LAPAROSCOPIC UTERINE SUSPENSION
This method involves shortening the ligaments between the uterus and pelvic walls, or fixing the uterus to the tailbone with a graft or strip of mesh through a small laparoscopic Band-Aid incision.
WHAT ABOUT THE OVARIES?
If a hysterectomy will accompany your prolapse or incontinence repair, you’ll need to decide whether to have your ovaries removed (oophorectomy) or to have them left behind. You’re probably well aware that up until menopause, the ovaries are your main source of estrogen; as for afterward, the debate surrounding estrogen replacement has become enormously complex.
If you’re postmenopausal, many gynecologists will favor oophorectomy. Ovarian cancer will develop in approximately 1 percent of women during their lifetime, and it remains one of the most difficult to detect of the female cancers; surgically removing the ovaries nearly eliminates this risk. Others disagree, arguing that the ovaries continue to play a valuable role in producing male hormones in small quantities, even after menopause, and that these substances may influence libido, sexual function, mood, and mental acuity. This data is interesting but by no means conclusive. Also, hormone replacement containing both male and female hormones is now commercially available.
If you’re premenopausal, the issues can be even more perplexing, since removal of the ovaries will induce the onset of menopause in women who haven’t yet naturally passed through “the change.” The presence of functional ovaries, as we’ve already discussed, is an important protector of so many aspects of your health, including a healthy heart and strong bones. As a result, removing the ovaries would typically be recommended only for women at an elevated risk for ovarian cancer, or those approaching natural menopause. Your age, family history, and personal feelings regarding hormone replacement after surgery all need to be carefully weighed.
A full exploration of the issues of oophorectomy before menopause, risk assessment, and hormone replacement are beyond the scope of this book. Work with your doctor to choose the approach that feels right for you.
Bowel Problems and Anal Incontinence
EXPLANATION AND REMEDIES FOR A NEGLECTED FEMALE PROBLEM
I thought that these problems were the price that all women pay for having children.
—Jennifer, thirty-nine, teacher and mother of two
Diminished control over the bowels, whether it’s stool or gas, is one of the most distressing and embarrassing problems faced by postreproductive women. Unfortunately, it’s far more common than once believed. By age forty-five, it is eight times more prevalent in women than men, occurring in around 25 percent of women who have had a previous vaginal delivery. Awareness and recognition of this problem have lagged far behind other problems of women’s health, but can you imagine one that is more elemental? If you’ve noticed symptoms in this department, or are concerned about your risk, it’s time to educate yourself.
Fecal Incontinence
To keep you continent of stool, the anal sphincter muscles normally encircle the anal opening like a donut. When functioning properly, these muscles provide constant involuntary pressure at the anal sphincter, even while you’re sleeping. Beyond that, we depend on the ability of these muscles to voluntarily contract. If you’re faced with a sudden urge while window-shopping after lunch, these muscles should be able to flex even more strongly, at least long enough to get you back to the office.
During childbirth, the anal sphincter muscles can be torn partially or completely, leading to a loss of bowel control. Vaginal delivery is the main cause of fecal incontinence in women. Among three million vaginal deliveries each year in the United States, it’s been estimated that nearly 5 percent (one hundred and fifty thousand) are complicated by a torn anal sphincter, and 25 percent of these injuries (forty thousand) will lead to anal incontinence later in life. A study from Sweden found that among those with a recognized anal sphincter tear at their first delivery, 32 percent had some form of both anal and urinary incontinence five years later. Another British study of 286 women during their first pregnancy found that anal incontinence increased from 1.4 percent, before pregnancy to 8.7 percent afterward. Some women will have trouble controlling only soft stool or diarrhea; others will become incontinent of solid stools also.
Even more surprising, a 1993 lead article in The New England Journal of Medicine showed with anal ultrasound that hidden injury to the anal sphincter occurs in up to 34 percent of seemingly uneventful first deliveries, and in up to 44 percent of women after two or more vaginal births. That’s a remarkable reflection on the physical stress of childbirth; only a fraction of these hidden injuries will cause a problem later on, depending on how a “problem” is defined.
Beyond that, a great number of women develop fecal urgency, meaning the presence of very strong urges to defecate. Reports of fecal urgency, an often overlooked bowel symptom, increased from 1 to over 10 percent after childbirth.
Flatal Incontinence
Flatal incontinence is the inability to avoid passing gas even in social situations. It’s as common among women in their postreproductive years as it is embarrassing, found in up to 26 percent of women after delivery. Many postreproductive women find that no matter how much they change their diet or bowel habits, this problem won’t go away. Why should this become a problem after childbirth?
Even if your external anal sphincter survives childbirth intact and keeps you continent of stools, damage to the less visible internal anal sphincter may have occurred, leading to flatal incontinence. Unlike the external anal sphincter, which resembles a donut, the internal sphincter muscle is a thin, sheetlike layer surrounding the rectal tube. An intact internal sphincter makes the rectum a high-pressure area, giving you the ability to sense the presence of gas and appropriately deal with it. If your internal sphincter is no longer functional after childbirth, you’ll often be completely unaware of gas until it’s too late.
