DIURETICS
Diuretics such as Lasix, Maxzide, and Diuril cause the transfer of water from around your body into your kidneys and bladder. These “water pills” are prescribed by doctors for the treatment of high blood pressure and heart disease, and also to relieve swelling from fluid retention (edema). By causing a rapid excretion of bodily fluids, diuretics can flood your bladder with urine; certain types can also irritate the bladder lining. If you’re coping with incontinence, some diuretics may be better for you than others—an issue worth discussing with your doctor. Never stop or start one on your own.
ASTHMA MEDICATIONS
Asthma puffers (Albuterol, Ventolin) often consist of adrenaline-like chemicals capable of causing urinary retention, overflow incontinence, and urinary frequency. Oral steroids—used for asthma and a wide range of inflammatory conditions, including skin rashes—can occasionally tip a weak bladder over the edge.
PAIN RELIEVERS
Certain pain or headache medications (Excedrin, Anacin) contain caffeine, which, as you’ve already learned, is not only a diuretic but also a bladder stimulant. Narcotic pain medications may cause constipation.
SEDATIVES AND SLEEPING PILLS
Certain antianxiety medications (Valium, Ativan, Xanax, Serax). relax the urethral sphincter muscles, in some cases enough to cause leakage.
PSYCHIATRIC AND ANTISEIZURE MEDICATIONS
Side effects of these drugs (Thorazine, Haldol, Clozaril) can include incontinence, urinary frequency, urgency, and nighttime urinary loss.
SOME ANTIDEPRESSANTS
Drugs such as Elavil and Prolixin might occasionally affect urinary symptoms or control.
CONSTIPATING DRUGS
Watch out for iron tablets, pain pills, or cough medicine containing codeine or another narcotic, and antacids containing calcium or aluminum.
GOUT MEDICATION
Colchicine, a common antigout medication, may aggravate urge incontinence.
JUDY AND HER MEDICINE CHEST
Judy was forty-two years old when she was evaluated for mixed stress and urge incontinence, as well as a small cystocele that hadn’t changed for years. It seemed, she said, that her bladder symptoms were almost intolerable in the spring and late summer, with greater frequency of urination and uncontrollable urges; yet during the rest of the year, they were manageable.
So we talked and charted her observations. What was making her so uncomfortable during those seasons? Her daily routine and diet seemed very consistent from month to month. She exercised regularly year-round. But medically, every month was not so equal. Judy was a mild asthmatic, bothered only during cold winter days and the dry weeks of the ragweed season. Ever since she could remember, she’d carried a small puffer in her purse, along with an antihistamine for her allergies. She showed them to me, and it became quickly clear that we’d found the culprits. These medications were each capable of tipping the balance of her bladder control; when she took them together, she didn’t stand a chance. In the end, finding relief for Judy was as simple as looking into the medications she’d been taking for years.
If you notice a change in your pelvic symptoms after taking medication for an unrelated problem, it’s probably not your imagination. More likely, it’s the effect of drugs on the nerves and muscles of the bladder, bowels, and pelvic floor.
QUICK AND EASY MEDICATION CHECKLIST
If You’ve Noticed One of These … Check if You’re Taking One of These
Difficulty starting your urine stream Weakening of stream Incomplete emptying Frequent urges Antihistamines Antidepressants Blood-pressure medications Cold medications (containing pseudoephedrine) Steroids or antiinflammatory pills Irritable-bowel medications
Worse stress leakage (with sneezing, coughing, lifting, exercise) Certain blood-pressure medications
Sleeping pills and muscle relaxants
Psychiatric medications
Frequent need to urinate Incontinence
Large amount of urine Diuretics/water pills
Constipation
Rectocele pressure or discomfort Pain medications (containing narcotic)
Iron supplements
WHAT ABOUT Herbs?
Just reading the labels of some herb supplements can inspire hope for curing your most persistent maladies. Their extensive claims of bodily benefits often stop just short of promising world peace. One herbal site that I stumbled across on the Internet even said, for instance, that oatmeal can rejuvenate your sex life (would you have guessed it, given the look of that Quaker Oats man?). Enticing as these claims may be, they’re rarely backed by science and shouldn’t be taken at face value without some medical advice.
