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  1. Dr. Romanzi

    Please post your questions by adding a comment here!

    1. M

      I think I might have Vulvodynia, but my doctor isn’t convinced. I’ve been dealing with this off and on since 1999. I’ve been tested for everything over the years, and only confirmed is HVS-2. The pain, and referred pain, and the burning in my feet and hands (among other areas) are so uncomfortable. I just want to scream. Intimacy is out of the question, which make me very sad. Is there any hope for me, or do I need to seek out a pain management doctor. I can’t believe my doctor has no answers. And yes, I’ve seen a top Urologist at Stanford back in 1999 and 2000. Any thing you can offer I will look into.

      Hello M,
      Vulvodynia is Latin for vulvar pain. If you have vulvar pain with no diagnosed cause, you have vulvodynia.What may be causing the vulvodynia may be a single condition, or may be multifactorial. I strongly suggest you visit these websites and consider making an appointment with one of these 2 brilliant colleagues who specialize in vulvodynia: Dr. Irwin Goldstein at http://www.sandiegosexualmedicine.com and Dr. Andrew Goldstein (no relation – opposite coast in Wash DC) at http://www.cvvd.org.
      Do not try to treat or diagnose yourself. Understand that, while most symptoms are diagnosible in 1-2 visits to the doctor’s office, pain syndromes are notorious for multiple visits, multiple trials of therapy (try-fail-try another – fail – try another – works a bit but not enough – keep that therapy and add another – see how that goes…) before a diagnosis and successful therapeutic regimen are formulated.

      Dr R

  2. Anonymous

    Hello Doctor,
    I am a 48 year old, one vaginal delivery with stress incontinence since. Recently had difficulty with tampon insertion during period….went to PCP and she said I have a cystocele and prolapse of uterus. I am so stressed about it. I am extremely active and lift weights and kickbox..do a lot of cardio with jumping. Now feels like I have a tampon in when I work out after. I have three fibroids…one in fundus meas. 5cm one central meas. 4.8cm and one at lower margin 2.8cm. I am pertrified of mesh support. What do you as a woman who understands uterine preservation emotionally for a woman think about myomectomy with ligament suspension shortening and pessary when exercising and tabel invertion therapy????? Curious as to what you think.

    Hello Susan,
    You bring many important issues to the table. Your fibroids don’t sound big enough to be an issue here, but the necessity of myomectomy or other fibroid specific therapy can only be determined with a live consultation and recent imaging. Assuming your fibroids are present but of no clinical relevance at present, you may not even need surgery. With mild prolapse, pessary use and Kegel exercise may be all you need to hold the prolapse at bay while you continue to kickbox and live a full and active life. I am very strongly biased toward uterine resuspension for women with prolapse, unless there is a very good reason, aside from the prolapse, to consider concomitant hysterectomy, and completely understand and validate your emotional attachment to your uterus. I also understand your reticence regarding mesh – all graft materials must be carefully considered, and there is a growing concern regarding plastic/permanent mesh support grafting for prolapse repair. There is no data on table inversion therapy for prolapse, but it certainly won’t make anything worse. Or as I say in my book, parachute jumping, no, bungie jumping, yes. If you can travel to NYC, you can ask to speak to my patient advocate, Judy, about scheduling a consultation. Or you may find my book on pelvic organ prolapse and vaginal rejuvenation helpful – exercises, pessaries, graft materials and all the current uterine resuspension techniques are described and illustrated – see http://www.plumbingandrenovations.com. For a specialist in your area, see http://www.augs.org.
    All the best!
    Dr. R

  3. Anonymous

    Hi Dr!
    I had a baby and since then I have problem, to urinate and so much pain that I can not have sex at all.

    I was wondering if you take patient from Québec.

    Hello Quebec,
    While I do take care of many patients from outside the States, I believe you will find your answers readily available close to home. Whether your symptoms are due to the common, transient thinning of vaginal skin in breastfeeding mothers or due to other childbirth factors, I am certain your obstetrician or midwife can help you without leaving home. If you’d like a second opinion, please do call my office, where my staff can help you arrange lodging in New York City.
    Best Regards,
    Dr. R

  4. Curious in Orange County

    I recently read your book, “plumbing and renovations” and appreciated the way you talked about topics that are typically viewed as ‘taboo’ in a conversational and optimistic way. My question is: how do you know if you are experiencing uterine prolapse, as opposed to vaginal prolapse? And which one is a more serious condition?

