ACKNOWLEDGEMENTS
This booklet was edited and compiled by the multidisciplinary Pelvic Floor Pathway Working Group of the Saskatchewan Ministry of Health,
with significant input from and oversight by gynecologists, urologists, family physicians, women’s health nurse practitioners and pelvic floor physical therapists from Saskatoon Health Region and Regina Qu’Appelle Health Region (RQHR) .
The contributions of everyone involved, especially patients who reviewed the contents in draft form, helped ensure this resource will serve the needs of patients.
The illustrations were created by RQHR Medical Media Services and are used with permission. Some photos used with permission from Dreamstime and iStockphoto.
See more information: www.health.gov.sk.ca/pelvic-floor
i
Introduction .........................................................................................................Page ii
Understanding the Problem ..........................................................................Pages 1-4
How the Bladder Works
Types of Incontinence
• Stressincontinence• UrgencyandUrgeIncontinence• Fecalincontinence
Vaginal Prolapse
Treatment Options .......................................................................................Pages 5-16
Self Management
• LifestyleChanges• BladderRetraining• PelvicFloorMuscleExercises
Pelvic Floor Physical Therapy
Medications for Urge Incontinence
Pessary
Surgery
• StressIncontinence• VaginalProlapse
Do I Want to Seek Treatment? ...........................................................................Page 17Thisworksheetmighthelpyoudecidewhetheryour symptomsarebothersomeenoughtoseektreatment.
Assessment and Diagnosis .............................................................................. Pages 18
Selecting a Treatment ................................................................................Pages 19-22
February 2013
TABLE OF CONTENTS
Urinaryincontinence(leakingurine)isacommonconditionthataffectsabout30%ofadultwomen.Sometimeswomenalsohaveotherproblemslikeabulgeorpressureinthevagina(prolapse).Thisbookletexplainswhatthesethingsare,whatcausesthem,andwhatcanbedonetohelp.
If you have any of these problems, this booklet is a good way to start learning more about them. Speak to a doctor or member of the Pelvic Floor Pathway Team to get a personal diagnosis or treatment.
INTRODUCTIONii
1
HOW THE BLADDER WORKS
Inyourbody,urineisstoredinanorgancalledthebladder.Yourbladderisrelaxedmostofthetime.Whenyouwanttourinate,yourbraintellsyourbladdertocontract,sendingtheurineout.
WHAT IS INCONTINENCE?
Urinaryincontinencemeansthatyouleakurinewhenyoudon’twantto.Aboutone-thirdofwomensometimesleakurine.Somewomenleakonlyalittle,andsomemayleakalot.Notallwomenfeelthatleakingisaseriousproblemforthem.
Therearetwomainreasonswhywomenleakurine:stress incontinenceandurge incontinence.
Stress incontinencemeansyouleakurinewhenyoucough,sneeze,exercise,bendoverorliftheavyobjects.Thisleakagehappensbecausetheseeventscauseanincreaseofphysicalpressureonyourbladder.
Withstressincontinence,theproblemisthatthemusclesandtissuesinyourpelvicfloorarenotstrongenoughtoresistexternalpressure.Whenextrapressureisplacedontheabdomenfromactivitieslikecoughing,laughing,jumpingorlifting,urineisforcedpastthemusclesthatkeeptheurethraclosed.Thiscanhappenwhenthemusclesinyourpelvicareaareweakenedbyhavingbabies,bychronicconstipationrequiringstraining,byobesity,orsimplybygettingolder.
PART I: UNDERSTANDING THE PROBLEM
If pressure from outside squeezes the urine out of the bladder, that is stress incontinence.
Urine
Bladder
Uretha Closed
Sphincter Muscles Squeezed Shut Sphincter Muscles Relaxed
Uretha Open
Coughingorsneezingincreasesthephysicalpressureonyourbladder.
2
Urge incontinenceiswhenyoufeelanurgentneedtopassurineandyouareunabletomakeittothetoiletintime.Yourbladderiscontractingwhenyoudon’twantitto!Youmayhavelittleornowarningthatthisisgoingtohappen,oryoumayhaveasuddenstrongneedtourinate.Theremaybetriggersthatcausethisurgency,suchashearingrunningwater,feelingchilled,arrivingatyourhousedoor,orstandingupfromachairorbed.Peoplewithurgeincontinencemayalsoneedtourinateoftenandgetupseveraltimesinthenight.Withurgeincontinence,theproblemisanoveractivebladdermuscle.
Manywomenhaveacombinationofstressandurgeincontinencecalledmixed incontinence.Itisgoodtoknowwhatkindofincontinenceyouhavebecausethecausesandtreatmentsaredifferent.
WHAT IS NORMAL?
