This month’s Ask the Doctor series features INTEGRIS urogynecologist Dr. Arielle Allen, an expert in female pelvic health. In honor of National Women’s Health Week, Dr. Allen is answering your questions about women’s bladder and pelvic issues.
The following questions were submitted by our readers to Dr. Allen via our Ask the Doctor page.
(Disclaimer notice: The Ask the Doctor series is intended to provide general medical information and to support the promotion of health and wellness. The answers provided by Dr. Allen do not constitute medical advice and are not intended to be a substitute for medical care or advice provided by your physician or qualified provider. Your participation in this article also does not create a physician/patient relationship, and if you have any specific questions about a personal medical matter, please consult your doctor or other professional health care provider).
1. I have a rectocele since I had my son very rapidly. It has gotten worse over the years. It is painful, affects my sex life, and is really hard to manage my bowel movements. My doctor acts like it isn’t a big deal and that I should just cope. How successful is surgery and are there any other options? I am a very active 59-year-old.
There are surgical and non-surgical treatment options for a rectocele, but these are determined based upon the stage of the rectocele (or how severe it is) and patient symptoms. It sounds as if the symptoms are bothersome and warrant treatment. The stage can be determined by a very detailed exam by a urogynecologist or female urologist. If the rectocele is severe enough, it might need surgical treatment. The success rates of surgical treatment depend on the severity of the rectocele, the surgeon technique and patient-determining factors (such as medical conditions, medications, previous surgeries, etc). It would be worth it to be evaluated by a urogynecologist or female urologist to hear about your options.
2. If I strain when having a bowel movement I get some tearing on the vaginal opening. Is this scar tissue?
It certainly might be scar tissue. It sounds like it should be evaluated, as it is impossible to tell you for sure without doing an exam of this area. If you have not had an examination regarding this issue, I recommend you make an appointment with a urogynecologist or colorectal surgeon.
3. After hearing a news report and reading the study from earlier this year in the American Journal of the Geriatrics Society, I found it interesting as to the differences in the causes and treatments for urge and stress incontinence. What would be your advice for approaching these conditions?
My advice is that patients with urinary symptoms should be seen and evaluated by a physician who specializes specifically in this area: a urogynecologist or female urologist. Patients should undergo a full physical examination by this specialist, which should include a thorough and detailed pelvic examination including urinalysis, as well as a neurologic examination. There are many different causes of urinary incontinence, and if nothing is found on a physical examination, then a bladder function study such as urodynamics might be warranted. Treatments are based upon physical exam findings and/or findings from the bladder function study. When offering treatments, the specialist should also take into account patient characteristics such as age, other medical conditions, medications, previous surgeries, etc. It is not appropriate to offer treatments for urinary incontinence just based on symptoms alone; an examination is a must.
4. Although I’m almost 60, I’m not ready to give up the sexual relationship my husband and I have. Intercourse is so painful. What are our options? Where can I go to get help? Is there truly something out there that will help my situation? Please help! I’m not sure where to turn anymore!
There are several different causes for pain with intercourse and most are very treatable. In order to figure out the cause of your pain, an examination is necessary. I recommend you make an appointment with a gynecologist or urogynecologist to discuss treatment options. The treatments are based upon the examination findings and your current medical status.
5. I have just recently had a UTI and my doctor said tests show blood in my urine sample. Is this where infection comes from? And what does this mean? Should I be worried and will I continue to repeat the UTIs?
A urinary tract infection (UTI) is the most common cause of blood in the urine. The blood should resolve as soon as the infection is treated. If blood is found in the urine even when there is not an infection (UTI), then further testing is warranted. If your doctor has found blood in your urine even when there is no infection, please see a urogynecologist or urologist. Also, just because you have had one UTI does not mean you are at risk for having recurrent UTIs, although a lot of women do. It is considered normal if a woman has two or less UTIs in a 12 month period of time. If you have had three or more UTIs in a 12 month period, this warrants further testing and you should see a urogynecologist or urologist.
6. I am 74 years old. About 5 years ago I had a hysterectomy and failed bladder lift. No pain or other problems except that when I have to go, I have to go. Is another lift possible/practical?
There are surgical and non-surgical treatment options for a fallen bladder, and determining which treatment is appropriate for you depends upon the severity of the fallen bladder as well as your current medical condition and which previous bladder lift you had (there are many different types). A surgical treatment might certainly be appropriate, but an exam should be performed to determine this. I recommend you see a urogynecologist or female urologist.
7. I have pelvic floor prolapse as a result of my bladder dropping from having a partial hysterectomy where they took out my uterus. What can I do to strengthen the muscles and hopefully not have leakage a lot of the time?
I am a big believer in the benefit of kegel exercises! Doing regular kegel exercises can help strengthen the support to the pelvic organs, reduce the risk of prolapse and incontinence, and reduce the symptoms related to prolapse and incontinence. A lot of women, however, are unsure how to perform kegel exercises. In fact, a study done several years ago found that 50 percent of women did not perform kegel exercises correctly even if they thought they knew how to do them! I usually recommend doing at least 30 kegel exercises a day, holding each contraction for 3 slow seconds. If you have been instructed on how to do kegel exercises properly, do them! If you’re unsure how to do them, I highly recommend seeing a pelvic floor physical therapist. They help women every day with exercises for the pelvic floor, including kegel exercises. Most of the time, you will need a referral to the physical therapist from your physician. Make sure the referral is placed for a pelvic floor physical therapist, as not all physical therapists are trained in this area.
