Category — Urinary Incontinence

ivillage.com asked Dr. R to help out on a piece about urinary incontinence and many other embarrassing topics of the feminine persuasion – here’s a direct link to Dr R’s portion:

ivillage asks Dr R about exert and squirt urinary incontinence

Scroll through all the other topics as well. This review has something for everyone, guaranteed.

Pelvic organ prolapse, difficult urination, frequency, urgency and overactive bladder – for some women, it’s all related.

(C) Lauri Romanzi 2010

Pelvic organ prolapse and overactive bladder. de Boer TA, et al. Neurourol Urodyn. 2010;29(1):30-9.

Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.

Medical research comes in several forms. This particular study gathered all the research already published on the topic, pooling all the data in one big group for re-analysis. Called meta-analysis, studies that pool data from other studies advance medical science by reviewing smaller clinical trials to figure out if the findings have anything in common that might thereby be considered “true”.

courtesy womensvoicesforchange.org

Look at this picture – what a mess. There’s no way bladders caught in the clutches of severe pelvic organ prolapse can function properly. The urethra, a 2-3 inch straw-shaped tube that allows urine to pass out of the bladder, is often kinked or compressed by the prolapse. The muscles in the bladder wall, normally located above the urethra, are now below the urethra, forced to fight the mighty forces of gravity and the kinked or compressed urethra, in order to empty, and as a result, the emptying is often incomplete. So the bladder fills up more quickly, starting a whole cascade of symptoms, enough to make any bladder crazy.

Not emptying fully, the bladder fills more quickly. Result? Frequency. And a propensity to bladder infections from all that stagnant urine. You used to urinate a few times a day without much thought, but now bladder management is a part-time job. Urine flow is very slow, dribbling, and sometimes stop – and – start.  This condition is called bladder outlet obstruction.

Contracting extra-hard in this upside down position in order to bypass gravity and urethral obstruction from all that kinking or compression, the bladder starts to misfire, suddenly contracting without any warning of fullness, as if it can’t make up it’s mind. Result? Urgency, that horrible sensation of needing to get to the bathroom RIGHT NOW and wondering if you’re going to make it in time. Or not making it in time, literally peeing in your pants on your mad dash to the water closet (urge incontinence). This condition is called overactive bladder.

courtesy "Plumbing and Renovations"

The common findings in the studies included in this meta-analysis showed that any method of successfully managing the prolapse, be it pessary or surgery, allowed the bladder to return to normal function. Anything that un-kinks the urethra, re-positions the bladder so that it’s on top of, instead of underneath, the urethra, and repositions all the pelvic organs to their normal location will normalize bladder function in most cases. Why is this an important finding? Because it helps doctors understand that, in a woman with prolapse and bladder problems, just fixing the prolapse ought to fix the bladder problems, without overactive bladder medications or the need for constant antibiotics to fight all those urinary tract infections.

Here is a synopsis of the data (aka abstract) of this study:

Abstract

AIMS: In this review we try to shed light on the following questions: *How frequently are symptoms of overactive bladder (OAB) and is detrusor overactivity (DO) present in patients with pelvic organ prolapse (POP) and is there a difference from women without POP? *Does the presence of OAB symptoms depend on the prolapsed compartment and/or stage of the prolapse? *What is the possible pathophysiology of OAB in POP? *Do OAB symptoms and DO change after conservative or surgical treatment of POP? METHODS: We searched on Medline and Embase for relevant studies. We only included studies in which actual data about OAB symptoms were available. All data for prolapse surgery were without the results of concomitant stress urinary incontinence (SUI) surgery. RESULTS: Community- and hospital-based studies showed that the prevalence of OAB symptoms was greater in patients with POP than without POP. No evidence was found for a relationship between the compartment or stage of the prolapse and the presence of OAB symptoms. All treatments for POP (surgery, pessaries) resulted in an improvement in OAB symptoms. It is unclear what predicts whether OAB symptoms disappear or not. When there is concomitant DO and POP, following POP surgery DO disappear in a proportion of the patients. Bladder outlet obstruction is likely to be the most important mechanism by which POP induces OAB symptoms and DO signs. However, several other mechanisms might also play a role. CONCLUSIONS: There are strong indications that there is a causal relationship between OAB and POP