Anaveragewomanurinatesupto7timesduringtheday(aboutevery2-3hours).Itisnormaltogetuponceinthenighttourinate,andtwiceasyougetolder.Normalbladdercapacityis300–600ml(250ml=1cup)
Normalfluidintakeisabout6-8cupsofwaterorotherdrinksperday.Drinkingmoreorlessthanthisamountcanmakeleakingworse.Drinksthathavecaffeine,liketea,coffeeandcolas,canalsomakeleakingworsebecausetheyirritatethebladder.
Fecal incontinencemeansanunwantedleakageofbowelcontents–gas,liquidorsolidstool.Somewomenhaveproblemswithbothfecalandurinaryincontinence.Thiscanbebecauseofpelvicfloormuscleweakness.
If your bladder suddenly contracts on its own, that is urgency; if urine leaks out, that is urge incontinence
PART I: UNDERSTANDING THE PROBLEM
3
WHAT IS VAGINAL PROLAPSE?
A vaginal prolapsecanhappenwhenthetissueandmusclesinsidethepelvisbecomeweak.Thisweaknessallowsthevagina,uterus,bowelorbladdertocomedown.Imagineasockturningitselfinsideout.
Themainsymptomofvaginalprolapseisabulgebetweenthelegsthatyoucanseeorfeel.Itmaygoinandoutofthevaginadependingonwhetheryouarestanding,sittingorlyingdown.Itfeelsbiggerwithactivitiesthatputpressureontheareasuchaslifting,coughing,strainingwithbowelmovements,andintheeveningafterbeinguprightallday.Prolapsemaystaythesamesizeforlongperiods
oritmaygetbiggerovertime.Forafew,thebulgebecomessmallerandlessnoticeable.
Prolapsehappensbecauseofweakness,damageorstretchingofthesupportstructuresatthebottomofthepelvisthatholdyourorgansin.Thesemusclesarecalledthe“pelvicfloor.”Althoughitcanoccurinanywoman,prolapseisoftencausedbyhavingbabies,increasingageandobesity.Otherfactorsthatmaystretchorweakenpelvictissuesincludeconstipation,chroniccoughorlong-termheavylifting.
Prolapsedoesnotusuallycausepainorconstipation,butitcanbeuncomfortableandmayaffectthebladder,bowelandsexualfunction.
Bladder
UrethraVagina
AnusRectum
Uterus
ddheenan©2012
Normal Anatomy
Pelvic Floor Muscles
Cervix
Uterus
Prolapsed Uterus
Pelvic FloorMuscles
Pelvic FloorMuscles
Normal Pelvic Anatomy
Illustrations courtesy Medical Media Services, Regina Qu’Appelle Health Region.
PART I: UNDERSTANDING THE PROBLEM
Anal Sphinter
Rectum
Rectocele
Prolapsed Bowel
Pelvic Floor Muscles
4
Prolapsed Bowel (rectocele): Whenthebowelcollapsesintothevaginafrombehind,stoolcangointhewrongdirectionwithstraining.Thiscancauseincompleteemptyingofthebowel.Somewomenmayneedtopushontheprolapsewiththeirfingersinthevaginatohelpemptythebowel.Changingthestoolconsistency,aimingforsoft,formedstoolandavoidingconstipation,pluslearningcorrectevacuationposturesandtechniquescanhelprelievesomeofthesesymptoms.
Prolapsed Bladder (cystocele): Whenthebladdercollapsesintothevagina,itcanmakeithardertoemptythebladdercompletelywhenyouurinate.Incompletebladderemptyingcancausebladderinfections.Somewomenwithbladderprolapsealsohaveurinaryincontinence.
PART I: UNDERSTANDING THE PROBLEM
Bladder
UrethraPelvic Floor
Muscles
Cystocele
Prolapsed Bladder
Pelvic Floor
MusclesAnal Sphinter
Rectum
Rectocele
Prolapsed Bowel
Pelvic Floor Muscles
Sexual function:Whenprolapseispresent,itisthewallsofthevaginathatcollapseinwardandcreateabulgebetweenthelegs.Somewomenfindthattheprolapsegetsinthewayofsexualintercourse.Thewomanorherpartnermayworryabouthurtingthewomanormakingtheprolapseworse,butthisisnot
thecase.Intercourseissafe,evenwhenprolapseispresent.Ifintercourseispainful,itmayberelatedotherfactors,suchasvaginaldrynessrelatedtomenopause.
5
SELF MANAGEMENT
A. LIFESTYLE CHANGES
With urge incontinence,theproblemisanoveractivebladdermuscle.Urgeincontinence can be improvedbyreducingthingsthatirritatethebladder.Thismayinvolvelifestylechangessuchasavoidingcaffeine(e.g.coffee,teaandcolas)andotherirritantssuchasalcohol,cigarettes,artificialsweeteners,spicyfoodsandcitrus.
