BTCanada

Question:  I had a baby vaginally and now my labia are growing together.  It seems to be getting worse, not better.  Do you have any ideas about how to reverse this without more vaginal surgery?  I can’t bear that thought after an hour being put back together after birth and I am feeling so ugly.

Answer:  How I wish we did have a way of reversing this without more surgery.  Labial fusion is a type of adhesion and adhesions are fibrin bands that stick surfaces together that aren’t supposed to be stuck together.  They are different than scar tissue.  Genital tract adhesions can result in painful intercourse, genital pain, urinary obstruction and urinary/vaginal infections.  They also negatively impact your body image which negatively impacts everything else.  [Any mother can tell you that the world doesn’t find labial fusions very sexy just as no one thinks stretch marks, excess abdominal skin and the extra weight are considered beautiful.  We often hear women tell us they were told to adjust what their idea of beautiful is.  We have to wonder what planet these people come from.  Blaming women for not feeling beautiful in a world that doesn’t consider them so is cruel and counter-productive.]

Surgical separation is the only effective solution we know of.  Often post-operative topical estrogen is prescribed as well to try and prevent re-adhesion.  Adhesion formation seems to increase in low estrogen situations and estrogen levels are low during the postpartum, while breastfeeding and post menopause.

No discussion about adhesions would be complete without discussing surgical adhesions after cesarean (or any other surgery).  Adhesions in the abdomen or pelvic area can lead to pelvic pain, infertility, bowel obstruction and the need for more surgery (which can lead to more adhesion formation).  A skilled and competent surgeon has a number of options available to minimize adhesion formation during surgery (surgical techniques, various barriers between layers – usually they dissolve quickly, keeping tissues moist, enzyme treatments, etc.) some of which are relatively new surgical advancements.  But even the most skilled surgical teams can’t reduce the risk to zero.  Much of it depends on how your body heals and every body is different.  Most abdominal and pelvic adhesions don’t cause problems just as most women who give birth vaginally don’t form problematic adhesions after birth.  That is cold comfort, however, to those that do.

Question:  My OB/GYN told me my incontinence is a minor problem that I should learn to work around.  He also said that fixing the problem can be worse than the problem itself.  Do you agree with that?

Answer:  Incontinence is never a minor problem.  Being unable to control basic bodily functions has a huge negative impact on a person’s quality of life and their ability to make a living.  Your OB/GYN’s language is the language of dismissiveness and irrational positivity and both are huge problems in obstetrics.  Many consider incontinence ‘minor’ if you aren’t soaking more than one pad a day. [These are the same ones who consider obstetrical lacerations < 2 cm deep as ‘trivial’ and ‘of no consequence’]  Neither is ever an acceptable way to handle distressing situations but it is what people do when confronted by situations they can’t change.   I’m going to give your OB/GYN the benefit of doubt and say he was just being people when he said this but I wasn’t there.  He may just as easily have been a jerk.  Go with your gut feeling on that one – you are the only one with a valid opinion.  Was this the same OB/GYN who attended your delivery and provided pre-natal care?  If so, he should have informed you of the incontinence risk after pregnancy and especially after a vaginal delivery.

Consider this story that illustrates the people being people thing clearly: 

A man and his brother hit a patch of black ice and the vehicle they were driving in rolled several times and ended up on its roof.  This man watched and listened to his brother die over the course of 20 minutes.  His own arm and leg were badly mangled.  There was blood everywhere.  Throughout this ordeal people stopped and watched.  Some tried to get them out.  Others kept saying everything is OK.  The emergency responders on the scene also said ‘Relax, everything is OK” But clearly things weren’t OK.  The man knew this.  He told me his last thought before losing consciousness was that he was about to die surrounded by the stupidest people he had ever met. 

These people behaved in a stupid way but they weren’t stupid people.  Behaving this way satisfies a base voyeuristic need and gives the ‘helpers’ a groundless sense of importance.  Again, neither of these helps.