(C) Lauri Romanzi 2010

Pelvic floor disorders include problems with urinary incontinence, pelvic organ prolapse, fecal incontinence, fistula, urinary tract infections, and mechanical sexual dysfunction. Who wants to think about this stuff?  Well, for starters, women who suffer these disastrous conditions.

Pelvic organ prolapse, on which I’ve written aplenty, can sometimes induce a rather nasty condition called overactive bladder. Overactive bladder happens when your bladder muscle (yes, the bladder is a muscle, an automatic muscle, like the muscles in your intestines or your heart) decides to EVACUATE, any time it wants to, whether you’re on the toilet or riding the bus. Women with overactive bladder often report a compelling, sometimes sudden urge to void (urinate) that is difficult or impossible to defer. She may find her bladder waking her from deep sleep many times at night with this same horrible urgency. When this urgency control is “difficult”, she’s Kegeling her legs off, squeezing her thighs together and sweating bullets trying to make that horrible urge feeling stop so she can uncross her legs and dash to the nearest powder room. When the urge to void is “impossible” to defer, she wets her pants. It’s messy, horrifying, and terribly unsexy.

Urge Incontinence from Overactive Bladder

While most cases of overactive  bladder are idiopathic (medicalese for “no apparent cause”), some cases are caused by prolapse.  When the bladder or uterus (or both) prolapse, the urethra can be kinked or compressed, obstructing urine outflow and making it difficult for the bladder to empty completely. Obstructed bladders are cranky bladders, often becoming overactive in response to this interference with emptying.

A recent multicenter European study published in Neurourology and Urodynamics showed a distinct correlation between severe pelvic organ prolapse, bladder outlet obstuction, and overactive bladder. Prolapse can obstruct bladder outflow and if it does, the bladder tends to become overactive, reminiscent of that vaudeville song, “The head bone’s connected to the … neck bone…”.  In this timely review, they also found that successful prolapse surgery often, but not always, calmed down bladder overactivity by un-blocking the urethra and normalizing bladder outflow. The connection between prolapse, bladder outlet obstruction and overactive bladder

Women with prolapse and bladder problems often want to know if surgery will fix both. This study helps us understand that it indeed may help fix both the prolapse and the obstructed/overactive bladder disorders in a large portion of women with this unhappy combination. For years, I’ve used pessaries (vaginal widgets that comfortably hold prolapse in place) to help predict whether or not prolapse surgery might also stop obstructed voiding and overactive bladder, and most of the time it correlates well to surgical outcome. And sometimes, the patient is so pleased with the pessary that she cancels the operation.

For a detailed case report on women with prolapse, obstructed voiding and overactive bladder, click on this MedScape review:

Dr R for MedScape- prolapse, overactive bladder, stress incontinence, obstructed bladder

http://cme.medscape.com/viewarticle/700135

One last note for women with prolapse and bladder problems – there is another urinary incontinence condition, called stress incontinence, that may actually increase with pessary use or prolapse surgery, because a stress – incontinent urethra may actually seal better with the kinking and compression caused by prolapse, and may therefore increase when the prolapse and kinking are mechanically corrected. Stress incontinence is caused by poor urethral closure that allows urine to leak out with strenuous physical exertion, like sneezing or coughing or opening a window or lifting heavy grocery bags. No urgency, just “exert and squirt”.

