Urinary incontinence affects millions of women (and men for that matter) worldwide. Shame, embarassment and misconceptions have many women suffering in silence, believing nothing can be done. To hear more on the topic from Dr. Romanzi, visit http://www.healthradio.net/component/mtree/Health-Radio-Shows/Ask-Dr-2E-DeSilva/Bladder-Weakness-3A–The-Condition-Women-Won’t-Talk-About-40905/details

Many women are confused about the current state of affairs when it comes to hormone therapy. I offer you here a timely, informative and wise review of this topic written by one of my favorite colleagues, Dr. Patricia Allen, founder of Women’s Voices for Change:

http://womensvoicesforchange.org/a-call-to-gynecologists-dont-let-menopausal-women-down.htm

As a contributor and member of NAFC (National Association For Continence), I bring to all of you a fantastic resource for anyone looking for information on pelvic floor disorders.  While the focus is on bladder and bowel control (as evidenced in the name), they do a great job of bringing information on sex and well being to the public as well.  To learn more about NAFC, read a review piece on vaginal rejuvenation by Dr. R, and an excellent piece on birth plans written by Sharon Bond, PhD, Certified Nurse Midwife, click here:

http://hosted.verticalresponse.com/289758/20b8b7b48f/1238002647/74c820b257/

or here!

THE INSIDE SCOOP ON VAGINAL REJUVENATION:
Vaginal rejuvenation is a fashionable concept with no strict definition. Yes that’s right, things vaginal are now fashionable.

 For many women, the years just before and after menopause come with pelvic, urinary or vaginal problems. Vaginal laxity, pelvic prolapse, poor bladder control, vaginal dryness, sexual pain, or waning sexual response can truly affect how you feel about yourself and your ability to enjoy your life. In medicine, we use “quality of life” questionnaires to measure the affect of such symptoms on health‐ mental health, ability to work, play, travel, and feel normal and intact as a woman. We hear you loud and clear; if things aren’t right, you have options.

Vaginal rejuvenation sprang onto the medical scene a few years ago, with no formal medical definition. It has since come to mean any variety of procedures and treatments, many with an established record of use for generations, and others with no history, no data, and, therefore, no predictable result. Women with vaginal laxity, prolapse or  incontinence  might not know what “prolapse” or “incontinence” truly mean, but all women instinctively understand the notion of vaginal rejuvenation.

For a new mother, vaginal rejuvenation may mean improving pelvic muscle tone, and vaginal snugness with Kegel muscle exercises in a formal postpartum rehabilitation program of biofeedback (vaginal video games) and pelvic floor electrical stimulation. For a 43 year old tennis‐playing mother of 3, it could mean minimally invasive surgery for “exert and squirt” type urinary incontinence (stress incontinence), with “perineoplasty” to restore the perineum (connective tissue between vagina and anus) back to normal, “rejuvenating” bladder control and vaginal snugness to pre‐baby condition. Or uterine resuspension, bladder lift, rectum reinforcement (rectocele repair), perineoplasty and a minimally invasive sling for combined prolapse and stress incontinence – what I call “the blue plate special.”

Vaginal Rejuvenation                   Traditional Medical Terminology

Vaginal muscle fitness       =          Pelvic Floor Rehabilitation

Lift a dropped bladder         =          Anterior Colporrhaphy*

Tighten a wide vagina        =          Perineoplasty

Restore the hymen              =          Hymenoplasty

Fix a bulging rectum           =          Posterior Colporrhaphy

Repair a leaky bladder        =          Urethral Sling

Recontour labia                   =          Labiaplasty

Restore anal control            =          Anal Sphincteroplasty

Lift a dropped uterus           =          Uterine Resuspension, aka Hysteropexy

*Also referred to as “posterior/anterior repair” 

Vaginal Rejuvenation                   Traditional Medical Terminology

Vaginal muscle fitness       =          Pelvic Floor Rehabilitation

Lift a dropped bladder         =          Anterior Colporrhaphy*

Tighten a wide vagina        =          Perineoplasty

Restore the hymen              =          Hymenoplasty

Fix a bulging rectum           =          Posterior Colporrhaphy

Repair a leaky bladder        =          Urethral Sling

Recontour labia                   =          Labiaplasty

Restore anal control            =          Anal Sphincteroplasty

Lift a dropped uterus           =          Uterine Resuspension, aka Hysteropexy

*Also referred to as “posterior/anterior repair”

Vaginal dryness, poor lubrication and clitoral sensitivity, common symptoms after menopause, are easily remedied with low‐dose vaginal estrogen therapy, treating the target areas without giving your body a full dose of estrogen. With “vaginal rejuvenation” in the public lexicon, many women with prolapse or incontinence eagerly seek out a littl rejuvenating, often the same women who reject the unsexy but medically accurate labels of “pelvic organ prolapse” or “incontinence.” For women over 50, the risk of severe pelvic organ prolapse or urinary incontinence are about 5%, and this increases in women who are overweight, or who have birthed children, particularly large babies and long pushing stage of labor. (1,2) A recent study of over 3000 women ages 50‐61 showed 6% with ymptomatic, high‐grade prolapse. (3)

Whether you call it prolapse repair or vaginal rejuvenation, the condition and the treatments are one in the same. Labiaplasty reduces large inner labia (labial hypertrophy), or restores symmetry to unbalanced labia (labial asymmetry). Vaginoplasty, a mystery term, most often refers to the established perineoplasty operation, which restores vaginal outlet snugness by reconstructing thinning of the perineum caused by childbirth. Hymen restoration involves careful reconnection of the hymen remnants to recreate a pseudo-virginal state, most commonly requested by women from cultures requiring virginity at the altar. Clitoral unhooding reduces or removes the skin folds overlaying the clitoris, an inherently risky procedure, given its proximity to the clitoral nerves. G‐spot amplification injects collagen into the front vaginal wall. The theory behind such an injection is to create a temporary (as collagen always absorbs and disappears) bump beneath the Grafenberg’s spot, allegedly enhancing sexual response.

In 2007, The American College of Obstetrics and Gynecology issued a warning about all of these cosmetic procedures, finding labiaplasty and perineoplasty “may be warranted in properly selected patients,” and reserving endorsement of G‐spot enhancement, the ill‐defined “vaginoplasty,” and clitoral unhooding, each lacking in the ethical considerations of safety and efficacy required of all surgical intervention.