    Hello Orange County,

    You ask an excellent question. Most commonly, vaginal and uterine prolapse occur together, because pelvic support of the uterus and vaginal walls are interdependent and vulnerable to the same prolapse-inducing forces. Neither would be “more serious” than the other, and each can occur to variable degrees, as, having read the book, you are likely aware. For women with prolapse, sometimes the different areas of prolapse alternate “taking the lead”, making things even more confusing for the woman with the condition. A careful examination in various positions (lying flat, standing and seated) with a prolapse specialist will give you all the answers. Thank you for your commentary!
    Best REgards,
    Dr. R

  5. Anonymous

    names locations doctors John Hopkins Baltimore &Florida Keys 33043 uterine resuspension NO HYSTERECTOMY YOUR PROCEDURE
    uterosacral vaginal hysteropexy
    THANK YOU
    Hello S,
    My specific procedure is available through me or a few colleagues I have trained, all here in New York. The good news, however, is that there are several techniques of uterine resuspension, and if you cannot come to New York (we take care of patients from all over, and have arrangements with several NYC hotels for surgical patients) then I recommend looking for specialists geographically close to you at http://www.augs.org, calling the offices and asking if the doctor advocates for and is experienced in uterine resuspension by another technique. For more information that is travel-free, you may want to peruse my book on prolapse and vaginal rejuvenation at http://www.plumbingandrenovations.com. All the various techniques areillustrated and explained in great detail in the book!

    Hello Shep,
    My specific procedure is available through me and a few colleagues I have trained, all here in New York. The good news, however, is that there are several techniques of uterine resuspension, and if you cannot come to New York (we take care of patients from all over, and have arrangements with several NYC hotels for surgical patients) then I recommend looking for specialists geographically close to you at http://www.augs.org, calling the offices and asking if the doctor advocates for and is experienced in uterine resuspension by another technique. For more information that is travel-free, you may want to peruse my book on prolapse and vaginal rejuvenation at http://www.plumbingandrenovations.com. All the various techniques areillustrated and explained in great detail in the book!
    Best Regards,
    Dr. R

  6. Anonymous

    Hi. I’m really scared and worried. I had sex a week ago and don’t really remember it due to an alcohol blackout (which is horrible in and of itself), but apparently it was for an extended period of time so I think I was pretty dry for the duration. I thought the first couple of days that I had a vaginal infection due to a lot of irritation and pain when urinating. I was constantly searching on the internet for an answer. (I couldn’t get in for a doctor’s appointment until this coming week – on 10/26.) Last Wednesday though, I noticed when I felt into my vaginal area, that it feels as though my vaginal walls have collapsed and it’s near my vaginal opening. I’m almost positive it’s a pelvic organ prolapse, but I haven’t read anywhere that it can be caused due to intercourse. Everything seems to mention childbirth and age being the causes. It must be possible through intercourse too because I think it’s happened to me. I’m horrified at how this will affect my life — quality of life, having kids, having sex. I’m only 36 years old and have not had children yet. Also I haven’t had very many partners and the last time I had sex before this was two years ago. If you would please respond back with any insight and advice, I would really appreciate it. Thanks.

    Hello Ms. M,
    By now you likely have your answer, as I was out of the country with little online access and could not review or respond to comments. Now, prolapse is definitely much more common in women who have given birth, but can also occur in young, fit healthy women who have never been pregnant. Sex is not a known cause of prolapse – if you DO have prolapse, likely it was happening to you gradually with the sex/irritation/self-palpation of prolapse a coincidence. My youngest “never pregnant” patient with prolapse was a 31 year old, very fit, dancer, yoga practitioner who came in with severe enterocele and uterine prolapse. It can happen to anyone is the point, even if you are thin, young, fit and never pregnant. If you do have prolapse, it needs pessary support to keep it from getting worse, or surgical repair done carefully to resuspend the prolapsed parts without using any permanent graft materials that might complicate a pregnancy. Keep me posted – and for more information, you may want to peruse my book on prolapse and vaginal rejuvenation – see http://www.plumbingandrenovations.com.

