Urinary and Pelvic Prolapse Problems
Women's Health Articles - Urinary Problems
By Date of Release Topic November 19, 2000 What is the significance of microscopic hematuria? July 30, 2000 Voiding Difficulty after an Incontinence Procedure July 9, 2000 Kegel's Exercises and Devices for Stress Urinary Incontinence May 7, 2000 Having Prolapse, Cystocele and Rectocele Fixed Without Hysterectomy February 27, 2000 Urethral Dilatations for Recurrent UTIs - Are They Helpful? August 1, 1999 Drugs That Cause Urinary Incontinence May 16, 1999 Basic Tests for Women Who Leak Urine February 21, 1999 Cystocoele, Rectocoele and Pelvic Support Surgery June 14, 1998 Interstitial Cystitis - Pelvic Pain from the Bladder May 31, 1998 Urinary Tract Injuries During LAVH May 17, 1998 How Common is Urinary Incontinence? November 2, 1997 Does High Impact Activity Cause Incontinence?
What can a woman who is having urinary leakage with urgency or cough or stress expect when she goes to the doctor's office? The basic diagnostic evaluation needed for urinary incontinence must determine whether or not the loss of urine falls into one of several categories:
- stress incontinence - produced by any intraabdominal straining such as coughing or straining
- urge incontinence - leakage caused by the bladder detrusor muscle contracting involuntarily or causing a very small bladder capacity
- mixed incontinence - a combination of the above two types
- overflow incontinence - in which the bladder is distended and has somewhat lost sensation of fullness so that when it just gets overfilled, the bladder muscle contracts on its own.
- other types such as a fistula (hole) in the bladder or the ureter tubes coming into the bladder, or spinal cord or brain problems affecting the bladder nerves.
There have been published guidelines for the basic work-up of this urinary loss by the Agency for Health Care Planning and Research (AHCRP) but studies have shown that work-up developed by experts may misclassify incontinence by as much as 30%. A recent quarterly report, Vol. XVIII, No 2, 1999, from the American Urogynecologic Society by Steven Swift MD, Basic evaluation of the incontinent female presents us with the answers to several questions about this subject.
|Diagnostic category||Questions the doctor may ask|
|stress||Do you lose urine when you cough, sneeze. or laugh suddenly?|
|stress||Do you lose urine when you stand up, sit down or bend over?|
|type III stress (intrinsic urethral insufficiency)||Do you have almost continuous loss with any little movement?|
|urge/ type III stress||Is there a history of radiation treatment to pelvis?|
|urge||Do you get the urge to void and not get to the bathroom in time?|
|urge||Do you have a history of neurological diseases/trauma/strokes?|
|urge or overflow||Do you lose urine suddenly without any warning or straining?|
|obstruction/ detrusor-sphincter dyssynergia||Do you have difficulty voiding?|
|overflow||Do you wet the bed at night and are unaware of it?|
|overflow/continuous||Do you have a history of previous surgery on urethra/bladder?|
|overflow / obstruction||Do you fail to empty your bladder completely?|
|continuous||Do you stay wet all the time without any urge to void?|
|*indicates cystoscopy needed||Do you have frequent (>3 per year) urinary tract infections?|
|*indicates cystoscopy needed||Do you have blood in your urine?|
|*indicates cystoscopy needed||Do you have pain when you void?|
|*indicates cystoscopy needed||Do you urinate very frequently (>14 per 24 hours)?|
|* indicates there may be a mechanical, irritative disease in the bladder causing incontinence|
Diuretics do not cause incontinence but they certainly can worsen it just as too much caffeine or too many fluids each day can aggravate symptoms. Smooth muscle relaxants such as Valium®, Klonopin®, and Xanex® also can worsen urinary leakage by relaxing the external urethral sphincter.
Other risk factors for incontinence include cigarette smoking, constipation, obesity, and strenuous physical activity. Most women who have stress incontinence have undergone vaginal childbirth But childbirth does not always lead to incontinence in later life.
What does the doctor check for on examination?
