Ever Since I Had My Baby

by Roger Goldberg

  CHOICES, EFFECTIVENESS, RISKS, RECUPERATION, AND WHAT TO DO WHEN THINGS DON’T FEEL FIXED

  The only “minor” surgery is one performed on somebody else!

  —Wise woman

  I’m playing in a softball league this summer for the first time in three years. It wasn’t much fun when I was always soaking wet by the third inning.

  —Forty-six-year-old after incontinence surgery

  Five Key Questions to Ask Before Your Operation

  So you’ve decided, “Enough with pessaries, gadgets, and pills—fix me!” If that’s the case, rest assured—there’s a very good chance that a very good surgical correction is waiting for you, one that may dramatically improve your lifestyle if it’s been diminished by urinary or fecal incontinence, prolapse, even sexual dysfunction. Despite the countless medications, exercises, and innovative devices available to treat your postreproductive problems, many women each year bite the bullet and decide to have surgery. Up to 11 percent of the general female population will make this choice during their lifetime for prolapse and incontinence alone. In order to find the best operation for you, and to enter into it with the most realistic expectations, you’ll need to sort through an array of choices. Not all operations are alike, and not all surgeons will not give you the same advice. Before signing on, make yourself an informed consumer.

  Let’s assume that you’re frustrated with leakage when you cough, sneeze, and exercise—a straightforward case of urinary stress incontinence. You might have heard through the grapevine that surgery can offer wonderful results with high rates of success, and a quick return to work, exercise, and a full daily routine. But which method of surgery is right for you? The vaginal, laparoscopic, or open abdominal route each has its own risks, benefits, results, and recovery time. The repair of a cystocele, rectocele, or other prolapse bulge could involve anything from ordinary stitches to man-made mesh or even cadaver-tissue grafts, and each technique has its own track record. How will the success of these surgical alternatives compare not only for tomorrow but for ten or twenty years in the future?

  When it comes to having surgery for a postreproductive problem, you’ll often face a broad range of alternatives. Though these conditions all relate to weakness and relaxation within the fairly confined region of the pelvic floor, there are a surprising number of ways to rebuild strength and support; this means many choices and countless questions. Amid all of the testing, talking, and fear of the unknown, let’s focus on a few key questions that will help you to arrive at your own best choice of surgery.

  QUESTION #1: WHY HAVE SURGERY?

  Though postreproductive problems may severely threaten your lifestyle, they’re almost never life-threatening. Even pelvic-prolapse bulges that may look rather dramatic are rarely medically urgent in the way a bowel hernia might sometimes be, so in most cases, surgery is not a requirement, it’s a choice. When it comes to choosing surgery for prolapse or incontinence, take your time and make your decisions with a few simple thoughts in mind. Surgery might be a good option if:

  You’re bothered. Incontinence, prolapse, or vaginal relaxation that does not cause symptoms usually does not need to be fixed just for the sake of restoring your anatomy back to a picture-perfect state. Ask yourself how these problems are affecting your life. How much do they detract from your physical activity, social routine, and intimacy? For some women, even a great deal of leakage, bulging, or a change in sexual functioning may have little effect on happiness; for others, minor accidents or small physical alterations may make it impossible to enjoy exercise, work, travel, or sex.

  You’ve explored and know your options. By now you’ve learned about the many nonsurgical alternatives for the most common postreproductive problems; before having surgery, explore any that sound attractive. Some women consider life far too busy for exercise routines, devices, pessaries, magnetic chairs, or injections, and they choose the quick fix of surgery right from the start. Others will do anything and everything to avoid the operating room and will embark on a stepwise approach even if it involves committing to a daily effort or combining several therapies. In this day and age of countless options, there’s only one rule that applies to all women in choosing a treatment plan: to each her own!

  You’re informed and feel comfortable with what you’ve learned. Take whatever time you need to clearly understand the procedure your doctor is recommending, including the typical recovery and potential complications. No matter how simple a surgery is intended to be, your recuperation can always turn out to be more difficult than expected. If you’re still uneasy, ask if you can speak with a patient who has undergone the procedure.

  Is prolapse surgery ever medically urgent? Not often, but on very rare occasion, it becomes medically important to proceed with surgery for a postreproductive problem. This operation is no longer truly elective. The most common example is when severe prolapse causes blockage of urine flow from the kidneys to the bladder. In this predicament, watching and waiting can eventually lead to kidney damage.

  QUESTION #2: IS NOW THE RIGHT TIME?

  Though you may choose to call upon family, friends, or others for opinions and advice, the final decision to have an operation is yours alone. It’s your body, and the recovery after surgery, whether smooth or rocky, will be yours alone to cope with. How will you know when the time is right?

  Think about your family planning. Are you absolutely certain that your childbearing years are behind you, or are you still keeping family-planning options open? Many operations for incontinence and prolapse are best delayed until childbearing is complete, to minimize the risk of weakening the repair and needing yet another operation in the future. If you do plan to have more children, using a pessary or continence device may provide temporary relief until the time is right for surgery. However, if symptoms become severe, surgery may sometimes become a consideration even if you do want to have a future pregnancy. In this case, be sure to plan an operation that will preserve your fertility and ability to withstand pregnancy, and discuss how its long-term success might be affected by a future pregnancy and delivery. Many operations will allow you to have a baby afterward, but all of the issues need to be discussed.

