Posts Tagged ‘stress urinary incontinence’

Ladies, If You Leak When You Exercise

June 30, 2018

Andrew Siegel MD  6/30/18

Exercise is of vital importance to physical and psychological health, reduces risk for diabetes, cardiovascular disease and cancer, is a great stress reducer and improves muscle strength, endurance, coordination and balance. It is an important factor in maintaining a healthy weight, decreasing body fat, increasing longevity and decreasing mortality. All good!girl-woman-sport-photographer-train-recreation-1165198-pxhere.com (1).jpg

image above, Creative Commons

Urinary incontinence is an annoying condition that women experience much more commonly than do men.  One of the main types is leakage with physical activities and exercise, a.k.a. stress urinary incontinence (SUI). When a woman suffers from SUI it often acts as a barrier to exercising because no one wants to be put in the embarrassing and inconvenient situation of wetting themselves every time they jump, bounce or move vigorously. Some women adapt by modifying the types of exercise that they participate in, while others give up completely on exercising, an omission that can contribute to poor physical and psychological health, a greater risk for medical issues, weight gain, etc.

What physical activities cause leakage?

The most common exercises that provoke SUI are high impact, vertical deceleration activities in which there is repeated contact with a hard surface with both feet simultaneously, e.g. skipping, trampoline, jumping jacks, jumping rope, running and jogging.

Other physical activities that commonly provoke SUI are exercises that combine dynamic abdominal and pelvic movements, e.g., burpees, squats, sit ups and weight bearing exercises, e.g., weighted squats, overhead kettle bell swings, etc.  The classic weight lifting style exercises are occasional triggers of SUI.

Activities that cause SUI (in order of those most likely to provoke the SUI)

  1. Skipping
  2. Trampoline
  3. Jumping jacks
  4. Running
  5. Jogging
  6. Box jumps
  7. Burpees
  8. Squats
  9. Sit ups
  10. Weighted squats
  11. Kettle bell swings
  12. Dead lifts
  13. Push ups
  14. Wall balls
  15. Shoulder press
  16. Clean and jerk
  17. Snatch
  18. Bench press
  19. Rowing

 So, what to do?

Many women figure out the means to improve or diminish the problem.  Common sense measures include urinating immediately before exercising and if possible taking washroom breaks during the activity (not always possible and inconvenient).  Even so, most women do not empty the bladder 100%, so if 1-2 ounces remain after emptying, there is still plenty of urine to potentially leak.  Other adaptive measures are fluid restriction (not particularly healthy before vigorous activity, risking dehydration).  Wearing a protective pad or incontinence tampon is certainly a way around the problem (although not ideal).  Another strategy is to modify one’s exercise program, such as reducing the duration, frequency or intensity of the activity.  Avoiding high impact exercises entirely and substituting them with activities that involve less impact is another possibility. However, these are adaptive and coping mechanisms and not real solutions.

There is a better solution

Urologists–particularly those like myself who have expertise in female pelvic medicine–can help manage the condition of stress urinary incontinence.  First line treatment is  Kegel pelvic floor exercises that—when done properly (as they are often not) with the right program—can often significantly improve the situation.

New video on pelvic floor exercises.

If a concerted effort at a Kegel program fails to sufficiently improve the situation, a 30-minute outpatient procedure called a mid-urethral sling is a highly effective means of treating the exercise incontinence.

Bottom Line: Physical activities most likely to induce urinary leakage are high impact exercises including skipping, trampoline, jumping jacks, jump rope and jogging.  Coping mechanisms and adaptive behaviors include fluid restriction (not healthy before exercise), urinating before activities (reasonable), taking breaks from exercise to urinate (inconvenient), pads (ugh), dialing down the intensity of exercising, modifying type of exercise or complete avoidance of exercising (undesirable).  If coping and adaptive behaviors are not effective, consider seeing a urologist who focuses on incontinence.  The goal of treatment is to be able to return to the physical activities that you enjoy without the fear of urinary leakage.   

Excellent resource: Urinary leakage during exercise: problematic activities, adaptive behaviors, and interest in treatment for physically active Canadian women: E Brennand, E Ruiz-Mirazo, S Tang, S Kim-Fine, Int Urogynecol J (2018)29: 497-503

Wishing you the best of health and a happy 4th of July holiday!

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

 

 

Advertisements

Kegels-on-Demand: Use Them As Needed

March 24, 2018

Andrew Siegel MD   3/24/2018

The concept of pelvic floor muscle training is not just to develop a strong and flexible pelvic floor, but also to put that capacity into practical use.  By knowing how to use your pelvic floor in real-life situations, you can improve your quality of life and many pelvic floor-related issues that may have surfaced over the years. This is the  essence of “functional fitness.”   Although this entry is primarily geared towards females, Kegels-on-demand on equally useful for men who have overactive bladder, stress incontinence, tension myalgia and premature ejaculation.

shutterstock_femalebluepelvic

 

Putting Your Pelvic Floor Muscle Training Into Action: Kegels-on-demand

Functional pelvic fitness is the practical and actionable means of applying pelvic floor muscle (PFM) proficiency to common everyday activities to improve pelvic function. This encompasses the knowledge of how to contract and relax PFM muscles through their full range of motion in the real world (as opposed to isolated, out-of-context contractions), when to do so, how often do so and why to do so.  For many women, this is the essence of PFMT–having stronger and more durable PFM to improve their quality of life.  These purposeful and consciously applied PFM contractions are not intended as exercise or training—although they will secondarily serve that purpose—but as management of the various pelvic floor dysfunctions at the times and moments that the problems become apparent.  When practiced diligently, these targeted PFM contractions can ultimately become automatic and reflex behaviors.

“Gotta” Go: Urgency Management

When you feel the sudden and urgent desire to urinate or move your bowels, snap your PFM several times, briefly but intensively. When your PFM are so engaged, the bladder muscle reflexively relaxes and the feeling of intense urgency should disappear. Understand that this is most effective when the bladder or bowels are not full, but are contracting involuntarily.

Staying Dry

For urgency incontinence, prior to exposure to the specific provoking trigger—hand washing, key in the door, running water, entering the shower, cold or rainy weather, etc.—snap your PFM rapidly several times to preempt the involuntary bladder contraction before it occurs (or diminish or abort the bladder contraction after it begins).

With respect to stress urinary incontinence (SUI), by actively contracting the PFM immediately before exposure to the activity that prompts the SUI, the incontinence can be improved or prevented. For example, if changing position from sitting to standing results in SUI, do a brisk short duration PFM contraction prior to and when transitioning from sitting to standing to brace the PFM and pinch the urethra shut.

Keeping Your Insides In

If you have pelvic organ prolapse (POP) and have defined activities that cause the prolapsed pelvic organ to drop or protrude—often standing, bending or straining—engage the PFM prior to or during these triggers. If you need to manually reduce the POP (by pushing the prolapse in with your fingers), after doing so, consciously engage the PFM to maintain the prolapsed pelvic organ in its proper anatomical position.

Better Sex for You and Your Partner

Integrate your newfound PFM powers in the bedroom and intensify your sensation as well as his by tightening your vaginal “grip” around his penis during sexual intercourse.  Alternatively, you can pulse your PFM rhythmically while pelvic thrusting or pulse your PFM without pelvic thrusting, the snapping providing penile stimulation in the absence of active thrusting.

As you develop increasing PFM proficiency, you may be able to selectively contract individual PFM in isolation, simultaneously, or in such a sequence that can result in a titillating experience for both you and your partner. You may be able to develop as much fine motor control of your vagina as you have of your fingers and hands! At the time of sexual climax, focus on the involuntary rhythmic contractions of your PFM and try to heighten the experience by explosively contracting them.

Try This: “Pompoir” is a technique in which a woman contracts her PFM rhythmically to stimulate the penis without the need for pelvic motion or thrusting. Women who diligently practice Kegel training can develop powerful PFM and become particularly adept at this, resulting in extreme vaginal “dexterity” and the ability to refine pulling, pushing, locking, gripping, pulsing, squeezing and twisting motions, which can provide enough stimulation to bring a male to climax. 