The general physical exam looks for any evidence of heart failure because when excess fluid in the legs is mobilized at night or lying down, this volume of fluid can contribute to nighttime voiding and urgency. A focused exam of the nerves is done, especially if there is any history or neurological injury, trauma or stroke.
On pelvic exam, the doctor will ask you to cough with a fairly full bladder to see if leaking is observed. While this may be embarrassing for you, it is a necessary test and the doctor is used to having urine leak and spray. The pelvic exam is done to check for associated relaxation of the anterior vaginal bladder wall (cystocoele), the posterior vaginal rectal wall (rectocoele) , the sides of the vagina (paravaginal defect), and the end of the vagina (prolapse or enterocoele). After that, the doctor may put a Q-tip (cotton tipped applicator) in the urethra using a little xylocaine gel to numb it. Then you will be asked to strain down to see if the tip of it moves up by more than 30 degrees. If it does, this may indicate the bladder neck drops down with straining and this may contribute to losing urine with straining and be treatable with surgery.
Yes you may. There are several reasons a catheter may be used. One is to get a sample of urine for culture. This is especially needed if you have a history of frequent urinary tract infections. It is commonly done after you have been asked to void to see if you are able to completely empty the bladder. Also, at the time of your office exam or perhaps at a later visit, a catheter may be used to put fluid in the bladder and measure the bladder pressure during a cystometrogram. This is needed to make sure you are not having "bladder spasms" or uninhibited bladder detrusor contractions. If you do have them, that may explain urgency symptoms of having to void frequently. Finally a cystoscopy may need to be done if you are having any symptoms suggestive of infection, stones, or interstitial cystitis. The cystoscopy is like a catheter being put in the bladder except a cystoscope is used to look inside. The cystoscope is about the same size as a catheter.
The doctor may ask you to fill out a voiding calendar to record how much you drink and how often and how much urine is lost. This can tell the severity of your leakage and also if you are drinking too much or too little fluids. Finally, the doctor may want you to have complex urodynamic studies in which the bladder, the urethral muscles and the capacity and sensation of the bladder are measured using a catheter and pressure transducer placed into the bladder. These studies are sometimes done routinely, but they are especially needed if you have any history of spinal cord or neurological problems, very frequent urgency symptoms, loss of urine with just minimal movement or exertion, or a past history of bladder repair surgery that is now not successful.
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Many women in the menopausal and perimenopausal age range, require surgery for pelvic support defects such as cystocoele (bladder dropping), rectocoele (rectum protruding), bladder neck dropping (stress incontinence), and uterine or post hysterectomy vaginal vault prolapse. There is not much information about these subjects in the usual health media so it is difficult for women to know what to expect as far as success rates, complications and recovery in general.
In one study by Robinson D et al., women aged 45-55 who did not present for incontinence or evaluation of pelvic relaxation, were questioned to see how often they had episodes of urinary loss with intraabdominal straining. Some degree of urinary loss was reported by 2/3's (66%) but daily loss was only reported by 8%.
|Frequency of urinary loss||Incidence (%)|
|Less than once per month||23.0%|
|Several times per month||13.0%|
|Several times per week||17.0%|
Robinson D et al. also measured the degree of vaginal and uterine prolapse in these asymptomatic, perimenopausal women aged 45-55. She found that only 3% had a degree of prolapse for which surgeons might recommend surgical repair depending upon symptoms.
|Degree of uterine or vaginal prolapse||Incidence (%)|
|Mild (Stage 1)||16%|
|Moderate (Stage 2)||3%|
|Severe (Stage 3)||0%|
|Complete/Total (Stage 4)||0%|
In a study by Kenton K et al, of 46 women undergoing rectocoele repair, preoperative symptoms that were felt to be due to the herniation of rectal tissue included protrusion of rectal tissue from the vagina, difficult defecation (bowel movement), constipation, dyspareunia (pain with sexual relations), and manual evacuation or the need to put fingers in the vagina and push down on the rectal protrusion in order to have a bowel movement.