Vaginal rejuvenation is whatever you need it to be‐ Kegel exercise to improve vaginal muscle tone, bladder control and orgasm; vaginal estrogen for lubrication and clitoral sensitivity; prolapse operations to resuspend the dropped uterus, bladder and rectum; perineoplasty for vaginal snugness; minimally invasive incontinence procedures or medications for bladders not controlled by Kegel exercise alone; and labiaplasty in carefully selected circumstances, each available as needed to get your pelvic life back on track.

http://www.kirkusreviews.com/kirkusreviews/discoveries/article_display.jsp?vnu_content_id=1004031728

Congo Chronicles October 2008 -

Fishing boats at dusk, Lake Kivu, Democratic Republic of Congo

Standing in the middle of a battalion of Chinese soldiers on line at the Rwandan side of the Congolese border, apprehension tickles my belly as I contemplate the active end of the assault rifle resting over the shoulder in front of mine. Sent by Harvard Humanitarian Initiative to work at Panzi Hospital in Bukavu in the conflict-rife Eastern region of the Democratic Republic of Congo, I will myself to stay the course, thus far entailing 17 hours of flight time followed by a 5 hour ride from the airport in neighboring Kigali, Rwanda to the bordercrossings at which I now stand. Everywhere, dozens of troops in fatigues murmur in Chinese dialect.  Chuckling amongst themselves, exchanging cigarettes and places in line, their smug presence is a mystery that remains unsolved for the entirety of my time in this place.   Panic flirts all the way to the front window, with cultural disorientation and unrelenting challenges to personal space my only refuge.  New York-ing my way to the front of the line, the Rwandan customs officer brusquely dispenses me to the second half of this crossing, a 50 yard taxi ride over one rickety foot bridge overstuffed with  heavily burdened pedestrians crossing back and forth between Rwanda and the Democratic Republic of Congo (DRC). 

The road serves as sidewalk to an endless two-way stream of humanity afoot under bundles and burdens of all shapes and sizes- huge bags of mangoes, towering stalks of bananas, all manner of wood, hand pulled carts loaded with stones, school children with books, almost all of which is transported by head – for instance ten 14 foot long stripped sapling trees balanced on the head of a 12 year old, each end extended 7 feet beyond and behind his wafer thin frame. There is no time to contemplate the skill and grace required to maneuver such cargo through a packed crowd of fellow travelers, so distracting is my passenger’s view of the incessant near-contact between the car I’m in and pedestrians passing inches away on all sides- left, right, front and behind.

Safely over the footbridge,  piercing cries outside my car window, rivet my gaze to the sight of a Congolese policewoman smacking away at the face of a local peddler, on whose head perches a bundle of mangoes, again and again and again.  Gun waving in her other hand, the officer smirks at her victim’s unsuccessful attempts to alleviate her wrath.  No one dares help, the stream of burdens and bodies barely stopping to glance her way as she stumbles under the blows.  I cannot breath, cannot look away, cannot speak as she falls to her knees. My car pulls up another 5 yards where the scene disappears as quickly as it came, stopping in front of the muddy wood-framed Congolese customs house- part two of the border crossing.    Following the driver, the dim-lit dirt floored room harbors a table covered with filthy, crumpled Congolese currency being counted by a woman barely visible behind the shoulder-high pile of cash.  Hustled into a back room, my visa and letter of introduction to Panzi Hospital is scrutinized and stamped with flourish, and I am back in the car for another 5 yard ride to the “gate”.  Said gate, a comical 4 feet wide in the middle of an enormous road, is manned by two plainclothes guards, both of whom argue ferociously with the driver as he adeptly negotiates  the impromptu “gate fee”. 

On the short drive to Panzi Hospital, the driver shows me the sites of Bukavu, situated on a five-fingered peninsula jutting into Gran Lac.  Bukavu’s history as boating resort to the colonialist Dutch is difficult to envision as we bob in and out of endless unpaved, deeply rutted roads the color of Tennessee red clay and trundle through enclave upon enclave of wooden shack houses.. Passing an enormous, prison –looking building replete with window bars, I am informed that it is neither prison nor an armory, but rather a bank, a bank without money.  The treasury printing presses, I am told, were destroyed by rebel forces some years ago, and with no new money and no bank security, the bank, open for business, has no business to tend to. This tidbit fails to surprise me, as if all taking place on the other side of a looking glass.  Fifteen minutes on the other side of this glass is all that’s necessary to comprehend the difficulty of everything in the Democratic Republic of Congo.  

All the way to the hospital gate, dozens of mobile phone kiosks spill over with customers between stretches of boarded up shops.  Most commerce takes place roadside, merchandise displayed in neat rows on open sheets of cloth, tarp and plastic.  We dive headlong, no horn, no braking, into endless rivers of pedestrians battling bravely with the occasional private car, overstuffed commuter van or diesel transport truck for the prized sections of flat road. Monty the taxi driver, speaking just enough English to compensate for my utter lack of French or Swahili, barrels inscrutably through the crowds on his mission to deliver the Mzungu (Swahili for white) doctor to her destination. The 5 hour drive from Kigali to the border pales in comparison to the bravado and driving dexterity with which the driver, talking non-stop, wends his way to the hospital itself, where I am to spend the night before beginning the next week’s work. 

Panzi Hospital,  Democratic Republic of Congo, South Kivu

The low, flat buildings of the hospital grounds are a well kept, and tranquil oasis, reminiscent of an empty church on a hot Saturday afternoon, that sudden, soothing presence of something bigger than yourself.  Within the fenced-in hospital campus the generic tenor of suffering is buffered with solace and hope.  Various people live on the grounds, workers and patients.  Female patients with live “in the back”, down a hill in a wooded area of encampment.  There is a large, covered hangar style room with tables.  The women’s clothing is hung on branches and rock piles to dry after laundering.  These are the fistula women and the female war victims. 

Women living on the grounds of Panzi Hospital

My colleague, Dr. Julia Van Rooyen, is gathering gender-based violence data on these victims de guerre as part of her fellowship with Harvard Humanitarian Initiative and it is she who sent me here, to help with the surgical overload created by decades of political chaos and the current brutalization of the populace by competing rebel forces.  In the clinic, the women with childbirth fistula carry medical booklets labeled “VVF” for vesicovaginal fistula, and those of the women with rape-induced fistula are labeled “PTG” for post-trauma de guerre.

VVS = Fistula due to obstructed labor – PTG = Fistula due to rape trauma

Next morning, I am introduced to my colleague Dr. JeanBaptiste Yunga, a relentless, wiry thin surgeon with impeccable skills and compassionate work ethic to match. This place, perpetually short on supplies, is run as efficiently as any military operation. Sutures that are used for one knot in the States are used to close an entire incision here. The Panzi Hospital turn-over time between cases is minutes – back home, halves of hours, often more than one, are spent waiting for the lumbering paperwork beauracracy to move the patient from waiting area to operating room and then finally to rest on the operating table.  Here there is no such thing as informed consent – just patients who want to be dry, want to be normal, want to go home again, trusting the doctors and staff to make it happen for them.  We operate – fistula upon fistula, story upon story, one blending into the next til the surgical technician declares the list finished, the day over, and it’s time to go home. And you wonder, you hope, you imagine, that you made a difference, even the tiniest dent, in this tsunami of suffering.

