dogmom
09-17-2013, 09:17 AM
So I wanted to update you all on surgery I decided to have for stress incontinence. I have stress incontinence since my DS (9 lbs OP presentation, 4 hrs active labor). It was somewhat manageable, but after 45 it started getting worse due to perimenopause. (During menopause the tissue around this area looses substance and cannot support the urethra as much.) It got to a point where no amount of Kegels I did was going to stop all the leaks when I sneezed or coughed, and at times it would be a gush. I had it last fall and signed on for a complete Pelvic Floor work up, which includes evaluation of my voiding and retention which was all so much fun. I will say that I am very lucky to work at a larger teaching hospital with a great pelvic floor disorders specialty unit, so they have a wide range of experience. In the end I did have fairly significant stress incontinence and mild uterine prolapsed that did not need to be fixed. I was unprepared to wear diapers starting at age 48, so I had three options:
1) Pelvic Floor Physical Therapy: This involves working with a PT to really learn how to do Kegels correctly. They also work on core strength. I decided not to do this option because I had gone to PT for a hip issue and I already had an abbreviated workup for the pelvic floor as part of this issue. I knew how to do my Kegel’s correctly and I actually was too tight in my posterior floor muscles, probably from bearing down. So I didn’t driving in 2 ½ round trip once a week was really going to get me anything I didn’t already have.
2) A vaginal pessary: This is a device that goes into your vagina that you pretty much wear all the time to support the structures so when you cough/sneeze/bear down you don’t leak. http://www.webmd.com/urinary-incontinence-oab/vaginal-pessaries The good thing is they are non-invasive. When I asked who uses them they tend to be older women who don’t won’t surgery or women who still plan to have children and shouldn’t have surgery. Honestly, I just was not that thrilled with this option. If I was older I would have taken it.
3) A TVT urethral sling: http://www.webmd.com/urinary-incontinence-oab/tension-free-vaginal-tape-for-stress-incontinence-in-women basically they put a small, thin mesh under your urethra to prevent it from sagging with bearing down. It is inserted through the vaginal wall and there are two small incisions above your pubic mound when it is pulled up. It is a very quick procedure. My surgeon does it under minimal conscious sedation or general vs. local because she does not what a spinal to interfere with the voiding trial you do afterwards. This is not to be confused with the “Bad Drug Mesh Slings” that are advertised on daytime TV. Those are larger amounts of mesh that are put higher up and pinned higher up to support the entire prolapsed uterus or bladder.
The major complication rates run 1-3% and are as follows: Mesh erosion, where the mesh winds up wearing through the vaginal wall and becoming exposed. It sounds horrible, but it isn’t as big of a deal as it sounds, some people don’t even realize they have it. Infection actually is very rare because the vaginal tissue is actually exposed to the outside and very immunologically active and the mesh has a wide weave and allows the immune cells to get there. My surgeon says often they do nothing with mesh erosion, sometimes they take out, sometimes they graft. It doesn’t actually cause badness.
Some women have problems with establishing a regular voiding pattern, or feeling when they need to void, after the surgery. She feels like those are mostly the women who are always going to the BR to avoid incontinence and they don’t a normal voiding pattern now. They need retrained. Her quote was, “I never had a nurse have that problem, you all hold your pee too long.”
Other complication is problems with voiding. Since the area heals after the mesh and scar tissue forms, which is the plan they put it in loose, some people heal in such a way that causes problems with voiding. 20% of people need to go home with a catheter and all bus 1-2% of them will have it out within 2 days. (I did not need one.) If after 30 days there is problem voiding they just go in and snip the mesh and undo the surgery. I felt like this was the worst complication listed and since it seemed reversible it was an acceptable risk for me.
She said she really had but one or two individuals that complain of chronic pain afterwards, unlike the larger mesh surgeries. They she was trying to say something like, “Now pain is a very subjective thing and some individuals…” I was, you can stop right there! I know what you are talking about, not worried.
So I went to see her in April and decided to schedule the surgery for the fall so I wouldn’t take a month off during the summer for work. The recovery for most people is 3-4 days at home and then back to work, but no lifting more than 10 lbs for 4 weeks. Since I’m a nurse my surgeon has a pretty strict policy of us not working for 4 weeks. (She wisely does not trust us to be on a patient care unit and not lift 10 lbs. Heck, before I went out I had a 550 lb pt I was caring for.)
Another reason I decided to go with the surgery is my surgeon is a specialist in urogynecology and does a lot of these. She spent an hour with me on my first visit and another 30 minute for my preop. She does reconstructive surgeries for oncology patients, so this must all be a walk in a park to her. She works with a great, knowledgeable team. She’s not some gynecologist that just went to some weekend workshop. (Apparently people do this.)