Relaxing the High-strung Pelvic Floor

If you suffer with tension myalgia of the PFM, focus on consciously unclenching the PFM over the course of your day. Be particularly aware of the natural PFM relaxation that occurs when urinating or moving your bowels and strive to replicate that feeling of PFM release.

 Limber hip rotators,

A powerful cardio-core,

But forget not

The oft-neglected pelvic floor.

 

Wishing you the best of health!

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

 

 

 

Nuts and Bolts of Pelvic Floor Muscle Training: Part 4

March 3, 2018

Andrew Siegel MD   3/3/2018

There are few, if any, pelvic programs in existence targeted for specific pelvic floor dysfunctions, as what you will generally find is a “one-size-fits-all” approach.

What follows are focused pelvic training programs, each designed for the nuances of the specific pelvic dysfunction at hand.  I have designed a general program as well as programs for poor pelvic muscle endurance, stress urinary incontinence (SUI), overactive bladder (OAB), pelvic organ prolapse (POP)/vaginal laxity, sexual/orgasm issues, bowel incontinence and pelvic pain. These programs have been carefully crafted based on my specialized training in pelvic medicine and surgery, clinical experience, interactions with physical therapists, exercise/fitness experts, Pilates and yoga instructors, and most importantly, my patients.

 General PFMT Program

The general program is a balanced program that incorporates strength and endurance training.  It is intended for women who are found to have poor PFM strength or poor strength and endurance on the preliminary testing. It is also appropriate for women without specific pelvic issues who wish to pursue a PFM exercise program to make their PFM stronger, more durable and to help prevent the onset of pelvic floor issues.

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each week try to step up the intensity of the PFM contractions and duration of the short contractions; allot equal time to relaxing phase as contracting phase; refer back to previous pages if you need a refresher on snaps, shorts and sustained.

 Week 1: snaps x20; 2-5 second shorts x15; 10 second sustained x1 = 1 set 

 Week 2: snaps x30; 2-5 second shorts x20; 10 second sustained x2 = 1 set 

 Week 3: snaps x40; 2-5 second shorts x25; 10 second sustained x3 = 1 set 

 Week 4: snaps x50; 2-5 second shorts x30; 10 second sustained x3 = 1 set 

Week 5 and on: Advance to resistance training. However, if you were severely challenged by this non-resistance program or cannot or prefer not to use resistance—which requires the placement of a device in your vagina—you can continue this as a “maintenance” program, consisting of the Week 4 regimen performed twice weekly (as opposed to every other day).

 PFMT for Poor PFM Endurance

This program is designed for those with satisfactory PFM strength (Oxford grades 3-5), but poor endurance. The number of contractions performed and contraction duration are gradually increased over the course of the training program as adaptation occurs.

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; allot equal time to relaxing phase as contracting phase.

 Week 1: snaps x15; 2 second shorts x15; 6 second sustained x1 = 1 set 

 Week 2: snaps x25; 3 second shorts x20; 8 second sustained x2 = 1 set 

 Week 3: snaps x35; 4 second shorts x25; 10 second sustained x3 = 1 set 

 Week 4: snaps x50; 5 second shorts x30; 10 second sustained x4 = 1 set 

 Week 5 and on: Advance to resistance training.  If you found yourself severely challenged by this non-resistance program or cannot/prefer not to use resistance (which requires the placement of a device in your vagina), you can continue this as a “maintenance” program consisting of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for POP/Vaginal Laxity

Endurance training is especially relevant for those with POP and poor vaginal tone. Focusing on sustained contractions will benefit the slow twitch endurance PFM fibers that are the prime contributors to pelvic tone and support. 

 Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each successive week, work on stepping up the intensity of the PFM contractions; allot equal time to relaxing phase as contracting phase.

 Week 1: snaps x20; 2-5 second shorts x15; 10 second sustained x1 = 1 set 

 Week 2: snaps x30; 2-5 second shorts x20; 10 second sustained x2 = 1 set 

 Week 3: snaps x40; 2-5 second shorts x25; 10 second sustained x3 = 1 set 

 Week 4: snaps x50; 2-5 second shorts x30; 10 second sustained x4 = 1 set 

 Week 5 and on: Advance to resistance training.  However, if you were severely challenged by this non-resistance program or cannot or prefer not to use resistance—which requires the placement of a device in your vagina—you can continue using this as a “maintenance” program, which will consist of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for Sexual/Orgasm Issues

The PFM contract intensively at the time of climax with each contraction lasting about 0.8 of a second, about how long snaps last. A series of vigorous snaps is precisely the PFM contraction pattern experienced at the time of orgasm. If you have issues with achieving an orgasm or with orgasm intensity, this natural contraction pattern is replicated in this program, which focuses on high-intensity pulses of the PFM (snaps) that benefit the fast twitch explosive fibers.  Endurance training is also important for sexual function since sustained contractions benefit the slow twitch endurance PFM fibers that contribute to pelvic support and vaginal tone.    

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each week work on stepping up the intensity of the snap PFM contractions; allot equal time to relaxing phase as contracting phase.

Week 1: snaps x30; 2-5 second shorts x15; 10 second sustained x1 = 1 set 

Week 2: snaps x40; 2-5 second shorts x20; 10 second sustained x2 = 1 set 

Week 3: snaps x50; 2-5 second shorts x25; 10 second sustained x3 = 1 set 

Week 4: snaps x60; 2-5 second shorts x30; 10 second sustained x4 = 1 set 

Week 5 and on: Advancing to the resistance training.  However, if you were severely challenged by this non-resistance program or cannot/prefer not to use resistance—which requires the placement of a device in your vagina—you can continue using this as a “maintenance” program, consisting of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for SUI

Strength and power training are critical for managing SUI, with the power element (i.e., how rapidly you can maximally contract your PFM) vital in order to react quickly to SUI triggers.  Focusing on moderate intensity contractions that last for several seconds (shorts) will benefit SUI, as this type of PFM contraction deployed prior to and during any activity that induces the SUI will help prevent its occurrence.  Attention directed to these short contractions will allow earlier activation of the PFM with SUI triggers, as well as increased contraction strength and durability to counteract the sudden increase in abdominal pressure that induces SUI.  Effort applied to sustained contractions is equally important since the slow twitch endurance PFM fibers are prime contributors to pelvic tone and pelvic support of the urethra, which promote urinary continence.

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each successive week try to step up the PFM contraction intensity as well as the activation speed (how long it takes to get to peak intensity); allot equal time to relaxing phase as contracting phase.

Week 1: snaps x20; 5 second shorts x15; 10 second sustained x1 = 1 set 

Week 2: snaps x30; 5 second shorts x20; 10 second sustained x2 = 1 set 

Week 3: snaps x40; 5 second shorts x25; 10 second sustained x3 = 1 set 

Week 4: snaps x50; 5 second shorts x30; 10 second sustained x4 = 1 set 

Week 5 and on: Advance to resistance training.  However, if you were severely challenged by this non-resistance program or cannot or prefer not to use resistance—which requires the placement of a device in your vagina—you can continue this as a “maintenance” program, which consists of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for OAB and Urinary/Bowel Incontinence

Focusing on high-intensity pulses of the PFM (snaps) will benefit the fast twitch explosive fibers that are critical for inhibiting urinary and bowel urgency/urgency incontinence. These snaps will generate increased PFM strength and power to enhance the inhibitory reflex between PFM and the bladder/bowel, permitting a speedy reaction to urgency and facilitating the means to counteract urinary and bowel urgency, frequency and incontinence. Of equal importance is endurance training of the slow twitch, fatigue-resistant fibers that contribute to baseline tone of the voluntary urinary and bowel sphincters.

Perform the following: 3 sets; one-minute break between each set; do 3-4 times weekly; with each successive week try to step up the intensity of the PFM contractions; allot equal time to relaxing phase as contracting phase.

