Ask the Doctor at Saint John’s: New Incontinence Treatment Holds Up

Q: What’s the main cause of prolapse and incontinence, and what
treatment options are there?

By Amy E. Rosenman, M.D., Staff Physician at Saint John’s Health Center and Urogynecologist in private practice in Santa Monica

I’m trained as a gynecologist, and my particular interest is midlife urogynecological problems concerning prolapse of the pelvic organs. These conditions involve dropping of the uterus and bladder, and relate to incontinence and urinary loss.

Prolapse and incontinence crucially affect a woman’s quality of life. They can restrict the normal activities that make up one’s day-to-day existence.
The pelvic floor is a hammock of muscles the womb and uterus sit on. This hammock surrounds the vagina and rectum, and keeps a woman’s organs in place. When the hammock is properly situated and all nerves are operating correctly, a woman can run, sneeze, and laugh with complete control. All of her voiding faculties stay in place.

One of the main ways a woman’s pelvic floor can be damaged is through childbirth. The stretching that results from pressure on specific organs can eventually lead to less support for them. If the distortion caused by the baby’s head passing through occurs for too long, vascular and nerve injury can result. If the process occurs too fast, muscle tears can result.

There’s been an evolution of thought as to the best way to deal with this problem. When I first started practicing, the idea was to avoid cesarean delivery at all costs. It was viewed as expensive and painful. We eventually determined, however, that cesarean delivery was sometimes being rejected out of hand when it should have been the method of choice. Cesarean delivery, properly used when the
situation calls for it, can help prevent prolapse and incontinence later.

In prolapse, the uterus and cervix slide. If there’s relatively insignificant repositioning, the woman may feel nothing. It’s not a problem that needs fixing. A lower bulge from greater sliding, however, creates a “bulky” sensation in the patient. Corrective action may be called for.

What can be done? Before the uterus has completely fallen, Kegel exercises can sometimes strengthen the pelvic floor. But many women with prolapse have significant nerve damage. This negates the benefit of muscular strengthening.

Fortunately, we are able to perform a one to three hour reconstructive operation that usually takes care of everything in one fell swoop. It’s done vaginally, and the patient’s up and around in two weeks.

When incontinence first occurs after 50, the cause is usually not childbirth but neurological. The good news is that a variety of options including medications, biofeedback and other treatments can often be effective.

Dr. Rosenman is Chair of the Credentials Committee at Saint John’s Health Center. A gynecologist in private practice in Santa Monica, she is president of the American Urogynecologic Society. For more information about Dr. Rosenman or other Saint John’s services, please call (310) 829-8990 or visit the website at www.stjohns.org. For a physician referral or a second opinion, please call 1-888-ASK-SJHC.

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