    Hello Mae,
    By now you likely have your answer, as I was out of the country with little online access and could not review or respond to comments. Now, prolapse is definitely much more common in women who have given birth, but can also occur in young, fit healthy women who have never been pregnant. Sex is not a known cause of prolapse – if you DO have prolapse, likely it was happening to you gradually with the sex/irritation/self-palpation of prolapse a coincidence. My youngest “never pregnant” patient with prolapse was a 31 year old, very fit, dancer, yoga practitioner who came in with severe enterocele and uterine prolapse. It can happen to anyone is the point, even if you are thin, young, fit and never pregnant. If you do have prolapse, it needs pessary support to keep it from getting worse, or surgical repair done carefully to resuspend the prolapsed parts without using any permanent graft materials that might complicate a pregnancy. Keep me posted – and for more information, you may want to peruse my book on prolapse and vaginal rejuvenation – see http://www.plumbingandrenovations.com.
    Best Regards,
    Dr. R

  7. Anonymous

    Hello! Thank you for a wonderful website!
    Are there any surgeons trained to do the Uterosacral Vaginal Hysteropexy
 proceedure in Asheville, North Carolina?
    Hello Ms. S,
    My specific uterine resuspension technique is known to a few colleagues in the specialty, thus far all in and around New York. You may be able to find a specialist skilled at an alternative uterine resuspension procedure, however, by going to http://www.augs.org find a physician page and asking the office staff whether uterine resuspension is something specialists close to home can do for you. Or come on up to New York – I take care of patients from all over, and for out of town patients we have arrangements with several hotels. If you want to learn more about the alternatives, you may also find my book a helpful and portable resource – see http://www.plumbingandrenovations.com. I am pleased that you are better informed about your prolapse options!
    Best Regards.
    Dr. R

  8. Anonymous

    My period is on it’s 3rd day. And a moment ago when I went to pee. I wiped myself and felt something somewhat hanging out. So I took my finger and pushed it back in. And then I relized it is my uterus. And this would explain why for the past 11 months. I was not able to empty my bladder fully. I have no pain, and my periods are normal. But, it makes so much sense now. And I did some research saw that they can go back in and re-attach it. So to tell you the truth. I am not that worried anymore. Along with I do have a 15 year old young man. And I am 34 years old & still single! So I am nervous but, not scared anymore. So what do you think?
    Hello,
    I think you are an excellent diagnostician, and an excellent candidate for uterine resuspension along with whatever concurrent vaginal prolapse issues may also be present, such as cystocele, rectocele, perineocele, and laxity, if indeed a physical exam proves you right. You also have the option to use a pessary, which would allow you to avoid surgery until you are completed with childbearing, as pregnancy will increased the possibility of recurrent prolapse should you choose prolapse surgery, then proceed to have another baby.
    You are correct not to be afraid. It’s a connective tissue problem that can happen to any woman, even young women who have never been pregnant, and it can be managed to suit your lifestyle and personal goals. For a detailed explanation of prolapse, incontinence, pessaries and reconstructive surgery options including various methods of uterine resuspension, see http://www.plumbingandrenovations.com.
    Keep me posted. Thank you for sharing your story – it is bound to help someone else with prolapse feel less isolated and fearful.
    Best Regards,
    Dr. R

    1. admin

      I think you are very likely correct, and that your gynecologist can confirm this for you. Make the appointment soon. If the prolapse is diagnosed and is the source of voiding difficulty, you may be advised to consider pessary support or reconstructive surgery. Uterine prolapse surgery may be done without hysterectomy, using a procedure called uterine resuspension, aka hysteropexy. For more on this subject, see http://www.plumbingandrenovations.com, my book on prolapse, incontinence, and vaginal rejuvenation. Please don’t wait – make the appointment soon.