Week 1: snaps x20; 2-5 second shorts x15; 10 second sustained x1 = 1 set 

Week 2: snaps x30; 2-5 second shorts x20; 10 second sustained x2 = 1 set 

Week 3: snaps x40; 2-5 second shorts x25; 10 second sustained x3 = 1 set 

Week 4: snaps x50; 2-5 second shorts x30; 10 second sustained x4 = 1 set 

Week 5 and on: Advance to resistance training.  However, if you were severely challenged by this non-resistance program or cannot/prefer not to use resistance (which requires the placement of a device in your vagina), you can continue using this as a “maintenance” program, which will consist of the Week 4 regimen performed twice weekly (as opposed to every other day).

PFMT for Pelvic Pain Due to Tension Myalgia: “Reverse” PFMT

Focusing on the relaxing aspect of the PFM contraction/relaxation cycle is the key to “down-train” the PFM from their over-tensioned, knot-like state. Those with over-contracted and over-toned PFM will not benefit from the typical strengthening PFMT done for most PFM dysfunctions—and can actually worsen their condition—so the emphasis here is on the relaxation phase of the PFM. This is “reverse” PFMT, conscious unclenching of the PFM in which the PFM drop and slacken as opposed to rise and contract. Reverse PFMT strives to stretch, relax, lengthen and increase the flexibility of the PFM. 

“Reverse” Kegels can be a confusing and difficult concept, particularly because these exercises demand conscious relaxation of the PFM, which only occurs subconsciously in real life. Recall that the PFM have a baseline level of tone and that complete PFM relaxation only occurs at the time of urination, bowel movements, passing gas or childbirth. 

To make this easier to understand, think of a PFM contraction on a scale of 0-10, with 0 being complete relaxation and 10 being maximal contraction. I have arbitrarily chosen 2 as the baseline level of PFM tone.  In reverse Kegel exercises you strive to go from 2 to 0 as opposed to standard exercises in which the effort is to go from 2 to 10.  When you urinate, move your bowels or pass gas, the PFM relax to a level of 0, so this is the feeling that you should strive to replicate, while continuing to breathe regularly without straining or pushing.  A deep exhalation of air will facilitate PFM relaxation, as it does for other muscle groups.

Perform the following: A very gentle PFM contraction to initiate PFM engagement, followed by deep relaxation and release of the PFM lasting as long as the contraction; 3 sets; one-minute break between each set; do 3-4 times weekly.

Week 1: reverse snaps x20; reverse 2-5 shorts x15; reverse 10 second sustained x1 = 1 set 

Week 2: reverse snaps x30; reverse 2-5 shorts x20; reverse 10 second sustained x2 = 1 set 

Week 3: reverse snaps x40; reverse 2-5 shorts x25; reverse 10 second sustained x3 = 1 set 

Week 4: reverse snaps x50; reverse 2-5 shorts x30; reverse 10 second sustained x3 = 1 set 

Week 5 and on: There is no role for using resistance exercises for tension myalgia. Continue using this program as a “maintenance” program, consisting of the Week 4 regimen done twice weekly (as opposed to every other day). Make a concerted effort at keeping the PFM relaxed at all times, not just while pursuing the PFMT program.

…To be continued.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (the female version is in the works): PelvicRx

 

Stress Urinary Incontinence (SUI)—Gun and Bullet Analogy

November 18, 2017

Andrew Siegel MD   11/18/17

With all the violence and senseless shootings in the USA, I hate to even mention the words “guns” and “bullets,” but they do offer a convenient metaphor to better understand the concept of stress urinary incontinence

Stress urinary incontinence (SUI) is a spurt-like leakage of urine at the time of a sudden increase in abdominal pressure, such as occurs with sneezing, coughing, jumping, bending and exercising. It is particularly likely to occur when upright and active as opposed to when sitting or lying down, because of the effect of gravity and the particular anatomy of the bladder and urethra. It is common in women following vaginal childbirth, particularly after difficult and prolonged deliveries.  It also can occur in men, generally after prostate surgery for prostate cancer and sometimes after surgical procedures done for benign prostate enlargement. 7. SUIIllustration above by Ashley Halsey from The Kegel Fix

Although not a serious issue like heart disease, cancer, etc., SUI nonetheless can be debilitating, requiring the use of protective pads and often necessitating activity limitations and restrictions of fluid intake in an effort to help manage the problem. It  certainly can impair one’s quality of life.

The root cause of SUI is typically a combination of factors causing damage to the bladder neck and urethra or their support mechanisms.  In females, pelvic birth trauma as well as aging, weight gain, chronic straining and menopausal changes weaken the pelvic muscular and connective tissue support.  In males this can occur after radical prostatectomy, although fortunately with improved techniques and the robotic-assisted laparoscopic  approach, this happens much less frequently than it did in prior years.

An effective means of understanding SUI is to view a bladder x-ray (done in standing upright position) of a person without SUI and compare it to a woman or man with SUI.  The bladder x-ray is performed by instilling contrast into the urinary bladder via a small catheter inserted into the urethra.

A healthy bladder appears oval in shape because the bladder neck (situated at the junction of the bladder and urethra) is competent and closed at all times except when urinating, at which time it relaxes and opens to provide urine flow.  An x-ray of the bladder of a woman or man with SUI will appear oval except for the 6:00 position (the bladder neck) where a small triangle of contrast is present (representing contrast within the bladder neck).  This appears as a “funnel” or a “widow’s peak.” With coughing or straining, there is progressive funneling and leakage.

normal bladder

Above photo is normal oval shape of contrast-filled bladder of person without SUI

female sui relaxAbove photo is typical funneled shape of contrast-filled bladder of female with SUI

male suiAbove photo is typical funneled shape of contrast-filled bladder of male with SUI following a prostatectomy

female sui strainAbove photo shows progressive funneling and urinary leakage in female asked to cough, demonstrating SUI 

 

The presence of urine within the bladder neck region is analogous to a bullet loaded within the chamber of a gun.  Essentially the bladder is “loaded,” ready to fire at any time when there is a sudden increase in abdominal pressure, which creates a vector of force analogous to firing the gun.

What to do about SUI?

Conservative management options include pelvic floor muscle training to increase the strength and endurance of the muscles that contribute to bladder and urethra support and urinary sphincter control.  Surgical management includes sling procedures (tape-like material surgically implanted under the urethra) to provide sufficient support and compression.  Sling procedures are available to treat SUI in both women and men.  An alternative is urethral bulking agents, injections of materials to bulk up and help close the leaky urethra. On occasion, when the bladder neck is rendered incompetent  resulting in severe urinary incontinence, implantation of an artificial urinary sphincter may be required to cure or vastly improve the problem.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, Apple iBooks, Nook and Kobo:

 MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

Cover

These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

 

 

DON’T Exercise Your Pelvic Muscles… TRAIN Them

April 1, 2017

Andrew Siegel MD  4/1/2017

“Exercise” is not the same as “training” and “pelvic floor exercises” (“Kegels”) are not the same as “pelvic floor training.”

1116_Muscle_of_the_Perineum (1)

Male (left) and female (right) pelvic floor muscles–By OpenStax [CC BY 4.0 (http://creativecommons.org/licenses/by/4.0)%5D, via Wikimedia Commons

To anybody interested in the nuances of exercise science, “exercising” and “training” are as different as apples and oranges. Don’t get me wrong—they are both healthy and admirable pursuits and doing any form of physical activity is far superior to being sedentary. However, exercise is more of being “in the moment,” a “here and now” physical activity– the short view. On the other hand, training is a well-planned and thought out process pursued towards the achievement of specific long-term goals– the long view. Every workout in a training program can be thought of as an incremental steppingstone in the process of muscle adaptation to achieve improvement or enhancement of function. The ultimate goal of a training program is being able to apply in a practical way the newly fit and toned muscles to daily activities—functional fitness—in order to achieve a better performance (and when it comes to the pelvic floor muscles, an improved quality of life.)

