, he helps represent one of the largest centers for female urology and reconstructive genitourinary surgery in the country. He is also Associate Professor of Surgery (Urology) at the Cleveland Clinic Lerner College of Medicine and has a joint appointment with the Women's Health Institute.
Dr. Vasavada's main clinical interests lie in the areas of urinary incontinence, pelvic organ prolapse and complex reconstruction of the lower urinary tract, and management of complications of vaginal and lower urinary tract surgery. His current research interests are in the fields of refractory bladder overactivity and neuromodulation, and care pathways for optimizing care in patients undergoing incontinence and prolapse surgery. Dr. Vasavada serves with the Section of Urogynecology on the NIH-Pelvic Floor Disorders Network.
Let’s Chat About Prolapse & Incontinence: Regain Control of Your Active Life
Moderator: Welcome to our chat today with Cleveland Clinic's Glickman Urological & Kidney Institute specialist, Dr. Sandip Vasavada. We are thrilled to have him here with us to share his knowledge about prolapse and incontinence.
Incontinence & Over Active Bladder (OAB)
swh: I am a 55-year-old female and I am experiencing adult bedwetting periodically, about once or twice a month. I'm wearing something like "Depends" every night, just in case it happens. I don't want to live like this and especially don’t want to have to wear these "diapers" to bed every night. Is this common for women my age and what are the treatment options?
Sandip_Vasavada,_MD: It is not common. This condition has many causes, but a short list of concerns may include: too much fluid intake in the evening, swelling of the lower legs (edema), heart failure issues, overactive bladder and sleep apnea (snoring). Any of these may result in your problem and can be remedied. For insurance purposes, I would suggest you contact your carrier and see if they will do out-of-network coverage for Cleveland Clinic.
jlp152: I have urge incontinence. My ob-gyn has prescribed the In Tone® device. Do you have any thoughts or comments on the success rate of these?
Sandip_Vasavada,_MD: There is very little published data on the In Tone device, and only abstracts at present have been presented at meetings. They quote high success rates, which makes me a bit suspicious, as this is not in any peer-reviewed literature. Therefore, I am hesitant to recommend it.
lemas: I am 48 years old and like to do Zumba and dance, but with any jump I leak, and I have to wear pads because I also leak with any sneeze or cough. What do you recommend I do?
Sandip_Vasavada,_MD: If this is bothersome, our Cleveland Clinic Care pathway for stress incontinence (leaks with cough, sneeze, laugh) suggests the next steps are pelvic floor exercises if the patient is motivated to do so. Otherwise, surgery for stress leakage is recommended. This is usually a sling procedure done as an outpatient.
Lily Mack: Is it true that while stitching helps with bladder leakage, when sneezing, laughing, etc., it makes urge incontinency worse?
Sandip_Vasavada,_MD: By “stitching", I assume you mean support (sling or other therapy for leakage). It can make urge incontinence worse, but you should be evaluated for any obstruction (too tight) after the procedure as the cause for this.
domino2: Cutting caffeine is useful in avoiding urge incontinency. Shall I reduce wine consumption also?
Sandip_Vasavada,_MD: There is some diuretic effect from wine.
yorker5: Is there a simple surgery for slight leaking and sometime sudden urge?
Sandip_Vasavada,_MD: That depends on what is considered "simple". We helped the American Urological Association publish the Overactive Bladder (OAB) Guidelines and their most recent update a couple of months ago. In that document, we highlighted that all the medications for OAB (sudden urge to go to the bathroom) are basically the same in terms of how well they work. Other options include tibial nerve stimulation (ankle nerve stimulation done in an office weekly for 12 weeks and then monthly thereafter). The use of BOTOX is now approved for OAB and has garnered a lot of interest and is also office based. The Interstim, or sacral nerve stimulation device, also works very well but may require, in some cases, a sedation anesthesia in an operating room setting, but otherwise is still an outpatient procedure.
domino2: After a successful treatment for an overactive bladder with VESIcare®, I've been normal for about four months, but it seems that the previous symptoms may be returning. Is this normal?
Sandip_Vasavada,_MD: Medications like VESIcare only help when taking the medication, so if you are not on the medication, your symptoms will likely return. The OAB guidelines suggest considering caffeine and fluid modification as first line therapy for OAB in addition to pelvic floor exercises.
mflower: I had a prolapsed bladder in 1999. My OB-GYN did surgery and put in a mesh to hold my bladder up. After the surgery, I had to void twice in order to empty my bladder. The older I get, I find myself having a leak or a mild incontinence. My question is: was there a problem with any meshes in 1999 or could the mesh have grown into the bladder causing incontinence?