Stress Urinary Incontinence = "Exert and Squirt"

If you have prolapse and stress incontinence, your problems require therapies for prolapse and therapies for stress incontinence. Prolapse therapy options usually involve pessary use or reconstructive surgery. Stress incontinence options include Kegel exercises with pelvic floor physical therapy, medications, or procedures such as urethral bulking injections or minimally invasive sling operations. You can do prolapse reconstruction and urethral sling in one operation, for instance, taking care of both your plumbing and your renovation problems at the same time (on Plumbing and Renovations).

Prolapse or no prolapse, urge incontinence from overactive bladder and stress incontinence from a weak urethral seal can plague any woman at any age. About 13% of women with overactive bladder are under the age of 35, and up to 30% college female athletes report regular urinary incontinence of one sort or another during training and competition. It comes with the territory, and it increases in prevalence as women age.

1/3 of incontinent women suffer only stress incontinence, 1/3 only urge (overactive bladder) incontinence and 1/3 suffer a mixture of both overactive bladder / urge incontinence AND stress incontinence.

If you have incontinence, or prolapse and bladder problems, make sure you don’t undertake any therapeutic measures without first understanding if you have overactive bladder, bladder outlet obstruction, and/or stress urinary incontinence. It is absolutely possible, and not at all uncommon, to have all three conditions if you suffer severe prolapse. Take the time to sort it all out, make sure it’s clear in your mind, then work with your doctor to set a common-sense course of action to restore your core to normal anatomic and physiologic function.

I urge you all to check out the entire content on Women\’s Voices for Change, an online resource for grown women and the people who love them.

Betty, a woman with uterine prolapse, recently wrote in to this blog, asking advice after her doctor told her she would need a hysterectomy to fix her prolapse. We now understand that the mechanics of prolapse are all about those ligaments, and that the uterus, literally, contributes nothing to prolapse other than it’s change in position from “up there” to “out there”.  Dr. Pat Allen, Gynecologist extraordinaire and founder of Women’s Voices for Change, called me in to pinch hit on this one, and with bases full, Dr. R goes to bat:

Dear Betty,

You’ve done a great job of describing a condition that many women are intimately familiar with and, like you, embarrassed to talk about. I asked WVFC Medical Advisory Board member Lauri Romanzi, M.D., a specialist in reconstructive pelvic surgery and urogynecology, to respond. Which she did, pulling out a drawerful of medical illustrations to help explain what’s going on in your body, and why a hysterectomy isn’t the answer. —Dr. Pat

Betty\’s Prolapse Problem

(c) Lauri Romanzi 2010

Vaginal rejuvention, a mystical term with many facets, new darling of cosmetic surgery and battle cry of the “anti-medicalization of female sexuality” crusade, is a marketing term with no formal medical definition, this despite the American College of Obstetrics and Gynecology 2007 Clinical Practices Bulletin on the topic that was rife with both admonishments against some, and guarded approval of other, procedures advertised under this “VR” label. Some 3 years after the ACOG bulletin, concern and confusion reign on as the definition of vaginal rejuvenation continues to mutate.  

As a reconstructive pelvic surgeon and urogynecologist, I’ve been dealing with “Vaginal Rejuvenation” requests of all types since the term went public. As far as I can tell, the public’s interpretation of vaginal rejuvenation falls into three groups, listed here in order of increasing controversy and decreasing volume of safety & efficacy data:

Procedures to correct prolapse and incontinence

Procedures to alter the appearance of vulvar structures

Procedures alleged to enhance female sexual gratification

For a perspective-setting preview, consider reading this 2009 review of vaginal rejuvenation by Dr. R, and an excellent piece on birth plans written by Sharon Bond, PhD, Certified Nurse Midwife, here:

NAFC Quarterly Update Vaginal Rejuvenation & Childbirth Planning

These 2 articles, written for the National Association for Continence quarterly newsletter, dovetail nicely. As it turns out, much of what patients consider “vaginal rejuvenation” has a lot to do with childbirth-related changes in pelvic floor anatomy and function. As a contributor and member of NAFC (National Association For Continence, www.nafc.org), I share this fantastic online resource for information on pelvic floor disorders.  While the NAFC focus is on bladder and bowel control (as evidenced in the name), they do a great job of bringing up-to-date information on sex and well being to the public.

