Kegel Exercises: Patient Handout

Strengthening Pelvic Floor Muscles: Kegel Exercises

The Female Patient: Patient Handout

Kegel exercises are often recommended for women who experience urine leakage, or inconti­nence. Consistent Kegel repetitions may improve bladder control within a few weeks.

Reasons for urine leakage include pregnancy, childbirth, aging, or being overweight. When the pelvic floor muscles are weakened, there may be a loss of urine when a person cannot reach a bathroom quick enough or during laughing, coughing, exercising, or getting up from a chair.

What are Kegel exercises?

In the 1950s, Dr Arnold H. Kegel proposed exercises to strengthen the pelvic floor muscles that support the bladder, uterus, and bowel. While there are sev­eral options for treating or managing incontinence (from wearing protective pads, use of devices, injec­tions, and/or medication, to surgery) Kegel exercises are a good technique to make the pelvic muscles stronger. When these muscles become stronger, there will be less leaking of urine.

How are Kegel exercises done?

Start by finding the right muscles. Lie down and insert a finger into the vagina. Squeeze as if you are stopping urine from coming out. If you feel tighten­ing on your finger, these are the muscles for pelvic exercises. Another method for finding the right mus­cles is to stop urine midstream while on the toilet and becoming aware of the muscles being used (but do not continue to practice exercises during urination).

The process for performing a Kegel exercise is this:

  • First, empty your bladder.
  • Tighten the pelvic muscles and hold for 10 seconds.
  • Relax the muscles completely for 10 seconds.
  • Repeat the process for about 5 minutes (or 10 sets), 3 times each day. The exercises can be done any­where—standing, sitting, or lying down.

You can also try a single set at times when you are likely to leak, such as when getting up from a chair or having an urge to run to the bathroom.

What if I don’t do them right?

Don’t give up if you don’t have results after a few weeks. However, if you are not sure you are doing the exercise correctly, consult your clinician. Biofeedback is a method to monitor the contractions. A clinician can help find the right muscles to perform Kegel exercises or suggest other exercise aids.Don’t go overboard and do more than the recom­mended sets. This will not speed up progress and may instead cause muscle fatigue, which may increase leakage.

Interstitial Cystitis

INTERSTITIAL CYSTITIS (PAINFUL BLADDER SYNDROME)

Interstitial cystitis (IC) is a chronic bladder condition. Its symptoms are pain, pressure, or discomfort that seems to be coming from the bladder and is associated with urinary frequency and/or an urge to urinate. The symptoms range from mild to severe, and intermittent to constant. The more severe cases of IC can have a devastating effect on both sufferers and their loved ones. Many cases are of mild or moderate severity.

In the past, IC was believed to be a rare disease that was very difficult to treat. Now we know that IC affects many women and men. The following information should help you discuss this condition with your urologist and understand what treatments are available.

What happens under normal conditions?

After urine is made in the kidneys, it flows down the ureters into the bladder. The bladder is a hollow, balloon-like organ. Most of the wall of the bladder is made of muscle. As the bladder fills, the muscle relaxes so that the bladder expands and holds urine. During urination, the bladder muscle contracts to squeeze out the urine. The urethra is the tube through which urine passes from the bladder to the outside. The urethra has a muscle, the sphincter, which is completely different from the bladder muscle. The sphincter normally stays closed and makes a seal to keep urine from leaking. During urination, the sphincter opens and lets urine pass.

The bladder and urethra have a specialized lining called the epithelium. The epithelium forms a barrier between the urine and the bladder muscle. The epithelium also helps to keep bacteria from sticking to the bladder, so it helps to prevent bladder infections.

What is interstitial cystitis (IC)?

IC is a chronic bladder condition. Its symptoms may be mild or severe, occasional or constant. It is not an infection, but its symptoms can feel like those of a bladder infection. In women, it is often associated with pain upon intercourse. Interstitial cystitis is also referred to as bladder pain syndrome (BPS) and can be associated with irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, and other pain syndromes.

What are some risk factors for IC?

There are no specific behaviors or exposures (such as smoking) known to increase a person’s risk for getting IC. The tendency to get IC may be influenced by a person’s genes, and so having a blood relative with IC may increase the risk of getting IC yourself. About 80 percent of people diagnosed with IC are women, which suggests that being female may increase the risk of getting IC. However, the difference in rates of IC for men vs. women may not really be as high as we think, because some men diagnosed with “prostatitis” or similar conditions with different labels may really have IC.

How many people in the United States have IC?

It is estimated that 3.3 million women and 1.6 million men in the U.S. suffer from some form of IC.

What causes IC?

The causes of IC are being studied in medical centers around the world. Many researchers believe that IC is caused by one or more of the following: (1) a defect in the bladder epithelium that allows irritating substances in the urine to penetrate into the bladder; (2) a specific type of inflammatory cell (mast cell) releasing histamine and other chemicals that promote IC symptoms in the bladder; (3) there is something in the urine that damages the bladder; (4) the nerves that carry bladder sensations are changed, so pain is now caused by events that are not normally painful (such as bladder filling); and/or (5) the body’s immune system attacks the bladder, similar to other autoimmune conditions. It is likely that different processes occur in different groups of IC patients. It also is likely that these different processes may affect each other (for example, a defect in the bladder epithelium may promote inflammation and stimulate mast cells). Recent research shows that IC patients may have a substance in the urine that inhibits the growth of cells in the bladder epithelium. Therefore, some people may be predisposed to get IC after an injury to the bladder such as an infection.

What are the symptoms of IC?

The symptoms of IC vary for different patients. If you have IC, you may have urinary frequency/urgency or pain, pressure, discomfort perceived to be from the bladder or all of these symptoms.

Frequency is the need to urinate more often than normal. Normally, the average person urinates no more than seven times a day, and does not have to get up at night to use the bathroom. An IC patient often has to urinate frequently both day and night. As frequency becomes more severe, it leads to urgency. Urgency to urinate is a common IC symptom. Some patients feel a constant urge that never goes away, even right after urinating. While others with IC urinate often, they do not necessarily feel the urge to go all the time.

IC patients may have bladder pain that gets worse as the bladder fills. Some IC patients feel the pain in other areas in addition to the bladder. A person may also feel pain in the urethra, lower abdomen, lower back, or the pelvic or perineal area. Women may experience pain in thevulva or the vagina and men may feel the pain in the scrotum, testicle, or penis. The pain may be constant or intermittent.

Many IC patients can identify certain things that make their symptoms worse. For example, some people’s symptoms are made worse by certain foods or drinks. Many patients find that symptoms are worse if they have stress (either physical or mental stress). The symptoms may vary with the menstrual cycle. Both men and women with IC can experience sexual difficulties due to this condition; women may have pain during intercourse because the bladder is right in front of the vagina, and men may have painful orgasm or pain the next day.

How is IC diagnosed?

At this time, doctors have different opinions about how to diagnose IC. This is because no test so far has turned out to be completely accurate. All doctors do agree that a medical history, physical exam and urine tests are needed for evaluation. These tests are important to rule out other conditions that might be causing the symptoms. Some doctors believe that IC is present if a patient has IC symptoms and no other cause for those symptoms can be found. Other doctors believe that more tests are necessary to determine whether the patient has IC.