Sandip_Vasavada,_MD: There were some meshes with problems back in the late 1990s and may or may not be the cause of your issues. I would have this looked into, and that can often be done by studying the old operative report and having your physician do an office cystoscopy to look into the bladder. Even if it was a mesh that was having problems, it may or may not be the cause of your current leakage. I would not have the mesh removed unless one believes it is causing a problem.
megr: I have been told by a Cleveland Clinic urologist that my vaginal prolapse isn't very bad. I had a total hysterectomy at age 54 and am now 69. I want to do stomach crunches and weights, but every time I do them, the prolapse gets worse for days after. I do Kegel exercises but they only help until I do crunches. I exercise six days a week on my elliptical (level 19) for 50 to 60 minutes and am fit except for my stomach, which I hate. What can be done? I have very little incontinence so that isn't an issue. I want to be fit and look good at any age!
Sandip_Vasavada,_MD: It is fantastic that you are that active. We usually only treat prolapse that is symptomatic (i.e. causing problems) such as pressure, feeling of bulging, unsightliness, leakage, emptying problems, bowel emptying problems, bladder infections, and the like. Some patients follow with us to make sure they are not worsening, especially if they are physically active. Still, we only suggest doing something if there is a bother (even if the prolapse is worse.)
judithann: I am 75 years old. I had a bladder suspension 30 years ago. I have uterine and bladder prolapse. I use a pessary; it holds things in place. Also, I have a problem controlling my bladder. Is there anything that can be done? I feel very restricted in my activity.
Sandip_Vasavada,_MD: Good question. It depends on the type of leakage occurring, urge or stress (with cough, sneeze etc.). If it is the urge-type of leakage, sometimes medications help. If it is the stress-type of leakage, you can try a different type of pessary or ring. Otherwise, if it is bad, sometimes vaginal surgery can manage both the leakage and the prolapse. This type of surgery can, in many cases, be done as an outpatient or overnight stay and has a high satisfaction rate.
ArleneG: I had a hysterectomy to remove my prolapsed uterus three years ago. A web mesh was put in place to support my bladder, but my bladder prolapsed a year later. I now wear a pessary, which is very inconvenient and uncomfortable. I am 61 years old. I am afraid if I have another surgery something else might prolapse. I'm also concerned about the useless bladder mesh residing in my body. Are there any other treatments available?
Sandip_Vasavada,_MD: This is a good question and one we have been getting more and more often. There are many factors in play here, and they include physical activity, sexual activity and tissue quality. Still, surgery can, in many cases, be done if the patient is not satisfied with a pessary, and surgery is not a "one-size-fits-all" procedure. You should certainly see someone who has a lot of experience in this area, as your case sounds a bit more complex than most.
Poppy27: I was told at my last annual checkup that I have uterine prolapse. It mustn't be very bad because I can just feel the tip of the cervix, yet the constant pressure is very uncomfortable all the time. It always feels like there's pinching, like a tampon trying to come out on its own. What are my options and how effective are they?
Sandip_Vasavada,_MD: "Bad" uterine or other organ prolapse is based on how much it bothers you more than anything else, including how far out the organ is. More patients are bothered with symptoms (such as bulging, pressure, heaviness or bladder issues) when it is farther out. Treatment options include a pessary or ring placement, observation or surgery. The surgery discussion can entail uterine preservation vs. removal and should be an individual discussion with your physician.
beanjaker: Is there a current treatment for pelvic organ prolapse (when the prolapse is at the introitus) other than a pessary or tissue graft? The problem is that I have a muscle disease and pelvic rehab hasn't worked.
Sandip_Vasavada,_MD: Surgeons can still do a standard, suture-based repair in most cases, and data is good for these procedures. They need not use mesh or other graft.
muze: I have had a pessary for one year. It does not always work. What is the next step operation-wise?
Sandip_Vasavada,_MD: It depends on your sexual activity status and how you want to "use the vagina" (sexual activity). If you are not sexually active or looking to be, vaginal colpocleisis, or closure, is a fine option and can be done as an outpatient or 23-hour stay. Otherwise, other vaginal and abdominal or robotic reconstructions may be offered.
cao: What are the types of repair for bladder prolapse?
