Magnesium citrate, magnesium hydroxide (milk of magnesia). A relatively mild and fast-acting laxative.
Lactulose (Chronulac), lactitol, sorbitol. Stronger osmotic laxatives; less common for at-home use.
BOWEL LUBRICANTS
These products, also called emollients, are inserted from below to promote emptying of hard, constipated stool.
Mineral oil (Fleet). Can be used orally or as an enema, but unpleasant side effects are common.
Glycerine suppository. Occasional use may help a rectocele bulge to empty its stool contents.
CHEMICAL STIMULANTS
These substances act to stimulate the smooth muscle of the intestinal wall, with an effect that may last up to several days. They should be started only with your physician’s guidance and not used on a regular basis.
Bisacodyl (Correctol, Dulcolax). Oral and suppository forms are available.
Senna, Cascara. Natural substances available in pills (Senokot) or herbal forms ranging from tinctures to seedpods or tea.
Per Diem. Fiber supplement available in a few forms, one including a stimulant laxative.
Remember to consult with your doctor before starting a bowel regimen that includes laxatives. Some of these medications contain salts or sugars that should be avoided by women with certain medical conditions. Overstimulation of the bowel with chemical laxatives can lead to dependence and even more severe constipation. Constipation and other changes in your bowel patterns may sometimes signal a more serious underlying problem. Speak with your doctor before treating yourself to be sure that an examination or testing isn’t necessary.
BOWEL SLOWERS
For women dealing with even a subtle loss of control over the bowels, routine situations can quickly become a nightmare when diarrhea strikes. For some individuals, a waxing and waning pattern of diarrhea and constipation called irritable bowel is a chronic state. In this case, you should be evaluated by a gastroenterologist, who can confirm the diagnosis and recommend dietary and medical strategies. But for others, sporadic and unexpected attacks occur infrequently and unpredictably. A few key medications may provide short-term relief by slowing the bowels. These pills should always be used very sparingly so that constipation doesn’t result. But when you just can’t risk an accident—for instance, during your well-deserved winter trip to Mexico, or your daughter’s graduation ceremony—they can be a cherished companion.
Some options are loperamide, Lomotil, cholestyramine resin, and diphenoxylate.
PELVIC STIMULATION, IMPLANTS, AND PACEMAKERS: NEW NONSURGICAL OPTIONS FOR ANAL INCONTINENCE.
As you learned in chapter 8, a number of stimulation devices and relatively easy office procedures can be used to help restore bladder control. If you’re coping with a major loss of bowel control and dietary and behavioral changes have failed to solve the problem, these alternatives may be worth checking into. In general, their use for anal incontinence is relatively new, even experimental in some cases. But a number of specialists are looking into the use of these options before recommending surgery.
Biofeedback. Just as with urinary incontinence, learning to identify and strengthen your pelvic muscles could help to improve anal incontinence in up to 72 percent of cases.
Interstim. The pelvic pacemaker, an amazing new therapy for urge incontinence and other bladder problems, may have a future use for anal incontinence. A clinical study is ongoing—stay tuned for results.
Neotonus. In general, responses to magnetic therapy are difficult to predict, even for its main indication of urinary incontinence. But its effectiveness for fecal incontinence is being tested, and since from the patient’s perspective, it’s as easy as sitting in a chair fully clothed, it might be worth asking about.
SURGERY FOR ANAL INCONTINENCE
Surgery to repair an anal sphincter injured during childbirth is best performed right after delivery, during the episiotomy repair; years later, the healing is far more complicated and the outcomes are far from guaranteed success. Only a very select group of women troubled by poor bowel control should consider the option of surgery later in life.
REASONS FOR SURGERY
Your doctor has identified an anal sphincter defect by physical examination and/or ultrasound tests.
You have fecal incontinence with solid and well-formed stools.
You’ve been unable to control the problem using dietary and behavioral strategies, such as the bowel drill and the bowel diet.
You’ve tried physical therapy: for instance, biofeedback, pelvic-floor stimulation, or the Interstim pelvic pacemaker.
You’re willing to accept the possibility that even after a challenging recovery, the operation may fail to improve your fecal incontinence.
TYPES OF SURGERY
Anal sphincteroplasty is by far the most common surgical approach for anal incontinence. Through an incision in the perineum extending to the anal opening, the torn edges of the anal sphincter muscle are stitched back together, re-creating its circular donut shape. Often the edges of the circle are overlapped during surgery, forming a double-layer of muscle where the “defect” previously existed—this is called the “overlapping sphincteroplasty.”
The postanal repair, levatorplasty, and other procedures utilizing nearby muscles to wrap around and strengthen the anal sphincter are performed only on rare occasion, usually by colorectal surgeons. The artificial anal sphincter is an even more uncommon procedure and is considered an option only for highly symptomatic patients who have failed other repairs.