Muscle training is all about adaptation. Our muscles are remarkably adaptable to the stresses and loads placed upon them. Muscle growth will only occur in the presence of progressive overload, which causes compensatory structural and functional changes. That is why exercises get progressively easier in proportion to the effort put into doing them.  As muscles adapt to the stresses placed upon them, a “new normal” level of fitness is achieved. Another term for adaptation is plasticity–our muscles are “plastic,” meaning they are capable of growth or shrinkage depending on the environment to which they are exposed.

One obvious difference between pelvic floor muscles and other skeletal muscles is that the pelvic muscles are internal and hidden, which adds an element of challenge not present when training the visible arm, shoulder and chest muscles. However, the pelvic floor muscles are similar to other skeletal muscles in terms of their response to training. In accordance with the adaptation principle, incrementally increasing contraction intensity and duration, number of repetitions and resistance will build pelvic muscle strength, power and endurance.

The goal for pelvic floor muscle training is for fit pelvic muscles—strong yet flexible and equally capable of powerful contractions as well as full relaxation. The ultimate goal for pelvic floor muscle training—a goal that often goes unmentioned–is the achievement of “functional pelvic fitness.”  Pelvic floor muscle training really is the essence of functional fitness, training that develops pelvic floor muscle strength, power, stamina and the skill set that can be used to improve and/or prevent specific pelvic functional impairments including those of a sexual, urinary, or bowel nature and those that involve weakened pelvic support resulting in pelvic organ prolapse.

With occasional exceptions, most women and men are unable to perform a proper pelvic muscle contraction and have relatively weak pelvic floor strength. In my opinion, pelvic training programs should therefore initially focus on ensuring that the proper muscles are being contracted and on building muscle memory. It is fundamental to learn basic pelvic floor anatomy and function and how to isolate the pelvic muscles by contracting them independently of other muscles. Once this goal is achieved, pelvic training programs can be pursued.

Programs need to be able to address the specific area of pelvic weakness, e.g., if strength is the issue, emphasis on strength training is in order, whereas if stamina is the issue, focus on endurance training is appropriate. Furthermore, programs need to be designed for specific pelvic floor dysfunctions, with “tailored” training routines customized for the particular pelvic health issue at hand, whether it is stress urinary incontinence, overactive bladder, pelvic organ prolapse, sexual/orgasm issues, or pelvic pain. Aligning the specific pelvic floor dysfunction with the appropriate training program that focuses on improving the area of weakness and deficit is fundamental since each pelvic floor dysfunction is associated with unique and specific deficits in strength, power and/or endurance.

It is easiest to initially train the pelvic floor muscles in positions that remove gravity from the picture, then advancing to positions that incorporate gravity. It is sensible to begin with the simplest, easiest, briefest pelvic contractions, then advance to the more challenging, longer duration contractions, slowly and gradually increasing exercise intensity and degree of difficulty.

In my opinion, the initial training should not include resistance, which should be reserved for after achieving mastery of the basic training that provides the foundation for pelvic muscle proficiency.

Bottom Line: If you are serious about improving or preventing a pelvic floor dysfunction, you need to do pelvic floor muscle training as opposed to pelvic floor exercises. There are numerous differences including the following:

  • Training is motivated by specific goals and purposes while exercise is done for its own sake or for more general reasons
  • Training requires a level of focus and intensity not demanded by exercise
  • Training requires a plan
  • Training can be a highly effective means of improving and preventing pelvic floor dysfunction

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com

Leaking Havoc: Diagnosing And Treating Female Stress Urinary Incontinence

March 4, 2017

Andrew Siegel, MD  3/4/17

This is the completion of a blog entry uploaded last week entitled “Leaking Havoc: Female Stress Incontinence.”

How is Stress Urinary Incontinence (SUI) diagnosed and evaluated?

Listening carefully to the patient is usually sufficient to make the diagnosis of SUI, the typical complaint being: “Doc, I leak urine when I sneeze, cough and exercise.”

After hearing the details of the patient’s problem, the next step is a pelvic examination. The issue with an exam with legs-up-in-stirrups is that this is NOT the position in which SUI typically occurs, since SUI is usually provoked by standing, exertion and physical activities. For this reason, the exam must be performed using straining or coughing forcefully enough to demonstrate the SUI.

The pelvic examination is done after the patient empties her bladder. The exam involves observation, passage of a small catheter (a narrow hollow tube) into the bladder, a speculum exam and a digital exam.

Inspection determines tissue health and the presence of urethral movement with straining. After menopause, typical changes include thinning of the vaginal skin, redness, irritation, etc. The ridges and folds within the vagina that are present in younger women (rugae) tend to disappear.

A small catheter is passed into the bladder to determine how much urine remains, to obtain a urine culture in the event that urinalysis suggests infection and to determine urethral angulation. With the catheter in place, the angle that the urethra makes with the horizontal is measured. The catheter is typically parallel with the horizontal at rest. The patient is asked to strain and the angulation is again measured, recording the change in urethral angulation that occurs between resting and straining. Urethral angulation with straining (hyper-mobility) is a sign of loss of urethral support, which often is seen with SUI. The vagina is carefully inspected for other manifestations of pelvic organ prolapse (dropped bladder, rectum, uterus) that can accompany the SUI.

urethra-rest

                                     Image above: female urethra (woman in stirrups)–note that urethra points straight ahead, like the barrel of a rifle

urethra-strain

                             Image above: female urethra (woman in stirrups)– because of urethral hyper-mobility the urethra leaks at the moment she is asked to strain or cough

Finally, a digital examination is performed to assess vaginal tone and pelvic muscle strength (rated on a scale from 0-5). A bimanual exam (combined internal and external exam in which the pelvic organs are felt between internal and external examining fingers) checks for the presence of pelvic masses.

Depending on circumstances, tests to further evaluate SUI may be used, including an endoscopic inspection of the lining of the bladder and urethra (cystoscopy), sophisticated functional tests of bladder storage and emptying (urodynamics) and, on occasion, imaging tests (bladder fluoroscopy).                   

How is SUI managed?

There are a variety of treatment options for SUI, ranging from non-invasive strategies to surgery. There are no effective medications for SUI. If there is not an adequate response to first-line, non-invasive, conservative measures, surgery becomes an appropriate consideration. However, it is always sensible to initially use a conservative approach that is cost-effective, natural, uses few resources and is free from side effects.

Kegel Exercises for SUI

Kegels have emerged from obscure to mainstream…In fact the 2017 Oscar “swag bag” included a pelvic floor device called “The Elvie,” reviewed in my book THE KEGEL FIX.

 

one-sheet-poster

Combating SUI demands contracting one’s pelvic floor muscles (PFMs) strongly, rapidly and ultimately, reflexively. The goal of Kegels, a.k.a. pelvic floor muscle training (PFMT) is to increase PFM strength, power, endurance and coordination to improve urethral support and closure.

Who Knew? PFMT has the potential to improve or cure SUI in those who suffer with the problem and prevent it in those who do not have it.

The cough reflex is an automatic contraction of the PFMs above and beyond their resting tone when one coughs. This squeezes the urethra shut to help prevent leakage. This is nature’s way of protection against incontinence with a sudden increase in abdominal pressure, a defense against cough-related SUI. An extension of this principle is to exercise the PFMs to amplify strength and power to allow earlier activation and more robust contraction.

PFMT increases PFM bulk and thickness, reducing the number of SUI episodes. Additionally, PFMT improves urethral support at rest and with straining, diminishing the urethral hyper-mobility that is characteristic of SUI. It also permits earlier activation of the PFMs when coughing, more rapid repeated PFM contractions and more durable PFM contractions between coughs.

Who Knew? PFMT can cure or considerably improve 60-70% of women who suffer with SUI. The benefits persist for many years, as long as the exercises are adhered to on an ongoing basis. PFMT is equally effective for pre-menopausal and post-menopausal women with SUI.

Who Knew? PFMT is most effective in women with mild or mild-moderate SUI. Chances are that if the SUI is moderate-severe, PFMT will be less effective. However, if not cured, the SUI can be improved, and that might be sufficient.

