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Adapted from AUGS Public Relations Committee Jill Rabin, M.D. Stephen Young, M.D. Overactive Bladder Generally, it is considered normal to urinate up to eight times during a twenty-four hour period including waking up once at night. If a person is urinating more often than that, they are said to have urinary frequency. Sometimes, frequency is worse during certain times of day. When a womanhas an uncomfortably strong need to void that arises quickly this is called urinary urgency. If you need to urinate more than once a night and your sleep is being disrupted, this is called nocturia. Any combination of urgency, frequency, and nocturia with or without urine leakage are now oftenreferred to as overactive bladder. Diagnosis and Treament of overactive bladder is typically the same as urge urinary incontinence. I leak urine Uncontrollable urine leakage can be an embarrassing and debilitating disease that may lead to depression and social isolation if not treated. There are two main types of urinary incontinence in women known as urge incontinence and stress incontinence. Urge incontinence is urine leakage that occurs before a woman has a chance to get to the bathroom in response to an urge to urinate. This may happen during the day, at night or both. Stress incontinence is urine leakage that occurs with activities such as coughing, laughing , exercise or sneezing. I have to urinate frequently Generally, it is considered normal to urinate up to eight times during a twenty-four hour period including waking up once at night. If a person is urinating more often than that, they are said to have urinary frequency. Sometimes, frequency is worse during certain times of day. When a woman has an uncomfortably strong need to void that arises quickly this is called urinary urgency. If you need to urinate more than once a night and your sleep is being disrupted, this is called nocturia. Any combination of urgency, frequency, and nocturia with or without urine leakage are now often referred to as overactive bladder. I have to get to the bathroom fast Generally, it is considered normal to urinate up to eight times during a twenty-four hour period including waking up once at night. If a person is urinating more often than that, they are said to have urinary frequency. Sometimes, frequency is worse during certain times of day. When a woman has an uncomfortably strong need to void that arises quickly this is called urinary urgency. If a needs to urinate more than once a night and her sleep is being disrupted, this is called nocturia. Any combination of urgency, frequency, and nocturia with or without urine leakage are now oftenreferred to as overactive bladder. I have to get up from sleep too many times at night If you get up more than once a night to urinate and you feel that this is disrupting your sleep you have nocturia. Many women with this problemalso find that they leak on the way to the bathroom at night. When your bladder prevents you from sleeping well night after night, this can have serious health consequences. If you don't sleep well, you are more prone to injuring yourself driving or walking. You can become depressed. Yourpersonal relationships and your job may suffer because you are tired. It is important to try and determine whether it is really your bladder that is waking you up. If you wake up with an immediate strong urge to urinate, then your bladder is likely to be the culprit. However, some people wake up due to anxiety, insomnia or noise and then get in the habit of going to empty their bladder. If this is the case, then you still need to seek treatment for your sleep problem, but you may want to consult your primary care physician first. I can’t hold my urine when I get the urge to urinate Urge incontinence is urine leakage that occurs before a woman has a chance to get to the bathroom in response to an urge to urinate. Womenwith this type of leakage may also experience frequent urges to urinate and frequent night time waking to urinate. This type of leakage is usually due to uncontrolled spasms of the bladder muscle called the detrusor. Although there are many potential causes of urge incontience in women, usually, there is no specific illness identified and then the condition is known as detrusor overactivity. It hurts or burns when I urinate Dysuria is a painful feeling that accompanies urination is most often but not always due to a urinary tract infection(UTI). Other causes includeinfection of the urethra (called urethritis), and painful bladder syndromes such as interstitial cystitis (IC) which are not due to infection. A Herpes outbreak is occasionally a cause of severe pain with urination. I keep having bladder infections If you seem to be getting frequent urinary tract infections (defined as 3 or more urnary tract infections per