Ever Since I Had My Baby

by Roger Goldberg

  PELVIC-FLOOR BRACING

  What about those times you can’t avoid straining, coughing, or lifting heavy loads? Bracing the pelvic floor can at least help you reduce the risk of stressing it during those activities. Bracing—also referred to as the knack by some pelvic-floor specialists—means quickly squeezing the pelvic muscles a split second before the moment of physical exertion. By tightening and reinforcing the levator shelf and sling at just the right time, bracing counteracts the pressure working against the pelvic supports.

  If nothing else, bracing during moments of physical stress should help you to reduce leakage. One study from the University of Washington showed that with a deep cough, women taught the knack could reduce their cough-related leakage by nearly 80 percent, as compared with women who didn’t use the technique. For other women, bracing may even help to slow the progression of prolapse by strengthening the levator-muscle shelf that supports the pelvic organs, and reducing the downward bulge of these organs through the pelvic opening. Once you’ve developed a strong Kegel contraction, try to make pelvic-floor bracing one of your healthy habits.

  SEEING A PELVIC-FLOOR PHYSIOTHERAPIST

  Most urogynecology doctors and nurses know a great deal about pelvic-floor muscle training and can help get you to maximum strength. But women seeking the most natural approach may want to call upon a pelvic-floor physiotherapist. They have the training and the time to discuss and utilize a variety of techniques such as massage, pelvic-floor stimulation, and postural training. A physiotherapist may also work through nuances of pelvic-floor exercise not covered in the doctor’s office. For instance, some pelvic-floor physiotherapists may focus on strengthening abdominal muscles rather than relaxing them. Toning the transverse abdominals may, for instance, restore function to levator muscles that haven’t responded to routine Kegel exercises.

  BIOFEEDBACK: ZEN BUDDHISM

  MEETS THE PELVIC FLOOR

  The roots of biofeedback lie in Eastern meditation techniques. It was observed that with practice, individuals were able to gain control over bodily processes that typically weren’t under voluntary control, such as pulse or body temperature. Pelvic-floor biofeedback is an office method based on that principle, providing you with feedback during your pelvic-floor exercises. By allowing you to see what you’re doing down there, biofeedback helps you to focus on muscle groups that you’re probably not accustomed to sensing, making your Kegel exercises stronger and improving their impact. Electrode (electromyography) stickers are placed over the abdomen; a tamponlike sensor is inserted into either the vagina or rectum; and each is attached to a computer. On a visual or audio monitor, you’ll see when you’ve contracted the correct pelvis muscles and when you’ve flexed incorrect muscles, such as your stomach or legs. At each session, you can visually assess how strong your contractions have become and how much progress you’ve made since the last visit. Home devices are available for women interested in long-term use of this therapy. A low-tech but effective alternative involves the nurse or doctor simply examining the muscles as they’re flexed, and giving verbal feedback.

  When used as directed, biofeedback can improve many aspects of pelvic-floor function, including bladder and bowel control, pain syndromes, even sexual functioning: in other words, the same handful of benefits that can stem from an effective Kegel routine.

  One study of a structured biofeedback program optimistically showed reduced leakage episodes among 81 percent of women using biofeedback and pelvic-floor exercises, versus 69 percent using overactive bladder medication and 39 percent who received no treatment. Another, more recent study of women over age fifty-five showed a 70 percent reduction in leakage episodes using either high-tech or low-tech biofeedback techniques.

  According to one study of a three-visit biofeedback series over a six-week period, up to 75 percent of participants considered the method effective, though only around 20 percent or so were objectively shown, with office testing, to have improved bladder control. After biofeedback, the bladder may often feel better and more in control, even if the doctor can’t always prove that a cure has been achieved.

  Fecal incontinence can also be treated with biofeedback, with improvement reported for 50 to 90 percent of women. Special fluid-filled balloons are used to create the sensation of rectal fullness during these sessions, providing the patient with something to squeeze against.

  Sexual dysfunction, in some cases, can also be improved with the help of biofeedback sessions. The most likely women to improve are those with spasm of the pelvic-floor muscles, or the condition of vaginismus discussed in chapter 11.

  It’s not always necessary to jump into a biofeedback program without first trying simple pelvic-floor exercises on your own. A recent overview of the existing research on biofeedback found that doing Kegels alone usually fares quite well compared to pelvic-floor exercises accompanied by biofeedback. On the other hand, if you’ve failed Kegel exercises on your own, keep in mind that you might still find success using biofeedback.

  ANGELA: AN INSPIRATIONAL TALE OF BIOFEEDBACK SUCCESS

  Angela was a thirty-four-year-old mother of two-year-old twin girls. To balance her 24/7 duties at home, she’d vowed to preserve her sanity and fitness by hiring a baby-sitter one afternoon each week. On her own, she’d head out to enjoy her so-called selfish vices—a full-hour aerobics class, a power walk around town, capped by a long cup of coffee with a very junky spy novel.

