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Recognizing Your Postreproductive Problem

INCONTINENCE, PROLAPSE, SEXUAL DYSFUNCTION, AND OTHER COMMONLY OVERLOOKED CONDITIONS


The reason why mothers are more devoted to their children than fathers: it is that they suffer more in giving them birth.—Aristotle



Why didn't anyone tell me about this problem ten years ago?—Linda, age forty-one, considering surgery


"What's happened down there?" you've asked yourself, as have so many other women from time immemorial. Ever since that wondrous day you gave birth--for the first time or the fifth--your body has never felt quite the same. Was it embarrassment over the loss of urine you first noticed while lifting your child, laughing with your friends, or making a run to the bathroom? Was it your growing self-consciousness about controlling your bowel movements or gas? Or maybe it was your worry that sex didn't feel the same as it once did, and that your partner's satisfaction might have changed also.

"I feel way too young for this!" you've told yourself while mothering, working, exercising, nurturing relationships, and striving for a full and active life. Yet more and more, you've found that these problems really can't be ignored, because they're making you less active, your life less complete. Never, at this stage in life, had you anticipated such challenges to your sense of control, intimacy, and self-image, conditions that make you feel terribly alone and abnormal. What might the response be if you mentioned these problems to your peers?

More likely than not, their eyes would light up with interest and affirmation. Many of them have these problems, too. What's happened down there for you and many other women are the effects of pregnancy, labor, and delivery--of forceps, episiotomies, and a newborn's head, shoulders, arms, and legs--on your pelvic muscles, nerves, bladder, bowel, and vagina. They are long-term problems of the pelvic floor that modern obstetrics has overlooked in its efforts to make delivery safe and comfortable in the short term. Leaking, bulging, soiling, sexual dissatisfaction--women of past generations rarely complained about these "inevitable costs" of childbirth. After all, what could be done?



A New Chapter


Within the book of women's health, you've turned the first page of a new chapter whose time is overdue. Call it urogynecology, female pelvic medicine, or postreproductive women's health. By any name, it is finally centered on the female conditions that so often follow the most wonderful and dramatic physical event of your lifetime: childbirth. You've learned of the many ways to prevent and treat problems such as heart disease, breast cancer, and osteoporosis. But you've heard little about the countless ways to prevent and treat the physical effects of childbirth. From this chapter forward, you'll hear a great deal.

Along the winding road between childbirth and menopause, scores of women are affected by physical symptoms that often attest to the extraordinary physical demands of pregnancy, labor, and delivery. Some of these postreproductive changes are immediately apparent, affecting the quality of a woman's most vigorous years; other anatomic changes have no repercussions until decades later. Whether these physical transitions are subtle or severe, immediate or delayed, they are more common--and fortunately, more treatable--than you might think. Incontinence, prolapse, and pelvic and sexual problems are no longer the unspoken and inevitable costs of motherhood.

"Mom takes care of everyone, but who takes care of Mom?" The average working mother spends one and a half hours each day shuttling kids around, two hours preparing food and straightening the house, and what often seems like twenty-five hours listening to everybody else's problems! The time has arrived to better understand one of the most important physical events in your life, and learn how to treat the symptoms that are bothering you. Take a Calgon moment and read on. Doctor's orders.



Identifying Your Postreproductive Symptoms



URINARY INCONTINENCE AND LOSS OF BLADDER CONTROL



At least one of every three women will suffer significant loss of bladder control, and although incontinence affects many women without kids, up to 65 percent will notice this problem for the first time either during or after childbirth. Millions each year choose surgery for this debilitating condition, and millions more seek nonsurgical treatments; countless others silently endure their symptoms without ever seeking help. A loss of bladder control can make you feel lonely, ashamed, and antisocial, even unemployable. But what many women don't realize is that urinary incontinence, in most cases, boils down to a few common types--all of them treatable. Understanding your problem is your first step to reaching a cure.


Stress Incontinence


Allison

"I don't want to be Florence Henderson in diapers in a few years!"
"Excuse me?" I replied as I continued to jot down some notes on her medical history. It was her first office visit.
"I said, I don't want to become Florence Henderson!"

This was Allison, a thirty-three-year-old advertising executive, upbeat about everything except her four-year history of leaking urine. "Everything's felt different," she said, since the forceps-assisted vaginal delivery of her only child. During the months after delivery, she had begun to notice a few changes, a bit less control. Like a few of her friends, she'd wet her pants a bit when laughing or coughing hard. For security, she began wearing pads all month long. And for two years before coming to my office, she'd been doing occasional Kegel exercises at the recommendation of her internist. She hadn't noticed much improvement since starting with the exercises, although she couldn't swear that she'd been doing them correctly. I turned my chair toward Allison and, serving her up a bit of her own deadpan humor on that cold and rainy day, reassured her that in my medical opinion, her risk of becoming Florence Henderson was very, very small.

Allison's comment resonated in my mind as we continued her office visit, reviewed the testing plan, and discussed her most likely treatment options. Though I wasn't sure Mrs. Henderson ever advertised adult diapers or spoke publicly about incontinence, I understood the message loud and clear. Lurking behind Allison's campy quip was a great deal of anxiety--about youthfulness and aging, about losing control. She was facing a problem that, in her mind, belonged to the "Golden Girls," the Brady Bunch mom--not a young, working city slicker just starting her family life.