Once the PFMs are conditioned via PFMT, it is vital to apply the improved conditioning on a practical basis. The cough reflex can be replicated—voluntarily—when one is in situations other than actual coughing that induce SUI. In order to do so, one needs to be attentive to the triggers that provoke the SUI. By actively contracting the PFMs immediately prior to the trigger exposure, the SUI can be improved or prevented. For example, if changing position from sitting to standing results in SUI, consciously performing a brisk PFM contraction—an intense contraction for 2-5 seconds prior to and during transitioning from sitting to standing—should “clamp the urethra” and help control the problem. Such bracing of the PFMs can be a highly effective means of managing SUI and when practiced diligently can become automatic (a reflex behavior).

More Non-Invasive Strategies to Improve SUI

Manage the condition that provokes the SUI: Since discrete triggers often provoke SUI (e.g., when asthma causes wheezing, seasonal allergies cause sneezing, or when tobacco use, bronchitis, sinusitis, or post-nasal drip cause coughing), by managing the underlying condition, the SUI can be avoided.

Moderate fluid intake: With a sudden increase in abdominal pressure, there will tend to be more SUI when there are larger volumes in the bladder (although SUI can occur even immediately after urinating). Since there is a direct relationship between fluid intake and urine production, any moderation in fluid intake will decrease the volume of urine in the bladder and potentially improve the SUI. The key is to find the right balance to diminish the SUI, yet avoid dehydration. Since caffeinated beverages and alcohol increase urine volume, it is best to limit exposure (caffeine is present in coffee, tea, cola and even chocolate has a caffeine-like ingredient).

Urinate regularly: Based on the premise that there tends to be more SUI when there are greater volumes in the bladder, by emptying the bladder more frequently, SUI can be better controlled. Urinating on a two-hour basis is usually effective, although the specific timetable needs to be individually tailored. Voluntary urinary frequency is more desirable than involuntary SUI. An extension of this principle is to empty one’s bladder immediately before any activity that is likely to induce the SUI.

Maintain a healthy weight: Extra pounds can worsen SUI by increasing abdominal pressure and placing a greater load on the pelvic floor and bladder. Even a modest weight loss may improve SUI.

Who Knew? Bearing the burden of unnecessary pounds adversely affects many body parts. As much as obesity puts a great strain on the knees that support the body’s weight, so it does on the PFM.

Exercise: Being physically active can go a long way towards maintaining general fitness and helping improve SUI. In general, exercises that emphasize the core muscles—particularly Pilates and yoga—are most helpful for SUI. Unfortunately, and ironically, it is exercise that often provokes SUI.

Tobacco cessation: Tobacco causes bronchial irritation and coughing that provoke SUI. Additionally, chemical constituents of tobacco constrict blood vessels, impair blood flow, decrease tissue oxygenation and promote inflammation, negatively affecting function of the bladder, urethra and PFMs. By eliminating tobacco, SUI can be significantly improved.

Maintain bowel regularity: Achieving bowel regularity may improve SUI and prevent it from progressing. A rectum full of stool can adversely affect urinary control by putting internal pressure on the bladder and urethra. Additionally, chronic straining with bowel movements—similar in many ways to being in “labor” every day—can have a cumulative effect in weakening PFMs and can be a key factor in the development of SUI. To promote healthy bowel function, exercise daily and increase fiber intake by eating whole grains, fruits and vegetables.

The tampon trick: If SUI occurs under very predictable circumstances—e.g., during tennis, golf or jogging—a strategically placed tampon can be a friend. The tampon is not used for absorption purposes, but to support the urethra. By positioning the tampon in the vagina directly under the urethra, it acts as a space-occupying backboard. The tampon does not need to be positioned as deeply as it would be for menstruation, but just within the vagina. This may allow one to pursue activities without the need for a pad. Poise has come out with “Impressa,” a tampon available in three sizes designed specifically for SUI. It is placed via an applicator and can be worn for up to eight hours. In Australia and the UK, “Contiform,” a self-inserted, foldable intra-vaginal device that is shaped like a hollow tampon, is often used to help manage SUI.

Surgical Management of SUI: Mid-urethral sling

sling

Image above is of a mid-urethral sling in place under the urethra to provide the support necessary to cure/substantially improve the stress urinary incontinence

If conservative measures fail to sufficiently improve SUI, there are solutions. A relatively simple outpatient procedure—the mid-urethral sling—is the implantation of a synthetic tape between the urethra and vagina to recreate the “backboard” of urethral support that is defective. This creates a “hammock” to provide support and to allow compression and pinching of the urethra with any activity that increases abdominal pressure.

The sling procedure is performed via a small vaginal incision. The permanent material used for the sling is polypropylene tape, the same material as used by general surgeons to repair groin hernias. Mid-urethral refers to the placement of the sling beneath the mid-urethra, the channel that leads from the bladder to the urinary opening. Sling refers to the configuration created when the tape is firmly anchored to the soft tissues of the pelvis after being placed underneath the urethra. The sling procedure has a 85-90% cure rate for SUI.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health. Much of the content of this entry was excerpted from this book.  The book was written for educated and discerning women who care about health, well being, nutrition and exercise and enjoy feeling confident, sexy and strong.

The Kegel Fix is available in e-book format on the Amazon Kindle, iPad (Apple iBooks), Barnes & Noble Nook and Kobo and in paperback, all accessible via the following website: www.TheKegelFix.com. The e-book offers discretion, advantageous for books about personal issues, is less expensive, is delivered immediately, saves the trees, has adjustable fonts, as well as numerous hyperlinks—links to other sites activated by clicking—that access many helpful resources.

Leaking Havoc: Female Stress Urinary Incontinence

February 25, 2017

Andrew Siegel MD  2/25/17

*Credit for title “Leaking Havoc” goes to freelance writer Karen Gibbs who recently interviewed me for an article on this topic for New Jersey Family Magazine.

Stress urinary incontinence (SUI) is a very common condition that affects one in three women during their lifetimes, most often young or middle-aged, although it can happen at any age. An involuntary spurt of urine occurs during sudden increases in abdominal pressure, which can happen with coughing, sneezing, laughing, jumping or exercise. It can even happen with walking, changing position from sitting to standing, or during sex.

7. SUI

Illustration above of stress urinary incontinence, by Ashley Halsey from Dr. Siegel’s book : “The Kegel Fix”

In Europe, SUI is referred to as “exertion” incontinence, since some form of physical effort usually triggers it. This is less confusing than the American term “stress” incontinence since the word stress is most typically used in the context of emotional stress–but here I am referring to only the physical stress of a sneeze, jump, etc.

Who Knew? The triggers that most consistently provoke SUI are jumping up with a sudden stop as one’s feet touch down—jumping jacks, trampoline and jump rope.

 Who Knew? There are hereditary/racial differences in the prevalence of SUI with SUI being less common in women of African-American descent and more common in Caucasian women, thought to be on the basis of genetic differences in pelvic muscle bulk.

SUI most often occurs because the support to the urethra (the urinary channel that goes from the bladder out)—the pelvic floor muscles and connective tissues—has weakened and no longer provides an adequate “backboard” to the urethra. This allows the urethra to be pushed down and out of position at times of sudden increases in abdominal pressure, a condition known as urethral hyper-mobility.

The key inciting factors for SUI are pregnancy, labor and delivery, particularly traumatic vaginal deliveries of large babies. SUI is uncommon in women who have not delivered vaginally or in women who have delivered by elective Caesarian section (a C-section without experiencing labor). However, emergency C-section done for failure of labor to progress has a similar risk for SUI as vaginal delivery.

Many women experience SUI during pregnancy. By their third month of pregnancy, 20% of women report SUI, as do 50% at full term. There are many reasons for its occurrence, including the pressure of the enlarging uterus on the bladder and stretching of the pelvic floor muscles and other connective tissues.