year) it is very important to have a urinalysis and urine culture BEFORE you are placed on antibiotics. Many symptoms that seem to be signs of infection are due to other problems. Both the urinalysis and urine culture are necessary to see if your symptoms are really due to infection. If you are confirmed to have frequent infections, this requires careful investigation by a clinician experienced in this area. Urogynecologists and urologists are both appropriate physicians to evaluate this problem. I have trouble emptying my bladder Voiding dysfunction describes people who have trouble initiating urination (hesitancy) and/or difficulty emptying the bladder adequately. Voidingdysfunction is a not a disease, but can be caused by many different problems involving the mind, the brain, the spinal cord, the bladder and the perineum. Certain medications can also cause difficulty with urination. Surgery on the pelvic organs can also be a common cause of voiding dysfunction as well. Sometimes I have to hold up my bladder to urinate Pelvic organ prolapse is a common condition – mostly found in women after age 50 - in which the uterus, vagina, rectum and/or bladder are bulging or falling out of the vaginal opening causing a variety of symptoms such as abdominal pelvic or back pain, a heaviness or pulling sensation, vaginal or pelvic pressure, and uncomfortable bulge, urinary incontinence or difficulty emptying the bladder, difficult defecation and problems with sexual intercourse. A woman with prolapse may describe that she feels like she is 'sitting on a ball'. The specific pelvic hernias are called rectocele, cystocele, enterocele and uterine prolapse. Theses findings frequently occur together in one patient. If left untreated, pelvic organ prolapse almost always gets worse. The one exception to that rule can occur shortly after having a baby. “New” prolapse (noticed by a patient or doctor in the early postpartum period) will often get better within the first year after the delivery. Treatment of prolapse should be based on your symptoms. In rare cases, severe prolapse can cause urinary retention that progresses to kidney damage or infection, When this occurs, prolapse treatment is considered mandatory. In most other cases, patients should be the ones to decide when to have their prolapse treated - based on the symptoms they are having. Health care providers use the term 'observation' when they are watching a condition (like prolapse) over time. If you choose to simply watch the prolapse problem and wait for your symptoms to become significant, here are some suggestions: Get yearly pelvic exams to watch for changes or problems, call between visits if you have increasing symptoms, and follow these suggestions: • • • • • • • Avoid heavy lifting (no more than 20 pounds). Watch your weight. Being over weight increases pressure on your pelvic floor. If you smoke, try to quit. Smoking decreases circulation to your pelvis, and a chronic cough will aggravate pelvic floor prolapse. Avoid constipation. Straining with bowel movements increases prolapse. If constipation is a problem for you, talk to us about treatment. Learn and practice pelvic floor exercise. Hormone replacement may be an option to increase the circulation to your pelvic, and restore some tissue tone. Be sure your doctor is measuring your prolapse in a systematic way – so that he/she will be able to notice subtle changes over time. The most commonly used system of measure for prolapse is called the “pelvic organ prolapse quantification” or POP-Q system. Ever since I delivered my baby, I leak urine Pregnancy, Childbirth and Your Pelvic Floor: Understanding the Connections Adapted from “Ever Since I Had My Baby” (Crown Publishers, 2003), by Roger P. Goldberg, M.D., M.P.H. Female Pelvic Medicine: A New Perspective on Childbirth and its Physical Effects You’ll find no mention of pelvic prolapse, urinary or fecal incontinence in prenatal classes, and little attention devoted to them in menopause guides. But ask a soccer mom or baby boomer about ‘leaking, bulging, pads and diapers’ in private, and you’ll be likely to hear a personal story, see a surgical scar, or be asked the question “you mean that’s not normal at my age?” Fortunately, incontinence and pelvic floor symptoms are finally gaining recognition as common problems that affect women young and old, ones that can severely diminish the selfconfidence and physical function of women trying to maintain full and active lifestyles. In many cases, pelvic floor problems attest to the extraordinary physical demands of pregnancy, labor, and delivery – though they often arise years or even decades afterwards. Female Pelvic Medicine is the first women’s health specialty devoted to the treatment of these disorders, and as such, is offering brand new perspectives on childbirth and its potential aftereffects. Indeed, the