THE INSIDE SCOOP ON VAGINAL REJUVENATION

UPDATE 2010

Vaginal rejuvenation is a tenaciously fashionable concept, still with no strict medical definition. Yes that’s right, things vaginal continue to be fashionable. And, as with fashion, much is left to creative interpretation.

For many women, the childbearing, peri- and post- menopausal years come with pelvic, sexual, urinary, rectal 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, enjoy sex, and feel normal and intact as a woman. If things aren’t right, you have options. These options, under the newly minted term “vaginal rejuvenation”, continue to spark controversy, raising concerns about safety, efficacy, and medical ethics.

With those options come obligations. Your obligation includes examining your motivations, taking stock of the overall impact of the condition(s) on your quality of life, and obtaining several medical or surgical opinions before you start any therapy or sign up for any surgery.  The doctor’s obligations include sorting out whether your condition(s) warrant physical, medical or surgical therapies or some combination thereof, and to help you understand what the risks, benefits and alternatives are for your personal mix of issues and symptoms.

Vaginal rejuvenation skipped onto the medical stage a few years ago, with no formal medical definition, in response to increased demand for  cosmetic alteration of gynecologic structures, most commonly the labia minora (inner vaginal lips). 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 established history, little to no safety or efficacy data, and no predictable result.

“Vaginal Rejuvenation” for pelvic organ prolapse, vaginal laxity, and incontinence

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 (think “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 a.k.a. Kegel Exercise

Lift a dropped bladder = Anterior Colporrhaphy*

Tighten a vagina permanently widened by childbirth= Perineoplasty

**Fix a bulging rectum = Posterior Colporrhaphy

Repair a leaky bladder = Urethral Sling or Urethral Bulking Injections

Restore anal control = Anal Sphincteroplasty

Lift a dropped uterus = Uterine Resuspension, aka Hysteropexy

***”Vaginoplasty” = creation of a vagina (often using  loop of intestine) in a woman born with congenital absence of the vagina, or creation of a vagina in a woman whose vagina is scarred shut from disease (fistula, radiation effect, infection, radical pelvic cancer surgery). More recently, under the marketing concept of vaginal rejuvenation, it has come to mean any combination of procedures from any of the basic three categories (prolapse/incontinence, cosmetic, sexual enhancement) for women without congenital or acquired obliteration defects of the vagina.

*Also referred to as “anterior repair”

** Also referred to as “posterior repair”

***On “vaginoplasty”, in the realm of “vaginal rejuvention” for women born with normal vaginal anatomy, this procedure, commonly attached to the word laser, as in “Laser Vaginoplasty” or “Laser Vaginal Rejuvenation”, carries no description in any medical or surgical textbook or peer review journal.  As of June, 2010, neither “laser vaginoplasty” nor “laser vaginal rejuvenation” are now or ever have been taught in any surgical or gynecological residency training program, nor in any urogynecology, female urology, plastic surgery, or other reconstructive surgical subspecialty fellowship training program. If you want to know about laser vaginoplasty, patient choice is restricted to consultation with a doctor who paid to be trained by the founder of the laser vaginal rejuvenation procedure. These doctors pay a fee to spend several days learning the procedure(s). The fee includes the franchise purchase, after which purchasing physician participates in an exclusive, robust webmarketing network restricted to purchasers of the franchise, the only doctors who may perform the laser vaginal rejuvenation procedures. These franchise-purchasing physicians are under contractual obligation that forbids discussing or otherwise disclosing the actual technique to anyone who has not purchased the franchise, including colleagues or the press. As such, and despite patient satisfaction testimonials on the franchise physician websites, there is no scientific, peer reviewed data in any peer reviewed medical journal documenting the actual technique, efficacy or safety of laser-based vaginal rejuvenation procedures