Who Knew? After giving birth to your newborn, in addition to buying diapers for your baby you may have to buy them for yourself!

Who Knew? The more vaginal deliveries one has, the greater the likelihood of developing SUI.

Who Knew? Numerous studies have demonstrated the benefits of pelvic floor muscle training (Kegels) in facilitating an early return of urinary control and improving the severity of SUI.

Some women experience persistent SUI after childbirth, while others find that it improves dramatically and resolves within 6 months. Others will not experience SUI until many years after childbirth, after promoting factors have kicked in. These factors include obesity, aging, menopause, weight gain, gynecological surgery (especially hysterectomy), and any condition that increases abdominal pressure. These include coughing (often from smoking), asthma, weight training and high impact sports (e.g., trampoline, gymnastics, pole vaulting, etc.) and occupations that require heavy physical labor. Chronic constipation is a major contributory factor because of pushing and straining on a daily basis, cumulatively causing the same weakening of urethral support as happens with obstetrical labor.

Who Knew? SUI is common in recreational as well as elite female athletes, particularly those who participate in high impact sports involving jumping. It can lead to poor athletic performance and ultimately avoiding sports participation.

The specific activities that provoke SUI and the severity of the leakage can vary greatly from woman to woman. Some only experience SUI with extreme exertion, such as when serving a tennis ball, swinging a golf club or with a powerful sneeze. Others experience SUI with minimal exertion such as walking or turning over in bed. Some women do not wear any protective pads or liners, changing their panties as necessary, whereas others wear many pads per day. Some are significantly bothered by even a minor degree of SUI, while others are accepting of experiencing many episodes of SUI daily.

Although the predominant cause of SUI is inadequate urethral support, it may also be caused by a weakened or damaged urethra itself. Risk factors for this are menopause, pelvic surgery, injury to the urethral nerve supply, radiation, and pelvic trauma. Such a severely compromised urethra usually causes significant urinary leakage with minimal activities and also results in “gravitational” incontinence, a profound urinary leakage that accompanies positional change.

Genuine SUI needs to be distinguished from other conditions that cause leakage of urine with increases in abdominal pressure that are not on the basis of inadequate urethral support or a weakened urethra. These other conditions can masquerade as genuine SUI. It is critical to distinguish between them since the treatments are very different. This is one reason why a thorough evaluation of SUI is important. The conditions that can masquerade as genuine SUI include: failure to empty the bladder; urethral diverticulum; vaginal voiding; and stress-induced involuntary bladder contraction.

Failure to empty the bladder can occur for a variety of reasons, including blockage of outflow of urine and an underactive bladder that contracts poorly. When the bladder is constantly full, it is easy to understand why a sudden increase in abdominal pressure can provoke leakage.

Who Knew? An extension of this is that if your bladder is full and you leak a small amount with jumping or laughing, it is not necessarily problematic, but just means that you need to urinate before engaging in such activities.

Urethral diverticulum is a small sac-like out-pouching from the urethra that can fill up with urine and leak during physical activities. The treatment is often surgical repair.

Vaginal voiding occurs in a small percentage of women who have an anatomical variation in which their urethral openings are internally recessed as opposed to the normal external urethral opening on the vestibule, immediately above the vaginal opening. When urinating, some of the urine pools in the vagina. Upon standing and physical exertion, the urine can then leak out of the vagina.

Stress-induced involuntary bladder contraction is a condition in which an involuntary contraction of the bladder (the bladder squeezing without its owner’s permission) is triggered by a maneuver that typically causes SUI. For example, a cough induces an involuntary bladder contraction, causing urinary leakage.

…To be continued next week when I will review how to diagnose and treat SUI.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health http://www.TheKegelFix.com.  Much of the content of this entry was excerpted from this book, written for educated and discerning women who care about health, well being, nutrition and exercise and enjoy feeling confident, sexy and strong.

The Kegel Fix is available in e-book format on the Amazon Kindle, iPad (Apple iBooks), Barnes & Noble Nook and Kobo and in paperback, all accessible via the following website: www.TheKegelFix.com. The e-book offers discretion, advantageous for books about personal issues, is less expensive, is delivered immediately, saves the trees, has adjustable fonts, as well as numerous hyperlinks—links to other sites activated by clicking—that access many helpful resources.

Female Bladder Works

February 11, 2017

Andrew Siegel MD   2/11/17

This entry is a brief overview of bladder anatomy and function to help you better understand the two most common forms of urinary leakage—stress urinary incontinence and overactive bladder— topics for entries that will follow for the next few weeks.  Having a working knowledge of the properties of the bladder will serve you well in being able to understand when things go awry. 

                          6. bladder

                             Drawing of the bladder and urethra by Ashley Halsey from “The Kegel Fix:                           Recharging Female Pelvic, Sexual and Urinary Health”

The bladder is a muscular balloon that has two functions—storage and emptying of urine. The stem of the bladder balloon is the urethra, the tube that conducts urine from the bladder during urination and helps store urine at all other times. The urethra runs from the bladder neck (where the urinary bladder and urethra join) to the urethral meatus, the external opening located just above the vagina.

Bladder Control Issues—More Than Just a Physical Problem

Urinary incontinence is an involuntary leakage of urine. Although not life threatening, it can be life altering and life disrupting. Many resort to absorbent pads to help deal with this debilitating, yet manageable problem. It is more than just a medical problem, often affecting emotional, psychological, social and financial wellbeing (the cumulative cost of pads can be significant). Many are reluctant to participate in activities that provoke the incontinence, resulting in social isolation, loss of self-esteem and, at times, depression. Since exercise is a common trigger, many avoid it, which can lead to weight gain and a decline in fitness. Sufferers often feel “imprisoned” by their bladders, which have taken control over their lives, impacting not only activities, but also clothing choices, travel plans and relationships.

Bladder Function 101

Healthy bladder functioning depends upon properties of the bladder and urethra. Bladder control issues arise when one or more of these go awry:

Capacity

The average adult has a bladder that holds about 12 ounces before a significant urge to urinate occurs. Problem: The most common capacity issue is when the capacity is too small, causing urinary frequency.

Elasticity

The bladder is stretchy like a balloon and as it fills up there is a minimal increase in bladder pressure because of this expansion. Low-pressure storage is desirable, as the less pressure in the bladder, the less likelihood for leakage issues. Problem: The bladder is inelastic or less elastic and stores urine at high pressures, a setup for urinary leakage.

Sensation

There is an increasing feeling of urgency as the urine volume in the bladder increases. Problem: The most common sensation issue is heightened sensation creating a sense of urgency before the bladder is full, giving rise to the frequent need to urinate. Less commonly there exists a situation in which there is little to no sensation even when the bladder is quite full (and little warning that the bladder is full), sometimes causing the bladder to overflow.

Contractility

After the bladder fills and the desire to urinate is sensed, a voluntary bladder contraction occurs, which increases the pressure within the bladder in order to generate the power to urinate. Problem: The bladder is “under-active” and cannot generate enough pressure to empty effectively, which may cause it to overflow when large volumes of urine remain in the bladder.

Timing

A bladder contraction should only occur after the bladder is reasonably full and the “owner” of the bladder makes a conscious decision to empty the bladder. Problem: The bladder is “overactive” and squeezes prematurely (involuntary bladder contraction) causing sudden urgency with the possibility of urinary leakage occurring en route to the bathroom.

Anatomical Position

The bladder and urethra are maintained in proper anatomical position in the pelvis because of the pelvic floor muscles and connective tissue support. Problem: A weakened support system can cause urinary leakage with sudden increases in abdominal pressure, such as occurs with sneezing, coughing and/or exercising.

Urethra

In cross-section, the urethra has infoldings of its inner layer that give it a “snowflake” appearance. This inner layer is surrounded by rich spongy tissue containing an abundance of blood vessels, creating a cushion around the urethra that permits a watertight seal similar to a washer in a sink. The female hormone estrogen nourishes the urethra and helps maintain the seal. Problem: With declining levels of estrogen at the time of menopause, the urethra loses tone and suppleness, analogous to a washer in a sink becoming brittle, potentially causing leakage issues.