lifestyle and childbirth decisions of today’s 30-year-old may impact key aspects of her physical function at age 40, 50 or 60. Just the same, incontinence, prolapse or sexual dysfunction experienced by a 50-year-old may relate to choices she made during childbirth, years before. Doctors, nurses and researchers in female pelvic medicine are committed to promoting a better understanding of these conditions and their causes, and to helping women make informed decisions at every stage. Are Incontinence and Pelvic Floor Problems Inevitable After Childbirth? Not inevitable – but common. Generations of women have regarded incontinence and pelvic floor problems as inescapable ‘costs of motherhood’, silently accepting their loss of control and selfconfidence. But the fact is that today – despite the fact that childbirth is a major risk factor leading to urinary incontinence, anal incontinence and pelvic prolapse – for most women these problems are either preventable or treatable. If you are an expectant mother or contemplating having a baby, learning about ‘what to expect while you’re expecting’ is important – but just as importantly, you should know what to expect over the years that follow, and understand how to prevent problems in the first place. Did you know that pelvic exercises might lower your risk of incontinence after delivery? Are you aware of the risks and benefits of forceps delivery or episiotomy, and what their proper role should be? What are the effects of perineal massage, and alternative pushing techniques? Did you know that the length of time you choose to push might relate to your risk of incontinence later on? When is ‘choosing a cesarean’ a reasonable option to discuss with your doctor or midwife? Certain decisions made during this process have consequences that can last a lifetime. If you’re already a mother and are contemplating having another child, you may be wondering if mild problems with bladder control will get worse, or whether your obstetrical strategy should be different than before. You should be aware that ‘normal life’ in the years ahead is not a daily routine of pads and liners, or a struggle with symptoms that diminish your enjoyment of life at home or work, at the gym or in the bedroom. Which Pelvic Floor Symptoms Are Most Common After Childbirth? Urinary Incontinence: Urinary incontinence affects 30-50% of mothers before age 40. Among women experiencing stress incontinence after childbearing, up to 63% report that it began during pregnancy. And whereas 18% of women report some incontinence before pregnancy, by their 3rd trimester over 50% have complaints. So even before giving birth, pregnancy alone can be enough to cause the problem. And if you already had incontinence before pregnancy, during those nine months your symptoms are likely to become worse. Anal Incontinence: Loss of control over gas or stool affects up to 25% of women who have given birth. Not all cases of anal incontinence are caused in the labor room, but childbirth injuries are indeed the key factor predisposing women to this problem. Sexual Dysfunction: Physical changes caused by childbirth affect female sexuality more often than most women are aware – manifested as pain, loss of sensation, or problems with orgasm. Six months after childbirth, roughly one quarter of women after a first vaginal birth experience diminished sexual function, and higher rates are seen following forceps or vacuum delivery compared to ‘spontaneous’ vaginal birth. Pelvic Prolapse: After childbirth, the vast majority ofwomen will develop some degree of weakening around the vagina, uterus and pelvic floor, at least enough to be visible to a doctor during a pelvic exam. Although a minority of women with mild changes to their pelvic supports will be bothered by symptoms, by age 80 up to 11% of the overall female population will undergo major surgery for prolapse or incontinence. Common types of prolapse include cystocele (‘dropped bladder’), rectocele (‘bulging rectum’), and uterine prolapse (‘dropped uterus’). Which Key Body Parts Might Be Affected? The ‘perineum’ is the span of tissue between the opening of the vagina and the anus.It represents the connection point for several muscles that form the opening of the vulva and vagina. The perineum is visible externally, and represents the tissue intentionally cut during an episiotomy. The levator muscles provide much of the foundation of your pelvic floor.Their condition can strongly influence the way you feel and function, as they provide the major support for the uterus, vagina, bladder and other pelvic organs – and are important for maintaining control over the bladder and bowels.After childbirth, loss of strength and detachment from their supports are commonly seen. Pelvic nerves are responsible for maintaining pelvic floor muscle strength – as the levator