Regulartoiletingevery2-3hoursmayalsohelpsomewomenwithurgeincontinencetopreventepisodesofleaking.
Stress and urge incontinence, and fecal incontinence, can be improved by changes like:
• Achievingahealthyweightbyeatinganutritiousdietandgettingregularexercise,
• Drinking6-8cupsoffluidperday,two-thirdsofwhichshouldbewater.
• Avoidingconstipation.
PART II: TREATMENT OPTIONS
Caffeine content of some common foods and drinks
Product Serving Size (unless
otherwise stated)
Milligrams of Caffeine
(approximate values)
oz ml
Coffee,filterdrip 8 237 179
Coffee,decaffeinated 8 237 3
Tea(leaforbag) 8 237 50
Green tea 8 237 30
Decaffeinatedtea 8 237 0
Colabeverage,regular 12 355 (1can)
36-46
Colabeverage,diet 12 355 39-50
Chocolatemilk 8 237 8
Candybar,milkchocolate
1 28g 7
Bakingchocolate,unsweetened
1 28g 25-58
Chocolatecake 2.8 80g 36
Chocolatepudding 5.1 145g 9
Source: Health Canada (www.hc-sc.gc.ca)
6
Fecal incontinence(leakingstool)canimprovewith:
• Dietarychangestoimprovestoolconsistency
• Pelvicfloormusclestrengthening
• Correcttoiletingtechniques
TheBristolStoolFormScale(shownhere)describesthedifferenttypesofstoolformorconsistency.Types1and2arehard,constipatedstoolwhichcanbedifficulttopass.Types3and4aresoft,formed,normalstoolwhichareeasytopass.Types5,6and7arelooseandverydifficulttocontrolespeciallyifthereisweaknessinthepelvicfloorandanalsphinctermuscles.ThedesiredstoolformisType3or4.
PART II: TREATMENT OPTIONS
BRISTOL STOOL FORM SCALE
Type 1 Separatehardlumpslikenuts(difficulttopass)
Type 2 Sausageshapedbutlumpy
Type 3 Likeasausagebutwithcracksonsurface
Type 4 Likeasausageorsnake,smoothandsoft
Type 5 Softblobswithclear-cutedges(passedeasily)
Type 6 Fluffypieceswithraggededges,amushystool
Type 7 Watery,nosolidpieces(entirelyliquid)
7
THE URGE CURVE
PART II: TREATMENT OPTIONS
B. BLADDER RETRAINING
Ifyouhaveurgency/urge incontinencetherearesomethingsthatyoucandoforyourselftocontroltheleaking.Forexample,youcanchangewhatyoueatanddrinktohelpreduceirritationofthebladder,asexplainedintheprevioussection.Youcanalsolearntocontrolthebladdermusclebetter.Thisiscalled“bladderretraining.”
Urge suppression and bladder retraining
Whenyourbladdermusclecontracts,theurgetourinateisstronganduncomfortable.Thecommonreactionistorushtothebathroomassoonaspossible.Butyoucanretrainyourbladdertowait,ifyouconsciouslytrytosuppresstheurge.
Thefeelingofurgencycomesinwaves.Itstarts,grows,peaksandfadesaway.Thiscantakeafewminutes.Whenyoufeeltheurgetourinate:
1. Stopwhatyouaredoingandbe still.
2. Sitdownandsqueezeyourpelvicfloormuscles.Thistechniqueisreferredtoas“freezeandsqueeze.”
3. Takeafewdeepbreathsandrelaxyourbodyandmind.
4. Distractyourmindbycountingbackwards,sayingthealphabet,recitingnurseryrhymesetc.
5. Whentheurgesubsides,calmlywalk to the toilet.
Ifyouhavecommontriggersforurgeincontinence(e.g.hearingrunningwaterorputtingyourkeyinthedoor),youcanusethistechniquetomanagetheurgeandbreakthehabit.Practicesqueezingthemusclesatthesametimeyouareconfrontedwiththetrigger.Withpractice,urgesuppressionbecomeseasierandmoresuccessful.
Selfcarecanstopyoufromleakingasoften,butitprobablywillnotstoptheleakingcompletely.Youmaystillwearpads,justincase.
USING INCONTINENCE PADS
Ifyouwearpadsallthetimeormostofthetime,youshoulduseabarriercreamtopreventirritation.
PEAKS
GROWS
squeeze
SUBSIDES
STOPS
walk to toilet
STARTS
be still waitdistract yourself
8 PART II: TREATMENT OPTIONS
C. PELVIC FLOOR MUSCLE EXERCISES
Strongpelvicfloormusclesgiveuscontroloverourbladderandbowel,andsupportourorgansinthepelvis.Strengtheningthepelvicfloormusclescanimprovestressandurgeincontinenceandpelvicorganprolapse.
