Courtesy – Regen lab

What is PRP?

Platelet rich plasma (PRP) is blood plasma with concentrated platelets (the body’s repairmen for damaged tissue). The concentrated platelets found in PRP contain growth factors that are vital to initiate and accelerate tissue repair and regeneration. These bioactive proteins initiate connective tissue healing and repair, promote development of new blood vessels, and stimulate the healing process.

How is PRP used in medicine?

PRP has been used extensively in dermatology, orthopaedics, sports medicine, joint repair, hair growth, wound healing, burn healing, dentistry and surgery for decades in this and other countries.  PRP comes from your own body.  Your own blood is drawn and sterilely processed in a highly specialized TGA approved collection kit and centrifuge to concentrate the platelets 6 times their natural values in pure plasma without any red cells.  This reaches the most optimal treatment value of 1.5 million platelets per unit.

What are the uses of PRP in women’s Health?

Lichen Sclerosis (LS) – This is an autoimmune condition affecting the labia, which makes the area have thick, white tissue, especially around the clitoris, causing pain, burning and scarring.  It is usually treated fairly well with chronic use of steroid ointments frequently applied directly to the abnormal tissue.  There is no specific cause, but it is well known to be associated with hypothyroid, low systemic vitamin D and high gluten and other inflammatory foods in the diet.  Wide area local injections with larger volumes of non-activated PRP have shown amazing success at treating this condition.  LS treatment requires a series of injections for best results, so please inquire about our specific LS package plan.

Lichen Planus (LP) – This is another autoimmune condition with no specific cause. Very often women have hot, dry, red streaks on the inner labia as well as a similar lacey appearance to the mucous membranes of the mouth.  It is also treated with chronic steroids or PRP.

Vulvodynia – This is a non-specific term meaning any chronic pain in the outer vaginal and labia area.  Once we determine the cause, PRP may be helpful in symptom resolution. 

Stress Urinary Leakage – Leaking urine with a laugh, cough, sneeze, run, jump or move.  Due to laxity of the pelvic floor muscle support at the bladder neck, one is unable to hold in the urine.  Also helped by vaginal estrogen and Pelvic Floor Physical Therapy.

Pain with Sex – This has many different causes, some of which can be improved with PRP.  Depending on the underlying reason, oestrogens, dilators, lubricants and good foreplay can be of great help. 

Vaginal Dryness – This always occurs in menopause, sometimes with low dose birth control pills, often with breast feeding and after treatment for breast cancer.  PRP might help lubrication, but it is not the main expected outcome. 

Female sexual Dysfunction

G-shot treatment

PRP use in sexual dysfunction is considered to be a revolutionary new nonsurgical outpatient treatment that helps improve both urinary incontinence and sexual dysfunction through using a woman’s own growth factors. The PRP is injected into specific areas of the vagina with the aid of local anaesthetic cream. This modality of treatment is also called the “O-shot.” PRP immediately activates tissue regeneration, and the enhancement in sexual response is dramatic. The desired response includes improved arousal, stronger orgasm, decreased pain during sex, and increased natural lubrication

What does PRP treatment involve?

PRP treatment usually takes around 40 minutes in total. One or two small vials of your blood are taken (8-16ml approx.) and placed in a specialised centrifuge that separates the plasma (containing the platelets) from the red cells. The plasma is then collected from the tube leaving the red cells behind. The plasma is injected into the target area(s) in small amounts using a thin needle and/or applied to the surface of the target area(s). There are no foreign materials injected with the PRP, so only the patient’s own cells (‘autologous’) are used.

Generally, the whole process involves minimal discomfort. However, some patients will find some areas of the vaginal more sensitive than other parts during injecting. Any swelling or bruising after the procedure will usually disappear overnight. For skin treatments (i.e. face, neck, vulva), any bruising disappears after a few days.

Patient preparation for PRP treatment

5-7 days before treatment:

  • Stop taking supplements that increase bleeding/bruising: green tea, fish oils, Evening Primrose oil, garlic, Echinacea, St John’s wort, Vitamin E, Non-steroidal drugs, aspirin (only after discussing with your doctor).

  • Drink plenty of water before and after your treatment.

Contraindications to treatment with PRP include:

Blood disorders/Platelet abnormalities/Anticoagulation therapy (if you have not stopped)/Steroid therapy.

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Hormone therapy was once routinely used to treat menopausal symptoms and protect long-term health. Then large clinical trials showed health risks. What does this mean to you?

Hormone replacement therapy — medications containing female hormones to replace the ones the body no longer makes after menopause — used to be a standard treatment for women with hot flashes and other menopause symptoms. Hormone therapy (as it’s now called) was also thought to have the long-term benefits of preventing heart disease and possibly dementia.

Use of hormone therapy changed abruptly when a large clinical trial found that the treatment actually posed more health risks than benefits for one type of hormone therapy, particularly when given to older postmenopausal women. As the concern about health hazards attributed to hormone therapy grew, doctors became less likely to prescribe it.

Hormone therapy is no longer recommended for disease prevention, such as heart disease or memory loss. However, further review of clinical trials and new evidence show that hormone therapy may be a good choice for certain women, depending on their risk factors.

What are the benefits of hormone therapy?

The benefits of hormone therapy depend, in part, on whether you take systemic hormone therapy or low-dose vaginal preparations of estrogen.

  • Systemic hormone therapy. Systemic estrogen — which comes in pill, skin patch, gel, cream or spray form — remains the most effective treatment for relief of troublesome menopausal hot flashes and night sweats. Estrogen can also ease vaginal symptoms of menopause, such as dryness, itching, burning and discomfort with intercourse.
  • Low-dose vaginal products. Low-dose vaginal preparations of estrogen — which come in cream, tablet or ring form — can effectively treat vaginal symptoms and some urinary symptoms, while minimizing absorption into the body. Low-dose vaginal preparations do not help with hot flashes, night sweats or protection against osteoporosis.

Long-term systemic hormone therapy for the prevention of postmenopausal conditions is no longer routinely recommended. But some data suggest that estrogen can decrease the risk of heart disease when taken early in postmenopausal years.

A recent, randomized, controlled clinical trial — the Kronos Early Estrogen Prevention Study (KEEPS) — explored estrogen use and heart disease in younger postmenopausal women. The study found no significant association between hormone therapy and heart disease.
For women who haven’t had their uterus removed, estrogen is typically prescribed along with progesterone or progestin (progesterone-like medication). This is because estrogen alone, when not balanced by progesterone, can stimulate growth of the lining of the uterus, increasing the risk of uterine cancer. Women who have had their uterus removed (hysterectomy) don’t need to take progestin.

What are the risks of hormone therapy?

In the largest clinical trial to date, a combination estrogen-progestin pill increased the risk of certain serious conditions, including:
Heart disease
Stroke
Blood clots
Breast cancer

A related clinical trial evaluating estrogen alone in women who previously had a hysterectomy found no increased risk of breast cancer or heart disease. The risks of stroke and blood clots were similar to the combination therapy.

Hormone therapy, particularly estrogen combined with a progestin, can make your breasts look more dense on mammograms, making breast cancer more difficult to detect. Also, especially when taken for more than 5 years, hormone therapy increases the risk of breast cancer, a finding confirmed in multiple studies of different hormone therapy combinations.

The risks of hormone therapy may vary depending on whether estrogen is given alone or with a progestin, and depending on your current age and age at menopause, the dose and type of estrogen, and other health risks such as your risks of heart and blood vessel (cardiovascular) disease, cancer risks and family medical history.

HRT and breast cancer – What is the current news?

Why is HRT linked to cancer?

Cancer growth is known to be stimulated by hormones so increasing levels could boost tumour growth. Some cancer drugs now work by targeting receptors on cancer cells to prevent hormones getting inside.

What is my risk of cancer if I take combined HRT?

The usual risk or cancer for a woman of menopausal age is around 14 in 1,000. The new study suggests that combined HRT raises that risk to 34 in 1,000.

Am I at risk if I take oestrogen only HRT?

There is no link between oestrogen only HRT and an increased risk of breast cancer. However, it is usually recommended for women who have already had a hysterectomy, as it can raise the risk of womb cancer.

What should I do if I am worried about taking combined HRT?

Many women will feel the benefits outweigh the risks, but women who are concerned should talk to their GP.

Who should consider hormone therapy?

Despite the health risks, systemic estrogen is still the most effective treatment for menopausal symptoms. The benefits of hormone therapy may outweigh the risks if you’re healthy and:

Experience moderate to severe hot flushes or other menopausal symptoms

Have lost bone mass and either can’t tolerate or aren’t benefitting from other treatments

Stopped having periods before age 40 (premature menopause) or lost normal function of your ovaries before age 40 (premature ovarian insufficiency)

Women who experience an early menopause, particularly those who had their ovaries removed and don’t take estrogen therapy until at least age 45, have a higher risk of:

Osteoporosis
Coronary heart disease
Earlier death
Parkinsonism (Parkinson’s-like symptoms)
Anxiety or depression

Early menopause typically lowers the risk of most types of breast cancer. For women who reach menopause prematurely, the protective benefits of hormone therapy usually outweigh the risks.