muscles depend upon a healthy nerve supply to maintain their strength, position and tone.One nerve called the ‘pudendal’ is particularly important – and injuries to this nerve are associated with incontinence and pelvic floor symptoms after childbirth, and especially after difficult deliveries. Pelvic “connective tissues” and ‘ligaments’ are tissues that help to secure the pelvic organs to their proper locations in the pelvis.During childbirth they routinely stretch, tear and weaken. Do ‘Childbearing Hips’ Matter? Most women know very little about this aspect of their body, or its potential importance during childbirth. But in fact, the shape of your pelvic bones may have important effects not only on how fast labor progresses, but also on the physical ease or difficulty you might encounter with childbirth, and the types and extent of pelvic injury that might occur, and lead to symptoms afterwards. Your doctor can determine your ‘pelvic shape’ by taking a series of measurements during a pelvic examination called ‘pelvimetry’. Except for extreme cases, however, the ability to predict difficult labors based on pelvimetry is limited. Which Stages of Childbirth Affect the Pelvic Floor? It is rarely appreciated that labor and delivery are among the most important physical events in a woman’s lifetime. But the fact is, whether childbirth is easy or difficult, long or short, one fact remains constant: your body will never be exactly the same after pregnancy, labor and delivery, as it was beforehand. All stages of pregnancy and childbirth have implications for the pelvic floor, to some degree. For instance, when the widest part of the fetal head secures itself within the pelvic cavity, the fetus is said to have become ‘engaged’. Some women may suddenly feel they’ve begun to ‘carry lower’. When engagement occurs in a first pregnancy, it’s considered by some practitioners to be a sign that a ‘good fit’ exists between mother and baby – perhaps reflecting an easier labor and delivery ahead. What if, though, you’re past the due date of your first pregnancy and the baby’s head is still unengaged? According to some obstetricians, this may represent an early warning that your pelvic shape and your baby’s head aren’t an ideal fit, and that you might be at a higher risk for a long or difficult labor, or one that fails to progress to successful vaginal delivery. Labor’s ‘first stage’ begins when uterine contractions become painful and frequent and the cervix begins to open. When the cervix is fully opened you’ve entered the ‘second stage’ of labor, which ends with delivery of your infant. At that point, most women are instructed to start pushing, encompassing the most physically stressful part of labor for both baby and mom. This involves a tremendous amount of stretching and compression throughout the most important pelvic areas: vagina, bladder, urethra, muscles and nerves. How is the Vaginal Opening Affected by Childbirth – And by Episiotomy? Injuries to the perineum and vaginal opening affect 35-75% of women during vaginal birth. Even after careful repair, permanent weakening may create vaginal ‘looseness’. Some women notice a bulging sensation near the vagina and rectum, or loss of sensation during intercourse. When the anal area is involved in the injury, it can lead to incontinence of gas and/or stool. ‘Episiotomy’ refers to an intentional cutting of the perineum during childbirth. Aside from cutting the umbilical cord, episiotomies are the most common obstetrical operations performed. Although episiotomies have an important place in the labor room, several studies have indicated that they may increase the likelihood of maternal bladder, bowel and pelvic floor problems afterwards. As a result, the general trends have favored the strategy of avoiding episiotomy whenever possible. Can Incontinence and Prolapse Occur, Even If I Never Gave Birth? Pelvic floor problems, even incontinence and prolapse, absolutely can occur even if you’ve never had a baby.Up to 47% of women with no previous pregnancy report some degree of incontinence by age 68. And although the ‘Women’s Health Initiative’ showed previous childbirth to be associated with significantly higher rates of pelvic prolapse later on, 19% of women with no previous delivery also had prolapse. Do ‘Big Babies’ Increase the Risk of Problems? “Macrosomia” is associated with more likely occurrence of perineal injury and episiotomies, nearly 2½ times the usual risk of rectal injury, and a higher risk of pudendal nerve injury. One study found that delivery of a newborn weighing more than 8.8 pounds carried twice the usual risk of urinary incontinence later on, and a higher risk of having to undergo later surgery to correct the problem. If you are found to be carrying a very large baby, it would be appropriate to discuss these issues with your doctor or midwife.