  9. Anonymous

    I am a 57 yo female with chronic health issues. My clitoris has shrunk to almost nothing and I noticed that when urinating It comes from inside my vagina. I can see where the urine is coming from. Can you tell me what has happened to cause this problem. Possible prolapse of the vaginal wall? I do not have any symptoms other than a vague feeling of fullness in my vagina. Any comments would be greatly appreciated. I do have an appt with gyn coming up on the 1st of Dec. Thanks

    Hello,
    Explain your symptoms to your gynecologist exactly as you did here, and ask about thinning and shrinking of the vaginal and vulvar skin and structures due to estrogen deprivation. This condition is called atrophy, and is common after menopause, causing many of the symptoms you describe here. I agree, your symptoms do not sound like prolapse, however you can ask your gynecologist to double check for prolapse just to be sure.
    Best Regards,
    Dr R

  10. Anonymous

    Yes I am a physically active healthy senior !
    Yes I do have four adult children!
    Yes I do wear an E-ring.
    Yes I was having a wonderful sexually active relationship.
    But now I have urethral prolapse and feel as if I cannot cope. Is there anyone willing to respond to my problem? Here at UCSF the idea that I would wish to continue feeling like a normal woman at my advanced age is not considered valid. yes I would travel for more care.
    Hello AF,
    I hear you! Regardless of age, no woman should suffer uneccessarily with pelvic floor disorders. And you need not travel – UCSF has a fantastic urogynecology team – please contact the department of gynecology to schedule a urogynecology appointment. Urethral prolapse is treatable and you need not travel far.

    Hello Aurelia Fort,
    I hear you! Regardless of age, no woman should suffer uneccessarily with pelvic floor disorders. And you need not travel – UCSF has a fantastic urogynecology team – please contact the department of gynecology to schedule a urogynecology appointment. Urethral prolapse is treatable and you need not travel far.
    Best Regards,
    Dr. R

  11. admin

    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 severa possible causes. You are best served by seeing your gynecologist or 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

  12. Anonymous

    hi its holly again sorry but i pressed enter by mistake. The pain is in the exact spot of my episiotomy(the five oclock hour on the vaginal entrance ) anyways my ob-gyn has tried cortisone creams as well as a hormonal cream and feels at a loss hes considering doing surgery to cut out that spot and resew it although isnt certain it will help. He’s baffled by the fact that there is no scar tissue or anything visible but is certain that there is some trigger point there. Is this something you deal with in your practice or is there someone you might know of that might im from the tri state area also i had come across something called a fentons procedure is that related to my issue thank you very much holly

    Hello Holly,
    It can be very difficult to figure out exactly what is causing this kind of vaginal pain when there is no evidence of scarring in the area. You may want to see a vulvar pain specialist, and I recommend http://www.cvvd.org for this condition. It is something that I see in my practice as well. I believe your doctor’s reticence to rush in and operate is wise, as the balance between relieving the pain and inducing more pain is clinically challenging even in the most experienced hands.
    Best Regards,
    Dr. Romanzi

  13. Anonymous

    Dr. Romanzi, I had a partial hysterectomy (only uterus removed) in 1999 because of Fibroid Tumors, there were so many of them the doctor lost count. My problem is now my bladder is weak and I have constipation. I went to a doctor recently and he told me about vaginal prolaspe because he could see it when he examined me. I was told I did not have to have any more pap smears because of the partial hysterectomy. My doctor says the ligaments from the removal of my uterus may be attached to my intestine cause my constipation. I am so miserable, I lucky if I have two bowel movements in a week, and when I do they are so hard and very little is defecated. He said I could have surgery to remedy all this, oh yes, I initially went to him because I have a large cyst on my left ovary that is now causing discomfort. He said the size is the size of a golf ball, it was 7 it is now 4, the cyst was found September of 09. Please advise and thank you.

    Hello Ms. C,
    Your prolapse, constipation, bladder control problems, ovarian cyst and pain are certainly a complex mix of problems. I suggest that you work carefully with your doctor, so that you understand what is contributing to these symptoms and how surgery may help you. It is often helpful to see a constipation specialist or a general gastroenterologist, so that diet and medications may be tried for the constipation symptoms even before going to the operating room for the ovarian cyst and prolapse. You may also benefit from non-surgical therapies for the bladder control problems, and these therapies are sometimes helpful even before prolapse surgery.
    Best Regards,
    Dr. Romanzi