So, what about herbs for the bladder?
Buchu tea (Agathosma betulina). Tea from the leaves of this South African shrub have been used by some for its diuretic and anti-inflammatory action in the urinary tract, and reportedly even as an antibacterial for treating cystitis.
Bearberry (Uva-ursi). Leaves from this plant have been used in diuretic and laxative preparations and as a popular urinary disinfectant in Europe. It’s sometimes recommended as a urinary aseptic for bladder and urethral inflammation. Bearberry is available in concentrated drops or tea to mix with water, or as a capsule or tablet.
Alfalfa. Taken as a pill, alfalfa is reported to reduce the odor of urine, like a deodorizing tablet for women prone to leakage. Vitamin C, according to some, may serve the same purpose and may also have an antibladder -infection effect.
Cornsilk. A few cups of cornsilk tea each day has been touted traditionally as bladder-soothing and a means for preventing cystitis.
Horsetail (Equisetum arvense). Horsetail is an herb that’s rich in silicon, cited as a urinary diuretic. It’s prepared as tea and also available in tablets and capsules.
Catnip tea (Nepeta cataria). Catnip has been touted as an antispasmodic. The Native Americans used it for colicky babies and gastrointestinal disorders.
Herbal remedies can be interesting to investigate, but an herbal panacea for bladder problems simply does not exist. The touted effects are rarely proven with medical research and should be discussed with your doctor.
DRUGS OF THE FUTURE: MAGIC PELLETS AND RED-HOT CHILI PEPPERS
In years to come, your medical options for treating incontinence and bladder dysfunction will look completely different from those of today. Trials are under way, for instance, to test a specially engineered capsule that inserts like a magic bullet into the bladder, slowly releasing medication for several months. Too tame for your imagination? How about capsaicin, an extract of red-hot chili peppers from the genus capsicum, instilled directly into the bladder? Not hot enough? Then imagine resiniferatoxin, another essence of peppers that’s a thousand times more potent. Even Botox has been used experimentally for treating the overactive bladder, with some encouraging early results. Only time will tell which innovations will fall by the wayside and which will become the next cutting edge. The field of urogynecology is moving fast—and the landscape up ahead looks promising.
QUICK AND EASY TIPS: KEEPING DRY AT THE GYM
One in every three women report leakage that occurs only during strenuous exercise. Are you one of them? Sure, you could decide to eliminate bouncing and straining activities from your routine, which would probably improve your symptoms. But who really wants to give up Tae-Bo for a stationary bike, or a brisk jogging routine for lazy walks on the treadmill? If you’re anxious to get a head start before even seeing the doctor, try these low-tech tips:
Use tampons. A regular tampon may sometimes provide just enough support beneath a weak vaginal wall to stabilize a floppy urethra and keep you dry during exercise. Especially if you experience only mild incontinence symptoms triggered by a high-stress workout, a tampon might prove helpful. After a shower or bath, the tampon can be more comfortably removed than when it is dry; or try lubricating it with a bit of K-Y jelly. Occasionally, a large diaphragm can serve the same purpose. Whenever using a tampon for a reason other than yo
ur period, discuss the idea with your doctor first, and remember to never leave a tampon inside beyond its recommended time.
Try over-the-counter medications. A few common decongestants may alleviate mild stress incontinence if taken an hour before exercise. Because they can increase your heart rate and blood pressure, they’re not recommended for everybody. Check with your doctor first.
Cool it with that water bottle. Proper hydration is important, especially when you’re exercising in dry or hot conditions. But some individuals (you know who you are) take it to the extreme. Overhydrating will challenge even the strongest bladder. Drinking only when you’re thirsty, and chugging just a bit less from that ever-present water bottle, may be the simplest way to make it through your workout without a dribble.
Tread lightly. Harsh landings may increase leakage. If you jump, try landing on the balls of your feet with some bend in your knees, rather than on a flat heel.
Pelvic Prolapse
BULGING, DROPPING, AND FALLING OUT: CAUSES, SYMPTOMS, AND TREATMENTS
I had only one itty-bitty baby, thirty years ago. Why did this happen?