What is the Pelvic Floor?
Thepelvicfloormusclesstretchlikeatrampolinefromthetailbone(coccyx)tothepubicbone(backtofront)andfromonesittingbonetotheother(sidetoside).Thesemusclesarenormallyfirmandthick.
Thebladder,uterusandbowellieontopofthepelvicfloormusclelayer.Thereare3openingsinthepelvicfloorlayerfortheurethra(thetubefromthebladder),thevagina,andtheanus(openingfromthebowel)topassthrough.Thepelvicfloormusclesnormallywrapfirmlyaroundtheseopeningstokeepthemclosed.Thereisalsoanextracircularmusclearoundtheanus(analsphincter)andtheurethra(urethralsphincter)tohelpwiththeclosure.
Whenthepelvicfloormusclesarecontracted,thepelvicorgansareliftedandthesphincterstighten,closingtheopeningsofthevagina,anusandurethra.
Pelvic Floor Exercises
Specialexercises,sometimescalledKegel exercises,helptostrengthenthemusclesofthepelvicfloor.Youcandotheseexercisesathomebyyourself.Manywomenfindthatcoachingfromaspeciallytrainedphysiotherapisthelpsthemtolearntheexercisesproperlyandgetthemofftoagoodstart.
Finding the right muscles:
Imaginethatyouaretryingtostopyoururinefloworaretryingtoholdbackgas.Youshouldfeelyourvaginaandyouranustighten.Liedownandinsertaclean,moistfingerintothevagina.Tightenthepelvicfloormuscles.Youshouldfeelasqueezearoundyourfinger.
Rectum
Vagina
Urethra
Pelvic Bones
Pelvic Floor MusclesPelvic Floor Muscles
Tailbone
9
Doing the exercises:
1. Startbydoingtheexerciseslyingdownwithyourkneesbent.
2. Squeezeyourpelvicfloormuscles.Holdfor5-10seconds.Relaxfor10seconds.Workyourwayuptorepeatingthisexercise5-10times.
3. Youmayonlybeabletoholdforafewsecondstostart.That’sokay.Startthereandworkyourwayup.
4. Repeattheseexercises2-3timesaday.
5. Challengeyourself!Dotheseexercisesinsittingorstandingpositions,whileyouwalk,sidesteporjump.Increasetherepetitionsanddecreasetheresttime.
Ifyouaredoingexercisesyourselfathome,herearesometips:
• Makesurethatyouareusingthepelvicfloormusclesonly,notthelegsorbuttocks.
• Avoidholdingyourbreathwhendoingtheseexercises.
• Usethepelvicfloorwhenyouneeditmost.Squeezebeforeyoucough,sneeze,laughor
liftsomethingheavy.Thisiscalled“theknack.”Squeezeifyoufeelastrongurgetoemptythebladderandfearlosingcontroloftheurgeadd(freezeandsqueeze).
Tips for remembering to sneak in a squeeze:
• Trytolinkyourpelvicfloorexerciseswithcertainactivities:morningandbedtime,watchingtelevision,waitingatredlights.
• Reddots:putstickersinplacestoremindyoutodoyourexercises.Forexample,putoneonthebathroommirror,rearviewmirror,bedsidetableort.v.
Keep it up
Dotheexercisesregularlyanddon’tgiveup!Itmaytakethreetosixmonthstoseefullresults.Youmaytestyourpelvicfloorstrengthonceamonthbytryingtostopyourflowofurine,butdo notdoyourexerciseswhileyouemptythebladder.Thatmightconfusethebladder.
PART II: TREATMENT OPTIONS
10 PART II: TREATMENT OPTIONS
PELVIC FLOOR PHYSICAL THERAPY Ifyouarehavingdifficultywiththeexercisesoryouarenotgettingtheresultsyouhadhopedfor,youmaybedoingtheexercisesincorrectly.Researchshowsthat50%ofwomencannotlearnpelvicfloormuscleexercisesfromhearingorreadinginstructions.Forthosewhoneedindividualcoachingandsupport,therearespecially trained physical therapistswhocanhelp.
Thetherapistwillperformaphysicalevaluation,includingavaginalexamination,toassessyourpelvicfloorfunctionandtailoranexerciseprogram
tomeetyourspecificneeds.Inadditiontoteachingyouhowtoisolateandcorrectlyperformyourpelvicfloormuscleexercisesinone-on-onesessions,thephysicaltherapistwillgiveyouacomprehensivehomeprogramofexercisesfor:
• Pelvicfloormusclestrengthening
• Abdominal(core)musclestrengthening
• Posturecorrection.
