Ever Since I Had My Baby

by Roger Goldberg

  To understand how and why this is the case, consider an analogy often described to patients in the doctor’s office: the garden hose on the grass. Imagine you’ve returned from a weeklong vacation to find that your neighbor’s six-year-old son, Kenny, whom you’d paid to water your flower and vegetable garden, has left a garden hose running in your backyard. After paying the taxi driver and setting down your suitcases, you raise your eyes to see water flooding your lawn and running like a suburban waterfall through your cellar window into your finished basement. You’d like very much, to say the least, to stop the flow of water in an expeditious manner. Rather than running around back to find the faucet valve, you hurry to the nearest loop of garden hose you can find on the ground, and step on it as hard as you can.

  Now, if the garden hose was left lying on top of your driveway, your task is relatively easy—stepping down with minimal force, you compress the hose shut. Problem solved. On the other hand, imagine that Kenny left the hose lying on grass that hadn’t been cut for weeks. In this case, you step on the hose, then a bit more firmly, and become quickly frustrated to see that the water has slowed but not yet stopped. You’ll need to apply a much greater pressure—possibly even using the weight of your whole body upon your heel—to fully compress the hose as it sinks into the tall green grass. During the time it takes you to create this pressure, your basement continues to flood.

  (Above) “Normal” urethra. (Center and Below) Changes leading to stress incontinence

  With that analogy in mind, take a look at the support of the urethra on the vaginal wall right beneath it. Like a garden hose, your urethra can lie across either a strong and intact upper vaginal wall, or a weakened vaginal surface. Childbirth causes this stretching and weakening of the vaginal walls from their supports, thus reducing the firmness of the urethra’s floor. When lying on a weakened vaginal wall, the floppy urethra sinks downward with the force of a cough, sneeze, or tennis serve, but is unable to compress itself shut. Luckily, the floppy urethra, while a very common cause of postreproductive incontinence, is also one of the most treatable.

  THE THIN-WALLED URETHRA

  The second major cause of stress urinary incontinence is thinning and weakening of the walls of the urethra. Imagine your garden hose again, but this time an older one with years of exposure to the elements, its rubber walls thin, dry, and brittle. The rigid, dry-walled hose is more open and less compressible. Even if it’s lying across the firm pavement, without some rubbery thickness within to help compress the inner surfaces of the hose together, this hose would have a difficult time forming a watertight seal to hold back the water’s flow.

  Likewise, your urethra requires some thickness within its walls to function normally. If your urethral walls become too thin and lose their spongy softness, they won’t effectively compress and seal to keep you dry. Stress incontinence due to a thin-walled urethra has been given a number of fancy names, including sphincteric deficiency, a low-pressure urethra, or drainpipe urethra. By any name, it’s thought by many doctors to reflect a more severe type of incontinence—a gush rather than a squirt with a cough, or leakage with minimal exertion such as casual walking.

  This type of incontinence usually calls for a different set of outpatient and surgical treatments, the objective of which is to re-create some thickness in the urethral walls.

  YOU OUGHTA BE IN PICTURES

  Collagen injections may look pretty good in Melanie Griffith’s pillowy lips; but they can look even better in the urethra. Whether you’re a Hollywood diva, a working woman, or a soccer mom, nothing is more beautiful than being dry!

  IF I HAD STRESS INCONTINENCE DURING PREGNANCY, WILL IT BECOME PERMANENT?

  Experiencing stress incontinence for the first time during or right after your first pregnancy is by no means a guarantee that you’re destined for leakage over the long run. But for large numbers of women, incontinence that arises in association with childbirth will eventually persist as a long-term problem, whether it’s months, years, or even decades later.

  When do you begin to worry? If you’re still noticing leakage when you’re lifting your baby at five months, eight months, or one year after delivery, you may have to concede that this problem is not going to disappear on its own. Actually, one study of more than three hundred women found that the presence of incontinence symptoms only three months after delivery meant a 94 percent chance that the problem would still exist five years later. That’s quite a remarkable statistic.