For some women, “rejuvenate” = “relubricate” (see When rejuvenate = relubricate). Vaginal dryness, poor lubrication and reduced 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 menopause-related vaginal dryness or problematic urinary incontinence eagerly seek out a little rejuvenating, often the same women who reject the unsexy but medically accurate labels of “pelvic organ prolapse” , “vaginal atrophy” 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.  A recent study of over 3000 women ages 50‐61 showed 6% with symptomatic, high‐grade prolapse.  Some estimates show 50% of women who’ve born children will have variable degrees of pelvic organ prolapse, from asymptomatic to gravely symptomatic.  By 2050, the number of women with urinary incontinence is expected to increase by 46%, and those with pelvic organ prolapse by 55%, with the number of American women with at least one pelvic floor disorder increasing from 28.1 million in 2010 to 43.8 million in 2050.

Whether you call it prolapse repair, incontinence therapy, or vaginal rejuvenation, pelvic floor disorders condition and related treatments (with “laser vaginal rejuvenation” the exception) come with generations of experience documented in medical and surgical texts and reams of data in myriad peer-reviewed medical journals.

“Vaginal Rejuvenation” to alter the appearance of the vulva and vaginal opening

Reduce and remodel inner labia = labiaplasty

Restore the hymen to a virginal state = hymenoplasty or “revirgination”

Reduce wrinking of outer labia = labial filler injections (of fat, collagen or other filler)

Labiaplasty reduces and remodels large inner labia (labial hypertrophy), or restores symmetry to unbalanced labia (labial asymmetry). Women requesting labiaplasty reduction and recontouring of the inner labia minora is often  report physical discomfort from labial catching, chafing, rubbing and folding in clothing or with sexual or other vigorous activities like tennis, yoga, running and biking. Women’s current propensity to depilitate all vulvar hair and wear thongs, the ad infinitum wearing of jeans formerly reserved for the under-30 set, intertwine with inevitable yet subtle changes in inner-outer labial consistency and relative size and natural age related vulvar wrinkling, resulting in unprecedented complaints of physical discomfort from this artificially increased labial exposure. I find many such patients adamantly unwilling to restore Mother Nature’s natural labial cushion that comes from full-growth pubic hair, full crotch underwear, and pants that aren’t painted on. I tell every labiaplasty patient every time, and 9 times out of 10, this (self-selected and therefore biased) group opts for the labiaplasty operation over nature’s blueprint.

The role of enculturation cannot be underestimated. On the other end of the labial alteration spectrum, from a region of the world more famous for rite-of-passage female genital mutilation than female sexual gratification, comes the regionally popular central African practice of labial elongation, believed to enhance female orgasm, female ejaculation, and sexual satisfaction for both male and female sides of the coital equation: Rwandan women enhance gratification with \”labial elongation\”

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, but gaining popularity here in the States from women seeking “revirgination”. This procedure meets with much scrutiny, given the inherent cross-cultural and socio-ethical issues involved.

Labial bulking of the outer labia reduces age-related wrinkling as the body’s youthful fat pads diminish not only in the vulva, but also in the cheeks, hips, extremities and around the joints. These fat pads are well understood by cosmetic surgeons, who commonly plump up  facial cheeks made hollow by age-related loss of facial fat, often using liposuctioned fat from the patient’s own buttocks, abdomen or thighs. Popularized by these same cosmetic surgeons, women with age-related fat pad volume loss in the labia majora reportedly undergo similar bulking filler injections into the labia majora in cosmetic surgery offices.

As with rhinoplasties, lip enhancements, cheek and buttock implants, liposuction and all other cosmetic procedures, these “not medically necessary” labial alteration procedures are not covered by insurance. The physician is obligated to evaluate patient motivations, and to do their professional best to avoid performing them on women addicted to cosmetic procedures or suffering from body dysmorphia, both contraindications to cosmetic procedures.