Thephysicaltherapistwillalsoteachyou:
• strategiesandtechniquestopreventurineleaksduetocoughing,laughing,sneezing,bending,liftingandmorevigorousactivities
• strategiesandtechniquestohelpyoucontrol/deferbladderurgency
• toiletingtechniquestohelpyoucompletelyemptyyourbladderifyouarehavingdifficultydoingsoandtohavebowelmovementswithoutstraining
Andwill
• Provideyouwithinformationandsupportforlifestylechangesthatwillhelpyoutoreduceincontinenceandsymptomsofprolapse.
Sixty(60)to75%ofwomenwhoparticipateinpelvicfloorphysicaltherapyprogramsaresatisfiedwiththeresults.
Therearenosideeffectsbutyoumustcontinuewiththeexercisesorlifestylechangesorsymptomswillreturn.
11
MEDICATIONS (FOR URGE INCONTINENCE)Medicationsusedtotreaturgencyandurgeincontinenceworktorelaxtheoveractivebladderandreducetheunwantedbladdercontractions.MedicationsareNOTavailableforstressincontinenceorprolapse.Medicationsmaydecreaseepisodesofurgeincontinenceby50-60%.Ifitissuccessful,medicationisalongtermtreatment.Youwillonlyseeimprovementaslongasyouaretakingthemedication.
Thereareseveraldifferentmedicationsthatcanbeusedforurgeincontinence.Youmayseeimprovementwithinafewdays.Yourconditionmaykeepimprovingforuptoamonthafterstartingthemedication.
Types of Medication
Oxybutininisacommonmedicationforincontinence.Yourdoctorwillprobablyrecommenditfirst.Ifyourespondtooxybutinin,yourdoctorcanadjustthedosetoyoursymptoms.Itmighttakesometimeandpatiencetofindtherightdose.
Oxybutininisfastactingandlastsabout8hours,so
itissometimesusedonanasneededbasis(suchaswhenyouaregoingout,goingtoworkortraveling).Ifsymptomsareonlybothersomeatnight,youmayuseitbeforegoingtobed.Ifsymptomsareonlybothersomeintheday,youmayuseitinthemorningortwiceperday.
Yourdoctorwillaskyouifyouhaveanysideeffectsfromtheoxybutinin.Iftherearesideeffects,orifthemedicationisnothelping,thereareothermedicationsyoucantry.Don’thesitatetotellyourdoctorifyouhaveanyconcerns.
Managing medications:
Ifyourmedicationisdoingagoodjobofcontrollingyourincontinence,youmaychoosetolivewithsomeofthesideeffects.Mostsideeffectsarenotserious,andwillgoawaywhenthemedicationisstopped.
Themostcommonsideeffectofthistypeofmedicationisdrymouth.Somepeoplenoticedryeyesornasalpassages.Drymouthmaybereducedbyloweringthedoseortryingthingsthatimprovetheflowofsaliva(sugarlessgumorcandyandoverthecountersalivasubstitutespraysorgels).Constipation,stomachupsetanddrowsinesscanalsooccur.
Yourdoctorwillnotprescribethistypeofmedicationforyouifyouhavecertainunderlyingmedicalconditions.Theseincludegastroparesis(aproblememptyingthestomach),sometypesofglaucoma,rhythmproblemsoftheheart,ordementia.Iftheseproblemsstartwhenyouareusingthemedication,stoptakingitandseeyourdoctor.
PART II: TREATMENT OPTIONS
Drug Trade name
oxybutinin Ditropan,DitropanXL,
Uromax,OxytrolGelnique
tolterodine DetrolLA
fesoterodine Toviaz
darafenacin Enablex
solifenacin Vesicare
trospium Trosec
12 PART II: TREATMENT OPTIONS
PESSARYApessaryisasiliconediscorringthatisspeciallyfitforyoubyadoctorornurse.Thepessaryisinsertedintothevagina(likeatampon)whereithelpstosupportthepelvicorgansandstopthemfromcomingdown(vaginal prolapse).
Apessarycanalsobeusedtotreatstress incontinence,becauseitputsgentlepressureontheurethra(tubethatdrainsthebladder)tohelpitstayclosed.Abouttwo-thirdsofwomenfindthatapessaryhelps.
Somewomentryapessarywhiletheywaitforstressincontinenceorprolapsesurgery,andothersuseapessarytoavoidsurgery.
Mostwomencanwearapessarysafelyforseveraldaysatatime.Pessariescanbeleftinformostactivitiesofdailylife,butshouldberemovedforsexualactivity.
Using a pessary
Youwillbefittedwithapessarythatistherightsizeandshape.Itmighttakeafewtriestofindapessarythatwillprovidesupportwithoutcausingdiscomfortorslippingout.Youwillbetaughttoinsertandremovethepessaryonyourown.Astringcanbeattachedtothepessarytoassistwithremoval.