The fact that he was honest with you about the cure being worse than the problem leads me to believe your OB/GYN belongs in the same category as the people trying to ‘help’ at the accident scene.  The assessment for incontinence and the treatments are thoroughly unpleasant and often painful and humiliating.  Many require a large allotment of your time and many require many trips to the doctor or physiotherapists office.  They can include physiotherapy for the pelvic floor (ie: vaginal cones, electricity applied to the genitals, various needles into the genital area and probes inserted into your vagina or rectum, sitting on a specialized magnetic chair – you get to keep your clothes on for that one), various pessaries, drugs, urethral plugs and surgery.  Surgery may solve the problem or be a dismal failure or just a temporary fix.  Never expect the pelvic floor to return to pre-childbirth condition.  Often you will still need to use incontinence products.  The stigma associated with incontinence also keeps women from pursuing treatments.  It is estimated that 75% of all women with incontinence never seek treatment.

We also hear from many women who are blamed because they can’t do Kegel exercises or because they can’t do them ‘right’.  It is unfair being on the receiving end of this self-righteous behaviour.  Kegels aren’t rocket science but they are impossible to do ‘right’ when you have suffered permanent nerve damage, irreparable damage to the musculature and connective tissue of the pelvic floor or when the connections between muscle and the pelvic bones are damaged or completely severed.  These things are common with vaginal deliveries and they are not your fault.

You can find more information about the specifics of assessment techniques and treatments in some of the books listed on the BOOK REVIEW page of this website.  We’ve re-produced some information about treatments for Stress Urinary Incontinence (SUI), Urge Urinary Incontinence (UUI) and anal incontinence.  

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SUI

Mayoclinic.com

Several procedures have been developed to treat stress incontinence. Most surgical procedures fall into two main categories: bladder neck suspension procedures and sling procedures.

Bladder neck suspension procedures
These procedures are designed to provide support to your urethra and bladder neck - an area of thickened muscle where the bladder connects to the urethra. The more common procedure is retropubic suspension. Needle suspension, also known as transvaginal suspension, was an alternative in the past but is rarely used anymore.

·         Retropubic suspension. For this procedure, your surgeon makes a 3- to 5-inch incision in your lower abdomen. Through this incision, he or she places stitches (sutures) in the tissue near the bladder neck and secures the stitches to a ligament near your pubic bone (Burch procedure) or in the cartilage of the pubic bone itself (Marshall-Marchetti-Krantz, or MMK, procedure). This has the effect of bolstering your urethra and bladder neck so that they don't sag.

Retropubic suspension generally has the highest likelihood of curing stress incontinence. The downside of this procedure is that it involves major abdominal surgery. It's done under general anesthesia and usually takes about an hour. Recovery takes about six weeks, and you'll likely need to use a catheter until you can urinate normally.

  • Needle suspension. Needle (transvaginal) suspension has a higher risk of failure and a lower long-term cure rate than does retropubic suspension. Most urogynecologists and urologists don't recommend needle suspension procedures except in rare circumstances. To do this procedure, a surgeon uses incisions in the vagina to place supportive stitches around the bladder neck and urethra. After the stitches are placed through the vaginal incisions, they're passed through a tiny abdominal incision and attached to the abdominal wall or pelvic bone.

Sling procedures
A sling procedure - the most common surgery to treat stress incontinence - uses strips of tissue or synthetic tape to create a pelvic sling or hammock around your bladder neck and urethra. The sling provides support to keep the urethra closed - even when you cough or sneeze.

In a conventional sling procedure, the surgeon inserts a sling through a vaginal incision and brings it around the bladder neck. The sling may be made of a synthetic tape, or occasionally your own tissue or animal tissue may be used. The surgeon brings the ends of the sling through a small abdominal incision and attaches them to pelvic tissue (fascia) or to the abdominal wall with stitches to achieve the right amount of tension.

A more recent trend is to use tissue friction to hold a synthetic mesh tape in place. No stitches are used to attach the mesh sling. Instead, tissue itself holds the sling in place initially. Eventually scar tissue forms in and around the tape to keep it from moving.