Sandip_Vasavada,_MD: Most can be managed vaginally, but if other compartments are prolapsing, then the surgeon may need to consider abdominal/robotic surgery routes.
focuson111: I am a 60-year-old woman dealing with vaginal protrusion and weakened vaginal walls. What are some of the options?
Sandip_Vasavada,_MD: Depending on bother, you can place a pessary or proceed with surgery. The surgery can be done vaginally or robotically (abdominally).
muze: I am 78 years old. My uterus was removed by age 48. Now I have pelvic organ prolapse and use a pessary, but often this does not work to my satisfaction. What is the next step?
Sandip_Vasavada,_MD: Unfortunately, if the pessary does not manage your problem well enough, surgery is the only option. This can be done, as previously stated, vaginally in most cases, but abdominally and robotically in select instances. This should be discussed with your surgeon.
cao: It sounds as if there aren't many options for correcting a prolapse. Is this because it's not a life-threatening issue or are there physical attributes that make the surgery ineffective?
Sandip_Vasavada,_MD: Yes to both. Options are observation or not doing anything, pessary or surgery. As far as surgery goes, the success is quite good, patients just have to be mindful of risks and benefits.
berniceb: I would like some information about the effectiveness of pessaries.
Sandip_Vasavada,_MD: That is a tough question, as there are not many studies on this, but satisfaction is overall high in patients who are motivated for this to succeed.
tasson: What are the pros and cons of pessary use? What stage of prolapse should you consider using them? If you can live without them, should you?
Sandip_Vasavada,_MD: If you can live without a pessary, then do so. Pros: It’s a non-operative solution to getting the bladder/uterus in position, and it may help emptying of the bladder. Cons: These include discomfort, pain, hygiene (discharge) issues and risk of tissue damage if not appropriately managed.
muze: How long can the pessary stay in before needing to take it out again?
Sandip_Vasavada,_MD: Ideally, patients should do this every day or two on their own. If they are not able, then a doctor’s office should do it every two to three months as routine care.
Maureen: How often does pessary size need to be increased? I have had the same size for three years. I put it in and take out myself. It is a round one and works great. I forget all about it, but it seems lower to me now.
Sandip_Vasavada,_MD: Only change sizes if it falls out or is uncomfortable. There is no set time for sizing changes for this reason.
muze: When taking out the pessary I really have to strain and push, is there any simple way?
Sandip_Vasavada,_MD: Lubricant jelly helps.
prolapse: Is their evidence-based research that supports robotic surgery vs. traditional surgery regarding morbidity and long-term outcomes for POP (cystocele, rectocele, uterine prolapse)?
Sandip_Vasavada,_MD: Not much long-term, evidence-based data exists on this topic. It depends on many factors and what the patient's needs are in deciding vaginal vs abdominal/robotic. Most robotic outcomes are still short-term but are encouraging enough that most centers are proactive in doing this procedure for appropriately selected patients.
Maureen: Do you use robotics?
Sandip_Vasavada,_MD: Our team has two people who do, and I specifically refer to them. I previously did robotics but have asked two of my colleagues to develop more interest in this area.
Maureen: So you would screen as to whether the traditional method or the robotic would be used? My local doctor didn't talk about anything but robotic.
Sandip_Vasavada,_MD: Each patient can be individualized, and we typically discuss all approaches and the pros and cons of each. A patient need not have robotics if she is not motivated to do so. Similarly, vaginally, you can consider other approaches but you have to balance risks/benefits.
DaisyAnn: Is there an advantage to robotic surgery as opposed to other minimally invasive types of surgery?
Sandip_Vasavada,_MD: Not really. It is up to the surgeon and their expertise. A recent Cleveland Clinic study showed comparable results with some parts favorable to laparoscopic more than robotic.
fixit7: I currently am using a pessary for prolapse of the pelvic organs and it does seem to help, but I cannot clean it myself and have to go in to see my doctor every six months so she can do that and check it. I just dread doing that because it is so very painful to remove it, and last time it tore my flesh and it bled. She suggested that I should just have surgery and stitch it closed. I am not sexually active and haven't been for eight years so that sounds good to me. Are there any reasons that this should not be done?
Sandip_Vasavada,_MD: Not really. The overall success and satisfaction rates with the procedure she describes (colpocleisis) is quite good. The major issue (as you stated) is the desire or not for sexual activity, as this procedure usually does not leave a vagina with good caliber to allow for vaginal intercourse. If that is not an issue, this is a fine surgery.