Yourdoctormightprescribelowdoseestrogencreamtouseforkeepingyourvaginaltissuehealthy.
Youwillbeinstructedtoremoveyourpessaryonceortwiceweekly.Forexample,removeitovernightonMondayandThursdayeveryweek.Ifyouaremenopausalanddonotuseestrogen,removalofyourpessaryisrecommendedeverynight.
Ontheeveningswhenthepessaryisremoved,youmayuseyourestrogenandpreparethepessaryforinsertionthefollowingmorning.
Pessary care
Thepessaryiswashedwithmildsoap(avoidingperfumes)andrinsedwell.Afterdrying,anewstringmaybeattached,sothepessaryisreadytobere-insertedthefollowingmorning.Boilingorsterilizingthepessaryisnotnecessary.
Overtime,pessariesmaybecomediscoloured.Theyonlyrequirereplacementifcracksdeveloponthesurface.
Youwillbeaskedtoreturnforafollowupcheckafterusingapessaryfor2-4weeks.
Itmighttakeafewtriestofindapessarythatprovidessupportswithoutcausingdiscomfort.(PhotocourtesySuperiorMedicalLimited.)
13
Is there a risk to using a pessary?
Apessaryisverysafewhenusersfollowtheinstructionsforcareandmanagement.Themainriskofusingapessaryisthedevelopmentofaninfectionorerosion(ulcer)inthevaginawhichcanresultinbleedingorafoulsmellingdischarge.Youshouldseeyourdoctorifyoudevelopthesesymptoms.Arestfromusingthepessarymaybenecessary.
Becauseemergenciesmayoccurwhereawomanisnotabletospeakforherself,sheshouldletsomeoneclosetoherknowaboutherpessaryusesoitcanberemoved.
PART II: TREATMENT OPTIONS
Pessary
14
SURGERY FOR STRESS INCONTINENCESurgerywillcureorreducestressincontinencein8outof10women.However,manywomenhavebothstressandurgeincontinence.Evenifstressincontinencegoesaway,theymaycontinueleakingbecauseofurgeincontinence.Thisisnotafailureofthesurgery.
Medicaltechnologyisalwayschanging,andnewoperationsarefrequentlyintroduced.Rightnowthemostcommonformofstressincontinenceoperation is a vaginal tape(meshtapeplacedundertheurethratohelpkeepitclosed).Whendonealone,thisprocedureisusuallydaysurgery(cometohospitalandgohomethesameday).
Ifyouareinterestedinsurgery,youwillmeetwithasurgeontodiscussyourcondition.Thesurgeonwilldescribethesurgicaloptionsavailable,andthetypeofoperationhe/shethinksisbestforyou.
About Surgery
Surgerycanbedoneunderlocal,spinal,orgeneralanesthetic.Withlocalorspinalanestheticonlythenervesofyourpelvicareaarefrozen.Withgeneralanestheticyouaregivenmedicationtorelaxyourwholebodyandputyoutosleepduringsurgery.Yourquestionsaboutanestheticcanbeansweredatyourpre-admissionclinicvisitorbyyoursurgeon.
Risks of Surgery
Risksofanysurgeryincludeinfectionatthesurgicalsite,bleeding,damagetosurroundingstructuresandanesthetic-relatedrisks.
Surgeryforstressincontinencemaycausethestreamofurinetoslowdown.Thisisnotconsideredasignificantproblem.However,thereisasmallriskthatthesurgerywillactuallymakeitdifficultforawomantourinate.Thisproblemisusuallytemporary,andrequiresthewomentourinatebyinsertingacatheter(tube)intoherbladder.Iftheproblemdoesn’tgoawaysoon,asecondsurgerymightberequired,butthisisrare.
Inrarecases,surgeryforstressincontinencecancauseurgeincontinencetogetworse.
Operationsthatusemeshorotherartificialmaterialmayhaveproblemssuchasexposureofthemesh,pain,orinfection.Thismayrequireremovalofpartorallofthematerial.
Pre-admission clinic visit
Thisvisit,ifrequired,takesplacepriortoyoursurgerydate.Nursesreviewyourhistory,answerquestions,andperformnecessarytests.Youmaybetaughthowtoputacatheter(tube)insideyourbladder.Youmayalsoseeananesthetistorothermedicalspecialist.
PART II: TREATMENT OPTIONS
15
Ifyouareusingmedicationforurgeincontinenceyoumaybeaskedtostopthemedicationadayortwobeforeyoursurgery.Besuretoaskyoursurgeonaboutuseofbladdermedicationsaroundthetimeofyoursurgery.
Postoperative care
• Youmayhavepaininyourincisionsanywherefromafewdaystoafewweeks.
• Donothavevaginalintercoursefor1month.