  But on her first few afternoons away, Angela realized that she had a problem. Unlike before her babies were born, her aerobics class was presenting a challenge beyond the exertion itself: leakage. Caught unprepared that first day, she tied her sweatshirt around her waist to cover the ring that had formed at the bottom of her workout pants. The next week, she wore a pad, but her sense of disappointment remained over losing this important part of her life that she’d vowed to preserve.

  For six months, she tried Kegel exercises at home, twice each day, to no avail. She had no desire for surgery at this stage in life, and she felt too young for devices. Eventually, Angela went to her doctor. When she squeezed her best Kegel, Angel’s gynecologist saw that she was hardly contracting her pelvic-floor muscles at all; what she thought was a squeeze was actually more of a push. Her exercise routine, in other words, had been all wrong.

  So she decided to try biofeedback. After two sessions, she’d already improved, with better tone, less leakage, even fewer pads. After the fourth visit, her pelvic-floor muscle strength was close to 100 percent. She was back to aerobics, power walking, and whatever other “selfish vices” this hardworking mom could find the time for.

  VAGINAL CONES: ADDING WEIGHTS TO YOUR WORKOUT

  As with lifting weights (but guaranteed never to become an Olympic sport), the pelvic muscles can be firmed and strengthened with the help of weighted vaginal cones. These tamponlike devices are inserted into the vagina and can be held inside while you’re standing with a Kegel-type contraction; the correct muscles must be contracted in order to hold a vaginal cone inside. Vaginal cones are usually made in one size but vary from twenty to over a hundred grams. Your initial goal should be to hold it inside for up to fifteen minutes, always while standing. If the cone falls out, move to a lighter weight. When you’re using the correct muscles, you should be able to feel, with the tip of your finger, the cone pulled up into the vagina during your squeeze. If you feel the cone pushing out, then you’re using the wrong muscle groups. When the lightest cone is no longer a challenge, perhaps you can graduate to the next higher weight in the set after a week or two. Challenge yourself by trying to hold the cone inside during light activities, such as climbing stairs or walking. As with a regular Kegel exercise, avoid flexing your thighs or buttocks.

  Vaginal cones require more privacy than a simple pelvic-floor workout and should not be used during pregnancy. But they can provide an ideal kick-start for building your pelvic-floor strength and reaping the full range of benefits that can result from a long-term Kegel exercise routine—in
cluding improved urinary continence, fecal control, and even sexual function.

  Appearance of vaginal cone, and position when inserted

  THE CUTTING EDGE AND PURELY CAMPY: OTHER FASCINATING PELVIC-FLOOR FACTS, GADGETS, AND UROGYNECOLOGIC GIZMOS

  Unlike the Chia Pet or the Clapper, you won’t learn about these items by watching late-night infomercials, because they’re just too strange. And they’re certainly not holiday stocking stuffers that you’ll want to share with the whole family. But during your search for another option to manage your postreproductive symptoms, you may come across one of these:

  Kegelmaster. A spring-loaded device for insertion into the vagina, with adjustable settings that create progressive resistance between the vaginal walls. By squeezing the two arms of the device together, the Kegel muscles may be trained.

  GyneFlex. Another vaginal resistance device that’s inserted and then squeezed with the pelvic-floor muscles until the two arms close together. The only device to proudly trademark the VTP system—which stands, of course, for vaginal tightening program. Tell me, does health-care marketing get any funkier than this?

  Kegelcisor, Kegel-Enhansor. These weighted stainless-steel devices are like barbells for the vagina. Made to insert and hold, like a vaginal cone.

  V-brace. Although its name may sound like an extremely weird women’s pro-wrestling hold, the V-brace is actually a feminine-support garment designed to lift and support the vaginal and perineal area with the help of multiple layers of elastic attached over a cotton panty. Intended to relieve symptoms for women with genital prolapse and incontinence.

  Belly dancing. Yes, the effects of Oriental dance on pelvic-floor muscle function have actually been studied—in Finland. Women familiar with this pelvic-centered dance style had a superior ability to flex their pelvic-floor muscles, over non–belly dancers. Based on these results, could it be long before doctors are recommending the hustle or the electric slide?

  APPENDIX B

  Voiding and Symptom Diary

  Postreproductive symptoms occur in very confusing areas of your body. You might sense that everything’s different or that nothing feels quite right, but your symptoms often stop short of revealing their specific origin. Pinpointing the basic qualities of your urinary, bowel, sexual, or other postreproductive symptoms—what these symptoms are, where they’re arising from, and when they’re bothering you—is the first step toward finding relief.

  Consider the bladder. Though at first it may seem that your symptoms are random or chaotic, with a symptom diary, you may discover that among a grab bag of symptoms, common patterns and underlying causes exist. How often do you void during the daytime and at night? Are your trips to the bathroom always prompted by an urge, or do you go by sheer habit sometimes? When are you most prone to leak or feel discomfort, and what usually triggers your accidents or pelvic symptoms? Do you lose control silently, or with an urge? Do you have difficulty starting your urine stream or bowel movements, or do you feel the need to strain? Is there pain or burning? Are your symptoms triggered by intercourse, the sound or feel of running water, the rush to open your front door when returning home, or after certain foods or beverages? Do your bladder and bowel symptoms seem to be related? These are some of the symptom patterns that may signal a postreproductive change: perhaps a cystocele or rectocele, a floppy urethra, a very overactive bladder. With the Voiding and Symptom Diary, you can play detective and make some sense of your problem even before seeing the doctor.