Your age, type of menopause and time since menopause play a significant role in the risks associated with hormone therapy. Talk with your doctor about your personal risks.

Who should avoid hormone therapy?

Women with current or a past history of breast cancer, ovarian cancer, endometrial cancer, blood clots to the legs or lungs, or stroke should usually not take hormone therapy. Women taking hormone therapy should not smoke.

Women who aren’t bothered by menopause symptoms and started menopause after age 45 do not need hormone therapy to stay healthy. Instead, talk to your doctor about strategies to reduce the risk of conditions such as osteoporosis and heart disease, which might include lifestyle changes and medications other than hormone therapy for long-term protection.

In general, it is not recommended for women over 60.

If you take hormone therapy, how can you reduce risk?

Talk to your doctor about these strategies:

Find the best product and delivery method for you. You can take estrogen in the form of a pill, patch, gel, vaginal cream, or slow-releasing suppository or ring that you place in your vagina. If you experience only vaginal symptoms related to menopause, estrogen in a low-dose vaginal cream, tablet or ring is usually a better choice than an oral pill or a skin patch.

Minimize the amount of medication you take. Use the lowest effective dose for the shortest amount of time needed to treat symptoms, unless you’re younger than age 45, in which case you need enough estrogen to provide protection against long-term health effects of estrogen deficiency. If you have lasting menopausal symptoms that significantly impair your quality of life, your doctor may recommend longer-term treatment.

Seek regular follow-up care. See your health care provider regularly to ensure that the benefits of hormone therapy continue to outweigh the risks, and for screenings such as mammograms and pelvic exams.

Make healthy lifestyle choices. Include physical activity and exercise in your daily routine, eat a healthy diet, maintain a healthy weight, don’t smoke, limit alcohol, manage stress, and manage chronic health conditions such as high cholesterol or high blood pressure.

If you haven’t had a hysterectomy and are using systemic estrogen therapy, you’ll also need a progestin. Your doctor can help you find the delivery method that offers the most benefits and convenience with the least risks and cost.

What can you do if you can’t take hormone therapy?

You may be able to manage menopausal hot flashes with healthy lifestyle approaches, such as keeping cool, limiting caffeinated beverages and alcohol, and by practicing paced relaxed breathing or other relaxation techniques. For vaginal concerns, such as vaginal dryness or painful intercourse, a vaginal moisturizer or lubricant may provide relief.

There are also alternative medicine approaches — such as tai chi, yoga and acupuncture — that you can try. Work with your doctor to find a healthy, effective approach that works for you.

The bottom line: Hormone therapy isn’t all good or all bad

To determine if hormone therapy is a good treatment option for you, talk to your doctor about your individual symptoms and health risks. Be sure to keep the conversation going throughout your menopausal years.

As researchers learn more about hormone therapy and other menopausal treatments, recommendations may change. If you continue to have bothersome menopausal symptoms, review treatment options with your doctor on a regular basis.

For further enquiries, please contact

Dr. A S Arun MD DNB CCST, FRCOG, FRANZCOG

Waikiki Specialist Centre
221 Wilmott Drive
Waikiki 6169
WA
Tel: 08 95500300
Fax: 08 95929830
Email: specialists@waikikiprivatehospital.com
Website: www.doctorarun.com.au

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A woman’s sexual desire naturally fluctuates over the years. Highs and lows commonly coincide with the beginning or end of a relationship or with major life changes, such as pregnancy, menopause or illness. Some antidepressants and anti-seizure medications also can cause low sex drive in women.
If you have a persistent or recurrent lack of interest in sex that causes your personal distress, you may have Hypoactive Sexual Desire Disorder (HSDD)— also referred to as female sexual interest/arousal disorder.
But you don’t have to meet this medical definition to seek help. If you are bothered by a low sex drive or decreased sexual desire, there are lifestyle changes and sex techniques that may put you in the mood more often. Some medications may offer promise as well.
If you want to have sex less often than your partner does, neither one of you is necessarily outside the norm for people at your stage in life — although your differences, also known as desire discrepancy, may cause distress.
Similarly, even if your sex drive is weaker than it once was, your relationship may be stronger than ever. Bottom line: There is no magic number to define low sex drive. It varies from woman to woman.
Some signs and symptoms that may indicate a low sex drive include a woman who:
Has no interest in any type of sexual activity, including self-stimulation Doesn’t have sexual fantasies or thoughts, or only seldom has them Is bothered by her lack of sexual activity or fantasies
A Silent Growing epidemic
The American Medical Association has estimated that several million US women suffer from what doctors often call Hypoactive Sexual Desire Disorder (HSDD).
However, currently there seems to be an HSDD bandwagon in North America, driven by doctors who think that nearly half the female population (43 per cent) lack sex drive. In order to be diagnosed with HSDD, women need to have low libido for at least six months and feel distressed about it.
But lack of sex drive alone isn’t a problem. While some women simply don’t want sex that often, low libido is often a temporary side effect of an external stressor, like a new baby or financial troubles.
And we’re not talking about postmenopausal women. These are women in their 20s, 30s, and 40s, who are otherwise healthy, happy, and in control of every area of their lives—except, suddenly, the bedroom.
When to see a doctor
If you’re bothered by your low desire for sex, talk to your doctor. The solution could be as simple as changing the type of antidepressant you take.
A woman’s desire for sex is based on a complex interaction of many components affecting intimacy, including physical well-being, emotional well-being, experiences, beliefs, lifestyle and current relationship. If you’re experiencing a problem in any of these areas, it can affect your sexual desire.
Physical causes
A wide range of illnesses, physical changes and medications can cause a low sex drive, including:
Sexual problems: If you experience pain during sex or an inability to orgasm, it can hamper your desire for sex.

Medical diseases: Numerous nonsexual diseases can also affect desire for sex, including arthritis, cancer, diabetes, high blood pressure, coronary artery disease and neurological diseases.

Medications: Many prescription medications — including some antidepressants and anti- seizure medications — are notorious libido killers.

Lifestyle habits: A glass of wine may make you feel amorous, but too much alcohol can spoil your sex drive; the same is true of street drugs. And smoking decreases blood flow, which may dampen arousal.

Surgery: Any surgery, especially one related to your breasts or your genital tract, can affect your body image, sexual function and desire for sex.
Fatigue: Exhaustion from caring for young children or aging parents can contribute to low sex drive. Fatigue from illness or surgery also can play a role in a low sex drive.

Hormone changes

Changes in your hormone levels may alter your desire for sex. This can occur during:

Menopause: Oestrogen levels drop during the transition to menopause. This can cause decreased interest in sex and dryer vaginal tissues, resulting in painful or uncomfortable sex. Although many women continue to have satisfying sex during menopause and beyond, some women experience a lagging libido during this hormonal change.

Pregnancy and breast-feeding.:Hormone changes during pregnancy, just after having a baby and during breast-feeding can put a damper on sexual desire. Of course, hormones aren’t the only factor affecting intimacy during these times. Fatigue, changes in body image, and the pressures of pregnancy or caring for a new baby can all contribute to changes in your sexual desire.

Psychological causes

Your problems don’t have to be physical or biological to be real. There are many psychological causes of low sex drive, including:

Mental health problems, such as anxiety or depression Stress, such as financial stress or work stress
Poor body image
Low self-esteem

History of physical or sexual abuse Previous negative sexual experiences

Relationship issues

For many women, emotional closeness is an essential prelude to sexual intimacy. So, problems in your relationship can be a major factor in low sex drive. Decreased interest in sex is often a result of ongoing issues, such as:

Lack of connection with your partner
Unresolved conflicts or fights
Poor communication of sexual needs and preferences Infidelity or breach of trust

Primary care doctors and gynaecologists often ask about sex and intimacy as part of a routine medical visit. Take this opportunity to be candid about your sexual concerns.

If your doctor doesn’t broach the subject, bring it up. You may feel embarrassed to talk about sex with your doctor, but this topic is perfectly appropriate. In fact, your sexual satisfaction is a vital part of your overall health and well-being.

What you can do

To prepare for this discussion with your doctor:

Take note of any sexual problems you’re experiencing, including when and how often you usually experience them.

Make a list of your key medical information, including any conditions for which you’re being treated, and the names of all medications, vitamins or supplements you’re taking.

Consider questions to ask your doctor and write them down. Bring along notepaper and a pen to jot down information as your doctor addresses your questions.

Questions your doctor may ask:

Your doctor will ask Screening questions based upon the tool –
Decreased Sexual Desire Screener (DSDS)
1. In the past, was your level of sexual desire or interest good and satisfying to you?
2. Has there been a decrease in your level of sexual desire or interest?
3. Are you bothered by your decreased level of sexual desire or interest?
4. Would you like your level of sexual desire or interest to increase?
5. Please circle all the factors that you feel may be contributing to your current decrease in sexual desire or interest:

A. An operation, depression, injuries, or other medical condition

B. Medications, drugs, or alcohol you are currently taking

C. Pregnancy, recent childbirth, menopausal symptoms

D. Other sexual issues you may be having (pain, decreased arousal or orgasm)

E. Your partner’s sexual problems

F. Dissatisfaction with your relationship or partner

G. Stress or fatigue

By definition, you may be diagnosed with hypoactive sexual desire disorder – if you frequently lack sexual thoughts or desire, and the absence of these feelings causes your personal distress. Whether you fit this medical diagnosis or not, your doctor can look for reasons that your sexual desire isn’t as high as you’d like and find ways to help.