  14. Anonymous

    Desperate to see another MD after two failed surgeries in less than 3 yrs. First had complete hysterectomy, sling proedure w rectocele repair. Second was sacral colpopexy using synthetic mesh. Saw same urogynocologist this wk who wants me to have anal sonogram defecography, standing pelvic mri. Would you consider seeing me? Otherwise healthy, trim, married. What are other options? This current Dr says pessary is temp solution. Please advise-thanks so much.
    Hello Ms. Lucente,
    You situation is most difficult. All reconstructive surgeries are prone to complications, like recurrence, or persistent dysfunction in the involved body parts even after everything is put back into place, and I am sorry this is happening to you. I can certainly help you if you want to contact the office to schedule an appointment. Please fax or email your operation reports, imaging, and other (cystoscopy, urodynamics, defecography, the MRI if you get it done…) in advance of the visit for my review. Or you may go to http://www.augs.org to find another urogynecologist in your area. If symptoms are primarily colon and/or rectum, you may also benefit from a consultation with a colorectal surgeon. My office number is 212.935.4343. Best Regards,
    Dr. Romanzi

  15. Anonymous

    My mother is 77 years old and her uterus is almost hanging out. It is protruding so much that you can see it. What do we need to do ?
    Hello Ms. Jones,
    The formal name for your mother’s condition is uterine prolapse. Prolapse may be managed without surgery using a pessary. Most gynecologists and gyn nurse practitioners (and a few midwives!) fit pessaries, so you might start with her gynecologist of record. Or you can use http://www.augs.org to find a prolapse specialist in your area to fit a pessary that her gynecologist can then manage for her. If pessaries don’t work, reconstructive surgery may be considered. I hope this helps – you may use my book on prolapse as a guide – http://www.plumbingandrenovations.com. While it is frightening, please keep in mind it is not life threatening and it can be managed comfortably almost all of the time.
    Best Regards,
    Dr. Romanzi

  16. Anonymous

    Saw you on Dr. Oz yesterday. I have bladder prolapse, 64 y.o. female. Rx given for Vagi-fem to help irritation in perianal area (original complaint). I use baby oil for sexual activity so have no pain during intercourse.Planning to have surgery in August to lift bladder. Will be taking Vagi-fem now help revive my interior so that the surgery will be more effective. Does that make sense? I will be using topical Vitamin E for external irritation.

    Hello,
    Estrogen applied topically to wounds has been shown to improve wound healing, so using Vagifem before your surgery is a good idea. The use of any oil for lubrication must be approached skeptically, as the vagina is not designed to be “oily” and chronic use of oils can throw things out of balance, resulting in chemical or bacterial vaginitis after prolonged use. Also, Vitamin E can thin the blood and increase bruising and bleeding, making it even more difficult to agree with your plan to use Vitamin E oil after the surgery. For more information on preparing for surgery, supplements to augment wound healing, and what to expect during recovery, you may find my book a helpful resource http://www.plumbingandrenovations.com
    Best Regards,
    Dr. R

  17. Anonymous

    On Dr OZ show, you talked about hormonal vaginal cream and suppository for painful sex during menopause. What are the names of the cream and suppository ?
    Thank you .

    Hello J-A,
    The vaginal estrogen cream may be compounded by your local pharmacist, or ordered by your physician. The one I most frequently use is called Estrace. The suppository likewise may be compounded by your pharmacist, or your doctor can prescribe VagiFem – this was the one I used on Dr. Oz show. The estrogen ring we talked about on the show is called Estring. You gynecologist can help figure out which one of these options is best for you. They all deliver plant-derived Estradiol, the major estrogen coming out of the pre-menopausal ovary. Keep me posted!
    Best,

    Dr. Romanzi

  18. Anonymous

    I’m a healthy 52 y/o with 8 months of bothersome clitoral hypersensitivity (new) and a clitoral soreness with intercourse . The onset of symptoms was temporally related to the cessation of my periods, as well as a trial with vaginal weights, leading to some soreness and a vague feeling that “something shifted” anteriorly. My clitoral exam is normal, but I have had a trial of topical estrogen with no improvement.

    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

  19. Anonymous

    I am 79 years old, live in the Chicago area. I have a urinary prolapse. Can you recommend a good urogynecologist for me to see
    Hello Chicago,
    You will find a comprehensive list of urogynecologists in your area by visiting http://www.augs.org and using the “find a physician” feature. You may also use my book on prolapse as a reference http://www.plumbingandrenovations.com for a description of all the surgical and non-surgical options, including how to figure out if a hysterectomy is smart for you, or if you would be just as well off with a uterine resuspension, should you choose reconstructive surgery.
    Best Regards,
    Dr. R

  20. Anonymous

    Dr. R, I had a partial Hysterectomy in 2002. I had been having pain on my right side. Find out that it is a cyst. The pain is very intense and is getting worsre. I want my doctor to finish the hysterectomy this time instead of just removing the cyst because he said it could come back. I am 43yrs old. Do you think this is wise to just go ahead and have the full hysterectomy this time? And also do you think that I would go straight into menopause at this age. I don’t want them to keep going in and out.