  But it doesn’t have to remain that high. If you’d been noticing mild back pain and were informed that unless you began exercises, you had a 94 percent chance of long-term symptoms, wouldn’t you pause to learn about proper lifting and physical therapy? Or if you were told about some early signs of bone loss, wouldn’t you modify your diet and exercise routine to hopefully prevent osteoporosis and future fractures?

  As with your bones and heart, prevention and planning deserve a place in the pelvis. If you’re still bothered by incontinence after all of your postpartum visits, whether it’s six months or six years later, optimism alone probably won’t solve your problem. As with preventing osteoporosis, high cholesterol, or chronic back pain, you should take the time to evaluate your habits, assess your goals, and adopt a plan to preserve the long-term health and function of your pelvic floor. With the help of home exercises, office therapy, simple devices, and remarkable new procedures, you can be dry.

  STRESS INCONTINENCE: IS IT VAGINAL CHILDBIRTH OR JUST PREGNANCY THAT INCREASES YOUR RISK?

  Stress incontinence absolutely does occur among women who have delivered their children by cesarean—and even in some women who have no children. But labor and vaginal delivery do appear to increase your risk. One survey of more than fifteen hundred women showed that twelve weeks after their first delivery, those who had a cesarean were less likely to be incontinent (5.2 percent) compared with those who had vaginal birth (24.5 percent). Other studies have arrived at similar conclusions, including one from Nova Scotia, which found that six months after a first childbirth, women who delivered vaginally had nearly three times the risk of incontinence compared to those who delivered by cesarean. Among women having twins or triplets, avoiding vaginal delivery reduces the risk by 50 percent. Despite these trends, as you’ve already learned, the issue of when to consider a cesarean to protect your body is far from simple, but it may be an important one to address.

  MEDICATIONS FOR STRESS URINARY INCONTINENCE

  Whether due to a urethra that’s floppy or thin, stress incontinence is not often treatable with medication. Nevertheless, a few over-the-counter pills can improve mild stress incontinence.

  Pseudoephedrine, ephedrine (Sudafed, Ephedrine). This adrenergic medication, contained in a variety of over-the-counter cold, flu, and diet pills, has an effect similar to adrenaline. By improving muscle tone around the bladder neck and urethra, it can occasionally improve control over stress incontinence.

  These drugs can make you feel like you’ve just polished off a double café latte. The list of potential side effects includes agitation, insomnia, heart palpitations, elevated blood pressure, and confusion, among others. Even though these medications are available over the counter, they can be dangerous if you have high blood pressure or thyroid or heart problems. Be sure to read the package labeling and speak to your doctor before trying one on your own.

  Phenylpropanolamine. This caffeinelike medication was available until recently in many prescription and over-the-counter cold, cough, and allergy medications, and was shown to improve stress leakage for some women. However, FDA approval was recently withdrawn due to potentially serious side effects, including strokes. Phenylpropanolamine should no longer be used.

  Imipramine (Tofranil). This medication, which will be discussed mainly for its role in the treatment of urge incontinence, can also have occasional benefit for treating mild stress incontinence.

  New possibilities. Research trials are under way for medications that may provide more selective be
nefit to the bladder—in other words, targeting it with fewer side effects elsewhere in the body. One medication under investigation, Duloxitene, has shown a decreased frequency of incontinence episodes as compared with placebo. However, at the present time, the most effective treatments for stress incontinence are the wide variety of minimally invasive operations, office procedures, or simple devices, all of which physically support the urethra in some way.

  IMPROVING STRESS INCONTINENCE THROUGH EXERCISE, PHYSICAL THERAPY, AND OTHER NONSURGICAL METHODS

  Over half of women evaluated for incontinence will ultimately be nonsurgically treated. Beyond medications, the wide range of options available at the doctor’s office—involving no scalpels, staples, or stitches—might help to put this postreproductive problem in its proper place and get you back to enjoying life again.