In addition to asking you questions about your medical history, your doctor may also:
Perform a pelvic exam. During a pelvic exam, your doctor can check for signs of physical changes contributing to low sexual desire, such as thinning of your genital tissues, vaginal dryness or pain-triggering spots.

Recommend testing: Your doctor may order blood tests to check hormone levels and look for evidence of thyroid problems, diabetes, high cholesterol and liver disorders.
Refer you to a specialist. A specialist may be able to better evaluate emotional and relationship factors that can cause low sexual desire.

Most women benefit from a treatment approach aimed at the many causes behind this condition. Recommendations may include sex education, counselling and sometimes medication.

Counselling

Talking with a sex therapist or counsellor skilled in addressing sexual concerns can help with low sexual desire. Therapy often includes education about sexual response and techniques and recommendations for reading materials or couples’ exercises. Couples counselling that addresses relationship issues may also help increase feelings of intimacy and desire.

Medication review
Your specialist will want to evaluate the medications you’re already taking, to see if any of them tend to cause sexual side effects. For example, antidepressants such as paroxetine (Paxil, Pexeva) and fluoxetine (Prozac, Sarafem) may lower sex drive. Adding or switching to bupropion (Aplenzin, Wellbutrin) — a different type of antidepressant — usually improves sex drive.

Hormone therapy
Oestrogen delivered throughout your whole body (systemic) by pill, patch, spray or gel can have a positive effect on brain function and mood factors that affect sexual response. But systemic oestrogen therapy may have risks for certain women.

Smaller doses of oestrogen — in the form of a vaginal cream or a slow-releasing suppository or ring that you place in your vagina — can increase blood flow to the vagina and help improve desire without the risks associated with systemic oestrogen. In some cases, your doctor may prescribe a combination of oestrogen and progesterone.
Testosterone

Hormones are often suggested as a treatment for HSDD, particularly the male sex hormone testosterone.

Doctors have been trying out testosterone on women for more than 40 years, rarely with much benefit. Possible side-effects include hairiness, spots, a deep voice and enlargement of the clitoris. However, there is some clinical evidence to support the use of testosterone as a treatment for low sexual desire.

In 2007 a testosterone skin patch called Intrinsa became available in the UK and a modest number of women used it. But at the end of 2012, it was withdrawn by the manufacturers, apparently for commercial reasons.

However, there are currently several other testosterone preparations available, though it may be difficult to find a doctor who is willing to prescribe them for a woman.

Flibanserin (Addyi)

Originally developed as an antidepressant, Flibanserin (Addyi) is a prescription medication approved by the Food and Drug Administration as a treatment for low sexual desire in premenopausal women. However, this is not currently available in Australia.

A daily pill, Addyi may boost sex drive in women who experience low sexual desire and who find the experience distressing. Potentially serious side effects include low blood pressure, dizziness and fainting, particularly if the drug is mixed with alcohol. Experts recommend that you stop taking the drug if you don’t notice an improvement in your sex drive after eight weeks.

Healthy lifestyle changes can make a big difference in your desire for sex:
Exercise. Regular aerobic exercise and strength training can increase your stamina, improve your body image, elevate your mood and boost your libido.

Stress less. Finding a better way to cope with work stress, financial stress and daily hassles can enhance your sex drive.

Communicate with your partner. Couples who learn to communicate in an open, honest way usually maintain a stronger emotional connection, which can lead to better sex. Communicating about sex also is important. Talking about your likes and dislikes can set the stage for greater sexual intimacy.

Set aside time for intimacy. Scheduling sex into your calendar may seem contrived and boring. But making intimacy a priority can help put your sex drive back on track.

Add a little spice to your sex life. Try a different sexual position, a different time of day or a different location for sex. Ask your partner to spend more time on foreplay. If you and your partner are open to experimentation, sex toys and fantasy can help rekindle your sexual sizzle.

Ditch bad habits. Smoking, illegal drugs and excess alcohol can all dampen sexual desire. Ditching these bad habits may help rev up your sexual desire as well as improve your overall health.

Low sexual desire can be very difficult for you and your partner. It’s natural to feel frustrated or sad if you aren’t able to be as sexy and romantic as you want — or you used to be.

At the same time, low sexual desire can make your partner feel rejected, which can lead to conflicts and strife. And this type of relationship turmoil can further reduce desire for sex.

It may help to remember that fluctuations in your sexual desire are a normal part of every relationship and every stage of life. Try not to focus all of your attention on sex. Instead, spend some time nurturing yourself and your relationship.

Go for a long walk. Get a little extra sleep. Kiss your partner goodbye before you head out the door. Make a date night at your favourite restaurant. Feeling good about yourself and your partner can actually be the best foreplay.

For further enquiries, please contact

Dr. A S Arun MD DNB CCST, FRCOG, FRANZCOG

Waikiki Specialist Centre
221 Wilmott Drive
Waikiki 6169
WA
Tel: 08 95500300
Fax: 08 95929830
Email: specialists@waikikiprivatehospital.com
Website: www.doctorarun.com.au

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Urodynamic tests check the function of your bladder and help to investigate the cause of any urinary incontinence you may have.

What are urodynamic tests?

Urodynamic tests help doctors assess the function of your bladder and the tube from your bladder that passes out urine (your bladder outflow tract, or urethra). They are often done to investigate urinary incontinence.

During the tests, your bladder is filled and then emptied while pressure readings are taken from your bladder and your tummy (abdomen). The idea is to replicate your symptoms, then examine them and determine their cause.

What are urodynamic tests used for?

Urodynamic tests are used to help diagnose:

Stress urinary incontinence,
Urge urinary incontinence,
Mixed urinary incontinence (stress and urge urinary incontinence)

They may also be helpful in investigating other causes of incontinence. Urodynamic tests are particularly important if surgery is being considered for the problem, to make sure the correct operation is performed.

Understanding urine and the bladder

The kidneys make urine all the time. A trickle of urine is constantly passing to the bladder down the tubes from the kidneys to the bladder (the ureters). You make different amounts of urine depending on how much you drink, eat and sweat.
The bladder is made of muscle and stores the urine. It expands like a balloon as it fills with urine. The outlet for urine (the urethra) is normally kept closed. This is helped by the muscles beneath the bladder that sweep around the urethra (the pelvic floor muscles).
When a certain amount of urine is in the bladder, you become aware that the bladder is getting full. When you go to the toilet to pass urine, the bladder muscle squeezes (contracts), and the urethra and pelvic floor muscles relax.
Complex nerve messages are sent between the brain, the bladder and the pelvic floor muscles. These tell you how full your bladder is and which muscles are right to contract or relax at the correct time.

Understanding incontinence

Urodynamic tests can help doctors assess which type of incontinence you have. The treatment that you receive will differ depending on the type of incontinence you have.

There are a number of different causes of incontinence including the following:

Stress incontinence is the most common type. It occurs when the pressure in the bladder becomes too great for the bladder outlet to withstand. It usually occurs because your pelvic floor muscles which support your bladder outlet are weakened. Urine tends to leak most when you cough or laugh, or when you exercise (such as when you jump or run). In these situations there is a sudden extra pressure (stress) inside your tummy (abdomen) and on your bladder.

Urge incontinence (unstable or overactive bladder) is the second most common cause. In this condition you develop an urgent desire to pass urine. Sometimes urine leaks before you have time to get to the toilet. The bladder muscle contracts too early and the normal control is reduced.

Mixed incontinence – Some people have a combination of stress and urge incontinence.

How do urodynamic tests work?

The first part of the tests checks how much urine leaves your bladder over a certain length of time. This is called the flow rate. A special toilet records the flow of your urine. A computer then checks for any abnormalities in flow rate.

A decreased flow rate can indicate problems with bladder emptying. For example, this could be an obstruction to bladder drainage or under activity of your bladder muscle.

The second part of the tests is called filling cystometry. For this test, thin tubes called catheters are inserted into your bladder and your back passage (rectum) or your vagina.

These can measure the pressure in your bladder and tummy (abdomen) as your bladder fills with fluid. Using these measurements, doctors compare the different pressure readings.

If urine leaks with no change in pressure in your bladder muscle, you may have stress incontinence. Leaking is brought on (provoked) by an increase in pressure inside your abdomen – for example, when coughing.

If involuntary bladder muscle activity causes an increase of pressure in your bladder and leads to leaking, you may have urge incontinence.

What happens during urodynamic testing?

Testing is done in the consulting room.

For the first part of the test, you will need to empty your bladder into a special toilet called a flowmeter. This measures how much urine you pass and the flow of the urine.

You will usually be left alone in the room whilst you are doing this. This is why you need to come to the test with a full bladder.

Once you have been to the toilet you will usually have an ultrasound test performed to see how empty your bladder is. This test is done by having some gel on the skin over your bladder and then an ultrasound probe being moved over this area.