Should she worry? Research suggests that even a completely problem-free vaginal childbirth would leave her with a significant risk of incontinence. And though forceps may have been used with good reason, they further increased the likelihood that she would develop bladder problems; she stood at several times the usual risk of severe stress incontinence by age forty, as compared to women with no previous forceps delivery. Furthermore, there is compelling evidence to suggest that her current symptoms would not improve over time but rather would progress to needing treatment. One study concluded that when certain types of urinary incontinence persist three months after delivery, the risk of long-term leakage approaches 94 percent.

The questions arise: how can Allison help herself, at this early stage, to feel better and prevent her problem from getting worse? How can she avoid joining the fifty thousand women undergoing surgery for stress incontinence each year? And how could we have helped her to avoid this scenario in the first place?

Stress incontinence refers to the sudden accidental leakage of urine when you cough, sneeze, laugh, lift a heavy object, hit a tennis or golf ball, or quickly change your position--in other words, during any activity that creates pressure or stress in your pelvic area. Does this sound familiar? If so, it should come as no surprise--stress incontinence is the most common type of urine leakage in women aged thirty to fifty. Up to a third of women in their thirties report significant loss of urine during exercise. If you're a gymnast, tennis player, or aerobics enthusiast, in particular, maybe you've noticed leakage with sudden straining. More bothersome urinary incontinence, which can mean leakage during simple walking or light lifting, becomes a problem for around 15 percent of women under sixty-five, and closer to a third of women above that age. If you're severely stress-incontinent, you may even leak silently--in other words, when you're hardly exerting yourself at all, such as during a bumpy car ride or while bending down to tie your shoes.

Stress incontinence results from a urethra that lacks enough strength to hold back urine when the bladder pressure rises during physical exertion. As you'll learn in chapter 8, it is a condition whose roots begin with pregnancy and childbirth in many but not all cases. Most importantly, you'll become familiar with a broad range of strategies--including exercise, lifestyle tips, office procedures, and minimally invasive surgical options--allowing you to toss those pads and enjoy an active life without concern over keeping dry.


THE COST OF LEAKING

Can you believe there are more than fifty thousand hospital admissions each year for the treatment of stress incontinence? In the United States alone, over $1.14 billion is spent on stress-incontinence operations, and that doesn't include the cost of nonsurgical treatments. For each woman seeking treatment, a silent handful just lives with the problem.

Urge Incontinence and the Overactive Bladder

Linda

"Who's the kid here?" Linda asked me on her first visit to my office. "Here I am trying to toilet-train my daughter, wearing pads myself, and wetting them each time I run after her." A thirty-nine-year-old occupational therapist and mother of two girls aged two and a half and six, Linda was simply too busy to be bothered with these problems.

She'd been waking two or three times each night with a strong urge to urinate, and reaching the bathroom in time had become a serious challenge. During the workday, tired from her poor night's sleep, she found it increasingly difficult to make it through her patients' thirty-minute occupational-therapy sessions, and several times each week, she actually leaked urine on the way to the ladies' room. Linda began emptying her bladder every half hour to minimize her chances of an accident, and she routinely mapped the nearest bathroom wherever she was. She even started to wear dark, baggy clothes, just in case. "My husband hates to travel with me! He gets frustrated when we're on the highway and we have to pull over . . . I know every bathroom in the city! It's taking the spontaneity out of my life." The problem also affected their relationship in the bedroom, as Linda's fear of leaking during intercourse was making it more and more difficult for her to relax and enjoy.

For two years, she had thought about finding a doctor to discuss the problem with. But somewhere between her older daughter's soccer practices and her younger daughter's preschool, she hadn't managed to act on that thought until now. Three weeks before our visit, Linda had been at her nephew's wedding. "There I am in this beautiful dress, and as I'm standing up from my chair, I have a huge accident. Thank goodness the dress was long and wide, and I was wearing a pad. But right then and there, I said to myself: 'Enough of this!' "

Across the top of her medical questionnaire, Linda had written, "I'm here because I need a bladder operation." Surprised by her assumption that these symptoms would require surgery, and curious to know whether that was the reason for her avoiding help all this time, I posed a few questions. Had she ever considered that she might not have a surgical problem at all? Was she aware that diet and exercise might be enough to control her symptoms, or perhaps physical therapy or a simple medication? Did she know how many other women were facing the same problem? As we continued that first office visit, Linda's expression spelled surprise, then relief, as she realized that one way or another, she might be feeling better soon.



Have you ever lost urine for no apparent reason, under stressless circumstances? Do you find yourself running to the bathroom with a strong urge that you sometimes can't control before reaching the toilet? Ever feel a sudden need to void when you hear running water, wash the dishes, or simply enter the house? Do you think of your bladder as undersized?

If so, you've probably experienced the other major type of urinary incontinence commonly affecting postreproductive women: urge incontinence, or the overactive bladder. An overactive bladder can occur at any age, even among women without any children. But it's more common after childbirth, following the loss of vaginal and pelvic supports, so it's a key concept to understand if you're coping with postreproductive pelvic symptoms. The overactive bladder can mean accidental leakage of urine for women who wet themselves during strong bladder urges; for others, the problem is urgency, frequency, and waking at night to void, as if the bladder were too small. In any of its forms, it can lead to a slow but steady withdrawal from an active daily life. According to a survey called the National Overactive Bladder Screening Initiative, sponsored by Pharmacoa & Upjohn, 26 percent of women with overactive bladder symptoms reported that they regularly avoided places and situations due to the concern that a bathroom may not be nearby.

Do these overactive-bladder symptoms sound familiar to you? The good news is that normal adult bladder behavior can be relearned, and urge incontinence can be controlled. In chapter 8, you'll learn all about the impact of simple habits and behavioral techniques, diet and medication, special exercises, electrical stimulators, magnetic chairs, implantable pacemakers, and more.