A woman seeking labiaplasty for severe congenital asymmetry or labia that routinely catch, tear or chafe with sporting or sexual activities are not the same as patients responding to cruel comments from an unworthy sexual partner or insecure because they “don’t look like the women in porn movies”. Labiaplasty procedures are included in surgical texts, with techniques and data published in peer reviewed medical and surgical journals. Much controversy surrounds labial and hymenal procedures, taken as yet another sign of the increased medicalization of female sexuality, with “female sexuality as a newly minted profit center for unethical surgeons and greedy pharmaceutical corporations” as the banner-head under which such protests march. (see Professor Leonore Tiefer)

The controversy rages on, hitting fever pitch with the next category of rejuvenation procedures:

“Vaginal Rejuvenation” to enhance sexual gratification

Clitoral unhooding

G-Spot amplification (a.k.a. the G-shot)

Sub-clitoral bulking injections

This category of VR procedures carry significant risks, with sparse to no efficacy data published in peer reviewed medical or surgical journals.

Clitoral unhooding reduces or removes the skin folds over the clitoris. As an anatomy instructor at Weill Cornell Medical College, I consider clitoral unhooding an inherently risky procedure, given its proximity to the clitoral nerves and the small and vulnerable clitoris.

G‐spot amplification, another “sexual enhancement” procedure involves an injection of collagen or other bulking agent (same fillers used for facial wrinkles) 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 to enhance sexual response.

Sub-clitoral injections underneath the clitoris using filler bulking agents such as collagen or hyaluronic acid are purported to “lift” the clitoris, increasing exposure of the sensitive clitoral glans, allegedly to enhance sexual sensitivity.  This poorly documented procedure continues to flirt around the Upper East Side of Manhattan, offered primarily in cosmetic surgical offices.

Each of these sexual enhancement procedures carries the risk of scarring, pain, infection and numbness. Benefits are unclear, as the miniscule amount of peer-review data currently available used non-validated patient questionnaires administered by the surgeons themselves as opposed to blinded reviewers, and did not include objective measures of nerve function and other measures of genital function and sensitivity.

What say the gynecologists?

In 2007, The American College of Obstetrics and Gynecology issued a warning about all of these vaginal rejuvenation cosmetic and sexual enhancement procedures in Bulletin #378,  finding labiaplasty and perineoplasty “may be warranted in properly selected patients,” while reserving endorsement of G‐spot enhancement, the ill‐defined “vaginoplasty,” the mystery-shrouded, copiously marketed laser vaginal procedures, and clitoral unhooding, until each procedure garners the necessary peer review safety, efficacy, and technique disclosure warranted by medico-ethical standards of clinical acceptability.

For synopsis ACOG bulletin: ACOG committee opinion #378 on cosmetic gynecology

What say the plastic surgeons?

Nothing, really.

from American Society of Plastic Surgeons: ASPS weighs in on vaginal rejuvenation, sort of

There are a number of different vaginal rejuvenation procedures that can be performed by board-certified plastic surgeons. Here, an ASPS Members Surgeon explains the reasons why women may seek out procedures such as this. Learn more about cosmetic procedures.

Note: Some of the procedures and technologies presented in the following videos may be under investigation and presented for research and educational purposes. More scientific study may be needed to determine efficacy and success rate. The American Society of Plastic Surgeons (ASPS) and the Plastic Surgery Educational Foundation (PSEF) do not endorse the procedures or technologies presented nor do the statements of the individual physicians represent the opinions, positions, or recommendations of the ASPS or PSEF.

From The American College of Surgeons, The American Society of Aesthetic Plastic Surgeons and the American Academy of Cosmetic Surgeons: Zero.