—Sixty-one-year-old, during a preoperative visit for uterine prolapse
Pelvic prolapse has complicated women’s lives from time immemorial—in fact, probably ever since women started having babies. So, how come you’d never heard of it before you started feeling symptoms? How come it hasn’t been mentioned in history books? Well, it has—as far back as the writings of Hypocrites. And it’s been treated in countless ways, many of them unfortunate. Women have been suspended from their feet upside down, or cauterized with hot iron and acids. In nomadic desert tribes, some women were known to place salt in their vagina after delivery to help shrink the vaginal walls and prevent prolapse.
Not until the nineteenth century were safe and effective treatments developed. Only then did most women with prolapse feel empowered to confess this problem to their doctors. Yet even today, the social embarrassment associated with these highly personal problems causes many women to underreport symptoms relating to prolapse, and as a result, it remains among the most challenging surgical conditions to diagnose, let alone treat. What we do know is that by age eighty, the estimated likelihood of undergoing an operation for prolapse or incontinence is 11.1 percent. Give that statistic a moment’s thought—you’re about as likely to have a major surgery for weakening of the pelvic floor as you are to experience breast cancer during your lifetime.
Only a Problem … If It’s Causing Problems
Almost all women enter their childbearing years with normal, strong pelvic supports. Depending upon childbirth, exercise habits, and work routines over the years, almost all women will eventually develop some degree of weakening down below, at least enough to be visible to a doctor during a pelvic exam. Fortunately, only a fraction of women with mild changes to their pelvic supports will be bothered by symptoms. For the rest, prolapse remains a physical feature that just happens to be there—the pelvic equivalent of wrinkling, of no consequence to daily function. Unlike high blood pressure or diabetes, which must be treated even during their silent early stages, asymptomic pelvic prolapse is rarely of medical importance. Prolapse is a problem only if it’s causing problems and diminishing your quality of life.
So … You’ve Noticed a Bulge
Did you first notice the problem while cleaning yourself on the toilet? Did you feel it during intercourse or actually see it in the mirror? However you discovered your prolapse, no doubt you wondered what it could possibly be. What could it be? A bulge at the vaginal opening almost always means you’ve lost some pelvic support. The more challenging question is where?
Figure 9–1 shows perfectly normal pelvic supports. The vagina is like a horizontal tube with strong upper and lower walls. As you’ve seen, the vagina’s upper vaginal wall provides the major support underneath the urethra and bladder, like a hose lying on the pavement. Beneath a sturdy lower vaginal wall, the rectum is kept down in its proper place. Finally, several ligaments that attach to the bones of the pelvis support the uterus, cervix, and upper apex of the vagina. So under normal conditions, as we’ve discussed in previous chapters, the strength within the vaginal walls, and their attachments to the pelvis, play essential roles in keeping the nearby organs—including bladder, rectum, and bowel—where they’re supposed to be.
When a bulge has developed, support might have been lost around one or all of these individual areas, including the vagina, cervix, or uterus. Even within the vagina, the bulge could be arising from the upper wall, lower wall, entrance, or apex. Not all bulges are alike. Different types of prolapse often cause their own distinct symptoms and call for different treatments.
“MY MOTHER NEVER HAD THIS PROBLEM … WHY ME?”
Prolapse is common among postreproductive women, even those whose mothers and sisters were never affected, though family history may play a role, according to one recent study from the Netherlands. The odds of vaginal prolapse appeared to be five times higher for those individuals who could recall that their mother had prolapse, in comparison to those who could not.
Normal pelvic anatomy (without prolapse)
Types of Prolapse
CYSTOCELE: THE DROPPED BLADDER
A cystocele is what women have long referred to as a dropped bladder and it is one of the most common prolapse bulges in postreproductive women. A cystocele forms when your normally flat upper vaginal wall loses its support and drops downward. Because the bladder is located right above the upper vaginal wall, when that wall starts to drop, the bladder will drop right along with it (see Figure 9–2A). In advanced cases, the bulge may become visible outside the vaginal opening.