|Rectocoele symptom||Incidence (%)|
In the same study from Kenton K et al, they looked at how well the initial presenting symptoms improved when remeasured at one year after the surgery. Basically, protrusion and painful sexual relations resolved by 90%, but difficult defecation, constipation and the need for manual evacuation only improved by 35-55%.
|Rectocoele symptom||Preoperative(%)||Postoperative (%)|
Any time the bladder is suspended to attempt to reduce urinary leakage with stress of the intraabdominal pressure, there is always the risk that voiding will go to the opposite extreme, i.e., difficulty or being unable to void at all. How often this occurs as a complication of surgery depends upon the type of surgery performed and how the tissues heal. This problem can occur as high as 5% of the time. Sometimes it can be due to just "being too tight", i.e., compressing the urethra shut during voiding. At other times, it can be due to a bladder that just does not contract well or its contraction during voiding is not coordinated with relaxation of the urethra.
Urodynamic studies (uroflow and cystometrogram) are used to diagnose which is the main problem but if it turns out that the support is just "too tight", the question becomes as to how the problem should be fixed. Should sutures just be cut either from the vaginal side or from the abdominal side? If the sutures are cut, does there need to be some sort of repair done again so that the stress incontinence does not just recur? Steele AC et al, reported that in their hands the abdominal approach to take down the scarring worked best because they had previously seen patients that had attempts at vaginal take down that did not improve the problem. All of their patients underwent abdominal incision for take down (retropubic vesicourethrolysis) and that successfully treated the voiding dysfunction without having to "resuspend" the urethra.
In their patients with voiding dysfunction that had weak bladder muscles, most of them improved with just physical therapy and self-catheterization over several weeks rather than having to have repeat surgery. While voiding problems after anti-incontinence surgery are not common, they can be sucessfully treated.
Different surgeons and different procedures can result in widely different "cure" rates for stress urinary incontinence. Surgeons also know that the cure rates depend on how long after the surgery you check them. Success will always be greater at one year than at five years and even lower at 10 years. This change in success is often due to aging effects that make tissues weaker over time. Surgeons would like to let women know what to expect, however. How likely is it that the surgery is going to cure the problem for a "very long time"?
Tamussino KF, looked five year follow-up results after anti-incontinence surgery. The cure rates varied from 50-60% for vaginal procedures (anterior repair alone or anterior repair with needle suspension) to 80% for the abdominal surgical approach (Burch retropubic urethropexy). These were overall results. They did note, however, that with just mild stress incontinence, the vaginal procedures alone had an 80% 5-year cure rate. Thus they felt the vaginal procedures still have a role in some cases, especially if the urinary loss is mild.
The many causes of pelvic pain make it a difficult diagnosis. Some of the causes, such as interstitial cystitis (IC), are even worse. The average patient may go as long as 3-4 years with symptoms before the diagnosis is made. For that reason it is important to recognize the symptoms of IC.
Interstitial cystitis is characterized by urinary frequency, urgency and pain. The pain can be a mild burning or discomfort to an excruciating pain in the bladder, lower abdomen, perineum, pelvis, vagina, low back pain and thighs according to Sant GR: Interstitial cystitis-- a urogynecologic perspective. Contemporary Ob/Gyn 1998;43(6):119-130.
The pain can flare-up or go into remission. It usually gets worse around the time of menses. Sexual intercourse makes the pain worse. Patients may void 8 times or more at night and sleep loss may lead to depression. Because the symptoms are similar to an acute bacterial infection, patients have often had multiple treatments with antibiotics when in fact the urine does not show infection at all.
Other conditions such as irritable bowel syndrome, spastic colon, abdominal cramping, hysterectomy, rheumatoid arthritis, fibromyalgia, hay fever, asthma and food allergies are often associated with interstitial cystitis. These multiple conditions make the diagnosis even more difficult.
If a woman is voiding more than 8 times during the day or more than 4 times during the night, IC should be considered especially if there is pain or urgency present. The diagnosis is made by cystoscopy in which either ulcers are seen or petechial hemorrhages. Biopsy of the bladder mucosa may not be needed if the appearance is typical.