  KEGEL EXERCISES

  When it comes to treating stress urinary incontinence in the least invasive way—without the use of any devices, medications, or surgery—there is one time-tested technique that you need be an expert on, if you’re not already: the Kegel exercise. Even if you ultimately select a more high-tech approach to your stress incontinence, pelvic-floor exercises can start you on the road to improving not only stress incontinence but also a number of other pelvic symptoms.

  Kegel exercises are, in simplest terms, a physical workout for the pelvic floor. Their ability to improve mild urinary stress incontinence is clear. In order to maximize their impact, approach them with a structured exercise routine, just like signing up at the gym.

  BEFORE GOING ANY FURTHER …

  Turn to Appendix A, where you’ll learn about Kegel exercises, how to get started, and all the dos and don’ts. Pelvic-floor exercises can be used alongside almost any other treatment for stress incontinence and won’t cost you a dime.

  VAGINAL CONES AND BIOFEEDBACK

  For women who are motivated to give Kegel exercises a try but run into trouble finding and strengthening the right muscles, a few devices can help. Vaginal cones are small devices of varying weights that are inserted vaginally, improving your ability to work the correct pelvic-floor muscles. Biofeedback is a somewhat more high-tech office technique that provides a visual or audio signal when you’re flexing the correct muscles of the pelvic floor, and another signal when you’re flexing the wrong muscles. Biofeedback and vaginal cones are also covered in Appendix A.

  ELECTRICAL AND MAGNETIC STIMULATION

  Another physical therapy–type alternative for treating urinary stress incontinence involves stimulation of the pelvic-floor nerves and muscles. A number of devices using the controlled delivery of either mild electrical currents or magnetic fields can trigger a passive workout for this area of the body. Rather than flexing your own pelvic-floor muscles, the device does the work for you by zapping your muscles and nerves into action. Because pelvic-floor stimulation can be used for both stress and urge urinary incontinence, it will be discussed in the section on mixed incontinence just ahead. However, this method has been shown to have only varying degrees of success, so it may not be right for you.

  VAGINAL CONTINENCE DEVICES (BLADDER-NECK SUPPORT PROSTHESES)

  Specialized devices similar to a diaphragm have been designed to fit in the vagina and stabilize a floppy urethra and, in so doing, relieve urinary stress incontinence. Like any other indwelling vaginal device, they need to be regularly removed and cleansed, and can be worn only if enough vaginal and perineal support remains to hold them in place. They’re inexpensive and worth a try if you’re troubled by stress incontinence but don’t want an operation. Remember, these devices are for stress incontinence only, and they will not relieve an overactive bladder or urge incontinence.

  Continence ring, continence dish. These devices are shaped like a dish or ring, with a knob on the outer ridge designed to compress the urethra between the vaginal wall and pubic bone during a cough, sneeze, or other moment of sudden stress.

  Introl. This flexible, ringlike device is inserted into the vagina like a diaphragm, with its two fingerlike prongs facing up toward the bladder. By stabilizing the upper vaginal wall and supporting a floppy urethra, 83 percent of stress-incontinent women may see improvement, according to one clinical trial.

  Pessaries. These vaginal devices, typically used for supporting prolapse bulges—which you’ll learn about in chapter 9—can be used to manage urinary stress incontinence. A Smith-Hodge pessary, with a shape that gives more support to the bladder outlet than most other pessary types, is a common choice.

  Balloon-shaped tampons. These have recently been developed for treating stress incontinence. One such product, the Conti-form device (not available in the United States at this time), can reportedly be left inserted for up to a month, with up to 75 percent of women reporting reduced overall leakage.

  Continence pessary

  WHAT A LITTLE BIT OF PAVEMENT CAN DO

  Remember the “garden hose on the grass” explanation for stress incontinence? Continence pessaries act like portable pavement that can be inserted beneath the urethra. By providing a firm surface for the urethra to compress against, one of these simple devices might help you to leave the doctor’s office dry.