I also have the benefit of knowing everyone involved. I got to pick my anesthesiologist and they ran me with all IV sedation so no postop nausea and vomiting for the first time. I think everyone I ran into in same day surgery and recovery room knew me because I teach ACLS to them. I realize I am really lucky to work in a great place that treats me like family. I was home by 5pm. I took some oxycodone for 36 hours and switched to Motrin on postop day 2. I’m back on my feet by postop day 4 and besides putting the hamper on the scale and adding one garment at a time until I get to 9 lbs to do laundry I’m fine. (My DH is still screaming at me about this.) No catheter. The biggest issue is getting my bowels moving and I also had my Mirena taken out so I’m having my first period in 4 .5 years.
I’ll update you all after a month to see how it works out. So far I would recommend the procedure.
1) Pelvic Floor Physical Therapy: This involves working with a PT to really learn how to do Kegels correctly. They also work on core strength. I decided not to do this option because I had gone to PT for a hip issue and I already had an abbreviated workup for the pelvic floor as part of this issue. I knew how to do my Kegel’s correctly and I actually was too tight in my posterior floor muscles, probably from bearing down. So I didn’t driving in 2 ½ round trip once a week was really going to get me anything I didn’t already have.
2) A vaginal pessary: This is a device that goes into your vagina that you pretty much wear all the time to support the structures so when you cough/sneeze/bear down you don’t leak. http://www.webmd.com/urinary-incontinence-oab/vaginal-pessaries The good thing is they are non-invasive. When I asked who uses them they tend to be older women who don’t won’t surgery or women who still plan to have children and shouldn’t have surgery. Honestly, I just was not that thrilled with this option. If I was older I would have taken it.
3) A TVT urethral sling: http://www.webmd.com/urinary-incontinence-oab/tension-free-vaginal-tape-for-stress-incontinence-in-women basically they put a small, thin mesh under your urethra to prevent it from sagging with bearing down. It is inserted through the vaginal wall and there are two small incisions above your pubic mound when it is pulled up. It is a very quick procedure. My surgeon does it under minimal conscious sedation or general vs. local because she does not what a spinal to interfere with the voiding trial you do afterwards. This is not to be confused with the “Bad Drug Mesh Slings” that are advertised on daytime TV. Those are larger amounts of mesh that are put higher up and pinned higher up to support the entire prolapsed uterus or bladder.
The major complication rates run 1-3% and are as follows: Mesh erosion, where the mesh winds up wearing through the vaginal wall and becoming exposed. It sounds horrible, but it isn’t as big of a deal as it sounds, some people don’t even realize they have it. Infection actually is very rare because the vaginal tissue is actually exposed to the outside and very immunologically active and the mesh has a wide weave and allows the immune cells to get there. My surgeon says often they do nothing with mesh erosion, sometimes they take out, sometimes they graft. It doesn’t actually cause badness.
Some women have problems with establishing a regular voiding pattern, or feeling when they need to void, after the surgery. She feels like those are mostly the women who are always going to the BR to avoid incontinence and they don’t a normal voiding pattern now. They need retrained. Her quote was, “I never had a nurse have that problem, you all hold your pee too long.”
Other complication is problems with voiding. Since the area heals after the mesh and scar tissue forms, which is the plan they put it in loose, some people heal in such a way that causes problems with voiding. 20% of people need to go home with a catheter and all bus 1-2% of them will have it out within 2 days. (I did not need one.) If after 30 days there is problem voiding they just go in and snip the mesh and undo the surgery. I felt like this was the worst complication listed and since it seemed reversible it was an acceptable risk for me.
She said she really had but one or two individuals that complain of chronic pain afterwards, unlike the larger mesh surgeries. They she was trying to say something like, “Now pain is a very subjective thing and some individuals…” I was, you can stop right there! I know what you are talking about, not worried.
So I went to see her in April and decided to schedule the surgery for the fall so I wouldn’t take a month off during the summer for work. The recovery for most people is 3-4 days at home and then back to work, but no lifting more than 10 lbs for 4 weeks. Since I’m a nurse my surgeon has a pretty strict policy of us not working for 4 weeks. (She wisely does not trust us to be on a patient care unit and not lift 10 lbs. Heck, before I went out I had a 550 lb pt I was caring for.)
Another reason I decided to go with the surgery is my surgeon is a specialist in urogynecology and does a lot of these. She spent an hour with me on my first visit and another 30 minute for my preop. She does reconstructive surgeries for oncology patients, so this must all be a walk in a park to her. She works with a great, knowledgeable team. She’s not some gynecologist that just went to some weekend workshop. (Apparently people do this.)
I also have the benefit of knowing everyone involved. I got to pick my anesthesiologist and they ran me with all IV sedation so no postop nausea and vomiting for the first time. I think everyone I ran into in same day surgery and recovery room knew me because I teach ACLS to them. I realize I am really lucky to work in a great place that treats me like family. I was home by 5pm. I took some oxycodone for 36 hours and switched to Motrin on postop day 2. I’m back on my feet by postop day 4 and besides putting the hamper on the scale and adding one garment at a time until I get to 9 lbs to do laundry I’m fine. (My DH is still screaming at me about this.) No catheter. The biggest issue is getting my bowels moving and I also had my Mirena taken out so I’m having my first period in 4 .5 years.
I’ll update you all after a month to see how it works out. So far I would recommend the procedure.