YOU’RE IN GOOD COMPANY, AND YOU CAN RESTORE CONTROL
Problems with bowel control are common and can be devastating to an individual’s self-confidence and quality of life. A number of childbirth-related changes—to nearby nerves, muscles, and connective tissues—help to explain why women are more often left to cope with these problems than men. Between 10 and 25 percent of all postreproductive women report symptoms to some degree; fortunately, their taboo status is quickly changing.
Whatever your age and whatever the nature of your problem, start with the simple tips we’ve discussed and mention the problem to your doctor. Most importantly, don’t stop pursuing help until you’ve found relief.
Sex After Childbirth and Beyond
RESTORING SATISFACTION, SENSATION, AND SELF-CONFIDENCE
I feel almost nothing during intercourse anymore.
—LeAnne, age thirty-six
I had a wonderful, fantastic, empowering home birth … but I went to feeling basically sexless for months and actually years.
—Demi, age forty-eight
It’s been estimated that sexual dysfunction affects anywhere from 19 to 50 percent of women. In the United States National Health and Social Life Survey of more than 1,700 women, sexual dysfunction was reported by 43 percent. Sexual disorders have been reported in approximately 14 percent of women following routine vaginal delivery; the risk is thought to be even higher after a forceps or vacuum delivery. If things haven’t been the same between the sheets ever since you had your baby, rest assured that you’re not alone.
Why, then, amid all the hype over hormones, osteoporosis, and heart disease, haven’t you heard much about this aspect of your postreproductive health? The answer is simpler than you might think—physicians haven’t asked. Medical office records show that questions relating to sexual function are asked of women at their routine doctor visits only 2 percent of the time. Another study has shown that adding just a few brief sex-related questions can trigger up to a sixfold increase in reported complaints. So it’s not that sexual dysfunction never existed in years past; rather, it’s that most women quietly accepted it as an inevitable change and weren’t told otherwise. The time is long past due that you’re not only asked about these legitimate problems but informed of their causes and provided with the best preventive strategies.
Sex is like a physiological play that takes place in several acts; not surprisingly, postreproductive sexual problems may take a number of different forms. A simp
le change in sexual energy or desire (libido), a diminished physical response (arousal), an inability to reach orgasm (anorgasmia), or perhaps even physical pain during intercourse (dyspareunia): all of these may be grouped under the broad umbrella of sexual dysfunction. By menopause, decreased libido can affect up to 40 percent of women; vaginal dryness affects a similar number; and over 20 percent of women report pain with intercourse. Overall, up to 59 percent of menopausal or postmenopausal women report some negative association.
For some women, sex starts to feel different long before “the change” ever arrives. For the vast majority of individuals, postreproductive sexual problems are short-lived and resolve on their own—but sometimes they don’t. Whatever your age, diminished sexual satisfaction should never be shrugged off as insignificant, if it’s enough to bother you. If you’ve felt a change in this department, it’s worthwhile to pause, consider the potential underlying causes, and take steps to restore this important bond between you and your partner.
Right After Childbirth:
Maximizing Healing and Rekindling Intimacy
Although most doctors give the green light to resume sexual activity at around six weeks after delivery, the reality of resuming intercourse is not necessarily that simple. During the first three months after delivery, up to 50 percent of women report diminished sexual desire, and 21 percent report a complete loss of desire or aversion to sexual activity. After all, life changes in wholesale ways from the moment you leave the hospital with your new bundle—physically, emotionally, hormonally, and logistically. Right from the start, these changes can take a toll in the bedroom. Because parenting books, support groups, and postnatal classes place little or no emphasis on a woman’s sex life after childbirth, keeping the flame of your relationship glowing bright is usually left up to the two of you, with little guidance at all.
THE MIND
Although we’ll see that physical anatomy and hormones are prerequisites for normal female sexual function, a woman’s sense of intimacy and sexuality, at any age, is at least as strongly shaped by psychological and emotional factors. An active sex life is more likely to be experienced by happy women: and that activity contributes, in turn, to happiness. Being stressed or depressed is a reliable predictor of trouble in the bedroom. It would be an understatement to say that in the aftermath of childbirth, many psychological and emotional transitions arise. It’s a time of unparalleled joy accompanied by inevitable doses of stress, anxiety, and fatigue; your perspective on the world has radically shifted, and your whole self feels different. Though the bond with your partner may stay strong or even grow stronger, your shared life begins to center around new and less sensual topics. Getting in the mood quickly gives way to getting the kids washed and ready for bed. Countless diaper changes and feedings sap your emotional and physical energy, making sexiness seem obsolete. Sheer fatigue can make sleep a higher priority than romance.
Find time for yourself. Make a conscious, planned effort to recharge your own energies from time to time. Let the kids spend some time with their father, aunt, or baby-sitter while you escape the house for a movie, an afternoon with a tall stack of magazines at a café, or a long walk with a friend. During those precious hours, try to reconnect with the activities and roles that gave you a sense of pleasure and independence during your pre-mommy adult life.