  Consider your life stage and support network. If you still have young children at home, will you be able to avoid lifting them during your recovery? Is there somebody who can help carry those grocery bags from the garage to the kitchen counter, or shovel snow off the front steps? Young mothers are often advised to delay having pelvic surgery until their youngest child is a toddler. By then the whole family should understand—or at least may understand—and can cope with the fact that Mom won’t be cleaning, carrying, or lifting at full steam for a little while.

  Examine your health. Later in life, your general health will begin to weigh into your surgical decisions. If you’re a good candidate to safely undergo surgery today, will you be as fit several years down the road? Your immune system, mobility, and overall cardiovascular status all factor into the way you’ll bounce back after an operation; unfortunately, all of them diminish with age.

  Have you tried the pessary test? If you’re undecided over surgery for pelvic prolapse, especially if your pelvic symptoms have been vague—such as a little bulging, a bit of pressure, or occasional pain—try wearing a pessary over a period of days or weeks. With the pessary inside, was your vaginal bulging, rectal pressure, or lower abdominal discomfort less severe at the end of each day? Were you able to empty your bladder or bowels more completely? Did your overall quality of life feel improved? When big questions are still blowing in the wind, try the pessary test. You can’t fail this exam, and it just might shed some much-needed light on your presurgical choices, such as which symptoms surgery might alleviate and which it might not.

  QUESTION #3: WHAT ARE MY CHOICES OF ANESTHESIA?

  Although the risks associated with modern anesthetic techniques are quite low, discuss your options before surgery and feel comfortable with your choice.

  General a
nesthesia. You’re put fully to sleep, and a breathing tube is inserted during the operation. For open abdominal and laparoscopic operations, a general anesthetic is almost always necessary. For vaginal procedures, you’ll often have the opportunity to choose between the following other options.

  Epidural and spinal. Injection of anesthesia into the spinal area, which results in temporary numbness of the lower body. Epidural involves the placement of a tiny catheter into the area around the spinal column, which is left for the duration of surgery. Spinal refers to a single injection of anesthesia, intended to last until the end of surgery.

  Local anesthesia. Injection of anesthetic (such as novocaine) into and underneath the skin. Local injections can be used throughout the body, including the vaginal skin and abdominal area. However, their use is generally limited to operations involving only small incisions.

  QUESTION #4: WHICH OPERATION IS BEST?

  If you ever decide to quiz two different pelvic surgeons on the very best operation for your postreproductive problem, be prepared— you’ll probably hear three different opinions. Surgery for incontinence and prolapse can be performed in a variety of ways, perhaps more than for any other area of the body. Some centers specialize in vaginal operations, others in the laparoscopic approach, and still others swear by open abdominal repairs as the gold standard.

  You should be aware of the pros and cons for each surgical alternative. Ask the following questions:

  Which operation has been around the longest?

  Which will get you back to work and exercise most quickly?

  Will minimally invasive procedures using small laparoscopic or vaginal incisions be as reliable as a traditional open approach over the long run?

  How did your doctor arrive at the decision to perform this particular operation or specific technique? When you ask about other alternatives, is your doctor defensive in explaining his or her choice, or confident and enthusiastic that it’s simply the best for you?

  What is your surgeon’s level of expertise? Just as important as the operation you choose is the surgeon who performs it. Don’t assume that all surgeons are doing the same procedures with the same level of experience. Some specialists perform three hundred surgeries each year, while others enter the operating room only once or twice a month, yet both may be excellent surgeons.

  QUESTION #5: ARE YOU PREPARED TO OPTIMIZE YOUR RECOVERY?

  Within the hustle and bustle of today’s medical marketplace, there’s a fast-track approach to postoperative healing. Hospital stays range from only a few hours, following laparoscopic and certain vaginal operations, to perhaps two or three days for open techniques. Gone are the days when postoperative hospital stays lasted a week, each patient backed by a cadre of nurses, candy stripers, hospital trays, and housekeeping. Recuperation after a pelvic operation, not unlike most other types of surgery these days, occurs mainly at home, among friends and family. It requires a good amount of work and the right attitude on your part.

  BACK IN THE SADDLE, BUT NO GALLOPING

  However enticing a quick return to normal life may seem, there are a few realities of the recovery process. Even in a new millennium filled with fast food, fast computers, and a back-in-the-saddle approach to recovery, healing follows its own lazy pace. Above all else, keep one very humbling statistic in mind: up to 30 percent of women who undergo reconstructive surgery for pelvic relaxation or incontinence will eventually have two or more future operations to fully correct their problem. Keep yourself out of this unenviable club by learning how to protect your new anatomy while resuming a healthy level of activity after surgery.

  You’ll Be Tired

  Even minimally invasive operations involve a recovery process, and as anyone who has undergone surgery can attest to, healing makes you tired for at least several weeks. Don’t fight it. Many women won’t feel 100 percent in terms of energy and drive for three to six months and even beyond.