    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

  21. Anonymous

    Dear Dr. Romanzi,
    (I bet you don’t get too many men writing you for help!) My dearest sweetheart suffers from a prolapsed uterus/bladder and is considering having a hysterectomy at the advice of her gyno. Being a former pre-med student and having seen what my mother and sister-in-law went through in their hysterectomies (cancer related…) I keep trying to convince her that this a radical surgical approach for a problem that demands far less. She has had 2 children, is 52 years old and is physically active. However, “the bulge” is causing her discomfort in her exercising and she is talking more and more of the hysterectomy. I am ordering your book tonight, but in the meantime had some questions… 1) Since she is past her childbearing years, is reconstructive surgery appropriate, or could a pessary work? 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, and 3) Is the reconstructive approach treated as “cosmetic” surgery from an insurance perspective, or is it usually a covered procedure. If the former, what does it typically cost? She is a women of limited means and this obviously comes into the equation. Thanks so much for your help. D

    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

  22. Anonymous

    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 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

  23. Anonymous

    Dr. Romanzi, 19 years ago I gave birth to my daughter, and while she was being delivered I was torn from my vaginal opening to my anus. The Dr. didn’t repair the torn skin correctly, and I am very self conscious about this. I also have a very hard time wipeing my BM all the way. Is their anything that can be done for this?

    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

  24. Anonymous

    Hi,
    Can you tell me if you have helped any patients suffering from OAB/IC with Ulcerative Colitis? Every medication I take for OAB is giving me a colitis flare up and I am desperate for help. I cannot take Elmiron b/c of the Colitis also. Can you offer any advice? Thanks, L

    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

  25. Lori

    Hi Dr. Romanzi,
    I have been on Enablix 7.5 for almost 3 weeks now. It had taken all my bladder symptoms away. Now today they are creeping up again. Can a medication just stop working like that? I am afraid to go up to the 15mg for bad side effects.
    Thanks,
    Lori
    Hello Lori,
    Bladder infection, dietary irritants and stress can all alter the efficacy of medication. Whenever overactive bladder therapy starts, frequent visits to alter and change and double check bladder response and dysfunction are not at all uncommon. In the event you need the higher dose, it is unlikely you will have bothersome side effects if you did not have them at the lower dose. Some people just need the higher dose, and won’t sustain efficacy at the lower. By now, you’re likely due to return to the doctor who prescribed the medication, and all these issues will be considered.
    Best Regards,
    Dr R

  26. Distressed

    Dear Dr. I was reading an article in the glamour magazine and came across your name. I’m 38 years old. I’ve two kids (5, 3) and married for 6 years. During these years, I had orgasm only one time with my husband. I have other problems going on in life too. But part of the reason is that my husband can tell that I don’t have orgasms. I never had sex before so when I got married at the age of 30, you could tell I was lost. My marriage is in the verge of breaking up. I used machine (rabbit) and it works. I just don’t understand why it won’t work with my husband. He said every girl he had sex before had orgasms, except for me. I do know that he doesn’t foreplay, all he wants is sex. And I don’t enjoy it like that. He knows that women like cuddling but still he won’t do that to me. What can I do? How can I improve myself?

    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

  27. Anonymous

    I am scheduled in two weeks for cystocele and rectocele repairs and I am getting very apprehensive about these surgeries..about 3 months ago I got very constipated due to the rectocele..this caused 2 anal fissures and for my hemorrhoids to get worse..i went to an awesome colorectal doctor who did the lateral sphincterotomy surgery and the hemorrhoid stapling..i was also impacted and have no idea how that happened because i was having bowel movements every day…the colorectal doctor took care of the fissures and the hemorrhoids and put me on a high fiber diet..i am doing great now as far as that’s concerned..i still have the rectocele but it’s not causing any problems right now..i have an extreme fear of having the surgery and having problems start again with my bowels..would vagifem and kegel exercises work better for me?.sorry this is such a long comment.

