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Vaginal Mesh Lawsuit Info News – 1/23/2012: Your doctor will perform the first examination for incontinence or prolapse in the same way as all gynecologic exams are done. The doctor will have you lie on your back on the examining table with your feet in stirrups. The uterus, fallopian tubes, and ovaries will be examined to make sure they feel normal. Even if you have had a hysterectomy, the doctor will perform an internal exam to make sure nothing else is pushing down on the vagina or rectum. The vagina will then be examined a bit more carefully to see if the bladder or rectum is pushing against a weakened vaginal wall, causing a visible bulge. You will be asked to cough or bear down so that any weakness in the muscles supporting the bladder or rectum is made more apparent. The extra pressure will make weakened areas bulge further. Childbirth, gravity, menopause, aging, and heredity may all contribute to the problem of sagging or dropping of these organs.
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The areas around the vagina and rectum will be touched with a Q-tip, and the doctor will record your ability to feel that touch. If you are unable to feel the Q-tip touching you, there may be a problem with die nerves in the area of the bladder or rectum. In that case, you may be referred to a neurologist for further evaluation. Some neurological conditions, such as back injuries, strokes, diabetes, and multiple sclerosis, can affect the muscles that aid bladder function. During the first office visit, your doctor will probably ask you how often you urinate, how much liquid you drink in a day, and how often you have accidents. The answers to these questions are a good start, but a written record of these events may more specifically illustrate what happens with your bladder during the course of your day. This written record is called a voiding diary, or urolog. It is intended to be a one- or two-day record of how much liquid you drink, the amount and frequency of your urination, and how much leaking you have. Because a written record is better than relying on your memory, the voiding diary is a very accurate method of determining just how significant the incontinence problem is.
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Some women wear pads to protect their underwear and clothes from urine leakage. Your doctor will probably ask you about this during the office visit. The size and absorbency of pads vary, as does die frequency that women change them during the day. In order to accurately measure the amount of urine you may be losing during die day, some doctors ask you to do a pad count For a day or two before your appointment, you will be asked to keep all the pads you use in a sealed plastic bag and bring them, along with one dry pad, to the doctor’s office. This is not the most pleasant task, but it does tell the doctor exactly how much urine you are losing during the day. We weigh the wet pads, then the single dry one, and calculate how much urine you have lost. In addition to measuring the number of pads you use during a day, the test can also calculate if whatever treatment we prescribe actually decreases the amount of urine lost.
In order for us to understand what is causing your incontinence, we sometimes need to figure out if the bladder muscle is working properly. The test for this is known as urodynamics, or UDS for short. Despite the peculiar name, this has nothing to do with jet planes or aerodynamics. The term urodynamics implies that we are able to see the bladder (uro), in action (dynamic). The muscular sac we call the bladder is supposed to stay relaxed and then comfortably expand while it collects and stores urine made by the kidneys. The bladder is supposed to work without any effort, or even awareness, on your part. Then, when you are ready to urinate, it should contract and force the urine out. The urodynamic study allows us to measure the way the bladder works: Does it fill up without the contractions associated with overactivity? Does it contract properly and at the right time? Can the bladder hold a reasonable amount of urine? Does it hold too little urine? Too much? When it contracts, does it get all the urine out?
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UDS testing allows us to answer these questions. Some women may need to have UDS testing done, especially if the diagnosis is not clear to the doctor after the initial tests described above. UDS testing is performed in the office, takes about one hour, and is painless. Your doctor will ask you to undress from the waist down and wrap a sheet around your waist. First you will sit in a special chair that supports your back, buttocks, and legs in a comfortable position. This chair allows your doctor to tilt you back to a lying position in order to perform the first part of the testing. Then, without your having to move, you can be tilted to a sitting position to see if your bladder functions any differently while you are upright—as you are for most of the day. The first part of the testing involves urinating into a specialized basin that measures how fast or slowly the urine comes out of your bladder. If something is blocking the urine, such as scarring inside the urethra or a bladder muscle that isn’t working properly, the flow will be slow.
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Many doctors feel they are able to tell the kind of bladder problem you are having based upon your answers to the questions and the examination in the office. However, a recent study found this approach to diagnosis much less than 100 percent accurate. The researchers asked a bladder specialist to look at the records of more than three hundred women who had bladder problems, with the exception of the results of urodynamic tests that were also performed. The specialist diagnosed one hundred women with stress incontinence based on answers to the doctor’s questions and physical examination. But a careful look at the urodynamics testing showed that only thirty-eight of those women really had pure stress incontinence. The other women had either an overactive bladder or a mixture of stress incontinence and an overactive bladder.
Urodynamics testing tells us about the pressures inside the bladder and urethra, but it does not tell us what the bladder and urethra look like when the bladder is filling or emptying. Some research centers have been testing video urodynamics equipment, which allows the physician to see the bladder on X ray as it fills, holds fluid and empties. By comparing this X-ray picture with the actual pressures recorded at the same time by the urodynamics instruments, they can get a good picture of how the bladder is actually working.
If the flow of urine out of the urethra is blocked, the video reveals where the blockage is. If the bladder and urethra are not working properly to let the urine out, the video may show the urethra closing when it is supposed to open. If the urethra is not strong enough to hold the urine in the bladder, the video shows it spread open, with urine leaking out. The video urodynamics equipment is very expensive, and for most women the additional information it makes available does not help to diagnose the problem. Therefore, your doctor may choose not to perform this test.
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Everyone who has had a child knows that once that baby is born, life is never the same again. Women also know that their bodies are never exactly the way they were before they gave birth. Recent evidence tells us more precisely how they change. Women who have not delivered a child vaginally rarely develop incontinence or pelvic muscle relaxation, while women who have vaginal deliveries sometimes do. Again, be assured that most women will not go on to develop incontinence after childbirth. There are many factors that can lead to incontinence; the strength of the pelvic supporting structures you were bom with; the forces these structures have resisted over the years, including childbirth, heavy lifting, and straining during bowel movements; your ability to heal if these tissues are injured; the effect of the aging process on the collagen that gives strength to these structures. Probably no one factor is completely responsible for the development of incontinence.
The connection between incontinence and childbirth has been assumed for a long time. When gynecologists see women for problems of incontinence, they are not surprised to find severe problems in women who have had many children or who have delivered large babies. Doctors have started working out the details of these relationships and are looking for the specific reasons why some women go on to develop incontinence and other women never have this problem. Although the studies are preliminary and involve only small numbers of women, details are starting to emerge.
About 10 to 20 percent of women who have a vaginal delivery will be bothered by prolapse—bulging of the bladder, rectum, or uterus into the vagina—by the time they reach the age of fifty. Women who deliver one child have a three times’ greater risk of developing prolapse than women who have not had children. Women who delivered two children have a five times’ increased risk, and women with four or more children have an eleven times’ greater likelihood of developing this problem. Women who need to push longer than one hour to deliver, or who deliver larger babies, appear to be at a greater risk of developing incontinence later in life. There is increasing evidence that childbirth is responsible for much of the injury to the muscles and nerves of the pelvis. This injury eventually leads to urinary loss and pelvic prolapse. Most women are not aware of this somewhat new information. In fact, many doctors are not apprised of the recently collected data. This chapter explains what we know, so far, about incontinence and childbirth.
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