Sling procedures take less time than do retropubic bladder neck suspension procedures, and because they're less invasive, they can be done under local anesthesia on an outpatient basis. The advantage of having local anesthesia is that the surgeon can adjust the tension of the sling while you're awake by asking you to cough. This minimizes the risk of over-tightening the sling, which can lead to urinary retention and prolonged catheterization after the operation. In addition, because of the instrumentation used, the tension-free sling requires less cutting at the neck of the bladder.

Recovery time for tension-free slings is fairly short - it's usually only a week or two before you're able to return to your regular activities.

Bulking agents

Bulking agents are materials, such as collagen, injected into tissue surrounding the urethra to tighten the urethral sphincter and stop urine from leaking.

A bulking agent procedure - usually done in a doctor's office - requires minimal anesthesia and takes about five minutes. The downside of the procedure is that most available bulking agents lose their effectiveness over time, and repeat injections are usually needed every six to 18 months. New and improved bulking agents are being developed, as well as new ways to make the injection process easier and more efficient.

The standard method of injecting a bulking agent is through a needle, which is inserted several times in different positions with the assistance of a cystoscope - a slender, tube-like instrument that allows the surgeon to view the urethral area.

Some materials that might be used as bulking agents include:

  • Collagen. Collagen is a natural fibrous protein found in connective tissue, bone and cartilage of humans and animals. Collagen can produce an allergic reaction in some people. For this reason, your doctor is required to give you a skin test before performing the procedure to see if you have a reaction. Over time, collagen tends to deteriorate within your body. Often, multiple repeat injections are required.
  • Carbon-coated zirconium beads. Carbon-coated zirconium beads consist of synthetic, nonallergenic material, which means they don't carry the risk of causing an allergic reaction. So far, carbon-coated zirconium beads appear to be as effective as collagen. Scientists hope that this bulking agent will last much longer in the body than does collagen and require fewer repeat injections.
  • Gel. A thick gel injected into the wall of the urethra provides relief for some women with stress incontinence. Once injected, the gel adds bulk to the urethral walls, bringing them closer together to prevent urine from leaking.
  • Fat. Abdominal fat, withdrawn through liposuction, also has been used as a bulking agent. Its advantages are that it's readily available, and it's compatible with your body, so it's unlikely to cause an allergic reaction. However, a potential rare side effect is pulmonary embolism, in which a fat particle escapes and creates an obstruction in an artery in a lung. This condition can lead to severe respiratory problems and even death. When compared with collagen, fat appears to have a substantially lower cure rate for urinary incontinence. As a result, fat is rarely used as a bulking agent.

Surgery for overactive bladder

Surgery for overactive bladder may involve implanting a nerve-stimulation device or increasing your bladder's capacity.

Sacral nerve stimulation
Sacral nerve stimulation inhibits messages sent by an overactive bladder to your brain signaling a need to urinate. Sacral nerve stimulation works by continuously sending small, electrical impulses to the spinal cord reflexes that control urination. The impulses are generated by a small, pacemaker-like device surgically placed in a "pocket" of fat beneath the skin of your buttock just below the belt line. Attached to the device - called a stimulator - is a thin, electrode-tipped wire that passes under your skin, carrying these impulses to the sacral nerve.

Because sacral nerve stimulation doesn't work for everyone, you can try it out first by wearing the stimulator externally, after the attached wire is placed under your skin in a minor surgical procedure. If the stimulator substantially improves your symptoms, then you can have it implanted permanently.

Surgery to implant the stimulator is an outpatient procedure done in an operating room under local anesthesia. You may be advised to limit activities for three or more weeks as your incisions heal. Once the stimulator is implanted, it functions for several years. After that, it can be replaced during an outpatient procedure. Your doctor can adjust the level of stimulation with a hand-held programmer, and you also have a control to use for adjustments. The stimulation doesn't cause pain and may improve or cure more than half the people with difficult-to-treat urge incontinence or urinary retention leading to overflow incontinence. The device can be removed at any time.

Hydrodistention
Hydrodistention involves filling your bladder with fluid until it's stretched beyond its normal capacity, allowing it to remain distended for several minutes. Stretching your bladder in this way can be painful, so the procedure is performed under general or local anesthesia, usually in a hospital. Most of the time, you're able to go home the same day. The effects of treating overactive bladder with hydrodistention are temporary - lasting around three months - and success rates vary widely.

