Nearly every woman with one of these postreproductive problems can enjoy a better quality of life by refusing to suffer in silence and seeking help sooner. You’ve hopefully gained an awareness of your physical changes, and you might even have taken steps to treat yourself at home. But if your symptoms are still a bother, and you’d like to find relief so you can channel your energies toward more exciting areas of your life, it’s time to seek some professional advice.
Types of Providers
Believe it or not, many doctors are either too busy or simply not familiar with treating these postreproductive problems. Others don’t encounter them often enough to recognize their impact on quality of life. Still others, surprisingly, are too embarrassed to ask patients about them. But many professionals are very interested, and your first task is to find one of them. Once you’ve brought incontinence, prolapse, or other postreproductive pelvic symptoms to your doctor’s attention, you may be referred to a specialist in female pelvic-floor disorders.
Urogynecologists first train in obstetrics and gynecology, then devote their specialty training to advanced gynecologic surgery and the lower urinary tract. They provide the full range of surgical and office treatments for pelvic prolapse, incontinence, and other disorders of the pelvic floor. In addition, their gynecological training spans the management of female reproductive and menopausal health care.
Urologists complete residency training in both male and female urology. Some then go on to complete further specialty training dedicated to female problems.
Nurses and nurse practitioners often play a key role in office care; they will participate in some of your visits and testing procedures, such as biofeedback and urodynamics.
Pelvic-floor physiotherapists are physical therapists specializing in pelvic-floor disorders, providing an array of noninvasive treatments such as pelvic-floor stimulation, massage, and biofeedback.
Gastroenterologists and colorectal surgeons may be called upon to help treat fecal incontinence in the office and/or operating room.
Whomever you choose to see, make it somebody who’s prepared to offer you a reasonable range of alternatives. Even if the doctor believes strongly in surgery for your problem, did you have the opportunity to at least discuss why physical therapy or nonsurgical therapy is not a good option? How many surgical procedures does your doctor perform each year? During your search for a provider, take the time to ask the opinions of your other doctors, friends, and colleagues, in order to find the professional whose outlook matches yours, with whom you’ll hopefully have a sense of rapport and trust.
YOUR MEDICAL HISTORY
At the doctor’s office, you’ll be asked to answer dozens of questions in the form of written questionnaires and face-to-face discussion. Your doctor will be reconstructing in detail when your symptoms first occurred, how they’ve progressed, and what seems to provoke them. Before the first visit, you may be asked to complete a voiding diary that logs every voiding and leakage episode over a period of one to four days. If you’ve already charted your own Voiding and Symptom Diary (see Appendix B), bring it in to show your doctor.
Before your visit, try to make a file of medical, surgical, or obstetrical records and a list of your medications, including over-the-counter pills and herbal supplements. Your doctor will be interested in medical conditions and daily habits that place you at risk for pelvic symptoms, and any medications that might affect your lower body. Don’t assume that any aspect of your medical history is irrelevant, since seemingly unrelated medical problems can sometimes create a higher risk for prolapse, incontinence, and other pelvic-floor symptoms. For instance, asthma, emphysema, and irritable bowel may play a role. Diabetes or congestive heart failure may affect your urine production at night. More unusual conditions, such as connective-tissue disorders, may affect the strength and resilience of tissues all around the body, including the pelvis. Your doctor should know of any prior surgeries, especially urologic, gynecologic, or abdominal. Any extensive injuries to the vagina, rectum, or bladder, forceps, deliveries, long labors, or very large newborns will be of special interest.
Finally, your lifestyle at home and work will probably be discussed. Patterns of heavy lifting, smoking, diet, and exercise will be evaluated as potential risk factors for pelvic-floor problems. Conversely, you may be asked about the impact of any postreproductive symptoms on your work, recreation, fitness, and overall enjoyment of life.
BEFORE-YOUR-FIRST-VISIT CHECKLIST
Write down your questions.
Complete your Voiding and Symptom Diary (see Appendix B).
Bring copies of any past surgical and medical records, including testing results and laboratory reports.
Bring a list of medications and dosages, including over-the-counter pills.
YOUR PHYSICAL EXAMINATION
Diagnosing your postreproductive problem requires a detailed physical examination in focused areas.
NEUROLOGICAL EXAM
A brief neurological exam will usually focus on the sensation, strength, and reflexes in both your legs and genital area, since neurological function in these areas mirrors that of the pelvic floor (they are supplied by the same sacral nerves). The neurological exam is particularly important if you have overactive bladder symptoms or retention of urine due to incomplete emptying, since on rare occasion, these problems may have a neurological cause.