  URETHRAL INJECTIONS

  Collagen and “urethral injection” materials can plump up the urethra to treat urinary stress incontinence. This might provide a great option if you’re looking to improve your control while avoiding surgery. These procedures are performed in the office, starting with an injection of local anesthesia around the urethra and placement of a catheter-sized telescope (see “Cystoscopy,” chapter 13). Then the actual bulking material is injected into the wall of the urethra. By narrowing the garden hose, urethral injections help to create a better seal between its walls.

  Urethral injections are generally safe and minimally invasive, allowing you to return home right afterward. If the injection is effective, you should notice the change right away. For doctors, it’s truly gratifying when a successful injection allows a woman who walked into the office wet to walk out dry, amazed at such a sudden change. The greater challenge of urethral injections, however, is achieving long-term success. Several treatment sessions are usually required to reach dryness, and for most women, periodic booster injections will be necessary.

  There are a few popular injection substances on the market, as well as several agents in development.

  Collagen. Collagen is a basic fibrous connective-tissue substance found throughout nature in various forms. It has become the most widely used product for urethral injection. Bovine collagen is relatively easy to inject and very well tolerated by the human body. The main disadvantage is its lack of permanence: the longevity of an injection is quite difficult to predict. For some women, the reduced leakage will last only a matter of weeks or months; for others, an injection may last for years. According to one study, improvement or cure was reported by 80 percent of women after one year; after two years, 50 to 69 percent were still improved. Estimates of long-term dryness vary widely, from 25 to 60 percent, depending on the severity of the stress incontinence and the type of injections used. Allergic reactions have been reported on rare occasion, so you will need a skin test several weeks before the first collagen injection.

  Durasphere. This newer substance, made of tiny carbon-coated beads suspended in a gel, is an alternative to collagen. Results for treating stress incontinence have been favorable. The major theoretical advantage is that unlike collagen, carbon beads do not dissolve or absorb. However, since the beads can lose their position over time, periodic reinjections may still be needed.

  Macroplastique. This product is composed of silicone rubber particles and has been a popular choice in Europe for years. FDA trials in the United States are currently under way, suggesting that Macroplastique might soon be available here.

  Periurethral injection

  Are injections for you? If you’re in search of a hands-free, pill-free, and surgery-free treatment for simple urinary stress incontinence, then you might think abou
t urethral injections. They can be especially useful for women who continue to have stress incontinence even after surgery, or those with a thin but not floppy urethra. Side effects—such as a thinner urinary stream or an inability to void right after the procedure, usually requiring catheterization in the office—are infrequent and seldom serious. Infections or blood clots (hematomas) can occur on rare occasion. Several office visits will probably be necessary over time, since a truly permanent injectable substance does not yet exist.

  WHAT WILL THEY THINK OF NEXT?

  Can you guess what bone, ear cartilage, Teflon, carbon beads, and liposuctioned abdominal-fat globules might have in common? Each has been injected into the urethral wall in an effort to treat stress incontinence. Trials are under way for a number of other experimental substances, including pastes made of synthetic bone and even tiny inflatable balloons that are implanted into the tissues around the urethra; they can be adjusted after insertion depending on the amount of leakage. As researchers continue to develop urethral injections, and if longer-lasting effects can be achieved, you may see more and more women choosing this alternative as a first-choice therapy for incontinence.

  BARRIER DEVICES: URETHRAL PATCHES, PADS, AND INSERTS

  Patches, pads, and inserts that fit over the urethral opening provide another solution for simple stress incontinence. Though they’ve been made in various shapes and sizes, they share the goal of occluding the urethral opening, and are meant to be inserted depending on when simple stress leakage is most likely to occur. None of these urethral plugs or patches has ever attracted a large following, perhaps because they don’t actually cure the underlying problem; they require more hands-on maintenance than most women are interested in; and they need to be removed if an active bladder or vaginal infection develops. Nevertheless, for those who are bothered by predictable moments of leakage—for instance, on the golf tee, tennis court, or ski slope—these devices may provide a handy alternative.