Except for ASPS saying “we can do it”, these non-gynecologic surgical societies, whose vaginal rejuvenating members aggressively online advertise cosmetic gynecologic procedures, provide no medico-ethical professional statements for us to consider, despite the widespread adoption of things gynecologic into the plastic surgeon’s arena. This “plastic/cosmetic surgeon as vaginal rejuvenator” phenomenon spawned a competitive explosion in the marketing of “vaginal rejuvenation”, replete with page after page of graphic, genital BEFORE AND AFTER images, something gynecologic surgeons had never previously adopted into office, online or related marketing practice. Given the robust vaginal and vulvar enthusiasm demonstrated by many plastic and cosmetic surgeons, you’d expect their professional societies to weigh in on the ongoing vaginal rejuvenation debate with something more than “we can fix your vagina and we have the images to prove it”  regarding this controversial corner of medicine.

If you’re interested in cosmetic “vaginal rejuvenation”, begin a conversation with yourself about your motivations and perspective: Cosmetic Gynecology Personal Perspective Litmus Test

While doctors, medical societies and health advocates rage on in the debate about what is and what is not acceptable vaginal rejuvenation, each patient is fairly clear about her individual rejuvenation goals. 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 to restore vaginal snugness after childbirth; minimally invasive incontinence procedures or medications for bladders not controlled by Kegel exercise alone, each available as needed to get your pelvic life back on track. The cosmetic procedures to alter the labia or hymen, and to a greater extent, the operations promising sexual ehancement, carry relatively escalated levels of scrutiny due to concerns about the medicalization of female sexuality, and the variable dearth of data regarding both safety and efficacy.

REFERENCES OF INTEREST

Medicalization of Sexuality:

Professor Leonore Tiefer Home Page

Forecasting pelvic floor disorders:

Pelvic floor disorders 2010 – 2050

Labiaplasty technique:

Labiaplasty overview and link to technique monograph

Labiaplasty technique

Clitoral unhooding and mixed genital plastic surgery:

Female cosmetic genital surgery

Multicenter study of female genital plastic surgery

Hymen restoration:

Should doctors do virginal reconstruction for adolescent girls? Cultural considerations cannot be ignored,

Reconstructing the hymen: mutilation or restoration?

Hymen reconstruction:ethical and legal issues

Perineoplasty:

Vaginal laxity and post-perineoplasty images

Perineoplasty in women with sensation of a wide vagina

Combined anal sphincteroplasty and perineal reconstruction for fecal incontinence in women.

Kegel muscles and sex:

female orgasm: role of pubococcygeus muscle

vaginal contractions in female orgasm

The Science of Sex circa 1982

Orgasm mechanics the same in women and men

Dear Dr. Romanzi,
I recently finished your book and found it quite informative. I had my first baby when I was 35, pitocin-induced with no pain medication. After a short but extremely intense labor, my labia tore off and although the doctor tried to repair it, it doesn’t feel (or look) quite right and seems to flap open all the time. I also feel like my vagina is a wind tunnel, especially when I do yoga–it makes a lot of noises. Ever since the birth I have suffered from stress incontinence but I’m not sure if I have prolapse. Several doctors have told me I am too young for a sling or surgery and simply recommended kegel exercises. I’ve tried kegels and even got the Myself (a biofeedback system) and nothing has improved my incontinence. I am now 38 and 20 weeks pregnant (not planning any other pregnancies). How soon I can get these issues fixed after I deliver? Do you think I am too young for a sling?