 Dr. JeanBaptiste de Yunga, center, and the Panzi Hospital OR team

 Welcome to DR Congo.  This central African country is the former Zaire and the current site of extensive, complicated rebel activity, Interhamwe, Mai Mai, and interminable political gang rivalry, that predate my arrival by many years, all of it brutal. Beyond imagination- men, women, and children routinely suffer the most heinous of atrocities for reasons that seem to have only one common underpinning- utter chaos makes for more profitable rape of the land itself- a legacy harking back to the Belgian colonialists. With avocadoes, bananas, and mangoes dripping year-round from every tree, Democratic Republic of Congo is truly The Garden of Eden meets Hell on Earth. 

 Apparently, the rebel forces, and there are several in this unclean fight- residual ex-pat Rwandan rebels known as the Interhamwe, Congolese in-fighting between fractious camps with presidential aspirations, and skirmishes triggered by global industries devoted to demineralizing the landscape for obscene profit margins, are particularly fond of the weapons available under the umbrella we call “sexual trauma’.  Women, men, children, raped, mutilated, held captive for months, some for years, “tending” to the rebel camps in slavery, subjected to physical and psychological carnage that would make Caligula pause. 

The stories terrify.

Women made to cut out the unborn baby of a live village-mate, leaving the mother to die as they are forced to cook, and then eat, said baby while the rebels taunted and beat them- parents made to watch as their children’s fingers were cut off, knuckle by knuckle, bleeding to death slowly, eviscerated at the last minute, dogs attacking the fresh intestines, as the parents were hauled into the bush to serve the rebels for months before they escaped with only their unimaginable story to show for it.  And rape, all sorts of rape, if you can imagine it, it’s been done to these people, and by people I mean everyone – the sexual mutilation is not restricted to women. My third morning, as I inhale a mandatory morning coffee and hover over a precious few minutes access to the unreliable internet, a query unlike any other interrupts my focus: “When a man’s penis is cut off, does that make him stutter?”  Distracted, I lift my gaze to meet the wide-eyed Brandi Walker,   red-headed, cracker jack American administrative coordinator. Hailing from the backwoods of Georgia with masters degrees in English and Public Health and a fierce devotion to the women of Eastern DRC- I ask her to repeat, and so she does.  “You know, if man’s penis is cut off, can it mess with his voice?  Make him stutter?  Can it affect the coordination of his tongue, make it hard to form words? A local man just burst into Dr. Mukwege’s office – he’s been walking for days, escaped from the Interhamwe.  They cut off his penis.  He couldn’t get his words out. He was shaking all over and no one could understand him.  So I was wondering, is there a connection?”  Apparently, male dismemberment is one of the latest trends of these self-proclaimed warriors, and I am told that most of those who do not perish immediately from the mutilation go on to commit suicide.

But I am not there to re-fashion dismembered penises, I am there to fix fistulas.  Childbirth fistula, the bain of women since time began, is a hole, an abnormal connection caused by a wearing away of skin and connective tissue that separates the bladder from the vagina (vesico-vaginal fistula) or between the rectum and vagina (rectovaginal fistula). 

Fistula due to obstructed labor in childbirth was a problem of Europe and North America too, until the advent safe anesthesia in the late 1800’s and the discovery of penicillin in the 1940’s turned cesarean section from a last ditch effort to save a baby from the belly of a dead mother into a routine procedure, single-handedly plummeting maternal mortality and obstructed labor-related vaginal fistula rates to near-zero.  New York City was host to the world’s first Fistula Hospital, located on the site of the Waldorf Astoria on Park Avenue until it was rendered obsolete by the advent of modern obstetrical practices.

In many poor nations lacking in civil infrastructure and modern medical care, the likelihood of dying as a result of pregnancy is no different than it was in 1800, as high as 1 in 7 pregnancies.  In Europe, North America and other wealthy regions with double-digit cesarean section rates, this child-bearing related death rate is 1:400,000 – an obscene difference beautifully exposed  by Dr. Lewis Wall, Director of the Division of Urogynecology and Reconstructive Pelvic Surgery at the Washington University School of Medicine in St. Louis, MO and Founder of the WorldWide Fistula Fund.  It’s simple, really.  In our natural state, babies tend to get stuck in labor, such mothers may die, stuck babies die, and women who don’t die from such labors where the baby is, literally, “stuck” in the soft-tissues of the vagina for days on end, survive the nightmare only to birth a dead baby and find themselves constantly leaking urine, feces, or both through the vaginal fistula holes located where normal healthy vaginal tissues used to be. 

A lucky, 18 year old fistula mother – her fistula was reparable and her baby survived.

A history professor once impressed me with the fact that resistance always starts in the lap of oppression, where to my naive mind it made the least sense.  I thought that the people in the safest areas with the most resources should recognize exploitation and iniquity in whatever form – slavery, racism, corporate corruption, caste systems, child prostitution, whatever – reaching out from their positions of privilege and strength to end the suffering of those less fortunate.  To  understand why the Civil Rights movement started in the deep South, why Toussaint L’Ouverture battled decade upon decade until the people of Haiti were freed to create the first black Republic in the Western Hemisphere, and years later, why the Berlin Wall had to come down from the inside out, not the outside in, remains one of the highlights of my formal education.  

And no less inclined to seek its own solution is this place, where the rebels are the oppressors and the indifferent are the government leaders of Congo, neighboring Rwanda and the world-at-large. This seed of resistance comes in the form of Dr. Denis Mukwege, a Shaquille O’Neal-sized son of the Congo, born in Bukavu, a few miles from this hospital in Panzi.

Dr Denis Mukwege  www.panzihospitalbukavu.org

Standing like an elm tree in a hurricaine, Dr. Mukwege , champion of his people, holds fast to his boyhood home with its memories of water skiing and international visitors coming to the lakeside resort that Bukavu used to be.  Now, the post office is inhabited by feral chickens and homeless families and his boyhood school sits abandoned on the point of a cliff overlooking stunning, and empty, Lake Kivu. 

I’ve worked in other fistula repair centers, but this is different.  Yes, as in other fistula-prone places, there are women from villages who speak their native tongue only, no French, no English, no reading, no knowledge of anatomy, no clue that the fistula is not their fault and not the results of evil spells.  But here in Bukavu, where all manner of NGO (non-governmental organizations) and UN Peacekeeping Forces cruise around in LandRovers and the unpaved roads turn to torrential rivers of mud during the daily downpours of the 9-month rainy season, the burden of conducting normal daily functions requires a resilience and fortitude that I’ve encountered in no other place.  If you can make it happen in DR Congo, you can make it happen anywhere.  Sorry, Frank, but this place makes Niger look palatial, and compared to New York?  Fuggedhaboudit.