One test that many doctors use is simple office cystoscopy, in which the doctor looks inside the bladder with a cystoscope while the patient is not under anesthesia. This test can rule out other problems such as cancer. Whereas simple cystoscopy can be performed in the doctor’s office, a more invasive test can be performed in the operating room. This involves a basic cystoscopic examination followed by a stretching or distention of the bladder by instilling water under pressure. This can reveal cracks in the bladder in more severe cases.

Cystoscopy was once part of the standard IC evaluation, but it is no longer always considered a necessary test for IC because the examination is usually normal. However, during cystoscopy, some IC patients will have small areas of bleeding, or actual ulcers, which the doctor can see through the cystoscope. If a person has symptoms of IC and the cystoscopy shows bleeding or ulcers, the diagnosis is fairly certain. Most people who have IC symptoms do not have these bleeding areas, but they may really have IC after all and may respond to the same treatments. The doctor will often then perform a bladder biopsy, which helps to rule out other bladder diseases. While this procedure is primarily used for testing, some IC patients may experience relief of symptoms afterwards. Some doctors believe that if a person has the typical symptoms of IC, and no other cause for the symptoms is found, then the patient has IC. This is still an area of controversy, and future research may help to resolve it.

Urodynamics evaluation is another test that was once considered to be part of the standard IC evaluation, but is no longer believed to be necessary in all cases. This test involves filling the bladder with water through a small catheter, and measuring bladder pressures as the bladder fills and empties. The usual results with IC are that the bladder has a small capacity and perhaps pain with filling.

Some doctors use a test called the potassium sensitivity test, in which potassium solution and water are placed into the bladder one at a time, and pain/urgency scores are compared. A person who has IC feels more pain/urgency with the potassium solution than with the water, but patients with normal bladders cannot tell the difference between the two solutions. This test is not diagnostic for interstitial cystitis, can be painful, and is not a routine part of the evaluation.

At this time, there is no definite answer about the best way to diagnose IC. However, if a patient has typical symptoms and a negative urine examination showing no infection or blood, then IC should be suspected.

Are there stages of IC

IC is a disease that often starts in a subtle way, sometimes beginning with urinary frequency that the patient may not notice or recognize as a problem. In other cases, the onset is much more dramatic with severe symptoms occurring within days, weeks or months. In many cases, the symptoms become chronic but the disease does not tend to progress after the initial 12 to 18 months. In rare cases, the bladder will become progressively smaller over time to the point where there is almost no capacity to store urine.

How is IC treated?

No one knows the cause of IC. Because there are probably several different causes, no single treatment works for everyone, and no treatment is “the best.” Treatment must be chosen individually for each patient, based on his or her symptoms. The usual course is to try different treatments (or combinations of treatments) until good symptom relief occurs.

At this time, two treatments are approved by the United States Food and Drug Administration (FDA) to treat IC. One is oral pentosan polysulfate. No one knows for certain exactly how it works for IC. Many people think that it builds and restores the protective coating on the bladder epithelium. It may also help by decreasing inflammation or by other actions. The usual dose is 100 mg three times a day. Possible side effects are very uncommon and the most common are nausea, diarrhea and gastric distress. Four percent of people will experience reversible hair loss. It often takes at least three to six months of treatment with oral pentosan polysulfate before the patient notices a significant improvement in symptoms. It is effective in relieving pain in about 30% of patients.

The other FDA-approved treatment is to place dimethyl sulfoxide (DMSO) into the bladder through a catheter. This is usually done once a week for six weeks, and some people continue using it as maintenance therapy (though at longer intervals; not every week). No one knows for certain how DMSO helps IC. It has several properties including blocking inflammation, decreasing pain sensation and removing a type of toxin called “free radicals” that can damage tissue. Some doctors combine DMSO with other medications such as heparin (similar to pentosan polysulfate) or steroids (to decrease inflammation). No studies have tested whether these combinations work better than dimethyl sulfoxide alone. The main side effect is a garlic-like odor that lasts for several hours after using DMSO. For some patients, DMSO can be painful to place into the bladder. This can often be relieved by first placing a local anesthetic into the bladder through a catheter, or by mixing the local anesthetic with the DMSO.

A wide variety of other treatments are used for IC, even though they are not specifically approved by the FDA for this purpose. The most common ones are oral hydroxyzine, oral amitriptyline and instillation of heparin into the bladder through a catheter.

Hydroxyzine is an antihistamine. It is thought that some IC patients have too much histamine in the bladder, and that histamine promotes pain and other symptoms. Therefore, an antihistamine can be helpful in treating IC. The usual dose is 10 to 75 mg in the evening. The main side effect is sedation, but that can actually be a benefit because it helps the patient to sleep better at night and get up to urinate less frequently. The only antihistamines that have been specifically studied for IC are hydroxyzine and (more recently) cimetidine. It is unknown whether other antihistamines will also help treat IC.

Amitriptyline is described as an antidepressant, but it actually has many effects that may improve IC symptoms. It has antihistamine effects, decreases bladder spasms, and slows the nerves that carry pain messages (for that reason, it is used for many types of pain, not just IC). Amitriptyline is widely used for other types of chronic pain such as cancer and nerve damage. The usual dose is 10 to 75 mg in the evening. The most common side effects are sedation, constipation and increased appetite.

Heparin is similar to pentosan polysulfate and probably helps the bladder by similar mechanisms. Heparin is not absorbed by the stomach and long-term injections can cause osteoporosis (bone thinning), and so it must be placed into the bladder by a catheter. The usual dose is 10,000 to 20,000 units daily or three times a week. Side effects are rare because the heparin remains only in the bladder and does not usually affect the rest of the body.

Many other IC treatments are also used, but less frequently than the ones described. Some patients do not respond to any IC therapy but can still have significant improvement in the quality of life with adequate pain management. Pain management can include non-steroidal anti-inflammatory drugs, moderate strength opiates and stronger long-acting opiates in addition to nerve blocks, acupuncture and other non-drug therapies. Professional pain management may often be helpful in more severe cases.

What can be expected after IC treatment?

The most important thing to remember is that none of the IC treatments works immediately. It usually takes weeks to months before symptoms improve. Even with successful treatment, the condition may not be “cured;” it is simply “in remission.”

Most patients need to continue treatment indefinitely, or else the symptoms return. Some patients have flare-ups of symptoms even on treatment. In some patients the symptoms gradually improve and even disappear.

Although most patients will find that their symptoms improve as they are treated for IC, not all patients will become completely symptom-free. Many patients still have to urinate more frequently than normal, or have some degree of persistent discomfort and/or have to avoid certain foods or activities that make symptoms worse.

Is it possible for IC to recur after successful treatment? How can recurrences be prevented?

It is possible for IC symptoms to recur even if the disease has been in remission for a long time. It is not known what causes recurrences. Also, there is no known way to prevent recurrences for certain. Some things that patients do to try to prevent recurrence include: (1) stay on their medical treatments even after remission; (2) avoid certain foods that may irritate the bladder; and (3) avoid certain activities or stresses that may worsen IC. The specific foods or activities that affect IC are different for different patients, and so each person has to form his/her own individual plan.