The next part of the test measures the way your bladder works as it fills up. You will be asked to lie down on a special bed. Two very thin tubes (catheters) are put into your bladder, by inserting them into the tube from your bladder that passes out urine (your urethra). You may find this a little uncomfortable. One is to fill up your bladder and the other is to measure the pressure in your bladder. Another catheter is put into your vagina or back passage (rectum). This allows the pressure inside your bladder to be compared with the pressure outside your bladder.

Once the catheters are in the correct position, fluid runs into your bladder at a controlled rate. This slowly fills your bladder whilst recordings are made. The doctor or nurse performing the test will ask you questions – for example, how your bladder feels and when it feels full.

Once your bladder is full, the bed will move and stand you upright.
If you leak urine when you cough, try not to feel embarrassed. If you leak at home when you cough, it is best for the test operator to see you leak during the test. It is important to remember that it is helpful to see how your bladder behaves on a day-to-day basis to make sure that the correct treatment is provided.

You will then be asked to empty your bladder into the special toilet again at the end of the test, with the catheters still in place.

What should I do to prepare for a urodynamic test?

If you are taking any medication for your bladder then it is likely that you will be asked to stop this for a week before this test.

Your hospital may ask you to arrive for your test with a comfortably full bladder. If this is difficult, some hospitals may ask you to arrive a little early so that you can have a drink to fill your bladder.

The test usually takes around 45min- 1 hour.

What can I expect after a urodynamic test?

After the tests some people feel a slight stinging or burning sensation when they pass urine. If you drink plenty of fluids these symptoms should quickly settle. If discomfort lasts more than 24 hours, you should take a sample of your urine to your GP for testing because it may be a sign of infection.

Some people find a small amount of blood in their urine when they go to the toilet. If this lasts more than 24 hours, you should also see your GP because it may be a sign of infection.

After having urodynamic tests there is a small possibility that you may develop a urinary tract infection. This is caused by putting the very thin tubes (catheters) into your bladder during the test. To help reduce the likelihood of developing an infection after the test, your hospital may advise you to:

Drink extra fluids for 48 hours after the test. This will help you to ‘flush’ your system through. Aim to drink about two and a half litres a day for the 48 hours after the test (9-10 cups of fluid).
Cut down on your tea and coffee intake for 48 hours after the test. This will reduce bladder irritation until your bladder returns to normal. Drink water, herbal and fruit teas, juices and squash.

When you go to the toilet to pass urine, take a bit longer to make sure that your bladder is fully empty. When you have finished passing urine, wait for a couple of seconds and then try again.
Are there any side-effects or complications from a urodynamic test?

Most people have urodynamic tests without experiencing any problems. As mentioned above, there is a small chance of developing a urinary tract infection. Contact your GP if you develop any of the following symptoms:

A stronger than usual urge to pass urine.
Your urine smells, is cloudy or has blood in it.

You want to pass urine more often during the day and night.
A burning or stinging sensation when you pass urine and feel that you are only passing small amounts at a time.

Lower backache or pain in your kidneys.
If you feel hot and develop a high temperature.

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What is Vulvodynia?

Vulvodynia is a chronic pain, burning or discomfort involving the vulva in the absence of relevant visible findings or a specific, clinically identifiable, neurological disorder.

What are the types of Vulvodynia?

  • Generalized vulvodynia – affecting the whole vulvar area:
pain is felt over the entire vulvar area.
  • Localized vulvodynia – affecting a specific area of the vulva.

What is Provoked Vestibulodynia?

Provoked Vestibulodynia (Fig.1) (formerly known as Vulvar vestibulitis syndrome) is a specific form of localized vulvodynia. In VVS, the pain is felt only in the vestibule (the area around the opening of the vagina), usually in response to touch or pressure.

What causes Vulvodynia?

The precise cause is not known.
Researchers believe that many factors acting together are involved.
Some of these factors include the following:

  • Damage or irritation of the nerves of the vulva which can be after childbirth.
  • Increased number of nerve endings in the vestibule
  • Increased production of chemicals by cells in the vulva that lead to inflammation
  • Long-term reactions to certain infections
  • Changes in responses to hormones
  • History of sexual abuse

Who gets it?

  • Vulvodynia is not hereditary and it affects women of all ethnic groups.
  • Lifetime prevalence has been estimated at 8% and is constant across all decades up to the age of 70.
  • Provoked vestibulodynia is the most common presentation.

How is vulvodynia diagnosed?

  • Your specialist will try to rule out other known causes of pain first. You may be asked questions about your symptoms and medical history, such as when symptoms occur, what treatments you have tried, and whether you have any chronic infections or skin problems.
  • Your specialist will examine the vulva and vagina carefully. The specialist uses a cotton swab to touch areas of the vulva and vestibule to find out whether the pain is generalized or localized. The goal is to find where the pain is and whether it is mild, moderate, or severe. Taking swabs to look for infection or a biopsy (removal of a small sample of skin under a local anaesthetic to examine under the microscope) may occasionally be needed to rule out other causes.

How is vulvodynia treated?

Various treatments can be tried. The following are sensible lines of treatment:

  • Avoid soap, bubble baths, shower gels, shampoos, special wipes and deodorants in this area. Wash with a soap substitute, as this will keep your skin soft and provide a barrier against irritation.
  • Greasy ointments are a good soap substitute, and can be bought over the counter from chemists and at supermarkets without a prescription. Use petroleum jelly to protect the area from chlorine when you are swimming.
  • Local anaesthetic ointment can be used to numb the area, reducing discomfort. Lignocaine cream and ointment can be bought without a prescription. These medications are applied to the skin for short-term pain relief, or they can be used for extended periods. 
Occasionally long term use of this ointment can cause allergy to lignocaine, but this is rare.

If these measures do not give you enough relief, then prescribed oral medication may be needed. Three types are commonly used:

  • Amitriptyline. This is an anti- depressant but is now used for many pain problems. It is available as cream or in tablet form.
  • Gabapentin or Pregabalin. This is an anti-epileptic drug, which is also used for pain.
  • Vaginal diazepam pessary can be obtained from a compounding pharmacy.

Other treatments include:

  • Pelvic Physiotherapy: Patients with vulvodynia who have sex- related pain frequently have pelvic floor muscle dysfunction. 
Physical therapy can relax tissues in the pelvic floor and release tension in muscles and joints. Biofeedback is a form of physical therapy that trains you to strengthen the pelvic floor muscles. Strengthening these muscles may help to lessen your pain.
  • Trigger Point therapy: Trigger point therapy is a form of massage therapy. A trigger point is a small area of tightly contracted muscle. Pain from a trigger point travels to nearby areas. Trigger point therapy involves soft tissue massage to break up the trigger point and relax muscles. An anesthetic drug also can be injected into the trigger point to provide relief.
  • Self-care (What can I do?) 
This condition is not life threatening or contagious. Wear cotton underwear and switch to cotton menstrual products if regular ones are irritating. Pay close attention to what makes your symptoms worse, and avoid the things that aggravate your pain. While you are experiencing pain, applying cool gel packs may bring relief.
  • If intercourse is painful this may have emotional and psychological effects on sexual relationships. It is important to understand this, and to communicate fully with your partner, discovering techniques and lubricants that are comfortable and suit you both.
  • Psychotherapy: A counsellor can help you learn to cope with chronic pain. This may help reduce stress and help you feel more in control of your symptoms. Sexual counselling can provide support and education about this condition for both you and your partner.

Is surgery an option for Vulvodynia?

If you have a type of vulvodynia called provoked vestibulodynia (Fig.1), your specialist may suggest vestibulectomy to remove painful tissue, especially if other treatments have not worked. The procedure may help relieve pain and make sex more comfortable. It is not recommended for women with generalized vulvodynia.

Vestibulectomy

This is an operation where the inflamed skin is removed and the area is covered over by the back wall of the vagina.

Benefits – The benefit of this is that it cures or improves the problem in about 80% women treated. In selected patients that up to 80% gain partial or even complete long term improvement.

Risks – The major risk is failure to resolve the problem. There can be short term discomforts and spasm of the pelvic floor muscles but this usually resolves after two to three weeks.

For Treatment enquiries, please contact

Dr. A S Arun MD DNB CCST, FRCOG, FRANZCOG
Waikiki Specialist Centre
221 Wilmott Drive
Waikiki 6169
WA
Tel: 08 95500300
Fax: 08 95929830
Email: specialists@waikikiprivatehospital.com
Website: www.doctorarun.com.au

Provoked Vestibulodynia
Fig.1 Provoked Vestibulodynia
Generalized Vulvodynia
Fig.2 Generalized Vulvodynia

 

 

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Although many women experience pelvic pain, a Health study indicates that only a small fraction of these women report their symptoms to their doctors and seek treatment, leaving some health problems unresolved.

It’s important that women get treatment for pain, because aside from the obvious effects, pain also affects women’s overall health and how they feel about themselves. The researchers found that women who reported higher levels of pain also reported having a lower overall quality of health.

What is chronic pelvic pain?

Chronic pelvic pain is pain in the area below your bellybutton and between your hips that lasts six months or longer.

It is common and affects around 1 in 6 women. It can be distressing and affect a woman’s ability to carry out everyday activities

What are the symptoms?