On October 5th, Dr. Romanzi will participate in the health seminar for More Magazine’s Reinvention Convention held at Pier 60, Chelsea Piers, NYC.  We do hope you will join us for this day-long event.

(c) 2007, Urogynics, PLLC

It was my second voyage as a volunteer fistula surgeon to the landlocked desert country of Niger. The flight to Niger takes 5 hours from Charles De Gaulle airport in Paris, a labrynthe of terminals connected by shuttle buses. And here the tribal excursion begins, standing on line, all of us united beyond the limits of language and culture as one group complains in narcissistic theatricality, another crew sniffs and pouts in feigned, sullen indifference, another in stoic silence and another in cadenced soft murmurs looking from prayer compass to clock. The flight is 5 hours of time and 200 years back in economic development, to a place where life has little to do with nuance and luxury, and everything to do with survival and resilience. In the capital city of Niamey, airport porters battle with jobless locals to control the baggage from claim area to bus. Children with one hand, men with one leg and people crawling to and fro on polio twisted limbs are sprinkled throughout the crowd, scouring for hand-outs or the opportunity to work. If there is anything palpable on the way from the plane to the bus it is the bleak absence of opportunity.

The topography of Niger is… dusty. A landlocked desert relieved only by the Niger River coursing through the southernmost terrain, Niger is ranked last on the United Nations Development Fund index of human development (CIA-The World FactBook Dec 2006). Literacy rates for men are 21% and about 7% for women. Average life expectancy is 42 years of age. Medical colleagues born and raised in Niger command salaries of 100-300 USD per month. It is a place of want.

The National Hospital of Niamey, Niger
The hospital is a former military installation built for quarantine in a network of single story low, flat-topped buildings connected by covered walkways and cement courtyards. Winding through the access road to the surgery building, women wrapped in Kinte cloth and long tunics and men in flowing robes and Tuareg turbans mill about in the universal comings and goings of people seeking and rendering healing. Outside, ubiquitous wood smoke spices the air, inside the low slung building the faint odor of disinfectant mixes with the dry heat. The operating rooms are doubled up with OR tables .
The fistula women are waiting to be seen, having camped out in the “fistula courtyard” for days or weeks, arriving from the remotest areas of Niger and the surrounding countries of Benin, Nigeria, Burkina Faso and Mali. For some, an entire year’s earnings fund the journey to this hospital. The surgery building has a sunken courtyard on one side, and after traversing the cool tiled hallways, you emerge on the courtyard cat walk to see dozens of women and their children living, some for months, others for years, in a “sisterhood of suffering”. Naked foam rubber mats, rinsed out daily with a garden hose lay flat in the sun to dry, ready for another night of urine-soaked sleep. The women are immaculate and enterprising, making beaded jewelry and learning to sew on machines donated by the International Organization for Women and Development (IOWD) a non-governmental organization (NGO) that sponsors the only American surgical mission to Niger (http://www.nigerfistula.org/).

Tenacity rules courtyard life; all hardship is greeted with determination and a smile.

Fistulas are abnormal connections between organs, most commonly between bladder and vagina, and also between rectum and vagina, urethra and vagina, bladder and uterus, and ureter and vagina. Fistulas occur rarely in industrialized countries, at a rate of less than 2%, most commonly a result of gynecologic surgery (82%) and less often due to childbirth injury (8%), radiation therapy (6%) and eroding cancers or infections (4%).

For women in developing countries in Africa, Asia and Latin America, the odds are the inverse, with 92% of fistulas due to childbirth and the remainder (8%) caused by complications of gynecologic surgery, cancers or infections (Nigeria 1985, Ghana 1996). Fistula rates in high-incidence countries are difficult to calculate, since countries lacking the medical infrastructure of industrialized nations also lack the bureaucratic infrastructure to gather accurate statistics. Given, however, that childbirth fistula occurred during a birth that could have easily killed the mother, fistula rates are linked to maternal mortality, and therefore maternal mortality statistics, tracked by international health organizations, are a barometer of all childbearing trauma, including fistula.
Worldwide maternal mortality rates are 430/100,000 woman, with a wide discrepancy between the US/Europe (11/100,000) and the poorer sections of Africa (1000/100,000), due primarily, if not entirely, to the lack of medical and obstetrical infrastructure. (WHO 1996). Lewis Wall, renowned author on the topic of childbirth injury, highlights a more meaningful statistic in his work, the lifetime risk of maternal death, or “LRMD”, which reflects the likelihood that the mother will not survive any given pregnancy and the number of times she will likely become pregnant based on regional birth rates. Overall, the global LRMD is 1:60. In industrialized nations the likelihood is 1:1800; in North America and Europe the rates drop even further to 1:4000. In poor countries, the overall rate is 1:48 with rates as high as 1:7 per-pregnancy death risk in the poorest nations. (WHO 1996). Niger, one of the 1:7 LRMD nations, is a country of 12 million people medically served by 2 urologists and 10 obstetrician – gynecologists with a fecundity rate that is one of the highest on the planet, at an average of 8 children born per woman.

Dr. Ghaichatou, of the National Hospital Niamey, and liason to the United Nations Fistula Prevention Association. She is the first of her Tuareg family to earn a medical degree.

We arrive at our lodgings for the trip, a local hotel in the capital city of Niamey, nestled on the bank of the Niger River, a winding waterway populated from dawn to dusk with dugout canoes pushed about on poles by local gondoliers.
We set up the rooms, and begin, in this former French colony where most are illiterate speaking only the tribal language to which they were born and the “market language” of neighboring tribes, the dance of translation; English to French to Djerma to Hausa to Fula to Tamachek back to French to English as we slowly pull the stories out of this and that woman. These women do not understand the anatomy of their condition. They trust doctors implicitly and believe they have no right to question. This triad of ignorance, trust and submissiveness turns informed consent translations into farcical monologues met with stony, stoic forebearance.
Language is no barrier to the alien realization that many of these women don’t know how old they are, and no fewer number blame not the lack of healthcare dollars nor the dearth of strategically located medical facilities as reasons for their damaged physical selves. For many, stillborn babies and the purgatory of living with fistula are the work of evil curses or divine punishments. For them, the standard of obstetric care taken for granted in industrialized nations is quintessentially foreign.