Repairing or even looking for injury to the internal anal sphincter is uncommon in routine obstetrical care. Probably because women rarely mention flatal incontinence, doctors are unlikely to give its obstetrical causes a great deal of thought. Amid all of the drama on childbirth’s stage, this issue simply hasn’t drawn the attention it deserves, during birth or afterward.
Other Bowel Problems After Childbirth
If your pelvic floor weakens after childbirth, the overall function of your bowels can also become slower and weaker. Due to a diminished functioning of nerves and muscles, a shift in anatomy, or both, some women will notice a change in their bathroom habits, requiring more proactive strategies for keeping the bowels moving, which we’ll discuss soon.
Of all bowel problems, it’s fairly common to notice hemorrhoids for the first time during or after pregnancy. If you already had them before childbirth, chances are they got worse. Whether they’re old or new, for a good number of postreproductive women, hemorrhoids become a steady companion and a source of burning, itching, bleeding, and pain.
There are specific reasons why hemorrhoids grow during and after childbirth. As the pregnant uterus expands, its size and weight become large enough to compress the hemorrhoidal veins that run through your pelvis and carry blood back to the heart from your lower body. Compression of these veins leads to sluggish blood flow and pooling into varicose veins. Imagine a tourniquet tied tightly around your upper arm, causing the downstream veins in your hand and wrist to bulge. That’s very similar to what occurs in the pregnant pelvis. As the growing uterus begins to compress the nearby blood vessels, varicose veins in the lower legs often flare. They flare around the anal area as well. The only difference is that the anal variety is given a special name and a shelf in the pharmacy aisle.
If all of this sounds alarmingly familiar, don’t despair. Did you know that up to 80 percent of anal incontinence can be alleviated without procedure or surgery?
LIFESTYLE AND HABIT CHANGES FOR COPING WITH ANAL INCONTINENCE
THE BOWEL DRILL
Your bowels are yet another
creature of habit, and somewhere along the line, after childbirth, you might have noticed that habits in this area began to change. Anal incontinence, frequent sudden urges to move your bowels, trouble urinating unless your bowels have emptied, never feeling finished after trying to empty, or soiling your underwear: all of these are potential signs of a postreproductive change, and many can be improved with behavior alone. For instance, using only dietary changes and pelvic exercise, fecal incontinence can be improved or eliminated at least 50 percent of the time. As with the bladder, the bowels can be retrained to some degree. The following three steps should help to keep your bowels well behaved.
Step #1: Prevent Constipation. Chronic constipation occurs in up to 25 percent of the population, and it’s more than just an inconvenience: it’s one of the genuine archenemies of your pelvic floor. Hard stools and constipation encourage heavy valsalva straining on the toilet, a habit that can further stretch and weaken the pelvic nerves and muscles. Over time, this may lead to increased floppiness, causing incontinence, and the bulges of pelvic prolapse. Less commonly, impaction can occur, meaning that the colon is temporarily blocked by hard stool resulting from severe constipation. If the rectum is filled with impacted stool, it can form a bulge that presses against the urethra or bladder outlet, making urination more difficult and causing the bladder to overfill. For that reason, women with rectoceles, especially, may notice that their urine flows easier after their bowels have been emptied. For these reasons, although maintaining regular bowel movements is a healthy habit at any stage of life, it’s particularly important for your postreproductive body.
Fiber and hydration. These are the key ingredients to keeping your stools bulky yet not too hard. Just ahead, you’ll learn the basic ingredients for a healthy bowel diet. Good hydration is another component, although the mantra of eight glasses a day is not necessary for most women.
Exercise. This may be the most overlooked aspect of bowel control. A regular exercise routine is critical for keeping the bowels moving, and it may also keep your pelvic floor healthier over the long run. Even a brisk twenty-minute walk each day will greatly improve your function.
Step #2: Time your movements. Preventing constipation is sometimes as simple as making the effort to move your bowels regularly. Amid a hectic daily schedule, it’s common to postpone trips to the bathroom; this can lead to constipation, as the stool loses its water content and the bowel muscles pass up their best shot at fully emptying. Unlike bladder drills—where resisting the urge to urinate can be therapeutic—with the bowels, it’s almost always best to go to the toilet as soon as you notice an urge. Empty your bowels, or at least try to do so, after breakfast and other meals. At those times, your colon and rectum will tend to most fully evacuate due to the natural stimulation of the bowels that occurs after eating. As a result, rectoceles will be less likely to retain stool contents, leaving you less prone to soiling and accidents. Take your time on the toilet, and avoid straining. Between one and three movements each day is considered normal.
Step #3: Learn your patterns. You may need to tailor your habits for different times of the day or even month. For instance, some women notice variation in their bowel habits during different phases of the menstrual cycle. In the week before your period, high levels of progesterone tend to encourage constipation by relaxing the smooth muscle of the bowels, causing them to fail to move stools along as efficiently. As a result, you may need to add stool softeners during these times. Your Voiding and Symptom Diary (see Appendix B) may help you to identify these patterns.