When asked to locate your pain, you might sweep your hand over your entire pelvic area rather than point to a single spot. You might describe your chronic pelvic pain in one or more of the following ways:

Severe and steady pain
Pain that comes and goes (intermittent)
Dull aching
Sharp pains or cramping
Pressure or heaviness deep within your pelvis
In addition, you may experience:

Pain during intercourse
Pain while having a bowel movement or urinating
Pain when you sit for long periods of time
Your discomfort may intensify after standing for long periods and may be relieved when you lie down. The pain may be mild and annoying, or it may be so severe that you miss work, can’t sleep and can’t exercise.

When to see the specialist?

With any chronic pain problem, it can be difficult to know when you should go to the specialist. In general, make an appointment with your specialist if your pelvic pain disrupts your daily life or if your symptoms seem to be getting worse.

What causes chronic pelvic pain?

Chronic pelvic pain is usually caused by a combination of physical, psychological and/or social factors rather than a single underlying condition, although for many women a cause cannot be found.

Some common causes include:

endometriosis, a condition where the lining of the womb (endometrium) is found elsewhere in the body, usually in the pelvis – endometriosis and adenomyosis
(a condition where the endometrium is found in the muscle of the womb) can
cause pain around the time of a period and during sex
Bladder pain Syndrome/interstitial cystitis (bladder inflammation)
For example, a woman might have both endometriosis and interstitial cystitis, both of which contribute to chronic pelvic pain. This is called evil twins of Pelvic Pain.

80% women with Pelvic pain may have one or other or both of these conditions.

pelvic inflammatory disease, which is an infection in the fallopian tubes and/or pelvis
irritable bowel syndrome (IBS)
musculoskeletal pain (pain in the joints, muscles, ligaments and bones of the pelvis)
Pelvic congestion syndrome. We believe enlarged, varicose-type veins around your uterus and ovaries may result in pelvic pain.

Psychological factors. Depression, chronic stress or a history of sexual or physical abuse may increase your risk of chronic pelvic pain. Emotional distress makes pain worse, and living with chronic pain contributes to emotional distress. These two factors often become a vicious cycle.

What happens when you see a specialist?

Figuring out what’s causing your chronic pelvic pain often involves a process of elimination because many different disorders can cause pelvic pain.

In addition to a detailed interview about your pain, your personal health history and your family history, your specialist may ask you to keep a diary of your pain and other symptoms.

What tests or exam I would need?

Pelvic exam. This can reveal signs of infection, abnormal growths or tense pelvic floor muscles.
Lab tests. During the pelvic exam, your specialist may order labs to check for infections, such as chlamydia or gonorrhea. Your specialist may also order bloodwork to check your blood cell counts and urinalysis to check for a urinary tract infection.
Ultrasound. This test uses high-frequency sound waves to produce precise images of structures within your body. This procedure is especially useful for detecting masses or cysts in the ovaries, uterus or fallopian tubes.
Other imaging tests. Your doctor may recommend abdominal X-rays, computerized tomography (CT) scans or magnetic resonance imaging (MRI) to help detect abnormal structures or growths.
Laparoscopy. During this surgical procedure, your specialist makes a small incision in your abdomen and inserts a thin tube attached to a small camera (laparoscope). The laparoscope allows your specialist to view your pelvic organs and check for abnormal tissues or signs of infection. This procedure is especially useful in detecting endometriosis and chronic pelvic inflammatory disease.
Cystoscopy.This involves passing a small telescope (cystoscope) into your bladder through your urethra (the tube that carries urine from the bladder to outside the body)
Finding the underlying cause of chronic pelvic pain can be a long process, and in some cases, a clear explanation may never be found.

With patience and open communication, however, you and your specialist can develop a treatment plan that helps you live a full life with minimal discomfort.

What treatment may help?

If your specialist thinks that your pain is due to a particular cause then you should be offered treatment for that condition:

Bladder pain syndrome – several therapies are available.
Endometriosis- Following laparoscopy, you may be offered hormonal treatment.
irritable bowel syndrome (IBS) – medication and changes to your diet may help
infections should be treated (usually with antibiotics)
Some women find acupuncture or complementary therapies, or changing diet, helpful. 
Whatever your situation, you should be offered pain relief.

Chronic pelvic pain can be very difficult to live with and can cause emotional, social and economic difficulties. You may experience depression, difficulty sleeping and disruption to your daily routine.

For Treatment enquiries, please contact

Dr. A S Arun MD DNB CCST, FRCOG, FRANZCOG

Waikiki Specialist Centre
221 Wilmott Drive
Waikiki 6169
WA

Tel: 08 95500300
Fax: 08 95929830
Email: specialists@waikikiprivatehospital.com

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Although no one talks about it, pelvic organ prolapse is fairly a common problem in women. The term refers to one or more pelvic organs dropping from their usual positions.

Pelvic Organ Prolapse

Prolapse is a condition where there is a sensation of a mass bulging from your vagina, or a feeling of heaviness in your pelvic area. And even though millions of women are affected, studies show that women are reluctant to discuss it, even with a doctor. As a result, a silence persists that leaves women unaware they do not have to live with this.
Prolapse can be caused by muscles and ligaments that have been weakened or damaged. The most common causes include pregnancy, childbirth, menopause, obesity, aging or previous surgery.

Ask yourself the following questions:

Have you felt a bulge or lump in your vagina, or feel like something is falling out?
Do you experience pain or discomfort during intercourse?
Do you experience vaginal pain, pressure, irritation, bleeding or spotting?
Do you experience problems with urination, or difficulty with bowel movements?
Do you have frequent lower back pain?

Answering YES to any of these questions could be an indication that you may be experiencing some form of prolapse. What a relief to know that this condition is treatable – you don’t have to live with it – and there are now a number of minimally invasive, treatment options available.

What is the pelvic floor?

The pelvic floor is the hammock of muscles which spans the pelvis from front to back and is responsible for supporting all the pelvic organs and controlling the openings.

How does it work and what causes it to weaken?

The muscles are usually firm and slightly tense to prevent leakage from the bladder and bowel and to maintain the normal position of the organs and thus prevent a prolapse.
When you empty your bladder or bowels the muscles relax and then tighten again to restore control. The muscles can get weaker gradually, possibly over several years.
Childbirth, chronic constipation, being overweight are all factors which can weaken muscles and once this happens they cannot perform their functions of support and control as efficiently as before and this is when the problems usually become obvious.
Other factors affecting the pelvic floor muscles include aging, the menopause and reduction of oestrogen, being a smoker or having a chronic cough. An occupation that involves repeated lifting can also lead to a greater risk of pelvic floor dysfunction.

What is prolapse?

When the pelvic floor weakens, it causes the supports of the various parts of the vagina and sometimes the uterus to loosen. This results in these structures ‘dropping’ so that they can be felt outside the body, or cause problems with passing urine or stools without being replaced. This is commonly called prolapse.
Sometimes, the vaginal opening can be larger especially when a lady has had many vaginal deliveries.

Types of Prolapse

Normal Female Pelvic Anatomy
Normal Female Pelvic Anatomy

Cystocele (dropping of the bladder into the vagina) occurs when the wall between the bladder and the vagina weakens, causing the bladder to drop or sag into the vagina.

Screen Shot 2016-08-15 at 11.27.15 AM

Rectocele (pushing of the rectum into the vaginal wall) occurs when there is a bulge in the lower back vaginal wall caused by the front wall of the rectum sagging and pushing against it.

Screen Shot 2016-08-15 at 11.28.17 AM

Vault prolapse (sagging of the top of vagina after hysterectomy) occurs when there is a weakness to the support of the top of the vagina.

Screen Shot 2016-08-15 at 11.29.31 AM

Uterine prolapse (Bulging of the uterus into the vagina) occurs by itself or can be accompanied with cystocele, rectocele or enterocele.

Enterocele (Bulging of the small intestine into the vaginal wall) occurs when the small intestine bulges into the upper back vaginal wall.

How is a prolapse diagnosed?

Prolapse is diagnosed by a trained consultant or nurse when doing a pelvic examination.

What problems can it cause?

Feeling of something coming out of the vagina
Difficulty with passing urine or stools
Soreness and vaginal discharge with or without an infection
Backache and pelvic pain
Kidney pains in severe conditions with repeated urinary and kidney infections
Urinary leakage and recurrent cystitis
Difficulty with sexual intercourse

When do I need to see a doctor about prolapse?

If the prolapse is getting worse, or if there is any difficulty with passing urine or stools, you need to seek treatment as soon as possible
If you get repeated urinary tract infections and you know you have a prolapse you should seek treatment
If you feel your relationship with your partner is suffering as a result of your prolapse or urinary incontinence

Conservative treatment

Physiotherapy – pelvic floor exercises can be very useful in those women with mild degrees of prolapse and/or stress incontinence. Perseverance and professional help with these exercises is important.

Surgery

If conservative measures fail to improve the situation, the options of surgery may be discussed with a gynaecologist. The following operations are available:
Treating Uterine Prolapse – there are two surgical approaches to treating a uterine prolapse: removing the uterus altogether (hysterectomy) or lifting it and holding it in place (suspension).
Suspending the Uterus – treatments that suspend rather than remove the uterus are recommended for women who want to keep their uterus or have children in the future. Procedures can be done either vaginally or abdominally, and there is some evidence to suggest that abdominal repairs tend to have better long-term results. The options are between sacrocolpopexy (using special mesh) and sacrospinous fixation. Key hole surgery (laparoscopy) is usually used.