U82y: My mother, age 86, used a pessary for 40+ years, increasing size 10 months ago. The doctor found a vaginal erosion three months ago, and she has not used the pessary for three months to let it heal with the help of Estrace®. A surgeon inserted a #5 pessary, hoping not to do surgery. It fell out, so did the #6 and the #4. Also, during the night, she only had to urinate once or maybe twice when she had the pessary in. Without the pessary, she says she gets up five, six, seven times. The gynecologic surgeon emptied her bladder for her before the first exam. She had emptied it, not knowing he would want a sample. She could not go again for him. He emptied 22 OZ! He is now scheduling obliterative surgery (LeForte procedure). What will happen with her bladder?
Sandip_Vasavada,_MD: This is a good question and this is a concern. Without knowing more details, I might suggest some bladder function testing in advance of surgery (urodynamics) to determine how well her bladder is functioning. The reason for this is it may give insight into how well (or not well) her bladder may function after the LeForte procedure.
berniceb: I do not know of any women who are pleased with their surgical outcomes after two to three years. Do you have any reliable statistics from recent studies of outcomes?
Sandip_Vasavada,_MD: Patient satisfaction questionnaires are now one of the cornerstones to evaluating outcomes of prolapse surgery. There are several studies and well-conducted NIH trials we are part of that evaluate this. Satisfaction tends to be quite high, so hearing what you describe is a bit unusual. Still, some patients may have some leakage or other issues that develop after prolapse surgery. Incontinence surgery itself may also not be 100 percent, but satisfaction remains high (well over 80 percent).
bkatic: Will Medicare cover expenses for surgery, if needed?
Sandip_Vasavada,_MD: Medicare almost always covers surgery for these types of procedures.
Maureen: My bladder is right at my vaginal opening. I have no incontinence and am using a pessary. Is surgery the only option? I also have a rectocele. The pessary seems to help both just fine but the bladder is sinking lower. What is the recovery time from surgery?
Sandip_Vasavada,_MD: If you are not just observing (i.e. not using the pessary), then yes. If the bother is bad, surgery is the only other option. Most of the surgeries can be done transvaginally and can with in-and-out or an overnight stay in the hospital depending on how much the surgeon needs to do.
Boypugs3: I’ve seen many newspaper and TV advertisements for pelvic mesh issues from attorneys. Is the procedure not safe or guaranteed?
Sandip_Vasavada,_MD: This is a good question, and this topic has gained a lot of press. The FDA did NOT recall any meshes. They simply discussed concerns about the use of vaginal mesh for prolapse repairs and asked companies to do trials comparing their use with standard suture-based repairs (522 studies). If you had a mesh procedure done and are doing fine, there are no other issues of concern. There are no guarantees in prolapse or any other surgery that I am aware of.
Maureen: I have always suffered with constipation, and it is worsening as I get older. Will that compromise any repair? I hear that this surgery will only last so long.
Sandip_Vasavada,_MD: Constipation can put repairs at risk for premature failure. The adage that surgeries only last "so long" has been challenged recently based on knowledge that prolapse recurs some, but treatment is only necessary when symptomatic. Hence, the true recurrence rate (bothersome prolapse needing management again) is quite low.
megr: What are the downsides of surgery for prolapse?
Sandip_Vasavada,_MD: Risks exist with every surgery and prolapse surgery is no exception. Typical or common risks include bleeding, infection, leakage, injuries to adjacent structures, bladder or bowel control issues and vaginal pain.
Lily Mack: I see so many TV ads about the problems with surgical mesh. What are the other surgical options available for prolapse and incontinence issues?
Sandip_Vasavada,_MD: See other responses above. One can do prolapse surgery without mesh. Incontinence can be managed that way as well; however, success rates may not be as good.
Maureen: So, mesh isn't the only route?
Sandip_Vasavada,_MD: For sure not. Robotically and abdominally, the best data is supported by use of mesh (sacrocolpopexy). Vaginally, suture based repairs work well and routine use of mesh is not warranted. When looking at data, mesh use actually results in higher anatomic success but patients may need additional management for some complications, which are unique to mesh.
consuella: What medication is best for OAB following prolapse surgery if you have both urge and stress incontinence? My surgery is just four months old and I am having increased urgency.