    Hello W:
    The best situation for prolapse surgery, be it rectocele surgery, cystocele (dropped bladder) surgery, uterine prolapse surgery, or combination prolapse surgery, is when the benefits outweigh the risks. One of the advantages of considering prolapse surgery is that it is rarely if ever an emergency and usually not mandatory. So you have plenty of time to discuss the pros and cons with your surgeon, to get second, third, and fourth opinions, and to read more about your condition and treatment options, even if that means postponing the scheduled operation. I urge you to learn more about your options and the risks and benefits of each treatment option, surgical and non-surgical, before you undergo surgery that you are not sure you need. To find specialists in your area, visit http://www.augs.org find a physician page under patient resources. You can search by city or zipcode.

  28. Ms. R

    I had my one beautiful son at the age of 39 and experienced a serious uterine prolapse in my early 50’s. I had a hysterectomy, and within a couple years of that, the muscles holding up my bowel system and bladder weakened and that support was prolapsing (sigh). So I again had surgery to sew them both back up. After that point I had stress incontinence and then went back for urethral sling surgery. It was apparently too tight a sling, as urethral tissue was coming out of my urethral opening (a prolapse there!). I then went back and had this darned sling removed. Needless to say, my opinion about surgery as being the end-all answer for anything has suffered a serious blow. :) My concern, though, is that even with the sling out, my stress incontinence has returned and the urethral tissue is still exposed and often a crimson red. Could it be the incontinence is due to the inflammation? What else could be causing this inflammation? I’m just starting today to apply topical cortisone cream. I am not particularly trusting of my kind urogynocologist at this juncture and am thus writing you for some insight.

    Hello Ms. R,
    I can’t diagnose you over the internet, but one thing that comes to mind from your description is estrogen deprivation of the urogenital skin. This happens after menopause due to declining estrogen levels, and often responds to tiny doses of vaginal estrogen cream or low dose estrogen suppositories. Talk to your primary care gynecologist and urogynecologist about whether they believe low dose vaginal estrogen therapy would help you.
    Keep me posted!

    Dr. R

  29. R

    Hello Dr. R.
    I am a 43 year old mother who had a baby at 36 years old. After the horrible labor due to the attending doctor (not my OB), inducing my labor with insurmountable amounts of pitocin and me not remembering much during the actual delivery except hearing push, I was stitched so tight I could barely walk after delivery. Moving forward, I noticed years later after a BM, there would be a stain (approx. 3/8 inch) on my panty liner. Fast forward to July 2011, I decided to have the fistula surgery with a colorectal Dr. I knew it failed when the issue returned with a vengeance. I am presently losing my mind. I did return to my Dr. and she recommended “uro” Dr’s but the research on their experience in that area is nill to none. I would like your feedback on how I can reclaim my adult life without this issue. It is horrible and if anyone has a comment, please reply.
    I thank you for your time.

    I can definitely identify with the other responders with a similar issue…

    Re: Ask Dr. R: 32 year old new mother with perineal damage, fecal incontinence and sexual pain and anonymous.

    Hello “R” –
    Obstetric fistula is not infrequently difficult to diagnose and prone to recurrence when repaired. I strongly suggest you see both colorectal surgeons and urogynecologic specialists, either in the NYC area or elsewhere, such as Cleveland or Mayo Clinics, at your preference and travel capacities. See http://www.fascrs.org/patients/find_surgeon/ for colorectal surgeons and http://www.voicesforpfd.org/p/cm/ld/fid=81 for urogynecologic specialists. Your story, though not as common as it once was in the United States, reminds all of us of the real risks of pregnancy and childbirth. Before the advent of modern obstetric care, fistula was an all too common result of childbirth, and in many poor countries, it still occurs with frightful frequency due to minimal access to care. Unfortunately, the incidence of obstetric fistula is not down to zero, even in wealthy nations with the “best of care”. You are one of the unfortunate few who share this in common with a small group of North American women and a much a larger group of women living in remote villages the world-round. I am confident that you will benefit from another round of careful consultations. Living with genital fistula puts an enormous strain on not only the woman’s life, but the lives interwoven with her own, as you well know by now! It is quite possible that you may restore your anatomy and normal function with the proper mix of reconstructive surgery, pelvic floor physical therapy and short-course pain management. Keep us posted!

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