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Information for WomenAbout Incontinence & Vaginal Prolapse

Saskatchewan Pelvic Floor Pathway

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


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.


Anal Sphinter

Rectum

Rectocele

Prolapsed Bowel


4

Prolapsed Bowel (rectocele): Whenthebowelcollapsesintothevaginafrombehind,stoolcangointhewrongdirectionwithstraining.Thiscancauseincompleteemptyingofthebowel.Somewomenmayneedtopushontheprolapsewiththeirfingersinthevaginatohelpemptythebowel.Changingthestoolconsistency,aimingforsoft,formedstoolandavoidingconstipation,pluslearningcorrectevacuationposturesandtechniquescanhelprelievesomeofthesesymptoms.

Prolapsed Bladder (cystocele): Whenthebladdercollapsesintothevagina,itcanmakeithardertoemptythebladdercompletelywhenyouurinate.Incompletebladderemptyingcancausebladderinfections.Somewomenwithbladderprolapsealsohaveurinaryincontinence.


Bladder

UrethraPelvic Floor

Muscles

Cystocele

Prolapsed Bladder

Pelvic Floor

MusclesAnal Sphinter

Rectum

Rectocele

Prolapsed Bowel


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.


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


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.



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.


Drug Trade name

oxybutinin Ditropan,DitropanXL,

Uromax,OxytrolGelnique

tolterodine DetrolLA

fesoterodine Toviaz

darafenacin Enablex

solifenacin Vesicare

trospium Trosec


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.


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.


15

Ifyouareusingmedicationforurgeincontinenceyoumaybeaskedtostopthemedicationadayortwobeforeyoursurgery.Besuretoaskyoursurgeonaboutuseofbladdermedicationsaroundthetimeofyoursurgery.

Postoperative care

• Youmayhavepaininyourincisionsanywherefromafewdaystoafewweeks.

• Donothavevaginalintercoursefor1month.

• Donotliftmorethan10lbsorperformheavyworkfor1month.Timeoffworkdependsonyourtypeofworkandthetypeofsurgeryperformed.

• Youcannotdriveuntilyoucansafelygiveallyourattentiontotheroadwithoutpainorsedationfrommedications.Youwillneedaridehomefromthehospital.

Yourquestionscanbeansweredatyourpre-admissionclinicvisitorbyyoursurgeon.

Yourquestionscanbeansweredatyourpre-admissionclinicorbyyoursurgeon.



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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