Incontinence and Pelvic Floor Disorders
If the embarrassment of urinary incontinence or other pelvic disorders, such as prolapse, is keeping you from enjoying a full and active life, UMass Memorial Medical Center can help.
Our fellowship-trained team is the largest in Central Massachusetts and offers the most advanced symptom relief and therapies available today - all in a compassionate, comfortable environment sensitive to your needs. And with most appointments available within 48 hours, the decision about where to go for complete pelvic health is a simple and convenient one.
Dr. Michael Flynn discusses pelvic floor disorders as well as their causes and treatments.
Due to the overwhelming response to this offering see this archive of urogynecology questions/answers.
Physician
Michael K. Flynn, MD, MHS
Q:
I have a prolapse of the vaginal wall. Is there any other safe way to bring it back up into place again without using mesh of any kind? I was supposed to have surgery using mesh, but have decided against it.
A:
We understand how concerned patients are about the use of mesh in vaginal repairs. The TV and radio spots create a lot of worry for our patients. However, be reassured that there are many non-mesh surgical repairs as well as nonsurgical treatments available for the management of vaginal prolapse. Each approach is different and offers different risks, success rates and postoperative experiences. Fixing prolapse is not an emergency and you have plenty of time to find the right doctor who can help you find the right treatment for you. We recommend seeing someone with advanced training in urogynecology who can discuss your options in detail and help you find the right procedure for you.
Q:
My daughter (age 7) doesn't wet her bed; she pees her pants multiple times during the day. She states when she laughs, gets scared pee comes out. Her pelvic region is RED and sore. Bladder was tested in July; no infection. Any idea of what this might be? Should I schedule an appointment with a pediatric urologist? My insurance company said I don't need a primary MD referral.
A:
We're sorry your daughter is having so much trouble with continence. This sounds like a condition some providers call giggle incontinence and it's not uncommon among prepubertal children. A pediatric urologist may be able to offer a more thorough opinion and we have a well respected pediatric urologist starting at UMass Memorial Medical Center full time in mid-November. You can make an appointment by calling 508-856-5821.
Q:
I am up every hour to urinate. I am very tired from getting up so often.
A:
Getting up often at night to void is a common and very frustrating problem. Sometimes it's due to overactive bladder and bladder problems. If the bladder is causing this problem, then we would expect you to have similar problems with urgency and frequent void during the day as well as night. In this case, a urogynecologist or urologist specializing in female incontinence could offer effective solutions.
However, if you only have trouble with frequency at night and when you void at night you usually void large volumes of urine, then it's more likely that you have a condition called nocturnal polyuria. In patients with this condition, the kidneys make a lot of urine at night causing the bladder to fill quickly. Once the bladder is full, it's normal and expected that one would wake to empty the bladder. In this situation, the bladder is responding appropriately to the amount of urine that the kidneys make. This is more of a medical or kidney issue rather than a bladder issue and is best managed by an internal medicine physician.
Q:
For the past 2 ½ months I have been experiencing problems with bladder pressure and urinary frequency around the time that I ovulate - I have short menstrual cycles (24-26 days) so this has been a consistent problem for about four cycles now. The first time that it occurred I suspected a urinary tract infection so went to the doctor, had a urinalysis and was sent home with antibiotics. Within five days I felt better so didn't think much of it. The same symptoms occurred the very next month around the same time, I figured the UTI came back and took the same measures and again felt better within a few days (I am not clear if the doctor ever did an actual culture). When it came back yet another 23 days later, I began to suspect that something more was going on - I was also in a situation where I had a temporary lapse in health insurance so I decided to wait a few days. Sure enough the problem cleared within five days without any antibiotic this time.
