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Incontinence and Pelvic Organ Prolapse: Hard to Discuss, But Highly Treatable

Private: Vatche Arakel Minassian, MD, MPH
Contributor Vatche Arakel Minassian, MD, MPH

Overactive bladder. Weakening of the pelvic floor. These are the types of problems that can be difficult to bring up with your doctor. As a result, too many women suffer in silence.

Vatche Arakel Minassian, MD, MPH, chief of the Division of Urogynecology at Brigham and Women’s Hospital, sees patients with delicate health issues every day. He understands why women might hesitate to seek treatment for conditions like incontinence or pelvic organ prolapse. But given how much they can affect your quality of life, and even contribute to depression, doing nothing is rarely the best option.

“With life expectancy in the Western world continually rising, these conditions aren’t going away. If anything, they will become more and more prevalent,” Dr. Minassian said. “People shouldn’t be embarrassed to seek treatment. We’re here to help you navigate the process and offer access to treatments that are highly effective.”

Understanding the different types of incontinence

Urogynecology is a subspecialty within obstetrics and gynecology that focuses on diagnosing and treating pelvic floor disorders and related conditions.

One of the most common such conditions is incontinence, when you don’t have control of your bladder. One in 3 women experiences this condition in their lifetime. There are two main types of incontinence:

  • Urgency incontinence (overactive bladder), in which a person often has a sudden urge to urinate and can’t make it to the bathroom in time
  • Stress urinary incontinence, in which everyday activities like coughing, sneezing, lifting and laughing cause urine to leak out

Patients with both types of incontinence are said to have mixed incontinence.

“Incontinence is more widespread than many people realize, but most treatments are successful,” Dr. Minassian said. “Sometimes we can offer significant improvement; other times we have a cure.”

Treatment options for incontinence

Urgency incontinence is caused by unexpected spasms in the bladder. Dr. Minassian and his colleagues first recommend conservative treatment options, such as:

If conservative options for urgency incontinence don’t work, your doctor may recommend one of several medications and/or nonsurgical procedures.

Stress urinary incontinence is caused by weakness in the support structures under the bladder neck, which maintains the seal of urine during activity. Treatment typically involves physical therapy, exercises to strengthen the pelvic floor and/or minimally invasive surgery.

At the Brigham, the most common surgery for patients with stress urinary incontinence is a mid-urethral sling. “This is an outpatient procedure. Patients go home on the same day and recover within a week or two,” Dr. Minassian said. “Slings are about 85 to 90 percent successful.”

Pelvic organ prolapse: Symptoms and risk factors

Pelvic organ prolapse involves the sagging or bulging of one or more organs in the pelvis (uterus, bladder, rectum, small intestines and vagina). It occurs due to a weakening of the structures supporting the pelvic floor.

Symptoms of prolapse include:

  • Constipation
  • Difficulty passing the urine
  • Low back pain
  • Pelvic pressure
  • A feeling of bulge

Prolapse is more common in older women. However, anything that puts pressure on the pelvic floor increases a woman’s risk, including:

  • Being overweight or obese
  • Having multiple childbirths
  • Smoking
  • Chronic coughing
  • Heavy lifting

Prolapse treatment options

Some women are not overly bothered by prolapse and choose not to address it, especially at its early stages. For others, pelvic floor exercises may help, especially in cases of early prolapse. Having a pessary (a silicone device similar to a diaphragm) inserted into the vagina to support the prolapse is a popular nonsurgical option among women who are older and/or less active.

Reconstructive surgery to restore weakened connective tissues can provide improved long-term support of the prolapsed organs. This can be done vaginally or in a minimally invasive manner through the abdomen.

According to Dr. Minassian, roughly 15 to 20 percent of women undergo prolapse surgery in their lifetime. Success rates, he added, range from 80 to 95 percent, depending on the nature of the prolapse and type of surgery performed.

A bright outlook

No matter what the urogynecologic condition, relief is not just possible, but highly likely. If you’re having symptoms, be sure to let your doctor know and ask whether seeing a urogynecologist makes sense.

“As urogynecologists, we’re taking care of women with incontinence and prolapse day in and day out,” Dr. Minassian said. “And you can only get that kind of subspecialty expertise at a large academic medical center like the Brigham.”

Private: Vatche Arakel Minassian, MD, MPH
Vatche Arakel Minassian, MD, MPH

Vatche Minassian, MD, MPH, is Chief of the Division of Urogynecology at Brigham and Women’s Hospital and Associate Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School.

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