After the procedure, you may experience some pain in your pelvic area, especially when urinating the first few times. Your urine may contain some blood, but this is normal after the procedure. Discomfort may continue for a few weeks, but your doctor can prescribe pain relief medication to ease any pain or burning. Potential complications of hydrodistention include bleeding, urinary retention and bladder perforation, although these are fairly uncommon. Another potential complication is interstitial fibrosis, which leads to stiffening of your bladder wall.

Bladder augmentation
Bladder augmentation is an older procedure used to increase the size of your bladder. The operation is complex and involves major abdominal surgery. Your surgeon makes an incision in your abdomen and an opening at the top of your bladder. He or she then takes a strip of tissue, usually from your intestine or stomach, and attaches it onto the bladder opening. This added tissue patch increases the size of your bladder. The surgery is done under general anesthesia and may take several hours.

Recovery generally requires staying in the hospital until you're able to start drinking and eating again. It usually takes a few weeks after you leave the hospital for you to return to your normal schedule. Many people, especially those with underlying nerve damage, require lifelong use of a catheter after the procedure.

Bladder augmentation doesn't always cure incontinence and can have complications such as infection and chronic diarrhea. Two rare but potentially serious complications are spontaneous perforation of the bladder and development of bladder cancer.

One step at a time

Finding an effective remedy for urinary incontinence may take time, with several steps along the way. If a particular treatment approach isn't working for you, ask your doctor if there may be another solution to your problem.

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UUI

MEDICATION

Medications used to treat urge incontinence are aimed at relaxing the involuntary contraction of the bladder and improving bladder function. There are several types of medications that may be used alone or in combination:

  • Anticholinergic agents (oxybutynin, tolterodine, enablex, sanctura, vesicare, oxytrol)
  • Antispasmodic medications (flavoxate)
  • Tricyclic antidepressants (imipramine, doxepin)

Oxybutynin (Ditropan) and tolterodine (Detrol) are medications to relax the smooth muscle of the bladder. These are the most commonly used medications for urge incontinence and are available in a once-a-day formulation that makes dosing easy and effective.

The most common side effects of anticholinergic medicines are dry mouth and constipation. The medications cannot be used by patients with narrow angle glaucoma.

An antispasmodic drug is flavoxate (Urispas). However, studies have shown inconsistent benefit in controlling symptoms of urge incontinence.

Tricyclic antidepressants have also been used to treat urge incontinence because of their ability to inhibit or "paralyze" the bladder smooth muscle. Possible side effects include fatigue, dry mouth, dizziness, blurred vision, nausea, and insomnia.

SURGERY

The goal of any surgery to treat urge incontinence is aimed at increasing the storage ability of the bladder while decreasing the pressure within the bladder. Surgery is reserved for patients who are severely debilitated by their incontinence and who have an unstable bladder (severe inappropriate contraction) and poor ability to store urine.

Augmentation cystoplasty is the most frequently performed surgical procedure for severe urge incontinence. In this reconstructive surgery, a segment of the bowel is added to the bladder to increase bladder size and allow the bladder to store more urine.

Possible complications include those of any major abdominal surgery, including bowel obstruction, blood clots, infection, and pneumonia.

There is a risk of developing urinary fistulae (abnormal tubelike passages that result in abnormal urine drainage), urinary tract infection, and difficulty urinating. Augmentation cystoplasty is also linked to a slightly increased risk of developing tumors.

DIET

Some experts recommend a regimen of controlled fluid intake in addition to other therapies in the management of urge incontinence. The goal of this program is to distribute the intake of fluids throughout the course of the day, so the bladder does not need to handle a large volume of urine at one time.

Do not drink large quantities of fluids with meals -- limit your intake to less than 8 ounces at one time. Sip small amounts of fluids between meals. Stop drinking fluids approximately two hours before bedtime.

Additionally, it may be helpful to eliminate your intake of foods that may irritate the bladder, such as caffeine, spicy foods, carbonated drinks, and highly acidic foods such as citrus fruits and juices.