  Starting Your Diary

  The chart is a twenty-four-hour diary that you can use for yourself. Copy this diary and use it to record your symptoms for three to seven days.

  In the first two columns on the left, record what you drink and eat throughout the day. Columns three to five allow you to record each time you intentionally empty your bladder and the amount you empty. You can measure your urine in a regular measuring cup, or just about any disposable container marked with lines indicating the number of cups, ounces, or milliliters. Columns six to eight allow you to record each time you leak and what you were doing or what you felt at the time of leakage. Whether you were on the StairMaster, washing the dishes, bending over in the garden, or lifting the baby seat, write it down if leakage or any other symptom occurred along with that activity. Was there an urge, or was the leakage silent? Beneath the hour-by-hour grid, your medications can be recorded along with the time of day they were taken. Use the “Other Symptoms” area to track any other unexpected events. Did you have an episode of painful intercourse? Loss of bowel control?

  Recalling your symptoms at the day’s end can often be inaccurate, so be sure to fill in your diary throughout the day, rather than piecing it together from memory later on.

  INTERPRETING YOUR DIARY: DETECTIVE COLUMBO MEETS THE PELVIC FLOOR

  Now, after you’ve completed your own diary, take a look and compare your voiding to the following normal daily habits:

  Urinating every three to six hours (no more than eight times every twenty-four hours)

  Total urine output over twenty-four hours between 1,500 cc and 2,000 cc (70 fluid ounces); over two to three quarts is above the normal range

  Not waking with a bladder urge more than once at night

  Not feeling fullness right after you’ve emptied

  Able to move your bowels without heavy straining

  No accidental leakage of urine, stool, or gas on a regular basis

  Intercourse not painful

  Never avoiding activities or social situations for fear of accidents

  A life without pads!

  SEARCHING FOR PATTERNS

  Look a bit closer and see if you’re able to find a pattern to your symptoms.

  How does the daytime compare with the night? Are your symptoms at their worst in the early morning then gradually improve throughout the day, or is the opposite true?

  Are you at risk to leak only after drinking a cola, coffee, or other food or drink?

  If you’ve been bothered by bowel symptoms or sexual discomfort, are you able to track when these episodes occur and whether there is a particular trigger?

  Do you leak suddenly with physical stress (stress incontinence), or is it a problem when you’re holding back a strong urge (urge incontinence)? Is your leakage triggered by both strong urges and physical stress (mixed incontinence)?

  Is your daily urine output excessive, indicating that your problem with urinary frequency might be cured by laying off that water bottle a bit? Or does your frequency appear to reflect a low bladder capacity? Is your overall urine volume below normal because you’re reluctant to drink for fear of accidents?

  Is your urinary stream less forceful than you can remember it being before?

  Compare the pattern of your symptoms to the most common postreproductive problems you’ve learned about: the overactive bladder, stress incontinence, mixed incontinence, and pelvic prolapse.

  VOIDING & SYMPTOM DIARY

  * Stress: Physical exertion or sudden straining (for example, coughing, sneezing, exercising, lifting, or bending)

  * Urge: Sudden strong desire to empty your bladder (“I’ve gotta go!”)

  Your diary might seem a bit low-tech, but don’t be fooled by its appearance. Just as Detective Columbo always solved strange mysteries by taking a closer look at the facts right before him, your diary may reveal surprising clues and even hidden solutions to you and your doctor.

  IT HAPPENS EACH MONTH: UNDERSTANDING WHY INCONTINENCE AND OTHER PELVIC SYMPTOMS CAN VARY WITH YOUR MENSTRUAL CYCLE

  If you’re premenopausal and still have regular menstrual cycles, you may have noticed that certain postreproductive symptoms (such as incontinence or even the pressure resulting from prolapse) become worse at certain times of the month. This pattern highlights the role of the female hormones (estrogen and progesterone) in the urethra, bladder, vagina, and whole pelvic area. Stress incontinence is one such example. As the estrogen supply temporarily falls during the premenstrual week, the estroge
n-receptor-rich bladder neck and urethra may temporarily become a bit weaker, leaving you more prone to leakage if the pressure inside the bladder suddenly rises. As a new cycle begins, this estrogen-related symptom should improve. Try increasing the intensity of your Kegel routine, or consider asking your doctor about a continence device to use during these high-risk parts of the month (see chapter 8). In urogynecology, the uro and gyn are often closely connected.

  APPENDIX C

  Organizations, Resources, and References

  Remember that pelvic-floor symptoms can sometimes relate to important medical conditions that shouldn’t be neglected. Your doctor is the only one who can provide you with the most accurate information specific to your problem.

  Organizations and Websites

  UROGYNECOLOGY AND UROLOGY

  American Foundation for Urologic Disease

  1128 N. Charles Street

  Baltimore, MD 21201