I am once again experiencing the problem and a check at my calendar shows that it is at the exact same point in my cycle as the three other instances. My main symptoms are an intense bladder pressure anytime it is even slightly full. I am able to void without any burning or discomfort and I am producing urine each time I try to go and feel a temporary sense of relief, but the minute I drink even a cup worth of fluid the pressure comes back and I have the intense need to urinate again. Sometimes toward the end when my symptoms seem to be going away I will experience difficulty initiating urination for about a day or so and then the symptoms are gone. I have also noticed that during this time, my bowel movements are also not as they normally are and I tend to be on the constipated side. Some other details about my medical history that could be relevant:
- I was diagnosed with endometriosis via laparoscopy about 10 years ago and at that time had a couple ovarian cysts removed. I have had a couple small cysts since then that were monitored and went away on their own (last one was two years ago). Other than that and painful periods that significantly improved after I had my daughter (3 ½ years ago) I have had no other complications with endometriosis. Could this be a cyst that is pressing on my bladder? Or other endometriosis complication?
- I had a series of abnormal pap smears in my 20s which resulted in having three LEEPS performed. I have had normal Paps for seven years now.
- I am 35 years old. When I was in my early 20s I had a period of frequent UTIs (for about five years) which improved and up until now I have only experienced at most one to two per year for about the past 10 years.
- I have a sister that was diagnosed with interstitial cystitis - she had similar symptoms as I have now but she would also experience the inability to urinate (I do not have this). Her problem improved after having hydrodistention and she rarely gets symptoms anymore.
- I have been married and monogamous for seven years, am not on birth control and have one child that is 3 ½. She was delivered vaginally. I had a cerclage for incompetent cervix when I was pregnant with her (due to the several LEEPS that I had) and delivered her six weeks early.
A:
You have done a great job detailing your symptoms and associated factors. It's not clear what's causing these symptoms but given that they are intermittent and correlate very well with your menstrual cycles, it's likely related to your cycles. Given your history of endometriosis and that endometriosis responds to hormonal cycles, the most likely explanation is endometriosis. Infections are possible but your history is more suggestive of a hormonally responsive condition rather than recurrent infection. It's unlikely that your history of abnormal pap smears, prior LEEPs or cerclage with early delivery are playing a role in these symptoms. We recommend further evaluation by either a urogynecologist or a regular gynecologist with experience evaluating and managing endometriosis.
Q:
I was supposed to have pelvic mesh surgery three years ago and cancelled due to the bad publicity and lawsuits associated with the mesh. How prevalent are complications with this procedure?
A:
Thank you for raising a very important and controversial issue. In 2011 the FDA issued a warning about the use of transvaginal mesh repairs, and it's this warning that led to all of the lawsuits and television commercials. Transvaginal mesh repairs are performed by making incisions in the vagina and placing permanent mesh through the vaginal wall to treat pelvic organ prolapse. Over two to four years prior to the FDA warning, it had received a significant number of reports of complications from vaginal mesh. Based on those reports and a board of experts, the FDA recommended that these products be used with caution and appropriate counseling. The FDA didn't recall or recommend recall of the transvaginal mesh products. In addition, the FDA specifically recommended a vaginal mesh procedure called sacral colpopexy as the gold standard for prolapse repair. The FDA is reviewing midurethral sling procedures separately. Given our greater than 20 years of positive experience with midurethral slings all over the world, it's very unlikely the FDA will recommend any restrictions the sling
It's important to note that most women who received transvaginal mesh did very well. They suffered no complications and had complete resolution of their prolapse. However, a significant number of women had trouble with pain and mesh erosion, prompting the FDA warning. The rate of complication varies but many report rates up to 10%. At UMass Memorial Medical Center, we don't offer transvaginal mesh to our patients but have extensive experience with sacral colpopexy (performed laparoscopically or open) as well as with repairs that don't use any mesh at all. We encourage you to meet with experts in urogynecology to be sure you get accurate information on this issue
Q:
I am teased a lot by family about wearing Depends and laugh it off, but I am 56 and have to run to the bathroom before I leave to go anywhere and then again as soon as I get where I am going. I try to avoid drinking anything while I am out, but still have to go. Is this something I should worry about?