Sphincters

The urinary sphincters, located at the bladder neck and mid-urethra, are specialized muscles that provide urinary control by pinching the urethra closed during storage and allowing the urethra to open during emptying. The main sphincter (a.k.a. the internal sphincter) is located at the bladder neck and is composed of smooth muscle designed for involuntary, sustained control. The auxiliary sphincter (a.k.a. the external sphincter), located further downstream and comprised of skeletal muscle contributed to by the pelvic floor muscles, is designed for voluntary, emergency control. Problem: Damage to or weakness of the sphincters adversely affects urinary control.

The main sphincter is similar to the brakes of a car—frequently used, efficient and effective. The auxiliary sphincter is similar to the emergency brake—much less frequently used, less efficient, but effective in a pinch. The pelvic floor muscles are intimately involved with the function of the “emergency brake.”

Nerves

The seemingly “simple” act of urination is actually a highly complex event requiring a functional nervous system providing sensation of filling, contraction of the bladder muscle and the coordinated relaxation of the sphincters. Problem: Any neurological problem can adversely affect urination, causing bladder control issues.

Bladder Reflexes

A reflex is an automatic response to a stimulus, an action that occurs without conscious thought. There are three reflexes that are vital to bladder control:

Guarding Reflex: During bladder filling, the “guarding” (against leakage) pelvic floor muscles contract in increasing magnitude in proportion to the volume of urine in the bladder; this provides resistance that helps prevent leakage as the bladder becomes fuller.

Cough Reflex: With a cough, there is a reflex contraction of the pelvic floor muscles, which helps prevent leakage with sudden increases in abdominal pressure.

Pelvic Floor Muscle-Bladder Reflex: When the pelvic floor muscles are voluntarily contracted, there is a reflex relaxation of the bladder. This powerful reflex can be tapped into for those who have involuntary bladder contractions that cause urgency and urgency leakage.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.wordpress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery. Much of the content of this entry was excerpted from his recently published book The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health: http://www.TheKegelFix.com

He is also the author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

The Little Muscles That Could: The Mysterious Muscles You Should Be Exercising

November 5, 2016

Andrew Siegel MD 11/5/2016

This entry was a feature article in the Fall 2016 edition of BC The Magazine: Health, Beauty & Fitness.

(A new blog is posted weekly. To receive the blogs via email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com)

3-superficial-and-deep-pfm

Image above: female pelvic floor muscles, illustration by Ashley Halsey from The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health

00001

Image above: male pelvic floor muscles, illustration by Christine Vecchione from Male Pelvic Fitness: Optimizing Sexual and Urinary Health

There are over 600 muscles in the human body and they all are there for good reasons. However, some are more critical to health and survival than others. In the class rank it is a no-brainer that the heart muscle is valedictorian, followed by the diaphragm. What may surprise you is that the pelvic floor muscles (a.k.a. Kegel muscles) rank in the top ten of the hierarchy.

The pelvic floor muscles are a muscular hammock that make up the floor of the “core” muscles. They are located in the nether regions and form the bottom of the pelvis. They are among the most versatile muscles in the body, equally essential in both women and men for the support of the pelvic organs, bladder and bowel control and sexual function. Because they are out of sight they are frequently out of mind and often not considered when it comes to exercise and fitness. However, without functional pelvic muscles, our pelvic organs would dangle and we would be diapered and asexual.

Our bodies are comprised of a variety of muscle types: There are the glamour, for show, mirror-appeal, overt, seen and be witnessed muscles that offer no secrets—“what you see is what you get”—the biceps, triceps, pectorals, latissimus, quadriceps, etc. Then there are muscles including the pelvic floor muscles that are shrouded in secrecy, hidden from view, concealed and covert, unseen and behind the scenes, unrecognized and misunderstood, favoring function over form, “go” rather than “show.” Most of us can probably point out our “bi’s” (biceps), “tri’s” (triceps), “quads” (quadriceps), “pecs” (pectorals), etc., but who really knows where their “pelvs” (pelvic floor muscles) are located? For that matter, who even knows what they are and how they contribute to pelvic health?

Strong puritanical cultural roots influence our thoughts and feelings about our nether regions. Consequently, this “saddle” region of our bodies (the part in contact with a bicycle seat)—often fails to attain the respect and attention that other zones of our bodies command. Cloaking increases mystique, and so it is for these pelvic muscles, not only obscured by clothing, but also residing in that most curious of regions–an area concealed from view even when we are unclothed. Furthermore, the mystique is contributed to by the mysterious powers of the pelvic floor muscles, which straddle the gamut of being critical for what may be considered the most pleasurable and refined of human pursuits—sex—but equally integral to what may be considered the basest of human activities—bowel and bladder function.

The deep pelvic floor muscles span from the pubic bone in front to the tailbone in the back, and from pelvic sidewall to pelvic sidewall, between the “sit” bones. The superficial pelvic floor muscles are situated under the surface of the external genitals and anus. The pelvic floor muscles are stabilizers and compressors rather than movers (joint movement and locomotion), the more typical role that skeletal muscles such as these play. Stabilizers support the pelvic organs, keeping them in proper position. Compressors act as sphincters—enveloping the urinary, gynecological and intestinal tracts, opening and closing to provide valve-like control. The superficial pelvic floor muscles act to compress the deep roots of the genitals, trapping blood within these structures and preparing the male and female sexual organs for sexual intercourse; additionally, they contract rhythmically at the time of sexual climax. Although the pelvic floor muscles are not muscles of glamour, they are certainly muscles of “amour”!

Pelvic floor muscle “dysfunction” is a common condition referring to when the pelvic floor muscles are not functioning properly. It affects both women and men and can seriously impact the quality of one’s life. The condition can range from “low tone” to “high tone.” Low tone occurs when the pelvic muscles lack in strength and endurance and is often associated with stress urinary incontinence (urinary leakage with coughing, sneezing, laughing, exercising and other physical activities); pelvic organ prolapse (when one or more of the female pelvic organs falls into the space of the vagina and at times outside the vagina); and altered sexual function, e.g., erectile dysfunction or vaginal looseness.  High tone occurs when the pelvic floor muscles are over-tensioned and unable to relax, giving rise to a pain syndrome known as pelvic floor tension myalgia.

A first-line means of dealing with pelvic floor dysfunction is getting these muscles in tip-top shape. Tapping into and harnessing their energy can help optimize pelvic, sexual and urinary health in both genders. Like other skeletal muscles, the pelvic muscles are capable of making adaptive changes when targeted exercise is applied to them. Pelvic floor training involves gaining facility with both the contracting and the relaxing phases of pelvic muscle function. Their structure and function can be enhanced, resulting in broader, thicker and firmer muscles and the ability to generate a powerful contraction at will—necessary for pelvic wellbeing.

Pelvic floor muscle training can be effective in stabilizing, improving and even preventing issues with pelvic support, sexual function, and urinary and bowel control. Pursuing pelvic floor muscle training before pregnancy will make carrying the pregnancy easier and will facilitate labor and delivery; it will also allow for the effortless resumption of the exercises in the post-partum period in order to re-tone the vagina, as the exercises were learned under ideal circumstances, prior to childbirth. Similarly, engaging in pelvic training before prostate cancer surgery will facilitate the resumption of urinary control and sexual function after surgery. Based upon solid exercise science, pelvic floor muscle training can help maintain pelvic integrity and optimal function well into old age.

Bottom Line: Although concealed from view, the pelvic floor muscles are extremely important muscles that deserve serious respect. These muscles are responsible for powerful and vital functions that can be significantly improved/enhanced when intensified by training. It is never too late to begin pelvic floor muscle training exercises—so start now to optimize your pelvic, sexual, urinary, and bowel health.