Anterior Repair (colporrhaphy) – tightens up the front walls of the vagina – this procedure is used to treat prolapse of the bladder (cystocele), urethra (urethrocele) or both the bladder and urethra (cystourethrocele).

Posterior repair or posterior colporrhaphy – tightens up the back wall of the vagina – posterior repair is used to treat prolapse of the rectum (rectocele) and small bowel (enterocele). Mesh may be used.

Seeking help

Many women delay seeking help for this condition due to embarrassment.

For Treatment enquiries, please contact

Dr. A S Arun MD DNB CCST, FRCOG, FRANZCOG

Waikiki Specialist Centre
221 Wilmott Drive
Waikiki 6169
WA

Tel: 08 95500300
Fax: 08 95929830
Email: specialists@waikikiprivatehospital.com

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Urinary incontinence is leaking of urine that you can’t control. Many women suffer from urinary i­ncontinence. We don’t know for sure exactly how many. That’s because many people do not tell anyone about their symptoms. They may be embarrassed, or they may think nothing can be done. So they suffer in silence.

Urinary incontinence is not just a medical problem. It can affect emotional, psychological and social life. Many people who have urinary incontinence are afraid to do normal daily activities. They don’t want to be too far from a toilet. Urinary incontinence can keep people from enjoying life.

Many people think urinary incontinence is just part of getting older. But it’s not. And it can be managed or treated.

Key statistics

It is thought that urinary incontinence affects up to 37% of Australian adult women. Although it is commonly associated with pregnancy, childbirth and menopause, urinary incontinence affects women of all ages (although the prevalence increases with age) and is not restricted to women who have borne children – in fact, 12% of Australian women who have never had children and are aged under 30 have incontinence.

Studies show that many things increase risk. For example, aging is linked to urinary incontinence. Pregnancy, delivery, and number of children increase the risk in women. Women who have had a baby have higher rates of urinary incontinence. The risk increases with the number of children. This is true for cesarean section (C-section) and vaginal delivery.

Women who develop urinary incontinence while pregnant are more likely to have it afterward. Women after menopause (whose periods have stopped) may develop urinary incontinence. This may be due to the drop in estrogen (the female sex hormone). Taking estrogen, however, has not been shown to help urinary incontinence.

Obesity increases the risk of urinary incontinence. Losing weight can improve bladder function and lessen urinary incontinence symptoms.

What happens normally?

The brain and the bladder control urinary function. The bladder stores urine until you are ready to empty it. The muscles in the lower part of the pelvis hold the bladder in place. Normally, the smooth muscle of the bladder is relaxed. This holds the urine in the bladder. The neck (end) of the bladder is closed. The sphincter muscles are closed around the urethra. The urethra is the tube that carries urine out of the body. When the sphincter muscles keep the urethra closed, urine doesn’t leak.

Once you are ready to urinate, the brain sends a signal to the bladder. Then the bladder muscles contract. This forces the urine out through the urethra, the tube that carries urine from the body. The sphincters open up when the bladder contracts.

What are the types of urinary incontinence?

Urinary incontinence is not a disease. It is a symptom of many conditions. Causes may differ for men and women. But it is not hereditary. And it is not just a normal part of aging. These are the four types of urinary incontinence:

Stress Urinary Incontinence (SUI)

With SUI, weak pelvic muscles let urine escape. It is one of the most common types of urinary incontinence. It is common in older women.

SUI happens when the pelvic floor muscles have stretched. Physical activity puts pressure on the bladder. Then the bladder leaks. Leaking my happen with exercise, walking, bending, lifting, or even sneezing and coughing. It can be a few drops of urine to a tablespoon or more. SUI can be mild, moderate or severe.

Ways to manage SUI include “Kegel” exercises to strengthen the pelvic floor. Lifestyle changes, vaginal and urethral devices, pads, and even surgery are other ways to manage SUI.

Overactive Bladder (OAB)

OAB is another common type of urinary incontinence. It is also called “urgency” incontinence. It affects people’s lives. They may restrict activities. They may fear they will suddenly have to urinate when they aren’t near a bathroom. They may not even be able to get a good night’s sleep. Some people have both SUI and OAB and this is known as mixed incontinence.

With OAB, your brain tells your bladder to empty – even when it isn’t full. Or the bladder muscles are too active. They contract (squeeze) to pass urine before your bladder is full. This causes the urge (need) to urinate.

The main symptom of OAB is the sudden urge to urinate. You can’t control or ignore this “gotta go” feeling. Another symptom is having to urinate many times during the day and night.

OAB is more likely in women after menopause. It is caused by many things. Even diet can affect OAB. There are a number of treatments. They include life style changes, drugs that relax the bladder muscle, or surgery. Some people have both SUI and OAB.

Mixed Incontinence (SUI and OAB)

Some people leak urine with activity (SUI) and often feel the urge to urinate (OAB). This is mixed incontinence. The person has both SUI and OAB.

Overflow Incontinence

With overflow incontinence, the body makes more urine than the bladder can hold or the bladder is full and cannot empty thereby causing it to leak urine. In addition, there may be something blocking the flow or the bladder muscle may not contract (squeeze) as it should.

One symptom is frequent urinating of a small amount. Another symptom is a constant drip, called “dribbling.”

This type of urinary incontinences is rare in women. It is more common in men who have prostate problems or have had prostate surgery.

Diagnosing urinary incontinence

If you experience urinary incontinence, see your specialist so they can determine the type of condition you have.

Urinary incontinence is a common problem and it’s likely your specialist has seen many people with the condition.

Your SPECIALIST will ask you questions about your symptoms and medical history, including:

  • whether the urinary incontinence occurs when you cough or laugh
  • whether you need the toilet frequently during the day or night
  • whether you have any difficulty passing urine when you go to the toilet
  • whether you are currently taking any medications
  • how much fluid, alcohol or caffeine you drink?

Bladder diary

Your SPECIALIST may suggest that you keep a diary of your bladder habits for at least three days, so you can give them as much information as possible about your condition. This should include details such as:

  • how much fluid you drink
  • the types of fluid you drink
  • how often you need to pass urine
  • the amount of urine you pass
  • how many episodes of incontinence you experience?
  • how many times you experience an urgent need to go to the toilet

Tests and examinations

You may also need to have some tests and examinations so that your SPECIALIST can confirm or rule out things that may be causing your incontinence. Some of these are explained below.

Physical examination

Your SPECIALIST may examine you to assess the health of your urinary system.

Your SPECIALIST will carry out a pelvic examination, which usually involves undressing from the waist down. You may be asked to cough to see if any urine leaks out.

Your SPECIALIST may also examine your vagina. In over half of women with stress incontinence, part of the bladder may bulge into the vagina.

Your SPECIALIST may place their finger inside your vagina and ask you to squeeze it with your pelvic floor muscles. These are the muscles that surround your bladder and urethra (the tube through which urine passes out of the body). Damage to your pelvic floor muscles can lead to urinary incontinence.

Dipstick test

If your SPECIALIST thinks your symptoms may be caused by a urinary tract infection (UTI), a sample of your urine may be tested for bacteria. A small, chemically treated stick is dipped into your urine sample. It will change colour if bacteria are present. The dipstick test can also check the blood and protein levels in your urine.

Residual urine test

If your SPECIALIST thinks you may have overflow incontinence, they may suggest a test called residual urine test to see how much urine is left in your bladder after you go for a wee.

This is usually done by carrying out an ultrasound scan of your bladder, although occasionally the amount of urine in your bladder may be measured after it has been drained using a catheter. This is a thin, flexible tube that is inserted into your urethra and passed through to your bladder.

Further tests

Some further tests may be necessary if the cause of your urinary incontinence is not clear. Your SPECIALIST will usually start treating you first and may suggest these tests if treatment is not effective.

Cystoscopy

A cystoscopy involves using a flexible viewing tube, known as an endoscope, to look inside your bladder and urinary system. This test can identify abnormalities that may be causing incontinence.

Urodynamic tests

These are a group of tests used to check the function of your bladder and urethra. This may include keeping a bladder diary for a few days (see above) and then attending an appointment at a hospital or clinic for tests such as:

  • measuring the pressure in your bladder by inserting a catheter into your urethra
  • measuring the pressure in your abdomen (tummy) by inserting a catheter into your bottom
  • asking you to urinate into a special machine that measures the amount and flow of urine

Non-surgical treatments for urinary incontinence

The treatment you receive for urinary incontinence will depend on the type of incontinence you have and the severity of your symptoms. 

Conservative treatments, which do not involve medication or surgery, are tried first. These include:

  • lifestyle changes
  • pelvic floor muscle training (‘Kegel exercises’)
  • bladder training

After this, medication or surgery may be considered.

Medication for Overactive Bladder

Anticholinergics

If bladder training is not an effective treatment for your urge incontinence, your GP may prescribe a type of medication called an antimuscarinic.

Anticholinergics may also be prescribed if you have overactive bladder syndrome (OAB), which is the frequent urge to urinate that can occur with or without urinary incontinence.