They tell stories of being moved from the family hut to the edge of the village, of living, suddenly and for the first time in solitude, allowed to plant seeds but not harvest, forced from buses or banished to the roof with the luggage, of husbands marrying new wives, of the sheer madness and reeking odor of urine or stool, or both, coming constantly constantly constantly in the 120 degree heat in a hut with one door and no windows, of the urine crusted ulcerations extending from their most private areas to the tops of their feet. Even the most gregarious courtyard citizen turns shy entering this room full of strange hardware to confront the foreign prodding of these terrible, intimate questions. With the interview complete, the screening examination begins. Back home, fistula patients have pyelograms, MRIs, CT scans, cystograms, and any number of consultations before they land on the operating table for the big event. Here in Niger, even a pyelogram is inordinately difficult to arrange, and second opinions take place in the operating room. Most are evaluated with cystoscopy and blue dye fill tests. To save money we use blue food coloring mixed with sterile saline.
Some fistulas are easy to find; large holes between bladder and vagina the size of business cards. Others are more complicated, recurrent pinpoint fistulas with labrynthine and tiny caliber tracts connecting vagina to bladder, or connecting bladder to uterus to vagina through missing chunks of cervix. Yet others are cemented in by dense vaginal scarring, none more tragic than an 18 year old Tanzanian woman I met while working in East Africa last year, who had undergone 8 prior repairs after her first and only stillborn pregnancy. Once more at hospital to fix a recto-vaginal fistula sustained during the last (failed) attempt to recreate her vagina, she was to learn this time that all hope was gone, her vagina scarred shut from the trauma from the difficult birth and the many operations to close the hole. I could not bear to look in her eyes for more than a moment. She was the age of my daughter.

18 years old Tanzanian woman, one stillborn baby, 8 fistula surgeries, total vaginal obliteration. Kilimanjaro Catholic Medical Center, Moshi Town, Tanzania August 2006.

Some can be fixed, some cannot. Urinary diversions, the standard of care for irreparable fistulae in wealthy nations, entail a life time of follow-up, dietary supplements and access to acute care facilities to treat the unpredictable and life-long complications of such operations. In a third world setting, these reconstructive diversions are an ethical dilemma, the safest choice of which is to simply not do them. All fistula repair surgeons and aid programs know this phenomenon of the truly doomed too well. It is the step-child of fistula work. Robustly funded programs offer long term lodging and occupational training (www.fistulafoundation.org).

Dr. Clifford Wheeless, Dr. Lauri Romanzi and Dr. Gopal Badlani

second opinion evaluation, Niamey, Niger 2004

For those fortunate enough to be operable, the case lists include their names and the elaborate, multi-tribal translation of pre-op instructions is carried out.
Next morning, with two tables in each room, the OR hums with endeavor.

My first case on this mission was an enormous hole connecting the bladder to the uterus through a missing segment of cervix so that all the urine poured into the vagina non-stop.

Vesico-utero-cervico-vaginal fistula:
(bladder into uterus through defect in cervix into vagina) Niamey, Niger 2006

Foley Balloon visible in the fistula:

Reconstruction complete; stent in cervical os:

We were always prepared for a blackout, flashlights in our pockets and camping headlights around our necks to use until the generators kick into action.

Dr. Ghaichatou, Dr. Badlani and Dr. Romanzi operating by the light of a generator. Niamey, Niger 2004

It was on this second journey as a volunteer fistula surgeon to Niger that I met the woman who taught me what it truly means to expect the unexpected. She was the first patient I saw that day, 20 years old claiming never to have given birth at all, but only to have miscarried one time, 3 years ago. She had never gotten pregnant again after that. And mysteriously, about a year before making the trip to Niger, she began to leak, just a little at first, and not every day, and then slowly over months, the drip turned to a constant flow, and her world turned upside down. Her striking features highlighted by the tattooed black lips of her Fulani tribe, her eyes never left my face as she told her story to the translator. Two solid weeks it took her to walk to the capital. The American doctors had to fix her. All of her so that the leaking would stop and her fertility be restored. Her husband’s family was pressuring him to take another wife, one who could give him babies and live in his hut. Forced to exile herself to separate quarters, her world shrinking to a solitary confinement of ever increasing hardship, desperation was her sole companion.

Her story did not make any sense. She hadn’t birthed a baby, she had no fevers or infections, no surgery, no accidents or physical injury, so where was the urine coming from? I worried that she might have a congenital anomaly, literally born with faulty plumbing, one kidney and a misplaced ureter, perhaps. Sometimes these defects don’t become evident until a girl is a teenager. If so, the surgery might need to be done in stages, one surgery now, returning for the next part three months down the road when the next group of surgeons was scheduled to come to Niger. Would she be able to make it back to the capital on another 2 week walk? Or maybe there was something she wasn’t telling us. In the bush, local healers sometimes resort to harsh interventions to cure gynecologic maladies. Had she been made to sit on stones hot as coals or had rock salt inserted into her vagina to heal her infertility?

As she reclined on the examining table, the answers continued to evade me as I watched the urine drip onto the table pads, unusually pink-tinged with blood. Attempting to examine her, she flinched in pain; something rocky was in the vagina, or was it the bladder? It looked like a stone, very rare in a such young woman but not impossible. The “stone” was in the fistula hole, which was large, but the stone wouldn’t budge. Why hadn’t it passed? The hole was larger than the stone; it should have come out long ago. And why had it eroded through in the first place? Bladder stones don’t usually do that, even when they are the size of lemons. This one was the size of a small grape. An x-ray showed a bizarre calcified mass in the pelvis that was smooth and round on one end and spiky on the other. Bladder stones are usually smooth and round, like pearls. She had two kidneys; a big relief. But the puzzle of the bladder stone seemed to increase with each step of the evaluation.

Under anesthesia, we used an instrument called a cystoscope to look into the bladder were the spiky calcifications jutted out into the camera lens like spokes on a wheel. As the exploratory surgery continued, we found a fistula that connected the uterus to the bladder and the bladder to the vagina. The spiky parts of the calcification were stuck in the uterus, the smooth round part was pushing into the vagina. Exposing the defect to begin the tedious work of figuring out what went where and how to put her parts back together again, the mystery was solved. It wasn’t a stone at all; it was the balled up skeleton of a fetus. Carefully removed bone by bone, ribs the size of toothpicks and a tiny fossilized skull bore witness on the instrument table.

She had miscarried, true, but not completely, the bones stuck inside, acting like an IUD (intra-uterine device), preventing conception for all these years. And then, a year ago, the bones eroded through the wall of the uterus into the bladder and then into the vagina, causing as complicated a fistula as can be.

We restored her body, this is sure. I may never know if the same is true of her life, but I like to believe that this also is true. That she is back in her village, living in her husband’s hut, baby strapped to her back, faith in her future restored. I also like to believe that she, and all of her fistula sisters, have borne their share of hardships for one lifetime, each and every one granted a lifetime reprieve as they pass for the last time through the gate of the hospital onto the dusty road home.

It is tempting to presume that young marriage and poor nutrition cause these difficult, fistula inducing labors. To be honest, we really aren’t sure about that. In Niger, for instance, there is a bimodal distribution. Fistula happens with the first baby, which in third world countries usually occurs in young women because they marry young. Or fistula occurs after several babies, often the largest birthweight, to a woman in her 30’s or 40’s. It is very likely more a matter of how the baby “fits” than an absolute function of maternal age. Here in the U.S., teenaged mothers abound and fistula is almost unheard of. So, is maternal age the biggest issue? Very likely not.