Wishing you the best of health,

2014-04-23 20:16:29

www.AndrewSiegelMD.com

Andrew Siegel MD practices in Maywood, NJ. He is dual board-certified in urology and female pelvic medicine/reconstructive surgery and is Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and attending urologist at Hackensack University Medical Center. He is a Castle Connolly Top Doctor New York Metro area and Top Doctor New Jersey. He is the author ofTHE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health (www.TheKegelFix.com) and MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health (www.MalePelvicFitness.com). He is co-creator of PelvicRx, an interactive, FDA-registered pelvic floor muscle-training program that empowers men to increase their pelvic floor muscle strength, tone, and endurance. Combining the proven effectiveness of Kegel exercises with the use of resistance, this program helps improve sexual function and urinary function. In the works is the female PelvicRx pelvic floor muscle training for women. Visit: http://www.UrologyHealthStore.com to obtain PelvicRx. Use promo code “UROLOGY10” at checkout for 10% discount.

More About Pelvic Organ Prolapse (POP)

October 22, 2016

Andrew Siegel MD 10/22/2016

This is the second entry in a three-part series about pelvic organ prolapse.  It is important to understand that the issue in POP is NOT with the pelvic organ per se, but with the support of that organ. POP is not the problem, but the result of the problem. The prolapsed organ is merely an “innocent passenger” in the POP process.

How Much Of A Vaginal Bulge Can POP Cause?

The extent of prolapse can vary from minimal to severe and can vary over the course of a day, depending on position and activity level.  POP is more pronounced with with standing (vs. sitting or lying down) and with physical activities (vs. sedentary).

The simplest system for grading POP severity uses a scale of 1-4:

grade 1 (slight POP); grade 2 (POP to vaginal opening with straining); grade 3 (POP beyond vaginal opening with straining); grade 4 (POP beyond vaginal opening at all times).

Which Organs Does POP Affect?

POP can involve one or more of the pelvic organs including the following: urethra (urethral hypermobility); bladder (cystocele); rectum (rectocele); uterus (uterine prolapse); intestines (enterocele); the vagina itself (vaginal vault prolapse); and the perineum (perineal laxity).

Urethra

The healthy, well-supported urethra has a “backboard” or “hammock” of support tissue that lies beneath it. With a sudden increase in abdominal pressure, the urethra is pushed downwards, but because of the backboard’s presence, the urethra gets pinched closed between the abdominal pressure above and the hammock below, allowing urinary control.

When the support structures of the urethra are weakened, a sudden increase in abdominal pressure (from a cough, sneeze, jump or other physical exertion) will push the urethra down and out of its normal position, a condition known as urethral hypermobility. With no effective “backboard” of support tissue under the urethra, stress urinary incontinence will often occur.

sui

Urethral hyper-mobility causing stress urinary incontinence (the gush of urine) when this patient was asked to cough.

Bladder

Descent of the bladder through a weakness in its supporting tissues gives rise to a cystocele, a.k.a. “dropped bladder,” “prolapsed bladder,” or “bladder hernia.”

A cystocele typically causes one or more of the following symptoms: a bulge or lump protruding into or even outside the vagina; the need for pushing the cystocele back in in order to urinate; obstructive urinary symptoms (a slow, weak stream that stops and starts and incomplete bladder emptying) due to the prolapsed bladder causing urethral kinking; urinary symptoms (frequent and urgent urinating); and vaginal pain and/or painful intercourse.

untitled

Cystocele

Rectum

Descent of the rectum through a weakness in its supporting tissues gives rise to a rectocele, a.k.a. “dropped rectum,” “prolapsed rectum,” or “rectal hernia.” The rectum protrudes into the floor of the vagina. A rectocele typically causes one or more of the following symptoms: a bulge or lump protruding into the vagina, especially noticeable during bowel movements; a kink of the normally straight rectum causing difficulty with bowel movements and the need for vaginal “splinting” (straightening the kink with one’s fingers) to empty the bowels; incomplete emptying of the rectum; fecal incontinence; and vaginal pain and/or painful intercourse.

rectocele

Rectocele with perineal laxity

Perineum

Often accompanying a rectocele is perineal muscle laxity, a condition in which the superficial pelvic floor muscles (those located in the region between the vagina and anus) become flabby. Weakness in these muscles can cause the following anatomical changes: a widened and loose vaginal opening, decreased distance between the vagina and anus, and a change in the vaginal orientation such that the vagina assumes a more upwards orientation as opposed to its normal downwards angulation towards the sacral bones.

Women with vaginal laxity who are sexually active may complain of a loose or gaping vagina, making intercourse less satisfying for themselves and their partners. This may lead to difficulty achieving orgasm, difficulty retaining tampons, difficulty accommodating and retaining the penis with vaginal intercourse, the vagina filling with water while bathing and vaginal flatulence (passing air through the vagina). The perception of having a loose vagina can often lead to low self-esteem.

Small Intestine

The peritoneum is a thin sac that contains the abdominal organs, including the small intestine. Descent of the peritoneal contents through a weakness in the supporting tissues at the innermost part of the vagina (the apex of the vagina) gives rise to an enterocele, a.k.a. “dropped small intestine,” “small intestine prolapse,” or “small intestine hernia.”

An enterocele typically causes one or more of the following symptoms: a bulge or lump protruding through the vagina, intestinal cramping due to small intestine trapped within the enterocele, and vaginal pressure/pain and/or painful intercourse.

enterocele

Enterocele

Uterus

Descent of the uterus and cervix because of weakness of their supporting structures results in uterine prolapse, a.k.a. “dropped uterus,” “prolapsed uterus,” or “uterine hernia.” Normally, the cervix is situated deeply in the vagina. As uterine prolapse progresses, the extent of descent into the vaginal canal will increase.

Uterine POP typically causes one or more of the following symptoms: a bulge or lump protruding from the vagina; difficulty urinating; the need to manually push back the uterus in order to urinate; urinary urgency and frequency; urinary incontinence; kidney obstruction because of the descent of the bladder and ureters (tubes that drain urine from the kidneys to the bladder) that are dragged down with the uterus, creating a kink of the ureters; vaginal pain with sitting and walking; painful intercourse; and spotting and/or bloody vaginal discharge from the externalized uterus, which becomes subject to trauma and abrasions from being out of position. The most extreme form of uterine POP is uterine “procidentia,” a situation in which the uterus is exteriorized at all times and, because of external exposure, has a tendency for ulceration and bleeding.

 

uterus

Uterine prolapse

ulcerated-procidentia

Severe uterine prolapse (procidentia) with ulcerative inflammation surrounding cervix

Vagina

The most advanced stage of POP occurs when the support structures of the vagina are weakened to such an extent that the vaginal canal itself turns inside out. Vault prolapse, a.k.a. “dropped vaginal vault,” “prolapsed vaginal vault,”or “vaginal vault hernia,” is rarely an isolated event, but often occurs coincident with other forms of POP and most often is a consequence of hysterectomy. If the vagina is likened to an internal “sock,” vaginal vault prolapse is a condition in which the sock is turned inside out. When I explain vaginal vault prolapse to patients, I demonstrate it by turning a front pocket of my pants inside out.

To be continued…

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery. Much of the content of this entry was excerpted from his recently published book: The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health. For more info: http://www.TheKegelFix.com.

He has previously authored Male Pelvic Fitness: Optimizing Sexual & Urinary Health; Promiscuous Eating: Understanding And Ending Our Self-Destructive Relationship With Food; and Finding Your Own Fountain Of Youth: The Essential Guide For Maximizing Health, Wellness, Fitness & Longevity. Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro. Area and Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

The Kegel Fix is available in e-book format on the Amazon Kindle, iPad (Apple iBooks), Barnes & Noble Nook and Kobo and in paperback, all accessible via the following website: www.TheKegelFix.com. The e-book offers discretion, advantageous for books about personal issues, is less expensive, is delivered immediately, saves the trees, has adjustable fonts, as well as numerous hyperlinks—links to other sites activated by clicking—that access many helpful resources.  The book was written for educated and discerning women who care about health, well being, nutrition and exercise and enjoy feeling confident, sexy and strong.