• Donotliftmorethan10lbsorperformheavyworkfor1month.Timeoffworkdependsonyourtypeofworkandthetypeofsurgeryperformed.
• Youcannotdriveuntilyoucansafelygiveallyourattentiontotheroadwithoutpainorsedationfrommedications.Youwillneedaridehomefromthehospital.
Yourquestionscanbeansweredatyourpre-admissionclinicvisitorbyyoursurgeon.
Yourquestionscanbeansweredatyourpre-admissionclinicorbyyoursurgeon.
PART II: TREATMENT OPTIONS
16 PART II: TREATMENT OPTIONS
SURGERY FOR VAGINAL PROLAPSESurgerywillcureprolapseinabout7outof10womenwhochoosethistreatment.Onaverage,3outof10womenwhohavesurgerywillhaveasecondsurgeryforprolapseatsomepointinthefuture.
Thetypeofsurgeryyouneeddependsontheorgansthatneedtoberepaired.Inadditiontoliftingprolapsedorganssuchasthebladderorbowel,yoursurgeonmightrecommendremovingtheuterus(hysterectomy)orliftingthetopofthevagina(vaultsuspension).Surgeryforprolapsecanalsobecombinedwithsurgeryforstressincontinence.
Ifyouareinterestedinsurgery,youwillmeetwithasurgeontodiscussyourcondition.Thesurgeonwilltalktoyouaboutyourconditionandthetypeofoperationhe/shethinksisbestforyou.
About the Surgery
Prolapsesurgeryusuallyisdonethroughthevaginabutdependingontheanatomyofthepatientandthetrainingofthesurgeon,itmaybedonethroughtheabdomen.Afterprolapsesurgery,patientsaretypicallyinhospitalfor1-3days.Dependingontheoperationplanned,apatientmayoccasionallybescheduledasdaysurgery.
Risks of Surgery
Risksofanysurgeryincludeinfectionatthesurgicalsite,bleedinganddamagetosurroundingstructures(bladderandbowel).Thereisalsosmallriskofnerveinjuryrelatedtoyourpositionduringsurgery,bloodclotinthelegs/lung,medicalcomplications(suchaspneumoniaandcardiacproblems),andanesthetic-relatedrisks.
Thereisasmallriskthatprolapsesurgerywillmakeitdifficultforawomantourinate.Thisproblemisusuallytemporary,andrequiresthewomentourinatebyinsertingacatheter(tube)intoherbladder.Inrarecases,surgeryforprolapsecancauseonsetofurinaryincontinence.Anotherriskofprolapsesurgeryisshortorlongtermpainwithintercourse.
Pre-admission clinic visit
Thisvisit,ifrequired,takesplacepriortoyoursurgerydate.Nursesreviewyourhistory,answerquestions,andperformtests.Youmaybetaughthowtoputacatheter(tube)insideyourbladder.Youmayalsobeseenbyananesthetistorothermedicalspecialists.
Postoperative care
• Ifyouhaveacatheter,itmayberemovedinhospital,oryoumaycomebacktohaveyourcatheterremovedfollowingyourdischarge.
• Vaginaldischargeandirregularsmallamountofbleedingarecommonduringyourrecovery.
• Paintypicallylastsforafewweeks,butdependsonthesurgeryperformedandthepatient.
• Donothavevaginalintercourseuntilexaminedbyyoursurgeonatyourpostoperativevisit.
• Donottoliftmorethan10lbsorperformheavyworkfor6weeks.Timeoffworkdependsonyourtypeofworkandthetypeofsurgeryperformed.
• Youcannotdriveuntilyoucansafelygiveallyourattentiontotheroadwithoutpainorsedationfrommedications.Youwillneedaridehomefromthehospital.
Ifyouhavequestions,theycanbeansweredatyourpre-admissionclinicvisitorbyyoursurgeon.
17
THE FIRST DECISION: TREATMENT OR NOT?
Treatmentsareavailableforincontinenceandprolapse.Butitisuptoyoutodecidewhetheryouwanttoseektreatmentornot.Incontinenceandprolapsearenotlife-threateningconditions.Yoursymptomsmayormaynotgetworseasyougetolder.Thedecisiondependsonhowbothersomeyoursymptomsare.
Usethisworksheettohelpyouworkthroughthedecision.
Decision: Do I want to seek treatment or not?