Frequently Asked Questions:

How does diet affect IC?

Most (but not all) people with IC find that certain foods make their symptoms worse. There are four foods that patients most often find irritating to their bladders: citrus fruits, tomatoes, chocolate and coffee. All four of these foods are rich in potassium. Other foods that bother the bladder in many patients are alcoholic beverages, caffeinated beverages, spicy foods and some carbonated beverages. The list of foods that have been reported to affect IC is quite long, but not all foods affect all patients the same way. For this reason, each patient must find out how foods affect his or her own bladder.

The simplest way to find out whether any foods bother your bladder is to try an “elimination diet” for one to two weeks. On an elimination diet, you stop eating all of the foods that could irritate your bladder. IC food lists are available from many sources (www.ichelp.org or www.ic-network.com). If your bladder symptoms improve while you are on the elimination diet, this means that at least one of the foods was irritating your bladder.

The next step is to find out exactly which foods cause bladder problems for you. After one to two weeks on the elimination diet, try eating one food from the IC food list. If this food does not bother your bladder within 24 hours, this food is probably safe and can be added back into your regular diet. The next day, try eating a second food from the list, and so on. In this way, you will add the foods back into your diet one at a time, and your bladder symptoms will tell you if any food causes problems for you. Be sure to add only one new food to your diet each day. If a person eats a banana, strawberries and tomatoes all in the same day, and the IC symptoms get bad that evening, he/she will not know which of the three foods caused the symptom to flare up.

Does stress cause IC?

At this time, there is no evidence that stress makes a person get IC in the first place. However, it is well known that if a person has IC, physical or mental stress can make the symptoms worse.

Is IC hereditary?

There is some research that indicates that there is a genetic pattern. It is important to discuss the symptoms of IC with the family, especially the females, so that any other affected members can be screened and treated early in the disease process.

Reference:

Urology Care Foundation. The Official Foundation of the American Urological Association. http://www.urologyhealth.org/urology/index.cfm?article=67

Incontinence

What is Urinary Incontinence?

Urinary incontinence is the accidental loss of urine. More than 15 million American men and women suffer from this disease. Many of these people suffer in silence unnecessarily, and are prevented from doing activities and living the life they want to lead. Since incontinence can be managed or treated, the following information should help you discuss this condition and what treatments are available to you with your urologist. For millions of Americans, incontinence is not just a medical problem. It is a problem that also affects emotional, psychological and social well-being. Many people are afraid to participate in normal daily activities that might take them too far from a toilet, so it is particularly important to note that the great majority of incontinence causes can be treated successfully.

What happens under normal conditions?

Coordinated activity between the urinary tract and the brain controls urinary function. The bladder stores urine because the smooth muscle of the bladder (detrusor muscle) relaxes and the bladder neck and urethral sphincter mechanism are closed. The urethral sphincter is a circular muscle that wraps around the urethra. During urination, the bladder neck opens, the sphincter relaxes and the bladder muscle contracts. Incontinence occurs if closure of the bladder neck is inadequate (stress incontinence, or SUI) or the bladder muscle is overactive and contracts involuntarily (urge incontinence, also known overactive bladder or OAB).

What causes Urinary Incontinence?

Below are a list of conditions and diseases that contribute and/or cause urinary incontinence:

  • urinary tract or vaginal infections
  • effects of medications
  • constipation
  • weakness of certain muscles in the pelvis
  • blocked urethra due to an enlarged prostate
  • Diseases and disorders involving the nervous system muscles (e.g., multiple sclerosis, Parkinson’s disease, spinal cord injury and stroke).
  • some types of surgery
  • diabetes
  • delirium
  • dehydration
  • pregnancy and childbirth
  • overactive bladder
  • weakness of the muscles holding the bladder in place
  • weakness of the sphincter muscles surrounding the urethra
  • birth defects
  • enlarged prostate
  • spinal cord injuries

Multiple factors have been found to be associated with urinary incontinence, yet the leading culprits of incontinence have been neurologic disease, prostatic disease, and obstetric factors.

Studies have found that pregnancy, mode of delivery and parity (the number of children a woman has had) are all factors that can increase the risk of incontinence. Women who delivered babies (via cesarean section or vaginal delivery) have much higher rates of stress incontinence than women who never delivered a baby. Women who developed incontinence during pregnancy or shortly after delivery have higher risk of sustained incontinence than those who did not. Increased parity (having more babies) also increases the risk.

Age is also known to be a factor. As the human body ages, muscle loss and weakness occur and the urinary tract is not spared. Menopausal women can also suffer from urine loss as a result of decreased estrogen levels. Interestingly, replacement estrogen has not been found to help the symptoms. Many medications have been associated with urinary incontinence. These include: diuretics, estrogen, benzodiazepines, tranquilizers, antidepressants, hypnotics, and laxatives. Poor overall general health has been associated with incontinence. Specifically, diabetes, stroke, high blood pressure, smoking history, Parkinson’s, back problems, obesity, Alzheimer’s, and pulmonary disease have all been associated with incontinence.

What are the different types of urinary incontinence?

Stress urinary incontinence:

Stress incontinence is leakage that occurs when there is an increase in abdominal pressure caused by physical activities like coughing, laughing, sneezing, lifting, straining, getting out of a chair or bending over. The major risk factor for stress incontinence is damage to pelvic muscles that may occur during pregnancy and childbirth.

Urgency incontinence:

Also referred to as “overactive bladder,” this type of incontinence is usually accompanied by a sudden, strong urge to urinate and an inability to get to the toilet in time. Frequently, some patients with urge incontinence may leak urine with no warning. Risk factors for urge incontinence include aging, obstruction of urine flow, inconsistent emptying of the bladder and a diet high in bladder irritants (such as coffee, tea, colas, chocolate and acidic fruit juices).

Mixed urinary incontinence:

Mixed incontinence is a combination of urge and stress incontinence.

Overflow urinary incontinence:

Overflow incontinence occurs when the bladder does not empty properly and the amount of urine produced exceeds the capacity of the bladder. It is characterized by frequent urination and dribbling. Poor bladder emptying occurs if there is an obstruction to flow or if the bladder muscle cannot contract effectively.

How is Urinary Incontinences Diagnosed?

As with any medical problem, a good history and physical examination are critical. A urologist will first ask questions about the individual’s habits and fluid intake as well as their family, medical and surgical history. A thorough physical examination looking for correctable causes of leakage, including impacted stool, constipation, prostate disease and prolapse or hernias, will be conducted. Usually a urinalysis and cough stress test will be performed at the first evaluation. If findings suggest further evaluation is necessary, tests such as cystoscopy or urodynamics may be recommended.

Cystoscopy is performed by placing a small scope or camera through the urethra and into the bladder. Urodynamics is an outpatient test that is done with a tiny tube in the bladder inserted through the urethra and often with a second small tube in the rectum. The bladder is filled and the patient is asked to void while pressure measurements are recorded.

How is Urinary Incontinence Treated?

Treatment for incontinence depends not only on the type of incontinence a person has but also the gender of the patient. Certain treatment options are optimal for men while others are better suited for females. Below are the various treatment options for both men and women.