8. I have had two bladder lifts about ten years apart. I’m 69 and still have problems – I’m not dry. What should I do?
There are many different causes of urinary leakage and sometimes a bladder lift may correct an anatomic abnormality (e.g. a fallen bladder) but it may not correct a functional abnormality, if this is the cause of the leakage. Bladder function testing can identify a functional abnormality and thus help determine the best course of treatment for leakage. I recommend you see a urogynecologist or female urologist for evaluation of the urinary leakage as either of these specialists can determine if you need bladder function testing or not, and help with which treatment is the most appropriate for your leakage.
9. I had cystocele and rectocele surgery in February and cannot find any recommendations for exercises to strengthen my pelvic floor post-surgery. Should I contact a physiotherapist or do you have instructions I could follow? Maybe do’s and don’ts as well? I am a 40-year runner, age 70, and my doctor has said I can continue to run, but I have read this is not advised.
For the first part of your question, refer to the answer given for question #7. Running is usually fine in women who have had prior prolapse. I usually caution patients to avoid heavy lifting repetitively and avoid straining with bowel movements regularly, as these actions can really take a toll on the pelvic floor support.
10. What are the top exercises you recommend for pelvic floor health?
Hands down, kegel exercises are the best exercise for maintaining the strength of the pelvic floor. There are quick- and slow-contraction kegel exercises, both of which benefit the pelvic floor. Also, keeping your core strong can help benefit the low back, which can protect from pelvic floor irritation. A physical therapist who specializes in pelvic floor therapy can give you tailored recommendations.
11. My doctor suggested a bladder sling or kegel exercises. I would rather exercise, but I seem to forget. I am up at least every two hours, sometimes on the hour to urinate every night so I’m not getting much sleep. At 64, is the exercise really going to help?
Anyone at any age can benefit from kegel exercises, so I always recommend to my patients to do them! However, they don’t always take care of the problem completely, which can lead to the need for additional treatments and sometimes surgery. A bladder sling is a great surgical option for leakage associated with coughing, laughing, sneezing, lifting, etc. It does not necessarily treat frequent voiding at nighttime. Have you considered avoiding fluid intake for four hours prior to bedtime? If you have lower leg swelling at the end of the day, do you keep your feet raised for several hours prior to bedtime? If you take a water pill in the evening, see if your doctor would agree with you taking it in the morning. These are all things to consider with frequent voiding at nighttime. If none of these applies to your situation, I suggest revisiting the nighttime voiding issue with your doctor to see what other options he or she thinks is appropriate so you can get better sleep!
12. I am 23 years old and have a pubic cath. What are the latest alternatives?
Unfortunately there are not many alternatives to this, but it really depends upon your current medical situation. Sometimes women can intermittently self-catheterize to empty the bladder. Sometimes sacral neuromodulation can help with incomplete bladder emptying. Without knowing your current medical situation, it is difficult to provide options, as these may or may not be appropriate for you.
13. How does complete hysterectomy affect the pelvic floor?
This is a common question I get asked! There is an old wives tale out there that blames prolapse on having a prior hysterectomy. This is just not the case, however. Having a prior hysterectomy does not necessarily predispose someone to having prolapse. In fact, a really good study came out several years ago comparing rates of prolapse in women with prior hysterectomy and women who had not had a hysterectomy, and the rates of prolapse were the same! If a woman is at risk for prolapse it will happen whether she has had a hysterectomy or not. There are many risk factors that place women at risk for the development of prolapse: age, parity (number of births), family history of prolapse, postmenopausal status, chronic constipation, connective tissue disorders, and chronic pulmonary disorders.
14. After a repair of a herniated bladder, how do I strengthen so this doesn’t happen again?
Kegels kegels kegels! Doing regular kegel exercises can help strengthen the support to the pelvic organs and reduce the risk of recurrent prolapse after having a surgical repair. I usually recommend doing at least 30 kegel exercises a day and holding each contraction for 3 slow seconds. If you’re unsure how to do these exercises, get a referral from your physician to a pelvic floor physical therapist for tailored recommendations.
Arielle Allen, D.O. is a fellowship-trained and board-certified urogynecologist.
She dedicates her practice to the health and well-being of women and makes it her priority to educate women on the urinary and gynecologic changes that come with aging. Dr. Allen can provide tailored treatment plans for women suffering from pelvic-related problems.
A graduate of Oklahoma State University’s medical school and the University of Oklahoma’s fellowship program, Dr. Allen’s professional interests and experience include:
- Urinary incontinence
- Pelvic organ prolapse
- Overactive bladder
- Urinary tract infections
- Urogenital fistulae
- Revision and repair of pelvic mesh-related complications