THE PELVIC
Your pelvic examination will not be so brief. It will focus on all of the supports around the vagina, bladder, rectum, and pelvis. Using a speculum, the doctor will separately evaluate the upper, lower, sides, and top supports of the vagina while you’re asked to bear down forcefully. This is your doctor’s opportunity to diagnose all of the conditions we’ve discussed: cystocele, rectocele, enterocele, and prolapse of the uterus or vaginal vault. By straining as if you were giving birth, the increased pressure will provoke your maximum state of prolapse for the doctor to see. Often a separate evaluation is done in the standing position. Though somewhat awkward, the standing exam causes the prolapse to bulge out even farther, making it easier for the doctor to see and diagnose the full extent of your problem.
Q-TIP TEST
Remember the importance of upper vaginal wall supports and the floppy urethra? Your doctor may perform a Q-tip test to evaluate whether this is part of your problem. This involves placing a lubricated sterile cotton swab into the urethra and measuring its movement while you’re straining. It feels just like a small catheter being inserted, then removed a moment later.
KEGEL SQUEEZE
Your doctor might test your pelvic-floor contraction strength using an examining finger and guiding your technique as you squeeze. This will allow for a quick assessment of your levator muscles and the control you have over them.
STRESS TEST
As you’ve learned, accidental squirts or dribbles of urine during a cough, sneeze, change of position, or strain usually indicate stress incontinence. As part of your initial evaluation for this symptom, you may be asked to cough or strain while your doctor looks for sudden leakage from the urethral opening. If leakage occurs, the doctor may then support the upper vaginal wall around the urethra with a small instrument or with two fingers. If you stay dry with a cough when the urethra is supported in this manner, your stress incontinence is probably due to a floppy urethra (see chapter 8).
“HEY DOC, WHY ARE YOU TAPPING ON MY KNEES?”
If you finally made that first appointment with the urogynecologist only to find that the doctor bypasses the speculum and reaches instead for the reflex hammer to tap on your kneecaps, don’t worry. You didn’t walk into the wrong office! Certain clues to your pelvic-floor symptoms may, in fact, come from as far away as the knees and ankles. What’s that all about?
The same bundle of nerves arising from your lower spine supplies both your pelvis and your legs; as a result, identifying a neurologic problem in one of these areas can be the first tip-off that there’s a problem in the other. That’s why reflexes, s
trength, and sensations in your legs may be examined when you’re evaluated for certain pelvic symptoms.
Even more interesting are the ways in which these rather unlikely connections have enabled certain treatments. Pacemakers implanted near the lower back, for instance, can stimulate the sacral nerves and alleviate a number of troublesome pelvic-floor symptoms; amazingly, when these pelvic pacemakers are working effectively, they’ll trigger a muscle contraction in both the pelvic-floor muscles and the big toe! Acupuncture and stimulation treatments around the foot and leg, believe it or not, have also been utilized with modest success for the treatment of the overactive bladder and are still being investigated.
CATHETERIZED URINE SPECIMEN
At your first office visit, a urine sample will usually be obtained through a small urethral catheter around the size of a cocktail straw.
Urine culture. A portion of this urine will be sent to an outside laboratory for culture. This is the definitive test for ruling out a bacterial infection. The result is usually available in two to three days.
Urinalysis. This is a dipstick test of urine done right in the office, with immediate results, to look for evidence of infection or other substances not normally found in the urine (bacteria, white blood cells, blood). It cannot definitively confirm an infection.
Postvoid residual. This is one of the most important initial office tests. It determines not how much you void but how much you leave behind. Urinary retention means a volume greater than fifty to one hundred milliliters (roughly three ounces) left inside your bladder after urinating. Retaining small amounts of urine is rarely of concern; more severe retention, however, can indicate a definite abnormality and usually warrants a more detailed investigation. A handheld ultrasound machine, rather than a catheter, is sometimes used to measure postvoid residual.
UROFLOWMETRY
You may be asked to urinate into a specialized toilet seat rigged with a large funnel that spills your urine into a measuring sensor. This is uroflowmetry, a device that measures the rate of urine flow out of your bladder, the total time for urination, and the pattern of your void. Uroflowmetry is an initial test for detecting an obstructed or weakened urinary stream.
CYSTOMETRY
Cystometry is an office test that measures the bladder’s ability to fill to normal capacity (around twelve to twenty ounces of urine) and retain urine. The test involves slowly filling your bladder through a catheter while observing the pressure within the bladder. An abnormal rise in bladder pressure can indicate spasm of the bladder muscle. Cystometry can provide a quick and simple means for diagnosing an overactive bladder.
URODYNAMICS TESTING
Depending on your incontinence or prolapse symptoms, urodynamics may be recommended to determine the exact nature of your problem and the most effective treatment. Urodynamics examines the function of the bladder, urethra, and pelvic-floor muscles all at once. The test enables your doctor to play detective when symptoms become confusing. For instance, leakage provoked by a cough may reflect either weakness of the urethra (stress incontinence) or the triggering of a sudden involuntary bladder contraction (urge incontinence), and to the naked eye, these two conditions can appear identical. They can be distinguished with the help of urodynamics, allowing for proper treatment decisions.