What are the treatment options for stress incontinence in women?


In most cases of incontinence, conservative or minimally-invasive management is the first line of treatment. This may include fluid management, bladder training or pelvic floor exercises. However, when the symptoms are more severe, when conservative measures are not helpful or are unsatisfactory the next best treatment option is surgery.

Behavioral Modification:

Mild to moderate stress incontinence in the female is initially treated with behavior modification. Decreasing the volume of fluid ingested as well as eliminating caffeine and other bladder irritants can help significantly. Timed voiding can be helpful in preventing accidents by scheduling frequent trips to the toilet before leakage occurs.

Pelvic Floor Muscle Training:

Strengthening or Kegel exercises can fortify the pelvic floor and sphincter muscles and improve urinary control. These exercises include repeated contractions of isolated muscles several times a day. Sometimes techniques including biofeedback, electrical stimulation of the pelvic muscles, and weighted vaginal cones can be helpful in teaching the patient how to isolate these muscles.

Periurethral Injections:

One of the surgical treatments for this condition, used in both males and females, is urethral injections of bulking agents to assist the closing of the urethral mucosa. The injections are done under local anesthesia with the use of a cystoscope and a small needle. Bulking material is injected into the urethral sub mucosal layer under direct vision. Unfortunately, the cure rate with this treatment is only 10 to 30 percent despite multiple formulations on the market for use. This treatment can be repeated and sometimes acceptable results are seen after multiple injections. The operation is minimally invasive but the cure rates are lower compared to the other surgical procedures.

Sub urethral Sling Procedures:

The most common and most popular surgery for stress incontinence is the sling procedure. Today, most of these procedures are being called by the names TVT or TOT. In this operation, a narrow strip of material is used either from: cadaveric tissue (from a cadaver), autologous tissue (from your own body), or soft mesh (synthetic material). It is applied under the urethra to provide a hammock of support and improve urethral closure. The operation is minimally invasive and patients recuperate very quickly. For many years it was thought that biologic materials, the patient’s own fascia or cadaveric fascia, would create better and more sustainable outcomes. However, synthetic meshes have been found to have the ease of use with no need for harvest as well as superior long term results.

Retropubic Colposuspension:

Another option is abdominal surgery in which the vaginal tissues or periurethral tissues are affixed to the pubic bone. The long-term results are positive, but the surgery requires longer recuperation time and is generally only used when other abdominal surgeries are also required. This procedure can also be performed laparoscopically, however long-term results are typically not as good as with the open procedure.

Bladder Neck Needle Suspension:

A long needle is used in these procedures to thread sutures from the vagina to the abdominal wall. The suture incorporates paraurethral tissue at the level of the bladder neck. These procedures were found to be less effective than open retropubic suspensions and slings and as a result are rarely done today.

Anterior Vaginal Repair:

Sutures are placed in the periurethral tissue and fascia in order to elevate and support the bladder neck. This procedure has also fallen out of favor for inferior long-term outcomes compared to open retropubic suspensions and slings.

What are the side effects associated with the corrective surgeries for stress incontinence?

The potential adverse outcomes of surgical treatment include bleeding, infection, pain, urinary retention or voiding difficulties, de novo urgency, pelvic organ prolapse, and failure of surgery to fix leakage. With the use of mesh materials there is a very small risk of erosion of the material into the bladder, urethra or vagina.

What additional treatment options are available for stress incontinence in men?

Men should also initially be managed with behavioral modifications and pelvic floor exercises. Periurethral injections can be used in men as well. If these measures fail, surgical options are available, which are different from those performed in women.

Male Sling:

In male patients with stress incontinence, an alternative is to perform a urethral compression procedure, called a male sling. This is done with the use of a segment of cadaveric tissue or soft mesh to compress the urethra against the pubic bone. It is placed through an incision in the perineum (the area between the scrotum and the rectum). The results show decent success rates in patients with low volume incontinence, poor success is seen with severe incontinence. Long-term data is not currently available.

Artificial Urinary Sphincter:

The most effective treatment for male incontinence is implantation of an artificial urinary sphincter. This device is made from silicone and has three components that are implanted into the patient. The cuff is the portion that provides circular compression of the urethra and therefore prevents leakage of urine from occurring. This is placed around the urethra after an incision is made in the perineum. A small fluid-filled pressure-regulating balloon is placed in the abdomen and a small pump is placed in the scrotum, to be controlled by the patient. The fluid in the abdominal balloon is transferred to the urethral cuff, closing the urethra and preventing leakage of urine. When the patient needs to urinate he presses the scrotal pump which releases the fluid back to the abdominal balloon opening the urethra and allowing the patient to void.

What are the treatment options for urge incontinence?

For urge incontinence there are also multiple treatment options available. The first step is behavior modifications including drinking less fluid, avoiding caffeine, alcohol and spicy foods, not drinking at bedtime, and timed voiding. Exercising the pelvic muscle (Kegel exercises) can also help. It is important to keep a log on the frequency of urination, number of accidents, the amount of fluid lost, the fluid intake and the number of pads used. This helps the urologist tailor treatment to your specific needs.

Medications:

The mainstay of treatment for overactive bladder and urge incontinence is medication. This consists of use of bladder relaxants that prevent the bladder from contracting without the patient’s intention. The most common side effect of the medication is dryness of the mouth, constipation or changes in vision. Sometimes, reduction of medication takes care of the side effects. Combinations of medications can also be used in some situations.

Neuromodulation:

Other alternatives can be considered in patients who fail to respond to behavior modification and/or medication. A new and exciting technology is the use of a bladder pacemaker to control bladder function. This technology consists of a small electrode that is inserted in the patient’s back close to the nerve that controls bladder function. The electrode is connected to a pulse generator and the electrical impulses stimulate the bladder nerves and control bladder function. The exact mechanism of action remains unknown.

What are the treatment options for overflow incontinence?

The treatment for overflow incontinence is complete emptying of the bladder. When the bladder is allowed to cycle properly with filling and emptying on a regular basis urine loss is usually prevented. Patients with neurologic conditions, diabetic bladder, or patients with obstruction secondary to prostate disease or organ prolapse can develop this type of incontinence. Overflow incontinence due to obstruction should be treated with medication or surgery to remove the blockage. This may include resection of prostatic tissue or urethral stricture or repair of pelvic organ prolapse. If no blockage is found, the best treatment is to instruct the patient to perform self-catheterization a few times a day. By emptying the bladder regularly, the incontinence often disappears.

What can I expect after treatment?

The goal of any treatment for incontinence is to improve quality of life for the patient. In most cases, great improvements and even cure of the symptoms is possible. Treatments are usually effective, as long as the patient is careful with fluid intake and urinates regularly. Large weight gain and activities that promote abdominal and pelvic straining may cause problems with surgical repair over time. Using common sense and care will help ensure long-term benefit from these surgical procedures.

Because many of the incontinence treatments deal with implants and/or medical devices, adjustments and modifications may be required over time. Ask your doctor about typical follow-up procedures.

Reference:

Urology Care Foundation. The Official Foundation of the American Urological Association. http://www.urologyhealth.org/urology/index.cfm?article=143

HPV Vaccines

What is human papillomavirus (HPV)?