Fistula after the birth of her 7th child

(on bed, 14 years old) fistula after her first baby


Citizens of impoverished countries know well what most in the industrialized world have forgotten; childbearing is a life-threatening process. The harsh bonds between procreation and death live on in the romance literature of the 19th century, rife as it was with imagery of young women dying in the throws of childbirth leaving behind orphaned children to be raised by pining fathers and extended family, as did the golden-hearted but frail Melanie in “Gone with the Wind“.
Here in the US the transition from home birth to hospital birth occurred over a period of 15 years between 1940 (50%) and 1955 by which time 99% of US births took place in a hospital. This shift was in no small part due to the then novel utilization of cesarean to save the life or improve the outcome of the mother, and then eventually of the baby, as the operation was made reliably safe by the combination of antibiotics, antisepsis and modern anesthesia. (http://www.nlm.nih.gov-cesarian/ Section-a brief history, National Library of Medicine).
Prior to the late 1800’s, cesarean in Europe and the US was performed primarily to rescue live infants from dead mothers. With the advent of antibiotics and safe anesthesia, the transition from post-mortem neonatal rescue to maternal rescue to optimal outcome for both mother and baby was complete by the mid-20th century, and with it a concurrent plummeting in the incidence of obstetrical fistula. J. Marion Sims, father of fistula repair, contributed his portion to this legacy of operative birthing.
J. Marion Sims using silver wire to repair fistula 1870 (National Library of Medicine)

In most texts Sims is celebrated as a hero, working ceaselessly to perfect fistula repair among slaves, operating on some women dozens of times to relieve them of this horrid affliction. In other publications he is reviled as a butcher, operating on slaves without their consent and or consideration for their pain and suffering under the knife. Whichever your perspective, his pioneering surgical principles and techniques are used to this day and his discovery that silver wire sutures reduced wound infection was also introduced to the cesarean section (National Library of Medicine), facilitating the emerging technique of closing the uterus with sutures and reducing wound healing complications. His Fistula Hospital, opened in the 1850’s on New York City’s Park Avenue, was obsolete within 40 years, and was razed for the construction of the Waldorf Astoria Hotel that opened its doors in 1893.

Yes, it was here; our own fistula hospital and our own fistula problem vanquished by the advent of safe, modern obstetrical practice so that we now live with the luxury that any given woman will most likely survive any given pregnancy and have a healthy infant to show for it. We have the (justified) luxury of criticizing our healthcare system for the medicalization of pregnancy and the over-utilization of the very procedure that reduced the incidence of obstetrical fistula to almost nothing and we have the luxury of looking abroad in wonderment at the conditions under which the majority of the world’s women continue to give birth as if obstructed labor and fistula formation are truly, fundamentally foreign. These women are not foreign; these women are us.

Mariama and Hama, two repaired fistula patients trained as patient assistants for the IOWD fistula program (http://www.nigerfistula.org/)

Reliable epidemiologic data is a phenomenon of recent history; prior to World War II, most medical data was based on case series and institutional statistics. This makes it difficult to compare the rates of fistula in Africa now as compared to 100 years ago. Or here in the US, for that matter. But there is anecdotal evidence that cesarean section was actively and successfully practiced among African tribes before European coloniization.

Successful Cesarean section performed by indigenous healers in Kahura, Uganda. As observed by R. W. Felkin in 1879. (National Library of Medicine)

Not only was cesarean section a common and established practice, it was done with analgesia and antisepsis, both achieved with the judicious use of banana wine:
“……….., nineteenth-century travelers in Africa reported instances of indigenous people successfully carrying out the procedure with their own medical practices. In 1879, for example, one British traveller, R.W. Felkin, witnessed cesarean section performed by Ugandans. The healer used banana wine to semi-intoxicate the woman and to cleanse his hands and her abdomen prior to surgery. He used a midline incision and applied cautery to minimize hemorrhaging. He massaged the uterus to make it contract but did not suture it; the abdominal wound was pinned with iron needles and dressed with a paste prepared from roots. The patient recovered well, and Felkin concluded that this technique was well-developed and had clearly been employed for a long time. Similar reports come from Rwanda, where botanical preparations were also used to anesthetize the patient and promote wound healing.”(National Library of Medicine, nlm.nih.gov-Cesarian section)
Lister, a British surgeon and the “father of antisepsis”, promoted carbolic acid as a method by which infection’s impact on wound healing would be reduced starting in the mid-1860’s at a time when cesarian was done only to rescue yet living newborns from dead mothers (aka post-mortem neonatal rescue) And yet, for years if not decades prior, African healers were performing cesareans on live women to deliver live babies accomplished with sedation and antisepsis, not to mention reportedly good survival rates. What happened to these skilled African surgeons? Under what circumstances were these tribal cesareans performed, and how successful were they? Why did their obstetrical talents fade to a remote wood-block print in a national archive? Why are we not reading about their skills in our obstetrical history books? In a country that today as such a dearth of obstetrical care access, it is distressing to learn that 100 years ago the talent and skill to perform fistula-sparing cesarean were in Africa well before colonization. We leave these compelling questions for the medical historians and anthropologists.
Even today, epidemiologic data remains elusive throughout most of sub-Saharan Africa. Hospital-based data puts the rates in the ballpark of 350/100,000 births (Nigeria, 1985) and in some regions anecdotal estimates are much higher. On my travels in West and East Africa, the related morbidities of the obstructed labor injury complex, first described by Arrowsmith, Hamlin and Wall, are everywhere. Some women are repaired of fistula, but the scarred, sphincterless urethra results in urinary incontinence so profound that the patient’s life is not improved at all. Symphyseal separation and peroneal nerve neuropraxia (foot drop) are evidenced by the waddling step, the slapping foot, and the walking stick.
Women return to clinic still frantic with looming spousal abandonment, the vaginal vault so scarred that coitus is impossible, or the uterus so damaged that menses and fertility are never regained. The repaired anal sphincter is still too weak to prevent fecal soiling, or the strictured urethra so narrow that obstructive uropathy and urinary retention preclude a return to village life. Fistula has its bedfellows, each devastating. (Arrowsmith S, Hamlin EC, Wall LL. Obstructed labor injury complex: obstetric fistula formation and the multifaceted morbidity of maternal birth trauma in the developing world. Obstet Gynecol Surv. 1995;51:568-574.)
Fistula repair programs exist here and there, some decades old, some newly minted, some government sponsored, others parochial or secular non-governmental organizations, or the efforts of solo volunteers individually augmenting the local medical staff wherever their availability meets the need. Resources vary widely and success rates are cloaked in mystery. The sheer athleticism of providing surgical care in a third world setting makes even basic data collection an exhausting chore.
The Cadillac of fistula repair centers is in Addis Ababa, Ethiopia, founded in 1959 by Australian gynecologist Dr. Catherine Hamlin (http://www.fistulafoundation.org/). This East African facility is the second hospital dedicated to fistula repair in the world after J. Marion Sims former Park Avenue hospital. Colleagues tell me of clean sheets on every bed, running water in the wards, generous supplies, specially trained staff, occupational therapy and long term facilities for those who, for various reasons, do not return to their villages. More often than not, if you read about fistula repair in a lay publication, it is Dr. Hamlin’s program. A few months ago I had the privilege of talking with two Ethiopian colleagues who work with her in Addis. Gushing with admiration, I commented on how very proud they must be of the center’s reputation and how wonderful to be available to women year round in a dedicated facility. With a quizzical glance, as if I were a bit nutty, the senior surgeon responded gently; “I will be proud when the hospital is no longer needed and is replaced by a luxury hotel”.