Sandip_Vasavada,_MD: There is no best medication, just what is best covered by your insurance plan and tolerability profile that your doctor can review with you. You should avoid caffeine and other stimulants for the bladder, as well.
Star Girl: What about physical therapy vs. surgery? An article in Prevention magazine last year indicated that this was often a better option than surgery?
Sandip_Vasavada,_MD: For leakage, one must be mindful that this is Prevention magazine, and their mission is toward prevention, not therapy. Also, data shows if leakage is bad enough, it is not helpful to do pelvic floor exercises.
Lily Mack: Is surgery a good option for someone who already has issues with IBS?
Sandip_Vasavada,_MD: It depends on the bowel issues and straining. Surgery may not help IBS symptoms.
Exercise & Activity
rambofro: If I am in my 40's, how long should I expect the surgical repair of my prolapse to last? After I have recovered from my surgery, can I continue to lift weights and do my same job that requires lifting 50- to -75-pound boxes every day?
Sandip_Vasavada,_MD: Good question. Doing the lifting you’ve mentioned really depends on the type of repair (technique) and a few other factors. A lot of lifting may compromise your repair. We usually stress avoiding lifting that puts stress on the lower abdomen and pelvis.
Xomue: What are the best pelvic floor exercises to alleviate or prevent prolapse? Is there a website (Cleveland Clinic's or other) that I can use as a guide?
Sandip_Vasavada,_MD: The NIH has a nice website for this, but remember, there are no controlled studies that show these exercises actually prevent prolapse. Still, I would encourage you to be proactive in doing these!
Maureen: Can exercise before surgery help?
Sandip_Vasavada,_MD: There are no trials that suggest this makes a difference.
Maureen: What is NIH? You recommended it for exercise.
Sandip_Vasavada,_MD: NIH is the National Institutes of Health. Here is a link to their consumer health information site: www.nlm.nih.gov/medlineplus/.
Maureen: Does daily exercise make it worse over time?
Sandip_Vasavada,_MD: Anything that strains the pelvis may affect things worsening. Still, the prolapse may worsen even without that so it is hard to be exact in all cases.
sdu: I just wanted to know more about the connection between diastasis recti and subsequent prolapse?
Sandip_Vasavada,_MD: Diastasis recti may have some effect on prolapse but, interestingly, it usually takes pressure off of the prolapse. If a woman strains too much, this may cause both problems and may be the common connection.
prolapse: Understanding that Cleveland Clinic is a world-class facility, would you rate it one of the top five places for UROGYN surgery? Who would be number one in your opinion?
Sandip_Vasavada,_MD: The short answer is yes! We have been rated as one of the top programs in the US by U.S. News and World Report many years. In regard to female pelvic medicine and reconstructive surgery, we perform a high volume of these surgeries and manage many patients with high satisfaction rates.
prolapse: What is the best approach to obtaining a second opinion? Do you often see "occult" incontinence after POP surgery? If so, what is the frequency?
Sandip_Vasavada,_MD: Occult incontinence is not uncommon after prolapse surgery or even in advance of surgery. This is a somewhat controversial subject and should be discussed with your physician. Second opinions can be arranged through the Cleveland Clinic Urology appointment line 216.444.5600. You should bring as many operative reports and as much background information as possible in advance of the appointment.
Moderator: I am sorry to say that our time with Dr. Vasavada is now over. Thank you, Dr. Vasavada, for sharing your expertise and time to answer questions today.
Sandip_Vasavada,_MD: Thank you for joining this webchat. As you can see based on the great questions, there are many people who suffer from prolapse and incontinence, and management can be controversial. These decisions must be individualized and may not apply to all locations/countries. You should seek the help of a specialized provider in the discipline of Female Pelvic Medicine and Reconstructive Surgery (FPMRS).
If you would like to make an appointment with Dr. Vasavada or any of our other specialists in female urology in the Glickman Urological & Kidney Institute, please call 216.444.5600 or request an appointment online by visiting www.clevelandclinic.org/appointments.
For More Information
On Incontinence and Prolapse
There are a number of health articles about these conditions that may help to clarify some common questions. You may also visit clevelandclinic.org/health.
On Cleveland Clinic
Cleveland Clinic’s Glickman Urological & Kidney Institute has been ranked the #2 urology program in the U.S. by U.S. News and World Report. This includes the Center for Female Pelvic Medicine and Reconstructive Surgery, which 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.
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A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult.
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