Urodynamics is performed in an odd-looking chair with small catheters and wires. One small (spaghetti-size) catheter will be placed into your bladder, and another will be inserted into either the vagina or rectum. Your bladder will then be slowly filled until it reaches its maximum capacity. Afterward, the function of your bladder and urethra are measured as you force a cough or strain. You should expect the feeling of a very full bladder, but no pain. The doctor will analyze any leakage that occurs by studying the pressures within these various anatomic areas at the moment of leakage. Was it stress incontinence from a floppy urethra, or a thin urethra, or both? Was it an overactive bladder or mixed incontinence?
At the end of the urodynamics test, you’ll be asked to empty your urine into a special collection device. This voiding phase of the test will help your doctor to recognize problems with bladder function due to prolapse or other causes. Video urodynamics combines pictures of the bladder with computerized pressure readings; some specialists prefer it.
Urodynamics may sometimes be recommended even if your only complaint is a prolapse bulge, with no incontinence problem. If you have a large prolapse bulge repaired, there is a 30 to 80 percent risk of stress incontinence arising after surgery. Some women experience worse stress leakage while wearing a pessary even before their testing. Potential stress incontinence, as this is called, occurs because unsupported prolapse bulges tend to bend or kink the urethra, creating, in effect, an artificial valve that keeps you dry. To avoid the frustration of potential stress incontinence after a prolapse repair, urodynamics allows the doctor to plan a combined surgery that addresses prolapse and incontinence at the same time.
CYSTOSCOPY
To evaluate certain bladder symptoms, your doctor might recommend cystoscopy (cysto is the Greek root for bladder). The test is performed through a catheter-size telescopic camera, in either the office or the operating room, allowing your doctor to look directly into the bladder and urethra. During a five- to ten-minute procedure, the doctor checks for a handful of important conditions.
Inflammation. An irritated bladder and/or urethra is sometimes responsible for urinary symptoms, even a loss of bladder control. Interstitial cystitis is one type of noninfectious irritation that can be seen with office cystoscopy.
Tumors and polyps. Benign growths in the bladder or urethra can occasionally be the source of symptoms. Fortunately, malignant growths are rare.
Diverticulum. An outpouching of the bladder or urethral wall that can cause infection and irritation during and after urination.
Fistulas. These are abnormal connections or holes that can develop between the bladder or urethra and the vagina or bowel, sometimes leading to very severe or constant leakage of urine. They can be caused by prolonged pressure of the fetal head during a very extended childbirth, when the layers of tissue that separate these structures become badly damaged. In the developed world, where protracted labors are rare, fistulas due to childbirth are exceedingly uncommon; they can, however, occasionally result from pelvic operations, including hysterectomy. The risk is also increased by forceps delivery. The only remedy is surgical repair to close the hole.
Bladder stones. Various types of stones can develop all through the urinary tract. When they exist in the bladder, urinary frequency, urgency, and infections may result.
Foreign body. On rare occasion after pelvic or vaginal surgery, a stitch, staple, mesh, or graft can erode into the bladder or urethra and cause irritation. Finding any of these foreign bodies during cystoscopy may help to plan for their removal.
INTRAVENOUS PYELOGRAM (IVP)
This test is performed in the radiologist’s office, where a special intravenous dye creates an outline of the kidneys, ureters (tubes connecting the kidneys and bladder), and the bladder itself. An IVP is most commonly recommended when your doctor suspects the presence of a stone, narrowing, or other problem in the upper part of your urinary tract.
SPECIAL TESTING FOR ANAL INCONTINENCE
Anal sphincter testing (electromyography/EMG). This test measures the function of the anal sphincter nerves and muscles, using electrodes similar to an EKG’s stickers.
Anal ultrasound. A very slender probe is inserted rectally and used to create pictures of the anal sphincter muscles. Ultrasound can reveal obstetrical injuries that may be responsible for a loss of fecal control.
Manometry. Pressure measurements of the lower colon and rectum are used to evaluate the function of these structures, using specially designed balloons able to record pressure.
Barium enema. After air or opaque fluid is infused into the rectum, X rays of the pelvis and abdomen create a picture of the bowel.
Now, That Wasn’t So Bad, Was It?
/> From meeting the doctor to the examination and various types of testing, a complete urogynecology evaluation might entail a series of office visits and feel like a strange new world. Even when you come in with one symptom, it’s very common to find more than one underlying postreproductive problem. For instance, urinary incontinence may be diagnosed as mixed (stress and urge), or a bulging cystocele might be accompanied by potential stress incontinence (leakage that becomes apparent only when the prolapse bulge is supported during testing).
The tests outlined in this chapter are your doctor’s best tools for appreciating the big picture and offering you the most complete long-term relief. As you move along with your evaluation, keep your doctor’s treatment goals, and your improved future quality of life, in mind.
Preparing for Pelvic Reconstructive Surgery and Optimizing Your Recovery
Ever Since I Had My Baby Page 29