Dear Reader,
No one is “too young for a sling”, provided they suffer significant stress urinary incontinence. Two categories of incontinence apply to most women with bladder control problems, those being stress (”exert and squirt” leaking with cough, sneeze, lift, running, etc) and urge (overactive bladder, urination before seated on toilet), and about 1/3 of women with incontinence have a little of both problems.
Kegels are a good therapy for both types of incontinence in about 70% of cases, including mixed stress/urge. Once you’ve birthed the baby, you may be well served to spend 12 weeks working properly wtih a pelvic floor physical therapist rather than on your own with or without a Kegel exercise gadget. It’s like working with a personal trainer, typically yielding better results. If this fails, you may need medications or electric stimulation for urge incontinence, and a sling for stress incontinence. Slings do not reliably improve urge incontinence, an important distinction should a sling be recommended for you – it is likely that overactive bladder symptoms will persist after a sling, with the “exert and squirt” symptoms gone, or significantly reduced.
The vaginal laxity may also respond to Kegel exercise because the exercises can bulk up the vaginal muscles, making for snugger inner contour. If this does not work, reconstructive surgery may be done with or without concomitant sling, and your labum can be repaired at the same time. The exact best procedure for you, however, can only be determined with a proper pelvic support examination and bladder function testing.
Typically, women are advised to complete childbearing before undergoing reconstructive surgery for laxity, prolapse and stress incontinence, since pregnancy after said operation(s) may undo the results.
Thank you for sharing you story!
Best Regards, Dr R

Plumbing and Renovations was written to demystify prolapse and incontinence. For starters, if you have prolapse, you do NOT need a hysterectomy, even if your uterus (take the kids out of the room) is hitting your knees.
A few reviews from readers:
1 of 1 people found the following review helpful:
5.0 out of 5 stars Informative and a surprisingly easy read!, December 26, 2008
By L. Y (New York, NY) -
This review is from: Plumbing & Renovations (Paperback)
This book truly saved me! After 2 opinions that I should get a hysterectomy, I found an alternative and am now working on my second child! After having my first, I needed help getting my pelvis back in shape. An incontinence issue acquired during my pregnancy also needed addressing. This book spelled it all out for me and with its amazing illustrations and information, I have seen a real improvement all of the way around.
I am hoping to see more of these “Beauty Call” books from this author, as I think they touch on subjects rarely addressed, in a thorough, concise and amusing way. Kudos! <

5.0 out of 5 stars Finally! An intelligent (and hilarious) surgeon, April 7, 2009
By EG “never_enough_books” (Athens, Greece) -

This review is from: Plumbing & Renovations (Paperback)
Ladies, if you have a dropped uterus (you’d be surprised how many women do) read this book first! You probably don’t need a hysterectomy. You also want to read this book if you suffer from a dropped bladder, your vagina is loose, or you want to know what treatments are available to, among other things, improve your sex life. Eminently readable, informative and wise, this book should be issued as a textbook for sex education classes, so thoroughly does it cover the subject of the female anatomy. Dr. Romanzi, I Kegel as I write this. Thanks!

5.0 out of 5 stars A hilarious entree into what your mom forgot to tell you – or never knew, December 30, 2008
By A G (New York) -
This review is from: Plumbing & Renovations (Paperback)
A friend gave me this book and I was SHOCKED by what no one – not your mom, not your doctors tell you. I learned more about my body from this book than I ever could have imagined. Plus, its a riot. It should be recommended reading for women.

(c) Lauri Romanzi 2009

Stress urinary incontinence affects millions of women worldwide. Stress incontinence occurs when the sphincter of the urethra is weak, due to age, childbearing or trauma, and urine leaks out with physical exertion, commonly with sneezing and coughing.  This is “exert and squirt” leakage, and not associated with the sensation of urgency. Leaking with cough, sneeze, lifting, carrying, exercise and dancing are common symptoms for women with this condition.

 A minimally invasive sling may be your best option if these symptoms sound familiar. Learn more here from this Eyewitness News clip:
http://www.urogynics.com/pages/pops/fox.html

Hi

I have urge in urination . My uterus has one gland inside which is very small which is situated beside the bladder. Hope this is pressurising the bladder.
Please suggest to get rid of this.

Thanks

Hello -
Urge urination has several possible causes. Urge urination is most often due to the condition called overactive bladder.You are best served by seeing your gynecologist, a urogynecologist or female urologist for a bladder function evaluation to determine which therapies may work for you, and whether or not the cyst you describe in your uterus is contributing to your symptoms. 

Best Regards,
Dr. R