A number of different antimuscarinic medications that can be used to treat urge incontinence, but common ones include oxybutynin, and solifenacin.

These are usually taken by mouth daily, although an oxybutynin patch that you place on your skin twice a week is also available.

Your GP will usually start you at a low dose to minimise any possible side effects. The dose can then be increased until the medicine is effective.

Possible side effects of anticholinergics include:

  • dry mouth
  • constipation
  • blurred vision
  • fatigue

You will be assessed after four weeks to see how you are getting on with the medication, and every six to 12 months thereafter if the medication continues to help.

Your GP will discuss any other medical conditions you have to determine which anticholinergics are suitable for you.

Mirabegron

If anticholinergics are unsuitable for you (for example Glaucoma), or they have not helped your urge incontinence or have caused unpleasant side effects, you may be offered an alternative medication called mirabegron.

Mirabegron causes the bladder muscle to relax, which helps the bladder fill up with and store urine. It is usually taken by mouth once a day.

Side effects of mirabegron can include:

  • urinary tract infection(UTI)
  • High blood pressure
  • a rash

Your GP will discuss any other medical conditions you have to determine whether mirabegron is suitable for you.

Surgery and procedures for urinary incontinence

If other treatments for urinary incontinence are unsuccessful or unsuitable, surgery or other procedures may be recommended.

Before making a decision, discuss the risks and benefits with a specialist, as well as any possible alternative treatments.

If you are a woman and plan to have children, this will affect your decision, because the physical strain of pregnancy and childbirth can sometimes cause surgical treatments to fail. Therefore, you may wish to wait until you no longer want to have any more children before having surgery.

Surgery and procedures for stress incontinence

Tape procedures

Tape procedures can be used for women with stress incontinence.

A piece of plastic tape is inserted through an incision inside the vagina and threaded behind the urethra (the tube that carries urine out of the body). The middle part of the tape supports the urethra, and the two ends are threaded through two incisions in either the:

  • tops of the inner thigh – this is called a transobturator tape procedure (TOT)
  • abdomen (tummy) – this is called a retropubic tape procedure or tension-free vaginal tape procedure (TVT)

By holding the urethra up in the correct position, the piece of tape can help reduce the leaking of urine associated with stress incontinence.

The effectiveness of these tape procedures is similar, with around two in every three women not experiencing any leaking afterwards. Even those who still have some leaking after surgery often find this is less severe than it was before the operation.

However, it is not uncommon for women to need to go to the toilet more frequently and urgently after this procedure, and some find they are unable to completely empty their bladder when they go to the toilet.

In some cases, the tape can wear away or move over time and further surgery may be needed at a later stage to adjust it (for example, to make it looser) or to remove it.

Colposuspension

Colposuspension involves making an incision in your lower abdomen, lifting up the neck of your bladder, and stitching it in this lifted position. This can help prevent involuntary leaks in women with stress incontinence.

There are two types of colposuspension:

  • an open colposuspension – where surgery is carried out through a large incision
  • a laparoscopic (‘keyhole’) colposuspension – where surgery is carried out through one or more small incisions using special, small surgical instruments

Both types of colposuspension offer effective, long-term treatment for stress incontinence, although laparoscopic colposuspension needs to be carried out by an experienced laparoscopic surgeon.

Problems that can occur after colposuspension include difficulty emptying the bladder fully when going to the toilet, recurrent urinary tract infections (UTI) and discomfort during sex.

Sling procedures

Sling procedures involve making an incision in your lower abdomen and vagina so a sling can be placed around the neck of the bladder to support it and prevent accidental urine leaks. The sling can be made of:

  • a synthetic material
  • tissue taken from another part of your body (an autologous sling)
  • tissue donated from another person (an allograft sling)
  • tissue taken from an animal (a xenograft sling), such as cow or pig tissue

In many cases, an autologous sling will be used and will be made using part of the layer of tissue that covers the abdominal muscles (rectus fascia). These slings are generally preferred because more is known about their long-term safety and effectiveness.

The most commonly reported problem associated with the use of slings is difficulty emptying the bladder fully when going to the toilet. A small number of women who have the procedure also find that they develop urge incontinence afterwards.

Procedure for urge incontinence

Botulinum toxin A injections

Botox injections can help overactive bladder symptoms in women; not just for wrinkles

Botulinum toxin A, commonly known as Botox injections, best known worldwide for treating wrinkles and other cosmetic purposes. These injections are now approved for use in overactive bladder in Australia.

For these women, Botox injections to the bladder may be offered as a treatment.

What are Botox injections to the bladder?

Botox is a recently approved treatment for OAB that’s delivered via injection. It works by blocking the muscles and nerves that lead to a feeling of urgently needing to urinate. This involves passing a small telescope (cystoscope) into your bladder through your urethra (the tube that carries urine from the bladder to outside the body) and injecting between 10 and 20 injections of Botox® into your bladder wall from the inside. This helps to improve the symptoms of overactive bladder.

What are the benefits of Botox injections?

Botox is highly effective in relieving the frequency and urgency of needing to go to the toilet and reduces urinary incontinence in majority of women undergoing the injection.

For the majority of women, the beneficial effects are usually seen three to four days after the injection. The Botox injection is expected to last for six to twelve months, but this will vary for each woman.

For some women, a single treatment is all that is required: others will need repeated injections.

Any side effects?

 Sometimes urinary retention occurs (inability or difficulty to empty your bladder). In other words, the Botox injection works too well and women cannot pass urine on their own.

However, there is a small risk of you requiring to self catheterise (pass a tube/catheter in to the bladder yourself a few times a day) to empty the bladder.

Blood in your urine –This is usually minor and settles down without any treatment.

Urinary tract infection – Symptoms include increased frequency, pain or burning when passing urine and feeling unwell. This is treatable with antibiotics.

What happens after the treatment?

You can return to work the day after your Botox injection.

You will be seen in the clinic two weeks to one month after the injections.

Dr. A S Arun MD DNB CCST, FRCOG, FRANZCOG

For Treatment enquiries, please contact Dr Arun.

Contact Dr Arun
Read More

Menorrhagia is the medical term for menstrual periods with abnormally heavy or prolonged bleeding in consecutive cycles. Although heavy menstrual bleeding is a common concern among premenopausal women, it does not mean there is anything seriously wrong.

With menorrhagia, every period you have causes enough blood loss and cramping that you can’t maintain your usual activities. If you have menstrual bleeding so heavy that you dread your period, talk with your doctor. There are many effective treatments for menorrhagia.

A good indication that your blood loss is excessive is if:

  • you feel you are using an unusually high number of tampons or pads
  • you experience flooding (heavy bleeding) through to your clothes or bedding
  • you need to use tampons and towels together
  • Symptoms of anemia, such as tiredness, fatigue or shortness of breath

When to see a doctor

Seek medical help before your next scheduled exam if you experience:

  • Vaginal bleeding so heavy it soaks at least one pad or tampon an hour for more than a few hours
  • Bleeding between periods or irregular vaginal bleeding
  • Any vaginal bleeding after menopause

What causes heavy periods?
In most cases, no underlying cause of heavy periods is identified.

A number of conditions may cause menorrhagia.

Common causes include:

  • cervical or endometrial polyps – non-cancerous growths in the lining of the womb or cervix (neck of the womb)
  • endometriosis– when small pieces of the womb lining are found outside the womb, such as in the fallopian tubes, ovaries, bladder or vagina (although this is more likely to cause painful periods)
  • uterine fibroids – non-cancerous growths in the womb that can cause pelvic pain
  • Non hormonal intrauterine contraceptive devices Copper T (IUCD) (also known as “the coil”) – blood loss may increase by 40-50% after an IUCD is inserted.
  • Pelvic Inflammatory Disease (PID) – an ongoing infection in the pelvis that can cause pelvic pain, fever and bleeding after sexual intercourse or between periods
  • Polycystic Ovarian Syndrome (PCOS)– women with PCOS typically have a number of cysts in their ovaries
  • blood clotting disorders such as Von Willebrand’s disease
  • adenomyosis – when glands from the lining of the uterus become embedded in the uterus muscle
  • An underactive thyroid (Hypothyroidism) – this may cause fatigue, constipation, intolerance to cold, and hair and skin changes
  • Cancer of the womb (although it is rare)

Menorrhagia is most often due to a hormone imbalance that causes menstrual cycles without ovulation. In a normal cycle, the release of an egg from the ovaries stimulates the body’s production of progesterone, the female hormone most responsible for keeping periods regular. When no egg is released, insufficient progesterone can cause heavy menstrual bleeding.

Menstrual cycles without ovulation (anovulatory cycles) are most common among two separate age groups:

  • Adolescent girls who have recently started menstruating.Girls are especially prone to anovulatory cycles in the first year after their first menstrual period (menarche).
  • Older women approaching menopause.Women ages 40 to 50 are at increased risk of hormonal changes that lead to anovulatory cycles.

Excessive or prolonged menstrual bleeding can lead to other medical conditions, including:

  • Iron deficiency anemia.In this common type of anemia, your blood is low in hemoglobin, a substance that enables red blood cells to carry oxygen to tissues. Low hemoglobin may be the result of insufficient iron.