A:
Uterovaginal prolapse is very common. Most women have some descent of the vagina and uterus when they bear down or push, particularly if they have delivered children. If a woman's uterus or cervix drop a little bit in the vagina, it is usually completely asymptomatic and we typically reassure her that she is normal and needs nothing done. Prolapse does not tend to cause symptoms or problems unless the vaginal wall or cervix drop to the vaginal opening where a woman can then feel a bulge. Most women realize that they have prolapse when they feel something dropping to the vaginal opening. The bulge is usually worse with activity and prolonged standing and gets better with laying down. It usually does not hurt but can be uncomfortable or cause pressure.
When a woman feels something prolapsing it can be difficult for her to tell if the bulge she feels is the cervix or vagina. We would encourage anyone feeling a bulge to see a trained urogynecologist for evaluation and counseling on her many options
Q:
I frequent the bathroom too regularly, sometimes four times in an hour, just can't seem to empty the bladder. I have bought this concern to my gynecologist years back and she just noted it. As years have passed I now notice something coming through the hole of the vagina which has been there for quite awhile. I have been going to the gynecologist on regular basis and she never finds this odd. After all things I have been hearing about a prolapse bladder and now my sister had the same symptoms I have and today they diagnosed her with a prolapsed bladder. Should I go and get this checked out by a specialist before it becomes a painful condition like my sister is going through now? Or do I wait until it becomes worse and who would I see for a specialist in this field?
A:
The symptoms you're describing are very common. It's hard to tell if your urinary symptoms are being caused by your prolapse. It's likely that they're related and the treatment of your prolapse may improve your bladder emptying. Alternatively, the bladder symptoms may be unrelated to your prolapse and an evaluation by a specialist would be very helpful.
There isn't a rush to see someone but we encourage you to be seen sooner than later. In general prolapse tends to gradually progress and become more symptomatic. We encourage you to get good information so that you have plenty of time to consider the best treatment for you.
If your symptoms are due to prolapse, you have several surgical and nonsurgical options. We strongly encourage you to see a specialist for these symptoms. Urogynecologists are specifically trained to manage these problems and we recommend seeing a fellowship trained urogynecologist for an evaluation and counseling on your management options.
Q:
I have a dropped bladder which protrudes about half size of an egg. I am 87 years old and in very good health.
A:
It sounds to us that you may have vaginal prolapse and that you're asking about management options for this problem. As you can tell from the questions from other women, this is a very common condition. For our patients with prolapse we recommend that they make treatment decisions based on how much the prolapse limits her daily activities and on how much each treatment option can improve her quality of life. Some women are very bothered by their prolapse and treatment usually makes their lives much better. Other women aren't bothered by the bulge at all and in those cases, we generally don't do anything but follow the patients over time to see how they do.
At 87 years and good health you have many options including surgical and nonsurgical treatments. 87 is not too old for surgery but we obviously are cautious before recommending surgery for our senior patients. There are several minimally invasive procedures that our 80 and 90 year old patients have selected and they have done very well. Some of these may be reasonable for you to consider. Alternatively, many of our patients are successfully treated with nonsurgical treatments such as pessaries. We have many patients who have used them for decades with great effect. There are some patients for whom a pessary will not work well but it's almost always reasonable to try one.
We recommend seeing a specialist who is trained to care for patients in their 80s with vaginal prolapse and fully exploring your options. The urogynecologists at UMass Memorial have extensive experience with patients similar to you and we would welcome the opportunity to help you decide on a method that best works for you.
Q:
What is a dropped bladder and what are the treatment options?
A:
A “dropped bladder” or “cystocele” is the old fashioned term for anterior vaginal wall prolapse. The bladder sits in front of the uterus on the vaginal wall. If there is damage to the vaginal wall and it drops, the bladder often comes along for the ride. There is nothing intrinsically wrong with the bladder. The problem is that the vaginal wall under the bladder is failing. Sometimes other parts of the vagina such at the apex (or the top of the vagina where the cervix and uterus are) or posterior wall (over the rectum) will drop at the same time. Women with the feeling of something bulging out of the vagina should see someone trained in prolapse repair so that a full evaluation of all their areas of vaginal support are assessed before any intervention is taken.