BLADDER RETRAINING

Management of urge incontinence usually begins with a program of bladder retraining. Occasionally, electrical stimulation and biofeedback therapy may be used in conjunction with bladder retraining.

A program of bladder retraining involves becoming aware of patterns of incontinence episodes and relearning skills necessary for storage and proper emptying of the bladder.

Bladder retraining consists of developing a schedule of times when you should try to urinate, while trying to consciously delay urination between these times. One method is to force yourself to wait 1 to 1 1/2 hours between urinations, despite any leakage or urge to urinate in between these times. As you become skilled at waiting, gradually increase the time intervals by 1/2 hour until you are urinating every 3 to 4 hours.

KEGEL EXERCISES

Pelvic muscle training exercises called Kegel exercises are primarily used to treat people with stress incontinence. However, these exercises may also be beneficial in relieving the symptoms of urge incontinence. The principle behind Kegel exercises is to strengthen the muscles of the pelvic floor, thereby improving the urethral sphincter function. The success of Kegel exercises depends on proper technique and adherence to a regular exercise program.

Another approach is to use vaginal cones to strengthen the muscles of pelvic floor. A vaginal cone is a weighted device that is inserted into the vagina. The woman contracts the pelvic floor muscles in an effort to hold the device the place. The contraction should be held for up to 15 minutes and should be performed twice daily. Within 4 to 6 weeks, about 70% of women trying this method had some improvement in their symptoms.

BIOFEEDBACK AND ELECTRICAL STIMULATION

For people who are unsure if they are performing Kegel exercises correctly, biofeedback and electrical stimulation may be used to help identify the correct muscle group to work. Biofeedback is a method of positive reinforcement in which electrodes are placed on the abdomen and the anal area.

Some therapists place a sensor in the vagina (for women) or the anus (for men) to assess contraction of the pelvic floor muscles. A monitor will display a graph showing which muscles are contracting and which are at rest. The therapist can help identify the correct muscles for performing Kegel exercises.

About 75% of people who use biofeedback to enhance performance of Kegel exercises report symptom improvement, with 15% considered cured.

Electrical stimulation involves using low-voltage electric current to stimulate the correct group of muscles. The current may be delivered using an anal or vaginal probe. The electrical stimulation therapy may be performed in the clinic or at home. Treatment sessions usually last 20 minutes and may be performed every 1 to 4 days.

Another form of electrical stimulation called sacral neuromodulation involves the placement of a "bladder pacemaker," which stimulates the bladder nerves. This device may provide excellent relief of symptoms for those who do not respond to other therapies.

BOTOX

An experimental therapy involves injecting botulinum toxin (Botox) into the bladder muscle to help stop the involuntary contracts that lead to urge incontinence. Early study results suggest this is a promising treatment option for those who do not respond to other therapies.

ACTIVITY

People with urge incontinence may find it helpful to avoid activities that irritate the urethra and bladder, such as taking bubble baths or using caustic soaps in the genital area.

MONITORING

Urinary incontinence is a chronic (long-term) problem. Although you may be considered cured by various treatments, you should continue to see your provider to evaluate the progress of your symptoms and monitor for possible complications of treatment.

Outlook (Prognosis)  

How well you do depends on your symptoms, an accurate diagnosis, and proper treatment. Many patients must try different therapies (some at the same time) to reduce symptoms.

Instant improvement is unusual. Perseverance and patience are usually required to see improvement. A small number of patients need surgery to control their symptoms.

Possible Complications   

Physical complications are rare, but psychosocial problems may arise, particularly if incontinence results from an inability to get to the bathroom when urgency arises.

When to Contact a Medical Professional   

Call your health care provider for an appointment if symptoms are causing you problems, if pelvic discomfort or burning with urination occurs, or if symptoms occur daily.

Prevention   

Early initiation of bladder retraining techniques may be useful in reducing the severity of symptoms.

Update Date: 6/13/2006

Updated by: Neil D. Sherman, MD, Urologist, Essex County, NJ. Review provided by VeriMed Healthcare Network.

