Leakage, UTI, prolapse, oh my!
Don't worry, we'll fix this together.
Urinary issues are common and occur in women of all ages.
You may be seeing Dr. Chertack for issues with urination. This may include frequent trips to the bathroom, needing to run to the bathroom, urinary tract infections (UTI), feeling like you have a UTI, vaginal dryness, pain with intercourse, straining, or feeling like you cannot empty your bladder completely.
What is done at my initial visit?
Dr. Chertack recorded your symptoms and medical history. Usually you will need a pelvic exam to rule out any concerning conditions. This is usually shorter than a pelvic exam with your gynecologist, Dr. Chertack is mainly assessing the outside appearance of the vulvar area, along with checking for internal tenderness. You may have your urine checked for blood/infection (this result is not usually available until after your visit) and have a “bladder scan” to make sure you are emptying your bladder. You may also fill out a “AUA Symptom Score” to assess your symptoms.
Vaginal estrogen can improve your pelvic quality of life by leaps and bounds.
What is genitourinary syndrome of menopause?
This is a group of symptoms that occur during and after menopause due to the decreased estrogen level in your body. This can include urinary symptoms (urgency, frequency, burning), genital symptoms (dryness, irritation, burning), and sexual symptoms (decreased desire, pain, decreased lubrication). GSM can also lead to recurrent urinary tract infections - this is because of the loss of healthy, protective bacteria. Another common name for this condition is atrophic vaginitis.
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How is this condition treated?
Vaginal estrogen cream can be used to replenish your vaginal estrogen levels, and reverse many of the symptoms listed above! The two most common types are Estrace and Premarin. The cream can take time to work, up to 2-3 months while your vaginal lining is healing.
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How can I make sure I am applying the cream correctly?
When first prescribed, you need to apply it daily for two weeks. Then switch to twice a week. If you have trouble remembering which days you picked, try adding something to your calendar, your phone, or into your pill box as a reminder!
The cream comes with an applicator, but many patients find it difficult to use. Try using your finger instead, apply a pea-sized (or 1 gram) amount to your finger and applying directly to the vagina.
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I picked up my prescription but the side effects listed sound scary!
You may notice that the side effects of vaginal estrogen cream include things like breast endometrial or ovarian cancer, stroke, heart attack, and other severe conditions. Fortunately vaginal estrogen cream has not been shown to have these side effects and has been extensively studied. However, estrogen pills do have these side effects, and the FDA warning gets carried over to the estrogen cream. The cream has been shown to even be safe in patients with a history of breast or endometrial cancer.
The pelvic floor can be the key to improving your urination.
What is the pelvic floor?
Your pelvic organs are surrounded by a “hammock” of pelvic muscles known as the pelvic floor, or the levators. These muscles connect to your pelvic organs and the urethral and anal sphincter muscles. They also have many attachments to the bones of your pelvis. You also have many ligaments, fibrous connections between the different bones of your pelvis as well as your pelvic organs to help provide support and stability.
What is pelvic floor dysfunction?
Just like any other muscle in your body, your pelvic floor muscles can become tight, sore, and painful. This can lead to different symptoms including pain or difficulty with urination, pain with sex, and pain with bowel movements. Your physical exam may show that your pelvic floor (behind the vaginal wall) is very tense and painful to exam - this is not normal!
The best treatment for pelvic floor dysfunction is specialized physical therapy to help relax and stretch your pelvic floor muscles. Usually this does not require kegels, which tightens your pelvic floor and can make your symptoms worse.
Dr. Chertack will provide you with a referral for a local physical therapist who has specialized training in helping patients with their pelvic floor.
What is pelvic organ prolapse?
This is when the pelvic organs lose support and “fall” into the vagina and can even push out through the vaginal opening. This can be cause by aging, prior pregnancies, and prior surgery. You may have noticed this as a bulge in your vagina, or a need to push into your vagina to use the bathroom, or to push things back after using the bathroom. This is not usually dangerous, but can be bothersome.
If you find it bothersome, Dr. Chertack will refer you to a urogynecologist to discuss a variety of surgery options. You can also discuss surgery alternatives, mainly pessaries.
What is stress incontinence?
When “stress” is placed on the bladder it can cause leakage - stress can be from coughing, laughing, sneezing, or even just standing up. This can be due to weakness or laxity in the connections between the urethra, bladder, and the pelvic muscles and bones. This is not dangerous but can be bothersome, especially depending on how many pads you use.
Non-surgical options include pelvic floor exercises, weight loss, and pessaries. There are a variety of surgical options which Dr. Chertack can discuss with you if you are interested.
Sometimes it's as simple as changing up your bathroom routine.
What if I am an infrequent voider?
As we age, the nerves to and from our bladder age, this can lead to decreased sensation of bladder filling. Symptoms include voiding only a few times per day, sudden urge to void, and leakage before reaching the bathroom. Often this can be treated with behavioral changes alone (see below).
What does it mean to have an "overactive" bladder?
Your bladder can become “irritable” as you get older, leading to more frequent urination, sudden urge to void, nighttime urination, and leakage. Treatment options include behavioral changes (see below), medications to relax the bladder, and occasionally more invasive treatments. Dr. Chertack will discuss medication details with you if they are warranted.
What sort of behavioral changes can I make?
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Timed voiding: Set an alarm to get up and use the bathroom every 1-3 hours to ensure your bladder is empty. This prevents urgency and leakage.
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Double voiding: Use the bathroom, wash your hands, then use the bathroom again. This may decrease your frequent urination and help you better empty your bladder completely.
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Voiding diary: This has been provided as a separate handout to record your daily fluid intake and voiding habits, fill this out and bring to your next visit.
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Fluid management: It is a good idea to stay hydrated, most patients should drink 2-3 liters of water daily, although every patient is different (and some patients have restrictions).
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Avoid constipation: Having hard, infrequent stool can worsen your symptoms. Try to have a soft bowel movement every day. Dr. Chertack highly recommends Metamucil, Miralax (if you don’t drink very much water), or Citrucel - these can all be purchased without a prescription.