There are a several options to manage this problem. It is important to recognize that a vaginal wall prolapse is a quality of life problem and any treatment should take into account the expected changes in quality of life. Some women are not at all bothered by prolapse and elect to do nothing but wait and see if it gets worse. Many women will live years without their prolapse ever causing symptoms. Sometimes pelvic floor exercises or Kegel exercises will improve prolapse symptoms. For women who have symptoms and in whom Kegel exercises do not help, they may try either a pessary or surgical repair. A pessary is a soft molded rubber form placed in the vagina to support the prolapse. Many women have used pessaries for years with great satisfaction. Some patients try pessaries and we cannot find one that fits. Some women do not like the idea of something in the vagina and will proceed to surgery.
There are many surgical options available including laparoscopic, abdominal or vaginal approaches and there are many non-mesh repair options. A woman with symptomatic prolapse should be counseled about the risks and benefits of each procedure as it pertains to her. A detailed discussion of surgery is too lengthy for this response but a trained urogynecologist should be able to offer a detailed discussion.
Q:
In June 2013 I had a severe UTI, which was treated successfully and had a subsequent negative UA. I have had six treated UTIs since then. Urinalysis shows RBCs, WBCs, bacteria, etc. each time. I have seen a urologist who found no reason for the sudden onset and frequency of UTIs. I'm 55, postmenopausal and healthy. Do urogynecologists diagnose/treat chronic UTIs?
A:
Urogynecologists also assess and manage recurrent UTIs. Probably the most important tests to get are reliable urine cultures whenever you have an infection. This helps us determine if someone is getting new infections each time or if she has a persistent infection that is not resolving. Recurrent UTIs are not uncommon in postmenopausal women and it’s not clear why certain women have this problem. Sometimes we can manage this with vaginal estrogen cream if there is atrophy and other times, we use suppressive antibiotics. If this continues to be a problem, we recommend a second opinion with a urogynecologist or urologist who specializes in women.
Q:
I'm 28 years old and had two vaginal births. I can touch my uterus – my uterus is hanging at the opening of my vagina. When I walk, I can feel it in between my legs. I heard about prolapse. I'm planning to have more children. Can I be pregnant with or without treatment? I want to have treatment though.
A:
You’re describing typical uterovaginal prolapse. It sometimes occurs as young as 28 but usually starts to appear in women in their late 30s and 40s. Having prolapse is not a contraindication to get pregnant again and having prolapse will not threaten the pregnancy. There are many treatments available to manage this, thought most are surgical and usually involve the removal of the uterus. There are procedures that can be done that preserve the uterus and the ability to get pregnant. In general we recommend that women complete childbearing before having any surgical treatment and we encourage the use of pessaries for women who still want to be able to conceive. We recommend evaluation by a urogynecologist so that you can get a full evaluation and thorough counseling about all of your options.
Q:
I had multiple births and seems as though my insides down there sit low now since then. I am in my 40s and experiencing urine incontinence.
A:
Unfortunately, it’s not clear from your note what question is being asked. Here is some information we hope is helpful and addresses your concerns. The feeling that something is sitting low in the vagina suggests that there may be some pelvic organ prolapse present. Pelvic organ prolapse occurs when the vagina walls sag, allowing the pelvic organs like the bladder, rectum or uterus to descend into or even outside of the vagina. This is a common condition and multiple vaginal deliveries as well as age, genetics and menopause are all risk factors for developing this problem. Your urinary incontinence may also be caused by the vagina sagging although there are several types of incontinence and many causes of incontinence. Without more information about your incontinence, it’s difficult for us to give you better details about the possible causes of your leakage. The best way to figure out what is causing the feeling that your insides sit low and the urinary incontinence is to be evaluated by an expert in pelvic floor disorders. If you do have prolapse and incontinence, there are several options, surgical and nonsurgical, to manage these conditions.
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