Make time as a couple. Resuming sex after childbirth means two partners getting reacquainted with each other in some basic ways. Simply finding time alone for adult interaction, of any kind, becomes a major challenge. Schedule a date for just you and your partner. Even if it’s only once or twice each month, a date night will allow at least a partial escape from the roles of Mom and Dad for a short time, and hopefully an opportunity to resexualize your relationship. You may worry about still being attractive, which is natural considering the physical experience you’ve had. While your mutual physical attraction may never be exactly the same, with the right nourishment and a bit of patience, it can be even stronger. Parenting, though exhausting, can awaken attributes and passions that partners never appreciated in each other before building a family. Like taking a few steps back from an impressionist painting, you may discover entirely new and attractive dimensions in your partner and yourself that you’d never noticed before.
Rebalance work and play. Sex works better when you’re content with yourself. For some women, that means keeping a professional identity at work; for others, it’s freedom from the job and undertaking the new challenge of raising children. Striking the balance that’s fulfilling to you, whether that means being a working mom or a soccer mom, will always be best for your love life. According to one study from the University of Wisconsin, working moms place their sex life no more at risk than those who stay home. Among five hundred couples, the frequency of intercourse did not differ between individuals who worked full-time or part-time and those who did not work at all; only women who overworked, more than forty-five hours per week, were more likely to report a lack of sexual satisfaction.
THE BODY
However important are the countless psychological and emotional factors contributing to sexual function, our focus in this book is on a different set of postreproductive factors, often overlooked: the purely physical ones. Some of these you probably anticipated—physical symbols of femininity feeling different, your stomach stretch-marked and no longer washboard-flat, your lower body a bit wider. You feel physically more like a mom, perhaps, than a romantic partner. But apart from the superficial transitions, less visible changes to your lower body and pelvic floor can set the stage for other problems in the bedroom—sometimes right away but often not until years later. Facing them squarely, and learning how to optimize your postdelivery healing process, will be your best insurance policy for a healthy love life.
Keep in mind that only a decade ago, male impotence was labeled as psychological in all but a few cases; the physical causes of female symptoms, likewise, are only now starting to receive the attention they deserve. If physical changes have taken a toll on your sexual function, rest assured, it’s not all in your head.
PERINEUM AND VAGINA
The perineum is a highly sensitive area that is crucial for sexual function, and one, as we’ve discussed, that’s prone to injury. Poor healing or scarring can lead to painful intercourse during the postpartum period; even up to three months after delivery, perineal tenderness and pain will often persist. One Australian study found that one in five women took longer than six months to resume comfortable intercourse. A recent study from Harvard Medical School and the University of Nebraska found that women who had a perineal injury, or underwent forceps or vacuum delivery with their first vaginal birth, were at significantly higher risk of painful intercourse six months later.
Perineal laxity can occur if the perineum and vagina are put back together too loosely, or if stitches break down before they fully heal. This anatomic change can have a major impact on sexual pleasure, including a loss of sensation or lack of fullness during sex, or difficulty reaching orgasm during intercourse.
Anal sphincter injuries during vaginal delivery have been associated with painful intercourse in up to 48 percent of women afterward. Whether you had an episiotomy or a spontaneous tear of your perineum during childbirth, you should give this area all the attention that it deserves, and maximize its odds for a full recovery.
Avoid swelling and infection. During the first forty-eight hours after delivery, ice packs may help to reduce swelling around your sutures; switching to warm compresses may then be recommended in certain situations. Check with your doctor before using ice packs, especially if you’ve had an anal sphincter or rectal injury, since coldness can sometimes cause the muscular sphincter to spasm and feel worse.
Cleanliness is central to avoiding infection and breakdown of a perineal and vaginal repair. Shower regularly, or spray the perineum with a peri-bottle or handheld shower attachment. Let the water gently wash over your bottom; don’t scrub or use a high-pressure stream dire
ctly on the area of healing. Sitz baths, which are small plastic basins that fit onto a regular toilet seat, can be used to bathe your bottom without maneuvering into the tub. Finally, avoid tampons and douching during the healing process.
Avoid dryness. Vaginal dryness is common during breastfeeding, due to a drop in hormones, and may lead to sexual discomfort and even pain. Try a generous amount of water-soluble lubricant (Astroglide, Replens, K-Y jelly, Liquid Silk) when your doctor says it’s okay to do so. Avoid petroleum jelly and other nonwater-soluble lubricants.
Positions and perineal massage. The woman-on-top and side-by-side positions may give you the most control over the angle and depth of penetration, and allow you to reduce friction against the tender areas. You may notice that the perineum feels less flexible as the tissues heal; this does not necessarily indicate a problem. After six weeks, try massaging and gently stretching the perineum and vaginal opening with lubricant or a dab of olive oil, to familiarize yourself with the anatomic change, and get this area accustomed to pressure and touch. Estrogen-containing vaginal creams are also sometimes recommended. If tenderness is occurring deeper in the vagina during penetration, it might indicate a tender cervix or a repaired vaginal laceration that needs more time to heal. Finally, if you’ve had a cesarean, you’ll need to find positions that minimize pressure against your abdominal scar, which will probably remain sensitive for several months.
Ever Since I Had My Baby Page 23