Human papillomavirus (HPV) is a virus that can be passed from person to person through skin-to-skin contact. More than 100 types of HPV have been found. About 30 of these types infect the genital areas of men and women.

How is HPV spread?

HPV is primarily spread through vaginal, anal, or oral sex, but sexual intercourse is not required for infection to occur. HPV is spread by skin-to-skin contact. Sexual contact with an infected partner, regardless of the sex of the partner, is the most common way the virus is spread.

What diseases does HPV cause?

Approximately 12 types of HPV cause genital warts. Two types, type 6 and type 11, cause most cases of genital warts. Genital warts are growths that may appear on the outside or inside of the vagina or on the penis and can spread to nearby skin. They also can grow around the anus, on the vulva, or on the cervix. They can be treated with medication that is applied to the area or by surgical removal. The type of treatment depends on where the warts are located.

About 15 types of HPV cause cancer of the cervix. They also cause cancer of the vulva, vagina, anus, penis, and the head and neck. Most cases of cervical cancer are caused by just two types of HPV—type 16 and type 18.

How does HPV cause cancer of the cervix?

The cervix is covered by a thin layer of tissue made up of cells. If one of the cancer-causing types of HPV is present, it may enter these cells. Infected cells may become abnormal or damaged and begin to grow differently. It usually takes several years for cervical cancer to develop. Cervical cancer screening can detect early signs of abnormal changes of the cervix and allows early treatment so that they do not become cancer.

What HPV vaccines are available?

Two vaccines are currently available that protect against some types of HPV:

  • One vaccine protects against type 6 and type 11, which cause the most cases of genital warts, and against type 16 and type 18, which cause the most cases of cervical cancer.
  • One vaccine protects against type 16 and type 18.

How effective are the vaccines in preventing HPV infection?

The four-type vaccine is almost 100% effective in preventing cervical precancer and genital warts caused by four types of HPV. The two-type vaccine also is almost 100% effective in preventing cervical precancer caused by two types of HPV.

The vaccines are most effective if they are given before a woman is sexually active and exposed to HPV. If a woman is already infected with one type of HPV, the vaccines will not protect against disease caused by that type. However, the vaccines can protect against the other types of HPV included in the vaccines.

Who should get the HPV vaccine?

Both vaccines are recommended for girls and women aged 9 years through 26 years and are given in three doses over a 6-month period. The vaccines are not recommended for pregnant women but are safe for women who are breastfeeding. Boys and men can get the four-type vaccine beginning at age 9 years and up to age 26 years.

If I get the vaccine, do I still need to have regular cervical cancer screening?

The vaccines do not protect against all types of HPV and do not give complete protection against cervical cancer or genital warts. Therefore, women who are vaccinated should still have regular cervical cancer screening as recommended by their health care providers.

What side effects may be caused by the vaccines?

The most common side effect of the HPV vaccine is soreness in the arm where the shot is given. On very rare occasions, persons who received the shot experienced headache, fatigue, nausea, dizziness, fainting, or pain in the arm. These symptoms are mild and usually go away quickly.

Reference:

The American Congress of Obstetricians and Gynecologists. http://www.acog.org/Patients/FAQs/Human-Papillomavirus-HPV-Vaccines

High Blood Pressure During Pregnancy

Preeclampsia and High Blood Pressure During Pregnancy

What is high blood pressure?

Blood pressure is the pressure of the blood against the blood vessel walls each time the heart contracts (squeezes) to pump the blood through your body. High blood pressure also is called hypertension. Hypertension can lead to health problems. During pregnancy, severe or uncontrolled hypertension can cause complications for you and your baby.

What is chronic hypertension?

Chronic hypertension is high blood pressure that was present before you became pregnant or that occurs in the first half (before 20 weeks) of your pregnancy. If you took blood pressure medication before you became pregnant—even if your blood pressure is normal—you have chronic hypertension.

What is gestational hypertension?

Gestational hypertension

is high blood pressure that first occurs in the second half (after 20 weeks) of pregnancy. Although gestational hypertension usually goes away after childbirth, it may increase the risk of developing hypertension in the future.

What kinds of problems can hypertension cause during pregnancy?

High blood pressure during pregnancy can place extra stress on your heart and kidneys and can increase your risk of heart disease, kidney disease, and stroke. Other possible complications include the following:

  • Fetal growth restriction—High blood pressure can decrease the flow of nutrients to the baby through the placenta. The baby may have growth problems as a result.
  • Preeclampsia—This condition is more likely to occur in women with chronic high blood pressure than in women with normal blood pressure.
  • Preterm delivery—If the placenta is not providing enough nutrients and oxygen to your baby, it may be decided that early delivery is better for your baby than allowing the pregnancy to continue.
  • Placental abruption—This condition, in which the placenta prematurely detaches from the wall of the uterus, is a medical emergency that requires immediate treatment.
  • Cesarean delivery—Women with hypertension are more likely to have a cesarean delivery than women with normal blood pressure. A cesarean delivery carries risks of infection, injury to internal organs, and bleeding.

How is chronic hypertension during pregnancy managed?

Your blood pressure will be monitored closely throughout pregnancy. You may need to monitor your blood pressure at home. Ultrasound exams may be done throughout pregnancy to track the growth of your baby. If growth problems are suspected, you may have additional tests that monitor the baby’s health. This testing usually begins in the third trimester of pregnancy.

If your hypertension is mild, your blood pressure may stay that way or even return to normal during pregnancy, and your medication may be stopped or your dosage decreased. If you have severe hypertension or have health problems related to your hypertension, you may need to start or continue taking blood pressure medication during pregnancy.

What is preeclampsia?

Preeclampsia is a serious blood pressure disorder that can affect all of the organs in a woman’s body. A woman has preeclampsia when she has high blood pressure and other signs that her organ systems are not working normally. One of these signs is proteinuria (an abnormal amount of protein in the urine). A woman with preeclampsia whose condition is worsening will develop other signs and symptoms known as “severe features.” These include a low number of platelets in the blood, abnormal kidney or liver function, pain over the upper abdomen, changes in vision, fluid in the lungs, or a severe headache. A very high blood pressure reading also is considered a severe feature.

When does preeclampsia occur?

It usually occurs after 20 weeks of pregnancy, typically in the third trimester. When it occurs before 32 weeks of pregnancy, it is called early-onset preeclampsia. It also can occur in the postpartum period.

What causes preeclampsia?

It is not clear why some women develop preeclampsia, but the risk of developing preeclampsia is increased in women who

  • are pregnant for the first time
  • have had preeclampsia in a previous pregnancy or have a family history of preeclampsia
  • have a history of chronic hypertension, kidney disease, or both
  • are 40 years or older
  • are carrying more than one baby
  • have certain medical conditions such as diabetes mellitus, thrombophilia, or lupus
  • are obese
  • had in vitro fertilization

What are the risks for my baby if preeclampsia occurs?

If preeclampsia occurs during pregnancy, your baby may need to be delivered right away, even if he or she is not fully grown. Preterm babies have an increased risk of serious complications. Some preterm complications last a lifetime and require ongoing medical care. Babies born very early also may die.

What are the risks for me if preeclampsia occurs?