Menorrhagia may decrease iron levels enough to increase the risk of iron deficiency anemia. Signs and symptoms include pale skin, weakness and fatigue. Although diet plays a role in iron deficiency anemia, the problem is complicated by heavy menstrual periods.

Most cases of anemia are mild, but even mild anemia can cause weakness and fatigue. Moderate to severe anemia can also cause shortness of breath, rapid heart rate, lightheadedness and headaches.

  • Severe pain.Along with heavy menstrual bleeding, you might have painful menstrual cramps (dysmenorrhea). Sometimes the cramps associated with menorrhagia are severe enough to require prescription medication or a surgical procedure.

If your periods are so heavy that they limit your lifestyle, make an appointment with your doctor or the specialist.

Here’s some information to help you prepare for your appointment and know what to expect from your specialist or the doctor.

What you can do

To prepare for your appointment:

  • Ask if there are any pre-appointment instructions.Your doctor may ask you to track your menstrual cycles on a calendar, noting how long they last and how heavy the bleeding is.
  • Write down any symptoms you’re experiencing,and for how long. In addition to the frequency and volume of your periods, tell your doctor about other symptoms that typically occur around the time of your period, such as breast tenderness, menstrual cramps or pelvic pain.
  • Write down key personal information,including any recent changes or stressors in your life. These factors can affect your menstrual cycle.
  • Make a list of your key medical information,including other conditions for which you’re being treated and the names of medications, vitamins or supplements you’re taking.
  • Write down questions to ask your doctor,to help make the most of your time together.

For menorrhagia, some basic questions to ask your doctor include:

  • Are my periods abnormally heavy?
  • Do I need any tests?
  • What treatment approach do you recommend?
  • Are there any side effects associated with these treatments?
  • Will any of these treatments affect my ability to become pregnant?
  • Are there any lifestyle changes I can make to help manage my symptoms?
  • Could my symptoms change over time?

Don’t hesitate to ask any other questions that occur to you during your appointment.

What you can do in the meantime

While you wait for your appointment, check with your family members to find out if any relatives have been diagnosed with bleeding disorders. In addition, start jotting down notes about how often and how much you bleed over the course of each month. To track the volume of bleeding, count how many tampons or pads you saturate during an average menstrual period.

Your doctor will most likely ask about your medical history and menstrual cycles. You may be asked to keep a diary of bleeding and nonbleeding days, including notes on how heavy your flow was and how much sanitary protection you needed to control it.

Your doctor will do a physical exam and may recommend one or more tests or procedures such as:

  • Blood tests.A sample of your blood may be evaluated for iron deficiency (anemia) and other conditions, such as thyroid disorders or blood-clotting abnormalities.
  • Pap test.In this test, cells from your cervix are collected and tested for infection, inflammation or changes that may be cancerous or may lead to cancer.
  • Endometrial biopsy (Pipelle).Your doctor may take a sample of tissue from the inside of your uterus to be examined by a pathologist.
  • Ultrasound scan.This imaging method uses sound waves to produce images of your uterus, ovaries and pelvis.

Based on the results of your initial tests, your doctor may recommend further testing, including:

  • This exam involves inserting a tiny camera through your vagina and cervix into your uterus, which allows your doctor to see the inside of your uterus.

Doctors can be certain of a diagnosis of menorrhagia only after ruling out other menstrual disorders, medical conditions or medications as possible causes or aggravations of this condition.

Specific treatment for menorrhagia is based on a number of factors, including:

  • Your overall health and medical history
  • The cause and severity of the condition
  • Your tolerance for specific medications, procedures or therapies
  • The likelihood that your periods will become less heavy soon
  • Your future childbearing plans
  • Effects of the condition on your lifestyle
  • Your opinion or personal preference

Drug therapy for menorrhagia may include:

  • Iron supplements.If you also have anemia, your doctor may recommend that you take iron supplements regularly. If your iron levels are low but you’re not yet anemic, you may be started on iron supplements rather than waiting until you become anemic.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs).NSAIDs, such as ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve), help reduce menstrual blood loss. NSAIDs have the added benefit of relieving painful menstrual cramps (dysmenorrhea).
  • Tranexamic acid.Tranexamic acid (Lysteda) helps reduce menstrual blood loss and only needs to be taken at the time of the bleeding.
  • Oral contraceptives.Aside from providing birth control, oral contraceptives can help regulate menstrual cycles and reduce episodes of excessive or prolonged menstrual bleeding.
  • Oral progesterone.When taken for 10 or more days of each menstrual cycle, the hormone progesterone can help correct hormone imbalance and reduce menorrhagia.
  • The hormonal IUD (Mirena).This intrauterine device releases a type of progestin called levonorgestrel, which makes the uterine lining thin and decreases menstrual blood flow and cramping.

If you have menorrhagia from taking hormone medication, you and your doctor may be able to treat the condition by changing or stopping your medication.

You may need surgical treatment for menorrhagia if drug therapy is unsuccessful. Treatment options include:

  • Dilation and curettage (D&C).In this procedure, your doctor opens (dilates) your cervix and then scrapes or suctions tissue from the lining of your uterus to reduce menstrual bleeding. Although this procedure is common and often treats acute or active bleeding successfully, you may need additional D&C procedures if menorrhagia recurs.
  • Uterine artery embolization.For women whose menorrhagia is caused by fibroids, the goal of this procedure is to shrink any fibroids in the uterus by blocking the uterine arteries and cutting off their blood supply.

During uterine artery embolization, the surgeon passes a catheter through the large artery in the thigh (femoral artery) and guides it to your uterine arteries, where the blood vessel is injected with microspheres made of plastic.

  • This procedure involves surgical removal of uterine fibroids. Depending on the size, number and location of the fibroids, your surgeon may choose to perform the myomectomy using open abdominal surgery, through several small incisions (laparoscopically), or through the vagina and cervix (hysteroscopically).
  • Endometrial ablation.Using a variety of techniques, your doctor permanently destroys the lining of your uterus (endometrium) eg. Novasure. After endometrial ablation, most women have much lighter periods. Pregnancy after endometrial ablation can put your health at risk — if you have an endometrial ablation, you should use reliable or permanent contraception until menopause.
  • Hysterectomy — surgery to remove your uterus and cervix — is a permanent procedure that causes sterility and ends menstrual periods. Hysterectomy is performed under anesthesia and requires hospitalization. Additional removal of the ovaries (bilateral oophorectomy) may cause premature menopause.

Except for hysterectomy, these surgical procedures are usually done either local anaesthetic or general anaesthetic . Although you may need a general anaesthetic, it’s likely that you can go home later on the same day.

When menorrhagia is a sign of another condition, such as thyroid disease, treating that condition usually results in lighter periods.

Dr. A S Arun MD DNB CCST, FRCOG, FRANZCOG

For Treatment enquiries, please contact Dr Arun.

Contact Dr Arun
Read More

Botulinum toxin A, commonly known as Botox injections, best known worldwide for treating wrinkles and other cosmetic purposes. These injections are now approved for use in overactive bladder in Australia.

What is Overactive bladder (OAB)?

This is a condition in women when bladder contracts involuntarily too often or without warning leading to the constant urge to urinate and or leakage of urine. This is commonly referred as OAB.

What is the treatment for Overactive Bladder(OAB)?

In order to manage OAB, your doctor may recommend different types of treatments that work by calming the nerves and muscles around your bladder. These medicines are available in different forms, including tablets, patches, or liquids. Not all women get benefitted with this treatment. Some women may have tried more than two medications and cannot tolerate the side effects of the medications. These side effects may be dry mouth, constipation and lack of concentration and feeling drowsy. For these women, Botox injections to the bladder may be offered as a treatment.

What are Botox injections to the bladder?

Botox is a recently approved treatment for OAB that’s delivered via injection. It works by blocking the muscles and nerves that lead to a feeling of urgently needing to urinate. This involves passing a small telescope (cystoscope) into your bladder through your urethra (the tube that carries urine from the bladder to outside the body) and injecting between 10 and 20 injections of Botox® into your bladder wall from the inside. This helps to improve the symptoms of overactive bladder.

 

What are the benefits of Botox injections?

 

Botox is highly effective in relieving the frequency and urgency of needing to go to the toilet and reduces urinary incontinence in majority of women undergoing the injection.

For the majority of women, the beneficial effects are usually seen three to four days after the injection. The Botox injection is expected to last for six to twelve months, but this will vary for each woman.

For some women, a single treatment is all that is required: others will need repeated injections.

Any side effects?

 

Sometimes urinary retention occurs (inability or difficulty to empty your bladder). In other words, the botox inection works too well and women cannot pas urine on their own.

However, there is a small risk of you requiring to self catheterise (pass a tube/catheter in to the bladder yourself a few times a day) to empty the bladder.

Blood in your urine –This is usually minor and settles down without any treatment.

Urinary tract infection – Symptoms include increased frequency, pain or burning when passing urine and feeling unwell. This is treatable with antibiotics.

What happens after the treatment?

 

You can return to work the day after your Botox injection.

You will be seen in the clinic two weeks to one month after the injections.

 

For Treatment enquiries, please contact Dr Arun 

Read More

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