1. Whatisyourreasonformakingthisdecision?_________________________________________________
2. Whendoyouneedtomakeachoice?_______________________________________________________
3. Howfaralongareyouwithmakingachoice?
Ihavenotyetthoughtabouttheoptions Iamthinkingabouttheoptions Iamclosetomakingachoice Ihavealreadymadeachoice
4. Howmuchdothesymptomsofincontinenceorprolapseaffectyour… (Circle best answer to each question.)
Ability to perform tasks in your workplace or household? NotatAllSlightlyModeratelyGreatly
Ability to take part in physical recreation or exercise? NotatAllSlightlyModeratelyGreatly
Entertainment or participation in social activities? NotatAllSlightlyModeratelyGreatly
Ability to travel more than 30 minutes from home? NotatAllSlightlyModeratelyGreatly
Sex life? NotatAllSlightlyModeratelyGreatly
Emotional health (nervousness, depression, etc.)? NotatAllSlightlyModeratelyGreatly
Other_________________________________________ NotatAllSlightlyModeratelyGreatly
*adaptedfromIIQ-7
5. Overall,howmuchdoyoursymptomsaffectyourqualityoflife?
NotatAllSlightlyModeratelyGreatly
6. Whatisyourpreferredoption?
Seektreatment:getareferraltothepathwayclinic Notreatmentatthistime:youmaywanttorevisitthedecisioninsixmonthstooneyear Notsure:discusswithyourprimarycareproviderandcalltheclinicwithinonemonth
PART III: DO I WANT TO SEEK TREATMENT?
18
THE NEXT STEP
IfyoudecidetocontinueonthePathway,andseektreatmentforyourcondition,Step2isAssessment.AskyourdoctortoreferyoutoaPelvicFloorPathwayClinic(ifthishasnotalreadybeendone).YouwillneedtovisitaClinicinReginaorSaskatoon.
Beforeyourappointmentyouwillreceiveapackageofformsincluding:
amedicalhistoryform
athree-daybladderdiary(askingyoutorecordthetypeandamountoffluidyoudrink,thetimeandamountofurinevoided,andamountandnumberoftimesyouexperienceurineleakageoverathree-dayperiod)
questionnairesaboutyoursymptomsandhowtheyaffectyourqualityoflife
Your full cooperation is required in completing these forms and bringing them to your assessment appointment.
Atyourassessmentthehealthcareproviderwill:
Gooveryourformsandhistory
Discussyourproblemwithyou
Performatargetedphysicalexam including a pelvic examinationtoassessforprolapseandpelvicfloormusclestrength
Thehealthcareproviderwillhelpyoucomparetreatmentoptionsopentoyouandchoosefrom:
Pelvicfloorphysicaltherapy
Medication
Pessary
Surgery
Anytreatmentwillinvolvefurtherappointments,andsomewillrequiremoredetailedtestsandpelvicexaminations.Forsomeprograms,waittimesmayapply.
PART IV: ASSESSMENT & DIAGNOSIS
19
SELECTING A TREATMENT
Onceyouhaveacompleteassessmentandadetaileddiagnosis,youwillbereadymakeatreatmentchoice.Whetheryouareaffectedbyurgeincontinence,stressincontinence,vaginalprolapse,oracombinationofallthree,youwillfindthatthereareseveraltreatmentoptionsavailable.Yourhealthcareproviderwillhelptoexplainaboutyourconditionandthetreatmentoptions,butthedecisionabouttreatmentismadebyyou.
Itcanbehardtomakeachoicewhenthereareseveralgoodoptionsavailable.Itisagoodideatomakealistofallthetreatmentoptionsforyourcondition,andgatherinformationaboutthepositivesandnegativesofeachoption.Onthefollowingpages,youwillfindchartsthatsummarizetheprosandconsofeachtreatmentdiscussedinthisbooklet.Youmaywanttogetinformationfromothertrustedsources,too.Makealistofanyquestionsyouwanttoaskwhenyoumeetyourhealthcareprovider.
Onceyouhavereviewedalltheinformationabouttreatmentoptions,youmightbeabletoeliminatesomeoptions.Onthechartsprovided,youcancheckthe“pros”thatareveryimportanttoyou,orthe“cons”thatarenotacceptable.Thenyoucanmakeatentativedecisionaboutwhichtreatmentyouwanttotry.
WhenyouvisitthePelvicFloorPathwayClinic,ahealthcareproviderwillalsohelpyouthroughthestepsofthisdecision-makingprocessandletyouknowifyouroptionsarelimitedbyyourphysical
conditionand/oryourmedicalhistory.Explaintoyourhealthcareproviderwhichtreatmentyoutentativelyselected,andwhy.Yourhealthcareproviderwantsyoutomakeaninformedchoicethatisrightforyou.
Onceyouhaveselectedatreatment,pleasedoyourbesttofollowinstructionsandputeffortintoimprovingyourcondition.Butifthetreatmentyouselectdoesn’tseemtobehelping,youcanreturntothePelvicFloorPathwayClinicandbeginthedecisionmakingprocessagain.
PART V: SELECTING A TREATMENT
20 PART V: SELECTING A TREATMENTCo
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21PART V: SELECTING A TREATMENTCo
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22 PART V: SELECTING A TREATMENTCo
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