(c) 2007 Urogynics PLLC, all rights reserved

The Levator Ani Muscle; Dr. Kegel’s Holy Grail
Through the center of this muscle sheet pass a woman’s rectum, vagina and urethra. This anatomic proximity is why Kegel exercises help women with incontinence problems. Once you learn them, the benefits last a long time and might even keep you out of the operating room. In one study of Kegels and urinary incontinence, 66% of the women maintained “favourable effects” over a 10 year span. But you don’t have to have a leaky bladder to benefit from the sexy side effects…
These exercises were first introduced by Dr. Arnold Kegel in 1948, in a series of research papers that showed improved bladder and bowel control in women without resorting surgery. At the time it was a radical notion, but now these exercises are the cornerstone of incontinence therapy.

Dr. Kegel also advocated the teaching of pelvic muscle contractions to women of all ages whether they have incontinence problems or not. Somehow this part of his message was lost over the years, and only women who are pregnant or who suffer extreme pelvic floor disorders such as dropped bladder or urinary incontinence are taught these common sense exercises.
Keeping this muscle strong is great for getting back to normal after child birth so that the vaginal area rebounds back into pre-pregnancy shape. Research indicates that orgasm is may be easier to achieve and more intense when this muscle is worked-out regularly, even for women who have never been pregnant. We believe, although there is no definitive medical data, that keeping the pelvic muscles in shape will prevent problems with vaginal laxity, dropped bladder, and incontinence if a woman makes them a lifelong habit. Think of Kegel exercises as “the dental floss of pelvic health.”

While many women have natural control of this muscle group, and do the exercises properly on their own, research tells us that up to 30% of women will do the exercise incorrectly or not at all after reading simple illustrated instructions. This incorrect performance is due to the fact that the muscle is deep inside your body and contracts isometrically. Since you cannot see what you are doing, you must have a high level of internal body awareness to do them properly. Looking at your vulva in the mirror, the vaginal opening will pull back toward the tailbone and in toward the navel when the pelvic floor is contracting. Or, when you are urinating, if you contract the muscles midstream, you may slow or stop the flow. But many women with weak muscles will not see much movement in the mirror, or may not be able to slow or stop the urine stream at all, even if they are doing the exercises correctly, and will be discouraged if they try these self-check maneuvers, and possibly assume they are not doing the right thing. So if you want to make sure you Kegel correctly, ask for a pelvic muscle check at your next gynecologic checkup.

Below is a quick test of coordination, strength and endurance of this muscle group that your doctor can use to score your “Kegel Capacity” during a routine Gynecology checkup.

5 Second Pelvic Muscle Test

This test takes place during the gynecology exam after the Pap smear. Pressure generated around the examining fingers is rated for duration of maximal contraction effort and the degree to which the muscle contraction rotates the fingers toward the pubic symphysis. Detailed 5 second pelvic score directions for clinicians are below the reference list for this posting.

Office-Based Pelvic Floor Biofeedback Unit

There are two types of muscle fibers in the levator muscles, fast twitch and slow twitch. Fast twitch fibers keep you dry when you cough or sneeze, and contract rhythmically during orgasm. Slow twitch fibers maintain bladder control and pelvic support during activities of daily living, and help you “hold it” when you are on line for the bathroom. Biofeedback training programs work both types of fibers so that your pelvic muscles work to their fullest potential.

Today’s computer-based biofeedback regimens reflect the vision of Dr. Kegel’s original work, which included the premier of the modern world’s first pelvic floor biofeedback system, the “perineometer”.

Dr. Kegel’s Perineometer

In the spirit of Arnold Kegel’s original vision, home perineometers abound, available to any woman with an interest in feminine fitness.

The Gadgets:
There are many Kegel Exercise devices available without a doctor’s prescription. Some of the Kegel exercise units have clinical research data verifying that they enhance pelvic exercise programs, others have none, relying on design, testimonials and common sense to recommend their use. All of them provide rudimentary biofeedback. As your muscles gain strength, you will be able to move to the heavier cone, or will see more concentric rings on the screen, or will squeeze to a higher pressure on the gauge.

Cones are the most time-tested of the group, with data over the past 20 years proving utility as adjunctive tools in Kegel exercise programs. The lightest is the easiest to retain, and the heaviest is the most challenging. For women with vaginal laxity and moderate to severe pelvic organ prolapse, these cones can be difficult to work with, slipping out even if you do the contractions properly.

At the other end of the spectrum is this (”Myself”) device that mimics in-office biofeedback by showing your effort on a hand-held screen, with concentric rings lighting up to the degree that the muscles contract so that stronger contractions show more rings. These and many other Kegel exercisers show you how you are doing and motivate you to exercise regularly. Your clinician will help you choose the one best suited to your personal goals.

If you are very weak…

In some women, the levator ani muscles are thin and weak to a degree that makes even in-office biofeedback difficult. These atrophied muscles can be made to exercise with gentle, painless electrical stimulation, or “E-stim”. E-stim units are hand-held and easy to use, either as an adjunct to pelvic floor biofeedback, or on your own at home in 15-30 minute daily treatments. So even if you are literally “too weak to move”, there is a therapy for you.
(www.empi.com)

Bladder Control…Sex…what about Pelvic Organ Prolapse?

There is plenty of data showing that Kegels are good for bladder control and a few studies that show Kegels will give you a stronger orgasm, but none shedding light on whether or not Kegels will hold your pelvic organs in place nor even how best to do Kegels. The newest device, Colpexin, is the only one with clinical research showing that it actually reduces prolapse in addition to increasing pelvic muscle fitness.