Women who have had preeclampsia—especially those whose babies were born preterm—have an increased risk later in life of cardiovascular disease and kidney disease, including heart attack, stroke, and high blood pressure. Having preeclampsia once increases the risk of having it again in a future pregnancy. Preeclampsia also can lead to seizures, a condition called eclampsia. It also can lead to HELLP syndrome.

What is HELLP syndrome?

HELLP stands for hemolysis, elevated liver enzymes, and low platelet count. In this condition, red blood cells are damaged or destroyed, blood clotting is impaired, and the liver can bleed internally, causing chest or abdominal pain. HELLP syndrome is a medical emergency. Women can die from HELLP syndrome or have lifelong health problems as a result.

What are the signs and symptoms of preeclampsia?

  • Swelling of face or hands
  • A headache that will not go away
  • Seeing spots or changes in eyesight
  • Pain in the upper abdomen or shoulder
  • Nausea and vomiting (in the second half of pregnancy)
  • Sudden weight gain
  • Difficulty breathing

How is mild gestational hypertension or preeclampsia without severe features managed?

Management of mild gestational hypertension or preeclampsia without severe features may take place either in a hospital or on an outpatient basis (you can stay at home with close monitoring by your health care provider). You may be asked to keep track of your baby’s movements by doing a daily kick count and to measure your blood pressure at home. You will need to see your health care provider at least weekly and sometimes twice weekly. Once you reach 37 weeks of pregnancy, it may be recommended that you have your baby. If test results show that the baby is not doing well, you may need to have the baby earlier.

How is preeclampsia with severe features managed?

Preeclampsia with severe features usually is treated in the hospital. If you are at least 34 weeks pregnant, it often is recommended that you have your baby as soon as your condition is stable. If you are less than 34 weeks pregnant and your condition is stable, it may be possible to wait to deliver your baby. Corticosteroids may be given to help the baby’s lungs mature, and you most likely will be given medications to help reduce your blood pressure and to help prevent seizures. If your condition or the baby’s condition worsens, prompt delivery will be needed.

What steps can I take to help prevent preeclampsia?

Prevention involves identifying whether you have risk factors for preeclampsia and taking steps to address these factors. If you have hypertension and are planning a pregnancy, see your health care provider for a prepregnancy check-up to find out whether your hypertension is under control and whether it has affected your health. If you are overweight, weight loss usually is advised before pregnancy. If you have a medical condition, such as diabetes, it usually is recommended that your condition be well controlled before you become pregnant.

Reference:

The American Congress of Obstetricians and Gynecologists. http://www.acog.org/Patients/FAQs/Preeclampsia-and-High-Blood-Pressure-During-Pregnancy

Gestational Diabetes

What is gestational diabetes?

If your blood sugar level first becomes too high when you are pregnant, you have gestational diabetes. It usually goes back to normal after the baby is born.

High blood sugar can cause problems for you and your baby. Your baby may grow too large, which can cause problems during delivery. Your baby may also be born with low blood sugar. But with treatment, most women who have gestational diabetes are able to control their blood sugar and give birth to healthy babies.

Women who have had gestational diabetes are more likely than other women to develop type 2 diabetes later on. You may be able to prevent or reduce the severity of type 2 diabetes by staying at a healthy weight, eating healthy foods, and increasing your physical activity.

What causes gestational diabetes?

The pancreas makes a hormone called insulin. Insulin helps your body properly use and store the sugar from the food you eat. This keeps your blood sugar level in a target range. When you are pregnant, the placenta makes hormones that can make it harder for insulin to work. This is called insulin resistance.

A pregnant woman can get diabetes when her pancreas cannot make enough insulin to keep her blood sugar levels within a target range.

What are the symptoms?

Because gestational diabetes may not cause symptoms, you need to be tested for the condition. You may be surprised if your test shows a high blood sugar level. It is important for you to be tested for gestational diabetes, because high blood sugar can cause problems for both you and your baby.

Sometimes a pregnant woman who has symptoms has been living with another type of diabetes without knowing it. If you have symptoms from another type of diabetes, they may include:

  • Increased thirst.
  • Increased urination.
  • Increased hunger.
  • Blurred vision.

Pregnancy causes most women to urinate more often and to feel more hungry. So having these symptoms doesn’t always mean that a woman has diabetes. Talk with your doctor if you have these symptoms, so that you can be tested for diabetes at any time during pregnancy.

How is gestational diabetes diagnosed?

The American Diabetes Association recommends that all women who are not already diagnosed with diabetes be tested for gestational diabetes between the 24th and 28th weeks of pregnancy using the oral glucose tolerance test.1

How is it treated?

Some women with gestational diabetes can control their blood sugar level by changing the way they eat and by exercising regularly. These healthy choices can also help prevent gestational diabetes in future pregnancies and type 2 diabetes later in life.

Treatment for gestational diabetes also includes checking your blood sugar level at home and seeing your doctor regularly.

You may need to give yourself insulin shots to help control your blood sugar. This insulin adds to the insulin that your body makes.

There are pills called glyburide and metformin used for type 2 diabetes that some doctors are using to treat women who have gestational diabetes

Genital Herpes

What is genital herpes?

Genital herpes is a sexually transmitted disease (STD). Genital herpes is probably best known for the sores and blisters it causes. These sores can appear around the lips, genitals, or anus. The place where the sores appear is the original site where the virus entered your body. Genital herpes can be spread through direct contact with these sores, most often during sexual activity. However, it also can be spread even if you do not see a sore.

How does genital herpes infection occur?

The herpes virus can pass through a break in your skin during vaginal, oral, or anal sex. It can enter the moist membranes of the penis, vagina, urinary opening, cervix, or anus.

Once the virus gets into your body, it infects healthy cells. Your body’s natural defense system then begins to fight the virus. This causes sores, blisters, and swelling.

Besides the sex organs, genital herpes can affect the tongue, mouth, eyes, gums, lips, fingers, and other parts of the body. During oral sex, herpes can be passed from a cold sore around the mouth to a partner’s genitals or vice versa. You even can reinfect yourself if you touch a sore and then rub or scratch another part of your body, especially your eyes.

What are the symptoms of genital herpes?

Many people infected with herpes have no symptoms. When symptoms do occur, they can be mild (only a few sores) or severe (many sores). Symptoms usually appear about 2–10 days after the herpes virus enters your body. You may feel like you have the flu. You may get swollen glands, fever, chills, muscle aches, fatigue, and nausea. You also may get sores. Sores appear as small, fluid-filled blisters on the genitals, buttocks, or other areas. The sores often are grouped in clusters. A stinging or burning feeling when you urinate also is common.

The first bout with genital herpes may last 2–4 weeks. During this time, the lesions break open and “weep.” Over a period of days, the sores become crusted and then heal without leaving scars.

How is genital herpes diagnosed?

Several tests can be used to diagnose herpes. The most accurate way is to obtain a sample from the sore and see if the virus grows in a special fluid. Test results may take about 1 week. A positive result confirms the diagnosis, but a negative result does not rule it out. Blood tests also can be helpful in some cases. These tests check for the antibodies that the body makes to fight the virus. This test can help show if it is a new infection or a repeat outbreak.