  Use Your Body Wisely

  The following tips should help to maximize healing while keeping you in shape.

  Exercise smart. Yes, on rare occasion, a surgical repair can come undone after a stressful activity. Protect your lower body more carefully than usual for the first few postoperative months. Avoid lifting objects or children heavier than ten pounds, and don’t partake in weight-bearing exercises during that initial recovery period. Avoid aerobics, weight lifting, swimming, and biking until your doctor okays them. Brisk walking and other nonstraining exercises should be fine. Some surgeons advise their patients to never again engage in a strenuous job, lift over twenty pounds, or participate in regular high-stress exercises. The majority of surgeons, however, place no major restrictions on your lifestyle after the first two to three months. Discuss your specific surgery and lifestyle afterward, with your doctor.

  Pelvic-floor exercises. Also a fine idea, even if they’re not a real workout in the traditional sense. Building strong pelvic muscles will not only help you feel better but will also help to preserve pelvic function in a number of ways (see Appendix A).

  Avoid pelvic stress. The idea is to avoid large pressure increases in the abdomen and pelvis. If you must lift something heavy or suddenly exert yourself, exhale rather than holding your breath, and brace your pelvic floor instead of straining. Driving is usually not recommended for the first two to four weeks, for two reasons: first, because soreness may decrease your ability to quickly brake, increasing your odds of a fender bender. Second, because reaching for the pedals may strain the pelvic supports during their most fragile state of healing.

  Listen to your body. If whatever you’re doing hurts, pulls, pulsates, or pinches, stop or find another way to do it.

  AVOID THE BIG C’S—CHRONIC COUGH AND CONSTIPATION

  Chronic Cough

  Whether it’s from smoking, asthma, or bronchitis, repetitive coughing can present major stress to pelvic supports trying to heal. Call your doctor if you develop a bad cough, especially if it’s accompanied by colored sputum or a fever. High-potency cough syrups (containing codeine or an equivalent) may occasionally be necessary. Your doctor may prescribe antibiotics if he or she suspects bacterial sinusitis or bronchitis.

  Constipation

  You’ve already learned about this archenemy of a healthy pelvic floor. After surgery, straining to move your bowels can directly stress the areas of healing, particularly if your surgery involved the repair of a rectocele or relaxed perineum—and that’s the last thing you need after making it over the hurdle of your operation. A few basic tips should keep you regular:

  High-fiber diet. The same Bowel Diet discussed in chapter 10 will hold you in good stead after surgery.

  Stool softeners. Colace, Metamucil, or a generic stool softener should be strongly considered for the first twelve weeks, unless your stools are soft and regular with a careful diet alone.

  Occasional laxative. If stool softeners aren’t enough, try an occasional oral laxative or suppository (Dulcolax, glycerine, Fleet). Seek your doctor’s advice, especially before using stimulant laxatives (see chapter 10).

  Walking, exercise, hydration. The importance of these factors can’t be overlooked for maintaining normal bowel activity. Sometimes starting a walking routine or other exercise program is all you need to get your bowels back to normal after surgery.

  Minimizing narcotics. Narcotic pain medications (codeine, hydrocodone) will slow your bowels. The sooner you’re off them and switched over to nonnarcotic pain pills (ibuprofen, acetaminophen), the better.

  REMEMBER THE BIG E—ESTROGEN!

  If you’ve passed through menopause or had your ovaries removed, vaginal estrogen—in the form of creams, vaginal tablets, or an insertable vaginal estrogen ring—can improve the health of the vaginal skin and promote healing after surgery. In most cases, use of these products should be postponed until at least a few weeks after surgery, when the vaginal and perineal incisions have closed. Check with your doctor about whether local estrogen therapy might be the right choice for you.
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br />   KEEP IT SIMPLE DOWN THERE

  After surgery, treat your perineum and vagina just as you would after childbirth—gingerly. Avoid scrubbing, douching, and using perfumed or colored hygienic products. Also avoid vaginal creams or anesthetic jellies until your doctor says they’re okay. After most pelvic operations, you’ll be instructed to avoid intercourse and insert nothing in the vagina, including tampons, for six to twelve weeks.

  TIPS FOR PREPARING BEFORE SURGERY

  Optimize your weight. Let’s face it: few of us would be motivated to shed pounds before having an operation, let alone keep them off. But on occasion, extraordinary individuals do manage to slim down before pelvic surgery. These women enjoy not only the pleasure of looking trim but also reduced odds of their prolapse or incontinence returning over the long run. An optimal body weight means less strain on the pelvic floor, less stress on your surgical repair, and a lower risk of pulmonary and anesthetic complications during the operation and recovery period. A 1997 study from Mexico found that among 148 women, those who were obese had twice the risk of surgical failure after incontinence surgery.

  Stop smoking. Quitting within even a few weeks of surgery will improve the function of your lungs and lower your risk of complications. Over the long run, avoiding a smoker’s cough will reduce your chances of surgical failure due to chronic strain on the structures and supports of the pelvic floor.