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Laparoscopic vaginal assisted hysterectomy (LAVH) is a popular form of hysterectomy when it can replace the need for an abdominal hysterectomy with a procedure that offers much faster recovery. Recovery from a vaginal hysterectomy is 2-4 weeks while that from an abdominal procedure is 4-6 weeks. If all else is equal (costs, risks) then LAVH should replace many of the abdominal procedures.
Unfortunately LAVH takes longer than an abdominal hysterectomy and thus the costs as far as operating room and anesthesia time are greater. Most patients don't have to directly pay these increased costs because their insurers do. Physicians are sometimes hesitant to perform more expensive procedures because insurers keep track of financial profiles for each physician and physicians who are more expensive run the risk of not having contracts renewed.
Some risks seem to be higher with LAVH. Injuries to the urinary tract including the bladder and the ureter (tube connecting the kidney to the bladder) can happen with any hysterectomy. Recently a report, Tamussino KE, Lang PEJ, Breinl E: Ureteral complications with operative gynecologic laparoscopy. Am J Obstet Gynecol 1998;178:967-70 from Austria discussed the rate of ureteral injury, a fairly serious complication usually requiring further surgery. Normally the rate of ureteral injury in abdominal hysterectomies is 1-2%. In this study, the injury rate was 4.3%. There have been other reports that show the same rates and some that show lower rates of injury. Most physicians agree that urinary tract injury is higher with LAVH.
The question remains as to whether the higher injury rate and cost of LAVH is high enough to affect its use or its frequency of recommendation. The important issue is for women to know the different risks involved so they can make more informed decisions.
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How common is urinary leakage among women? Sometimes it seems to be a common problem. Many women themselves or their friends describe loss of urine with coughing or sneezing on occasion, but it's usually only a problem with a bad cold or severe allergies. To see if it needs treating, a doctor will ask if the urinary leakage is a socially embarrassing problem (wetting clothes) or a hygiene problem (odor or skin irritation from the constant moistness.
A recent Norwegian study has looked at how prevalent a problem this is. Holtedahl K, Hunskaar S: Prevalence, 1-year incidence and factors associated with urinary incontinence: a population based study of women 50-74 years of age in primary care. Maturitas 1998 Jan 12;28(3):205-211.
Of the 489 women in the study, some urine leakage was reported by 47% and regularly by 31%. For 19%, leakage was confirmed on physical exam and claimed to be a social or hygienic problem. Incontinence was associated with heavier body weight, with poor ability to contract pelvic floor muscles and with previous gynecological operations excluding hysterectomy. Three women (0.6%) developed regular incontinence during the year of investigation. There was no convincing case of spontaneous remission.
From the study, the authors conclude that in women aged 50-74 years, about one in five will need treatment of some sort. Urinary incontinence is a chronic condition with little tendency to go away without treatment.
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High impact activity such as track and field or gymnastics participation, can certainly worsen stress urinary incontinence if a woman already has it. The question is "does high impact exercise cause incontinence?"
In a study by Ingrid E. Nygaard MD, Does prolonged high-impact activity contribute to later urinary incontinence? A retrospective study of female olympians. Obstet Gynecol 1997; 90(5):718-22, former track and field and gymnast female olympians from 1960-1976 (high impact) were compared with swimmers (low impact) from those same years. She looked at outcome prevalance of symptoms of stress (loss of urine with increased abdominal straining such as cough or sneeze) and urge (loss of urine with an urge to void but cannot make it to the toilet in time) urinary incontinence.
She found no significant difference in symptoms of any stress incontinence between the high impact group (41%) and the low impact group (50%). When looking only at moderate or great bother from the stress incontinence, there was a difference in the high and low impact groups (10.7% vs. 4.2%) but it was not statistically significant. Interestingly, the high impact athletes reported a 36% loss of urine while doing their sport as olympians compared with only 5% of the swimmers. Other studies have noted up to a 25% prevalance of urinary incontinence in the varsity female athletes.
The bottom line is that while some loss of urine with straining is prevalent in many women, even trained athletes, impact from sports probably does not contribute at all to causing stress incontinence in later life.