How is genital herpes treated?

Oral medications help control the course of the disease. Medication can shorten the length of an outbreak and help reduce discomfort.

Can I get rid of herpes?

There is no cure for genital herpes. Although herpes sores heal in days or weeks, herpes does not leave your body. The virus travels to nerve cells near your spine. It stays there until some event triggers a new bout. The virus then travels along the nerves, back to where it first entered the body, and a new outbreak may occur. Sometimes the virus is present even when you do not see any sores.

What happens when lesions recur?

If lesions recur, you may feel burning, itching, or tingling near where the virus first entered your body. You also may feel pain in your lower back, buttocks, thighs, or knees. These symptoms are called a prodrome. A few hours later, sores will appear. There is usually no fever and no swelling in the genital area. Sores heal more quickly—within 3–7 days in most cases. Also, repeat outbreaks usually are less painful.

Is there any treatment that prevents repeat outbreaks?

If you have repeat outbreaks, taking medication on a daily basis can greatly reduce the symptoms. In many cases, it can prevent outbreaks for a long time. It also reduces the chance that you will give herpes to someone else.

How can I prevent transmission of genital herpes?

If you or your partner has oral or genital herpes, avoid sex from the time of prodromal symptoms until a few days after the scabs have gone away. Be sure that lesions and their secretions do not touch the other person’s skin. Wash your hands with soap and water after any possible contact with lesions. This will keep you from reinfecting yourself or passing the virus to someone else.

It is possible for you to pass herpes to someone else even when you do not have sores because the virus can be present without causing any symptoms. Using a condom may reduce your risk of passing or getting genital herpes, but does not protect against all cases. Although the virus does not cross through the condom, lesions not covered by the condom can cause infection. But using a condom will help protect you from other STDs.

How can having genital herpes affect pregnancy?

If you are pregnant and have herpes, tell your health care provider. During pregnancy, there are increased risks to the baby, especially if it is the mother’s first outbreak. Women who are infected for the first time in late pregnancy have a high risk (30–60%) of infecting the baby because they have not yet made antibodies against the virus. Although rare, when a newborn is infected, it most often occurs when he or she passes through the mother’s infected birth canal. A herpes infection can cause serious problems in newborns, such as brain damage or eye problems.

If you are infected with the herpes virus for the first time during pregnancy, there are medications you can take to reduce how severe the symptoms are and how long they last. If you have herpes but it is not your first infection, your health care provider may give you medication that makes it less likely that you will have an outbreak of herpes at or near the time your baby is born.

What if I have sores at the time I give birth?

If you have sores or prodromal symptoms at the time of delivery, you will need to have a cesarean delivery. A cesarean delivery may reduce the chance the baby will come in contact with the virus.

Rarely, a baby can be infected without passing through the vagina. This can occur if the amniotic sac has broken a few hours before birth. If a woman does not have sores or prodromal symptoms at the time of delivery, a vaginal birth may be possible.

Can women with herpes breastfeed?

A woman infected with genital herpes usually can breastfeed without infecting her child. The herpes virus cannot be passed to a baby through breast milk. However, the baby could get infected by touching a blister or sore on the mother’s breast.

If you have sores on your nipple, you should not breastfeed your baby on that breast. Pump or express your milk by hand from that breast until the sore is gone. Be sure the parts of your breast pump that touch the milk do not touch the sore while pumping. If this happens, the milk should be thrown away.

Reference:

The American Congress of Obstetricians and Gynecologists. http://www.acog.org/Patients/FAQs/Genital-Herpes

Frequent or Urgent Urination

Frequent or urgent urination

Frequent urination means needing to urinate more often than usual. Urgent urination is a sudden, compelling urge to urinate, along with discomfort in your bladder.

A frequent need to urinate at night is called nocturia. Most people can sleep for 6 to 8 hours without having to urinate. Middle aged and older men often wake to urinate once in the early morning hours.

Causes

Together, frequent and urgent urination are classic signs of a urinary tract infection.

Diabetes, pregnancy, and prostate problems are other common causes of these symptoms.

Other causes include:

  • Alcohol use
  • Anxiety
  • Bladder cancer (not a common cause)
  • Caffeine
  • Enlarged prostate or infection of the prostate
  • Interstitial cystitis
  • Medicines such as water pills (diuretics)
  • Overactive bladder syndrome
  • Radiation therapy to the pelvis, used to treat certain cancers
  • Stroke and other brain or nervous system diseases
  • Tumor or growth in the pelvis
  • Vaginitis

Drinking too much before bedtime, especially caffeine or alcohol, can cause frequent urination at nighttime. Frequent urination may also just be a habit.

Home Care

Follow the therapy recommended by your health care provider to treat the cause of your urinary frequency or urgency. It may help to keep a diary of the times and amounts of urine you void to bring with you to your health care provider.

In some cases, you may experience urinary incontinence for a period of time. You may need to take steps to protect your clothing and bedding.

For nighttime urination, avoid drinking too much fluid before going to bed. Reduce the amount of coffee, other caffeinated beverages, and alcohol you drink.

When to Contact a Medical Professional

Call your health care provider right away if:

  • You have fever, back or side pain, vomiting, or shaking chills
  • You have increased thirst or appetite, fatigue, or sudden weight loss

Also call your health care provider if:

  • You have urinary frequency or urgency, but you are not pregnant and you are not drinking excessive amounts of fluid
  • You have incontinence or have changed your lifestyle because of your symptoms
  • You have bloody or cloudy urine
  • There is a discharge from the penis or vagina

What to Expect at Your Office Visit

Your health care provider will take a medical history and perform a physical examination. Medical history questions may include:

  • When did the increased urinary frequency start?
  • How many times each day are you urinating?
  • Are you urinating more often during the day or at night?
  • Do you have an increased amount of urine?
  • Has there been a change in the color of your urine? Does it appear lighter, darker, or more cloudy than usual? Have you noticed any blood?
  • Do you have pain when urinating, or a burning sensation?
  • Do you have other symptoms? Increased thirst? Pain in your abdomen? Pain in your back? Fever?
  • Do you have trouble starting the flow of urine?
  • Are you drinking more fluids than usual?
  • Have you had a recent bladder infection?
  • Are you pregnant?
  • What medications are you taking?
  • Have you had any past urinary problems?
  • Have you recently changed your diet?
  • Do you drink beverages containing alcohol or caffeine?

Tests that may be done include:

  • Cystometry (a measurement of the pressure within the bladder)
  • Cystoscopy
  • Nervous system (neurological) tests (for some urgency problems)
  • Ultrasound (such as an abdominal ultrasound or a pelvic ultrasound)
  • Urinalysis
  • Urine culture and sensitivity tests

Treatment depends on the cause of the urgency and frequency. Antibiotics and medicine may be prescribed to reduce your discomfort, if needed.

Fibroids

How Do I Know If I Have Uterine Fibroids?

Uterine fibroids are scientifically termed leiomyomata. They are smooth muscle tumors of the uterus. They are nearly always benign.

Fibroids are often first found during a routine pelvic exam. To double check, an ultrasound may be performed, either transvaginally or abdominally. A three-dimensional (3D) ultrasound or an MRI (magnetic resonance imaging) can also be used to find the fibroids, a process called fibroid mapping.