Colpexin is worn for 16 weeks, during which time it tones and stimulates the levator ani muscles. At the end of the 16 week pre-clinical trial, 81% of the women had measurably lesser prolapse on examination by the doctor, 63% had stronger, more fit levator muscles, and 92-100% were happy with their results, reporting better vaginal muscle fitness and bladder control, stating they would recommend Colpexin to a friend. Colpexin is fitted to your individual muscle strength at the doctor’s office. (www.colpexin.com)

Other than the single study on the Colpexin device, we are not sure if Kegel exercises prevent or treat pelvic organ prolapse (dropped bladder, vaginal laxity, uterine prolapse). No other device or Kegel exercise technique has been tested for prolapse treatment. When it comes to Kegels and prolapse, one can only apply a healthy dose of common sense; it is probably very helpful to keep your levator ani muscles in good shape with Kegel exercises. If you have moderate prolapse, Kegels make pessary use more successful. On the other hand, if you have severe prolapse, it is unlikely that Kegels will do much to pull your parts back into position, any more than sit-ups would be likely to help a large groin or belly-button hernia.

Kegel Exercise: The Dental Floss of Feminine Fitness
Keeping pelvic muscles strong and bulked with exercise is a very large pound of prevention within the reach of all women of all ages, even if the muscles are thin and weak. Check your pelvic muscle score at your next gynecologic check-up. Or consult a physical therapist, urogynecologist or female urologist in your community; these clinicians are used to checking this muscle group and often have biofeedback equipment that can measure exactly how strong and coordinated you are. Exercise on your own, sign up for pelvic floor biofeedback, use a Kegel exercise device, or gently bring the muscles back to life with electrical stimulation.
Keeping your levator ani muscles in good working order with Kegel exercise is smart for your health and good for your sex life. Stay in shape from the inside out!

References:
1. Romanzi L, Polaneczky M, Glazer HI. Simple test of pelvic muscle contraction during pelvic examination: correlation to surface electromyography. Neurourol Urodyn 1999; 18:603-12.
2. Kegel AH. The physiological treatment of stress incontinence of the urine in women. Gynecol Prat. 1960;11:539-60.
3. Kegel AH. Early genital relaxation; new technic of diagnosis and nonsurgical treatment.Obstet Gynecol. 1956 Nov;8(5):545-50.
4. Kegel AH. Stress incontinence of urine in women; physiologic treatment.J Int Coll Surg. 1956 Apr;25(4 Part 1):487-99.
5. Kegel AH. Sexual functions of the pubococcygeus muscle.West J Surg Obstet Gynecol. 1952 Oct;60(10):521-4.
6. Kegel AH. Stress incontinence and genital relaxation; a nonsurgical method of increasing the tone of sphincters and their supporting structures.Clin Symp. 1952 Feb-Mar;4(2):35-51.
7. Jones EG, Kegel AH. Treatment of urinary stress incontinence with results in 117 patients treated by active exercise of pubococcygeal.Surg Gynecol Obstet. 1952 Feb;94(2):179-88.
8. Kegel AH. Physiologic therapy for urinary stress incontinence.J Am Med Assoc. 1951 Jul 7;146(10):915-7.
9. Kegel AH, Powell TO. The physiologic treatment of urinary stress incontinence.J Urol. 1950 May;63(5):808-14.
10. Kegel AH. The physiologic treatment of poor tone and function of the genital muscles and of urinary stress incontinence.West J Surg Obstet Gynecol. 1949 Nov;57(11):527-35.
11. Cammu H, Van Nylen M, Amy JJ. A 10 year follow-up after Kegel pelvic floor muscle exercisese for genuine stress incontinence.
12. Cammu H, Van Nylen M. Pelvic floor muscle exercises: 5 years later. Urology. 1995 Jan;45(1):113-7.
13. Morkved S, Bo K. Effect of postpartum pelvic floor muscle training in prevention and treatment of urinary incontinence: a one-year follow up. BJOG. 2000 Aug;107(8):1022-8.
14. Bo K, Talseth T. Long-term effect o pelvic floor muscle exercise 5 years after cessation of organized training. Obstet Gynecol 1996 Feb;87(2):261-5.
15. Bo K. Can pelvic floor muscle training prevent and treat pelvic organ prolapse? Acta Obstet Gynecol Scand. 2006;85(3):263-8.
16. Harvey MA. Pelvic floor exercises during and after pregnancy: a systematic review of their role in preventing pelvic floor dysfunction. J Obstet Gynaecol Can. 2003Jun;25(6):451-3.
17 Rosenbaum TY. Pelvic floor involvement in male and female sexual dysfunction and the role of pelvic floor rehabiitation in treatment: a literature review. J Sex Med. 2007Jan;4(1):4-13.
18. Bo K, Talseth T, Vinsnes A. Randomized controlled trial on the effect of pelvic floor muscle training on quality of life and sexual problems in genuine stress incontinent women. Acta Obstet Gynecol Scand 2000Jul;79(7):598-6-3.
19. Beji NK, Yalcin O, Erkan HA. The effect of elvic floor training on sexual function of treated patients. Int Urogynecol J Pelvic Floor Dysfunct 2003 Oct;14(4):234-8.
20. Wein AJ. Weighted vaginal cones for urinary incontinence. J Urol 2003 Sep;17(3):1045-6.
21. Herbison P, Plevnik S, Mantle J. Weighted vaginal cones for urinary incontinence. Cochrane Database Syst Rev. 2002;(1):CD002114.

22. Goode PS, Burgio KL, Locher JL, ROth DL, Umlauf MG, Varner RE, Lloyd LK. Effect of behavioral training with or without pelvic floor electrical stiumlation on stress incontinence in women: a randomized controlled trial. JAMA 2003Jul16;290(3):345-52.

23. Dannecker C, Wolf V, Raab R, Hepp H, Anthuber C. EMG-biofeedback assisted pelvic floor muscle training is an effective therapy of stress urinary or mixed incontinence: a 7-year experience with 390 patients. Arch Gynecol Obstet 2005 Dec;273(2):93-7.

Pelvic Muscle Rating Scale: Instructions for Clinicians

done at time of bimanual pelvic examination

Rating scale parameters:
· Pressure:

o weak – a flicker-like contraction which generates minimal or no resistance to digital retraction
o moderate – a contraction which generates definite but unsustainable resistance to digital apposition
o strong – a contraction which generates sustained resistance to digital apposition

· Duration:

· Displacement:

when examining the pelvis bimanually, the examiner’s fingertips are in apposition to the anterior vaginal wall. With active contraction of the pelvic floor, the entire vault is elevated caudad and rotated anteriorly. Given the position of the examiner’s fingers, it is reasonable to grade the degree of rotation of the anterior vaginal wall only when assessing displacement.
o slight anterior displacement of the anterior wall will elevate and/or rotate the distal portion of the examiner’s fingers only
o whole anterior displacement elevates and rotates the full length of the examiner’s fingers without causing the fingers to override each other
o gripped displacement will elevate and rotate the examiner’s fingers and cause the fingers to override.