Hello Distressed,
Many women (most women) need foreplay to fully enjoy sex and to achieve orgasm. Your husband’s premarital record of routine female orgasms without foreplay is remarkable, unusual and almost unbelievable.
Your relationship would benefit from couples counseling with a board certified psychiatrist or psychologist specializing in sexual function.
This is not a problem about YOU. It is a problem about your relationship and conflicting expectations between yourself and your husband. If your husband won’t go, you will benefit from going alone.
Best Regards,
Dr R

Hello L,
You may benefit from transdermal OAB medications, of which there are 2 options, one gel and one patch. If you’ve tried these already, you may do well with an old-school treatment regimen using tri-cyclic antidepressants, medications approved for depression, one of which has a track record as a successful incontinence medication. Or it may be time to give electrical stimulation, pelvic floor physical therapy with biofeedback and bladder retraining a try. With regard to Elmiron for interstitial cystitis (IC), there are other treatment options for IC. Therapies for OAB and IC are fundamentally different, although therapies may overlap in certain patients such as yourself who suffer both syndromes. Women with your mix of conditions often need a lot of tweaking and frequent follow up in order to find the individual regimen that works for you, no small task as you are well aware.
To find a consultant for second opinion evaluation (be ready to repeat tests you may have done in the past), see http://www.augs.org patient section, and http://www.ichelp.org.
Lastly, I trust you’ve already looked at dietary and lifestyle factors that may be exacerbating your conditions. If not, start with a nutritionist skilled with IC and UC management.
Best Regards,
Dr R

Thank K

Dear K,
Even with correct technique at the time of delivery these deep tears often don’t heal perfectly due to the swelling and hormonal changes in skin and deep connective tissues during pregnancy and delivery that result in less than optimal healing from childbirth tears. That said, it is very likely that your anatomy and function can be restored or significantly improved with reconstructive surgical repair of the perineum (perineoplasty) and/or anal sphincter (anal sphincteroplasty). Sometimes perineoplasty alone is enough. Whether one or both procedures might be advised can only be determined through clinical examination, after which various other imaging and colorectal tests might be advised to determine the optimal procedure(s) for your personal situation. It’s been 19 years! Pull this up to the top of your priority list and get the information you need. Thanks for sharing your story. Please keep us posted!

Dr R

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 with 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

Hello D,

Thank you for writing in – I know there are more men out there trying to help the women they love, and your willingness to post your questions will undoubtedly help other men actively advocate for the health of the women in the lives.
1) Since she is past her childbearing years, is reconstructive surgery appropriate, or could a pessary work?
She may do perfectly well with a pessary and I often advise pessary use before any other therapies are considered. But some women cannot be fit with comfortable pessary or a pessary that truly holds it all in due to the severity of prolapse (the worse the prolapse the more difficult to find a well fitting comfortable pessary) or idiosyncracies in the boney pelvis that make pessaries uncomfortable, in which case the next option is reconstructive surgery. Some women may be fitted for a pessary that works perfectly well, but they find it annoying or “unsexy” to use, in which case it may be worn until she has time to undergo reconstructive surgery and it’s recuperation (~4 weeks to return to work, 6-8 week til sex is possible). Pessaries that fit well physically and jive with lifestyle and body image provide an excellent non-surgical therapy for prolapse.
2) We are from Cincinnati, OH. I went to the AUGS website to try and find providers in our area, but I wasn’t sure if these are just gynecologists or OB’s who perform reconstructive surgery,
The major university medical centers all have urogynecology divisions run by fellowship trained specialists – these are a good place to start. You may want to obtain several opinions should you choose reconstructive surgery.
3) Is the reconstructive approach treated as “cosmetic” surgery from an insurance perspective, or is it usually a covered procedure
Prolapse surgery is the same as any other reconstructive surgery, be it a hernia, a knee repair or a rotator cuff repair. While not an emergency, it is a recognized condition that insurance companies do not consider cosmetic.
Finally, hysterectomy does not improve the durability of prolapse surgery, and she DOES NOT need a hysterectomy to benefit from excellent long term (hopefully life-long) results should she choose to undergo reconstructive pelvic surgery. Recurrence is possible with any and all reconstructive operations done anywhere in the body by any technique, and prolapse repair is prone to recurrence in the same way hernias may recur and damaged knee ligaments may not last forever after knee surgery. Reconstructive surgery puts things back together, unlike extirpative surgery that takes things out – appendix out, guaranteed you’ll never have to have it removed again! Hernia surgery – might need another one someday.
In order to help women understand the causes, therapies and surgeries for prolapse, I wrote PLUMBING AND RENOVATIONS as an in-hand resource for women with prolapse and/or incontinence (www.plumbingandrenovations.com). She may find this book helpful as the therapeutic options are considered. Thank you for writing in and please do keep us posted.

Best Regards,
DR R

Thanks Dr. R

Hello,
If indeed the cyst is the source of pain, something that only your examining physician can determine, then at minimum the cyst must be removed if it does not resolve spontaneously, and some cysts, particularly cysts that occur as a result of ovulation, do resolve spontaneously. Cysts that are large, twisting (called ovarian torsion), not associated with ovulation, or are suspicious of containing cancer must be surgically removed and sometimes cannot be removed without totally removing the ovary from which they arise.
To remove both ovaries will bring on abrupt surgical menopause to any woman at any age, unless of course she has already gone through natural menopause. The average age of menopause is 51, so the decision to induce this in yourself 8 years earlier than might otherwise occur requires careful counseling from your doctor and consideration from yourself. You may benefit from perusing the patient resources on the North American Menopause Society website: http://www.menopause.org/Consumers.aspx. As with all other complicated surgical decisions, you may want to obtain other clinical opinions from consultants who review your test reports combined with a physical exam to give you the answers to the issues outlined in this response. Obviously, given the pain involved, such second opinions are to be arranged urgently! Do not delay. Keep us posted…

Best Regards,

Dr R

I have longstanding cystocoele/rectocoele and significant urinary incontinence since the birth of my 2 children (birth weights 10lbs).
I am finally ready to consider surgical options for my chronic issues;
however, my specific question is
whether this type of clitoral sx can arise from mechanical changes of prolapse/tugging on pudendal?

thank you

Hello Grace,

I love your question, because it gets to the heart of pelvic floor disorders, that being the interaction between nerves and soft tissue collagen support and pelvic organ function. Your particular symptom, clitoral sensitivity, may not be directly caused by or indirectly exacerbated by the cystocele and rectocele, it may be “its own thing” totally unrelated to your cystocele and rectocele. The best reason to undergo cystocele and rectocele repair is always to correct bulges that are so far out that they bother you a lot almost every day. Clitoral sensitivity is a difficult condition to evaluate and treat properly. So… if the cystocele and rectocele themselves are bothering you a lot every day, you may consider having them fixed (without hysterectomy! Prolapse surgery does not require hysterectomy – see http://www.plumbingandrenovations.com) and see how the clitoral sensitivity changes, or not, thereafter. Or you may choose to evaluate the clitoral sensitivity all by itself without prolapse surgery, which would require a neurologic evaluation coordinated with a urogynecologic consultation.
In summary, it is most likely that these conditions – clitoral hypersensitivity & cystocele/rectocele – are true-true and unrelated.
Keep me posted!
Sincerely,
Dr. Romanzi