What Are the Treatments for Uterine Fibroids?

If your fibroids aren’t causing you any problems, it is reasonable to consider doing nothing. Not all fibroids grow. Even large fibroids may not cause any symptoms, and most fibroids shrink after menopause. But you should monitor their growth, especially if you develop symptoms such as bleeding or pain, by having exams every six months.

Hormone Therapy

To help prevent more growth of the fibroid, your doctor may recommend that you stop taking birth control pills or hormone replacement therapy. But in some cases, oral contraceptives are prescribed to help control the bleeding and anemia from fibroids, even though certain forms of the pill may cause fibroids to grow.

GnRH Agonists

Gonadotropin-releasing hormone (GnRH) agonists may be prescribed to shrink fibroids and reduce anemia anemia. These drugs are expensive and shouldn’t be taken for more than four months due to the risk of developing osteoporosis. A low-dose of estrogen may be given with GnRH agonists to avoid osteoporosis and menopausal symptoms. Once women stop taking the drug, the fibroids regrow.

SERMs

SERMs, or selective estrogen receptor modulators, may be able to shrink fibroids without causing menopause symptoms.

Fibroid Embolization

To shrink a fibroid, your doctor may recommend uterine fibroid embolization. In this procedure, polyvinyl alcohol (PVA) is injected into the arteries that feed the fibroid. The PVA blocks the blood supply to the fibroid, causing it to shrink. Uterine fibroid embolization is a nonsurgical procedure, but you may need to spend several nights in the hospital since nausea, vomiting, and pain may occur in the first few days afterward.

Myomectomy

Fibroids can be removed by a surgery known as a myomectomy. If you plan to become pregnant, a myomectomy may be recommended over other options. Even with myomectomy, though, surgery can cause scarring that may cause infertility.

Discuss any plans you have to conceive with your doctor before deciding on surgery. Women should wait four to six months after surgery before trying to conceive. In most women, symptoms go away following a myomectomy, although fibroids return in a quarter to a third of women who have this procedure. Successful surgery partially depends on the number of fibroids and whether they were all removed.

A less invasive type of myomectomy uses a hysteroscope — a long, thin lighted tube — to enter the uterus through the vagina and cervix. Fibroids can then be removed by a tool inserted through the hysteroscope.

Hysterectomy

Hysterectomy (surgical removal of the uterus), is the only treatment that guarantees a cure from fibroids. For many women, though, hysterectomy may not be necessary.

Home Remedies

When fibroids grow on the outside of the uterus, you may become aware of a mass on your abdomen. Lying down and placing a hot pack or hot water bottle on your lower abdomen may lessen pain. Apply the hot packs several times a day. NSAIDs like Advil and Motrin can also ease pain.

Endometriosis

Endometriosis is a problem many women have during their childbearing years. It means that a type of tissue that lines your uterus is also growing outside your uterus. This does not always cause symptoms. And it usually isn’t dangerous. But it can cause pain and other problems.

The clumps of tissue that grow outside your uterus are called implants. They usually grow on the ovaries, the fallopian tubes, the outer wall of the uterus, the intestines, or other organs in the belly. In rare cases they spread to areas beyond the belly.

Your uterus is lined with a type of tissue called endometrium. Each month, your body releases hormones that cause the endometrium to thicken and get ready for an egg. If you get pregnant, the fertilized egg attaches to the endometrium and starts to grow. If you do not get pregnant, the endometrium breaks down, and your body sheds it as blood. This is your menstrual period.

When you have endometriosis, the implants of tissue outside your uterus act just like the tissue lining your uterus. During your menstrual cycle, they get thicker, then break down and bleed. But the implants are outside your uterus, so the blood cannot flow out of your body. The implants can get irritated and painful. Sometimes they form scar tissue or fluid-filled sacs (cysts). Scar tissue may make it hard to get pregnant.

Experts don’t know what causes endometrial tissue to grow outside your uterus. But they do know that the female hormone estrogen makes the problem worse. Women have high levels of estrogen during their childbearing years. It is during these years—usually from their teens into their 40s—that women have endometriosis. Estrogen levels drop when menstrual periods stop (menopause). Symptoms usually go away then.

The most common symptoms are:

  • Pain. Where it hurts depends on where the implants are growing. You may have pain in your lower belly, your rectum or vagina, or your lower back. You may have pain only before and during your periods or all the time. Some women have more pain during sex, when they have a bowel movement, or when their ovaries release an egg (ovulation).
  • Abnormal bleeding. Some women have heavy periods, spotting or bleeding between periods, bleeding after sex, or blood in their urine or stool.
  • Trouble getting pregnant (infertility). This is the only symptom some women have.

Endometriosis varies from woman to woman. Some women don’t know that they have it until they go to see a doctor because they can’t get pregnant or have a procedure for another problem. Some have mild cramping that they think is normal for them. In other women, the pain and bleeding are so bad that they aren’t able to work or go to school.

Many different problems can cause painful or heavy periods. To find out if you have endometriosis, your doctor will:

  • Ask questions about your symptoms, your periods, your past health, and your family history. Endometriosis sometimes runs in families.
  • Do a pelvic exam. This may include checking both your vagina and rectum.

If it seems like you have endometriosis, your doctor may suggest that you try medicine for a few months. If you get better using medicine, you probably have endometriosis.

To find out if you have a cyst on an ovary, you might have an imaging test like an ultrasound, an MRI, or a CT scan. These tests show pictures of what is inside your belly.

The only way to be sure you have endometriosis is to have a type of surgery called laparoscopy. During this surgery, the doctor puts a thin, lighted tube through a small cut in your belly. This lets the doctor see what is inside your belly. If the doctor finds implants, scar tissue, or cysts, he or she can remove them during the same surgery.

There is no cure for endometriosis, but there are good treatments. You may need to try several treatments to find what works best for you. With any treatment, there is a chance that your symptoms could come back.

Treatment choices depend on whether you want to control pain or you want to get pregnant. For pain and bleeding, you can try medicines or surgery. If you want to get pregnant, you may need surgery to remove the implants.

Treatments for endometriosis include:

  • Over-the-counter pain medicines like ibuprofen (such as Advil or Motrin) or naproxen (such as Aleve). These medicines are called anti-inflammatory drugs, or NSAIDs. They can reduce bleeding and pain.
  • Birth control pills. They are the best treatment to control pain and shrink implants. Most women can use them safely for years. But you cannot use them if you want to get pregnant.
  • Hormone therapy. This stops your periods and shrinks implants. But it can cause side effects, and pain may come back after treatment ends. Like birth control pills, hormone therapy will keep you from getting pregnant.
  • Laparoscopy to remove implants and scar tissue. This may reduce pain, and it may also help you get pregnant.

As a last resort for severe pain, some women have their uterus and ovaries removed (hysterectomy and oophorectomy). If you have your ovaries taken out, your estrogen level will drop and your symptoms will probably go away. But you may have symptoms of menopause, and you will not be able to get pregnant.

If you are getting close to menopause, you may want to try to manage your symptoms with medicines rather than surgery. Endometriosis usually stops causing problems when you stop having periods.

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