Cystoceles can cause a number of symptoms, ranging from vague to quite specific. Vaginal pressure is common, especially when the full bladder bulges down from its normal pelvic location and is felt in the vagina. During intercourse, pressure may be even more pronounced against the vaginal bulge.
Slowing of the urinary stream may occur when the urethra and bladder sink lower, as the normally straight urethral tube develops a slight bend or kink. Postvoid fullness—the sensation of bladder fullness even after you’ve tried to empty—may be caused by retention of urine inside a cystocele bulge that fails to fully empty while you’re on the toilet. To compensate for this difficulty in emptying, many women with cystoceles begin a habit of double voiding, as discussed in chapter 8—several moments after they urinate, the urine retained inside the cystocele triggers a second urge, and they void a second time.
Finally, a cystocele bulge can also cause bladder infections. Like still water in a pond without a running river, cystoceles contain a pool of retained urine that doesn’t flush out of the bladder normally. As a result, any bacteria finding its way into the bladder will have the opportunity to linger, multiply, and eventually cause a full-blown bladder infection.
RECTOCELE: THE BULGING RECTUM
Just as a cystocele is a downward bulging of the bladder into a weakened upper vaginal wall, a rectocele results from upward bulging of the rectum into a weakened lower vaginal wall. Figure 9–2B shows a weak lower vaginal wall allowing the rectum to bulge upward, forming a rectocele. This abnormally wide area in the rectal tube can, in turn, lead to a number of troubling symptoms.
First, if you’ve developed a rectocele, it’s quite possible that your rectum never fully empties itself of stool, in contrast to a normal rectum, which fully empties after each bowel movement. As a result, rectocele-related symptoms include the sensation of rectal fullness and pressure, and difficulty pushing out stool even when it feels like it’s right there. These symptoms can become aggravated by constipation, as hard stools are more likely to become stuck in the rectocele. Some women with rectoceles rely on splinting to empty their rectum, placing a finger in the vagina and pressing down on its lower wall during bowel movements. Splinting straightens out the weak and bulging lower vaginal wall, flattens the rectocele bulge, and allows stool to pass through.
W
ith a rectocele, you’re also prone to experience some loss of bowel control. Soiling of your underwear becomes more common, since stool left behind within the rectocele bulge is located just a short distance from the anal opening. Even more distressing is fecal incontinence. This can become a problem, as the stool within the rectocele can accidentally slip by the anal sphincter while you’re exercising, lifting, or changing position.
If you have a cystocele, or a dropped bladder, your bladder itself is actually normal. It’s just sinking down into a weakening in your upper vaginal wall. By the same token, if you have a rectocele, there’s nothing wrong with your rectum—it’s just bulging up into a weakened lower vaginal wall. Cystoceles and rectoceles are not diseases of the bladder or rectum—they’re just mirror-image changes to the vaginal supports that allow those other organs to wander from their normal locations. Later in this chapter, you’ll learn about simple devices and surgical procedures that relieve cystoceles and rectoceles by restoring vaginal supports closer to their prechildbirth state.
UTERINE PROLAPSE
Uterine prolapse, or a dropped womb, occurs when the uterus and cervix drop down toward the opening of the vagina after the pelvic ligaments supporting them have weakened. Sometimes diagnosing uterine prolapse is easy—you see the cervix (an irregular bulge with a small, slitlike opening at its center) protruding outside the vagina, or feel it while inserting a tampon. But most of the time, your doctor will make the diagnosis during the office exam. Uterine prolapse is one reason for needing a hysterectomy, usually performed through a vaginal incision. The symptoms caused by uterine prolapse can vary widely. A dropped uterus may cause pressure sensations in the vagina or rectum, or even lower back pain. Or sexual discomfort can develop from the penis striking the cervix, which has dropped from its location high up in the vagina, to somewhere in the middle or lower portion. Finally, if the uterus drops a lot, you may actually see the cervix outside the vaginal opening. If the cervix hangs low for prolonged periods, it can become irritated and significantly enlarged, even causing a heavy vaginal discharge.
Ever Since I Had My Baby Page 19