SPLINTING
This term refers to using a finger, or several fingers, to push down on the lower vaginal wall in order to defecate. Though it’s rarely discussed outside of the doctor’s office, this is a common habit among women with rectoceles, due to stool becoming stuck in the bulge. It’s a habit that’s unnecessary, as the problems causing it are treatable. If splinting has become a necessity for you even after following these simple tips, be sure to discuss the problem with your doctor.
DIET AND SELF-HELP REMEDIES
THE BOWEL DIET
If you’re dealing with postreproductive bowel symptoms, such as a loss of control over stool or gas, fecal urgency, or soiling, simple changes to your diet may help.
Fiber, or roughage, is the part of plant food that passes through the bowels without being absorbed or digested. Fiber promotes larger, bulkier stools, making them easier to control—either holding back or letting go, depending on the situation. A bulky stool will be far less likely to accidentally slip past a weak anal sphincter or rectocele bulge to cause incontinence or soiling. Most Americans consume less than half of the recommended daily fiber intake.
You’ll find both major types of fiber, water-soluble and insoluble, in a number of basic food products. Aim for 28 to 30 grams of daily fiber, along with plenty of water. Introduce fiber into your diet gradually, to allow your bowels to adjust.
Bran: wheat or oat. Bran is the outer capsule of grain and a great source of fiber. Try bran cereal and muffins, oatmeal or high-fiber wafers, along with fruit or applesauce.
Wheat germ. Try one to six tablespoons in your daily diet, along with your favorite cereal, fruit, or cottage cheese.
Seeds, brown rice, fiber breads, fiber cookies.
Popcorn. An inexpensive, low-calorie source of pure roughage.
Psyllium. When soaked with water, psyllium husks become gelatinous, and when eaten, make the stool soft, bulky, and hydrated. Seeds and husks from the psyllium plant, or psyllium bran, are the raw product for several popular stool-softener supplements (Metamucil, Per Diem fiber, and generic equivalents).
Prune juice. Six ounces each morning to start the day.
Cooked or stewed fruits. Prunes are fat-free and even available in different flavors. Applesauce or cooked fruits can provide a tastier substitute.
Leafy vegetables and fresh fruits. Just like Mom always said, make lettuce, spinach, celery, or broccoli a regular part of your lunch and dinner.
Avoid fast food. Don’t just “hold the pickles, hold the mayo;” go one step further and hold the whole darn order. Fast foods are mostly fatty, low in soluble fiber, and likely to leave your bowel movements soft, fatty, and slow.
Watch for what stimulates, and know what slows:
Stimulates. Caffeine, spicy foods, and lactose can stimulate the bowel, loosen the stools, and make control a much bigger challenge.
Slows. Cheese and yogurt may have a binding effect on the bowels. On the other hand, for women with an irritable or lactose-intolerant bowel, they can sometimes act as stimulants. Bananas and rice are sometimes helpful for binding the stools and harnessing a runaway bowel.
TAKE THE PLEDGE: BECOME AN LOL
Little old ladies (LOLs) are known for eating fiber and stewed fruit and drinking prune juice by the six-pack. Why do you think, good reader, that might be? It’s not because these ladies’ taste buds are any different from yours, or that they’ve somehow lost their marbles. Quite to the contrary. The reason is that little old ladies know what works. Through daily fruit and fiber, they stay regular with the time-tested tricks that work the best. When it comes to a good bowel diet, remember that you’re never too young to become an LOL.
MEDICATION AND HORMONAL REMEDIES FOR ANAL INCONTINENCE
If you have anal incontinence—whether it’s the actual loss of stool or just fecal urgency or soiling—don’t skip this section. The majority of bowel problems such as these can be fixed with a combination of diet, behavior, and one or more basic remedies found in just about any pharmacy. Understanding the different products that can help to regulate your bowels is the first step.
BULK-FORMING STOOL SOFTENERS
Bulky stools will naturally stimulate the bowel, encouraging better peristalsis (intestinal activity) and more efficient emptying. If you have a rectocele, well-formed stools will make you less prone to fecal soiling and incontinence.
Psyllium (Metamucil), calcium polycarbophil (FiberCon), duco
sate sodium (Colace, Surfak), and generic equivalents
Husk supplements, malt extract
Add these agents slowly to your routine, and drink at least eight ounces of water with each dose. Using fiber supplements without adequate fluid intake can actually worsen constipation. Because they’re nonaddictive, you can use them daily without concern.
LAXATIVES
If your bowel movements remain infrequent (fewer than three or four per week) despite high fiber and good hydration, an occasional laxative may stimulate some action. But avoid regular use. Because certain laxatives fail to soften the stools, you may be better off with a more aggressive regimen of stool softeners. Also, the intestines can become dependent upon laxatives if they’re used too regularly, causing a lazy bowel. When you see the word laxative on the package, remember to use sparingly, and don’t hesitate to consult with your doctor. If your doctor okays their use, laxatives come in a few forms:
Water magnets. These agents, also known as osmotic laxatives, stimulate bowel activity by pulling water into the intestines. They are made of specific salts or sugars that are not absorbed by the bowels. Use these substances with care. If used excessively, they can cause abdominal cramping or an upset stomach.
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