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Anal incontinence

MayoClinic.com

To determine the cause of fecal incontinence, your doctor will ask you questions related to your condition — such as when and how often you experience an inability to control your bowels.

In addition to talking with you, your doctor may also perform a physical examination. The exam usually includes a visual inspection of your anus and the area lying between your anus and genitals (perineum) for hemorrhoids, infections and other conditions. Your doctor may use a pin or probe to examine this area of skin. Normally this touching causes your anal sphincter to contract and the anus to pucker. This test helps your doctor check for nerve damage.

Your doctor may perform a digital exam. This involves him or her inserting a gloved and lubricated finger into your rectum to evaluate the strength of your sphincter muscles and to check for any abnormalities of the rectal area. During the exam, your doctor may ask you to bear down. Bearing down helps him or her check whether rectal prolapse or certain other conditions exist.

A number of medical tests also are available to help pinpoint the cause of fecal incontinence. These may include:

  • Anal manometry. In this commonly used test, your doctor inserts a narrow, flexible tube into your anus and rectum. Once the tube is in place, a small balloon at the tip of the tube may be expanded. This test lets your doctor know how tight your anal sphincter is. It also measures the sensitivity and function of your rectum.
  • Anorectal ultrasonography. In this procedure, which evaluates the structure of your sphincter, your doctor inserts a narrow, wand-like instrument into your anus and rectum. This instrument, which is attached to a computer and video screen, emits sound waves. The waves bounce off the walls of your rectum and anus, producing video images of these internal structures.
  • Proctography. In this procedure, also known as defecography, your doctor uses a small amount of liquid called barium to coat the walls of your rectum. Barium makes your rectum more visible on X-rays, which are then taken. This test measures how much stool your rectum can hold. It also evaluates how well stool is evacuated from your rectum.
  • Proctosigmoidoscopy. In this test, your doctor uses a long, slender tube with a tiny video camera attached to examine your rectum and sigmoid — approximately the last 2 feet of your colon. This test detects signs of inflammation, tumors or scar tissue that may cause fecal incontinence.
  • Anal electromyography. This test involves the insertion of tiny needle electrodes into muscles around your anus that can reveal signs of nerve damage.

Complications

Fecal incontinence can be a source of embarrassment and shame. It's not uncommon for someone with fecal incontinence to try to hide the problem or to avoid social engagements. The loss of dignity associated with losing control over one's bodily functions can lead to frustration, anger and depression.

Besides the emotional aspects, fecal incontinence can irritate the skin. Because the skin around the anus is delicate and sensitive, repeated contact with stool can lead to pain, itching and, potentially, sores (ulcers) that require medical treatment.

Treatment

Fortunately, effective treatments are available for fecal incontinence. Your primary care physician may be able to assist you, or you may need to see a doctor who specializes in treating conditions that affect the colon, rectum and anus, such as a gastroenterologist, proctologist or colorectal surgeon. Treatment for fecal incontinence can usually help restore bowel control or at least substantially reduce the severity of the condition.

Depending on the cause of your incontinence, treatment may include dietary changes, medications, special exercises that help you better control your bowels, or surgery.

Dietary changes
What you eat and drink affects stool consistency. Your doctor may recommend changes to your diet to help improve your bowel movements.

For example, if chronic constipation is to blame for fecal incontinence, your doctor may recommend that you drink plenty of fluids and eat fiber-rich foods that aren't constipating. If diarrhea is contributing to the problem, your doctor may recommend that you increase your intake of high-fiber foods to add bulk to your stools, making them less watery. In general, your doctor will recommend a diet that helps you gain good stool consistency for increased control of your bowels.

Medications
Sometimes, doctors recommend medications to treat fecal incontinence, such as:

  • Anti-diarrheal drugs. Your doctor may recommend medications to reduce diarrhea and help you avoid accidents. A drug called loperamide (Imodium) may be used because it helps treat diarrhea.
  • Laxatives. If chronic constipation is to blame for your incontinence, your doctor may recommend the temporary use of mild laxatives, such as milk of magnesia, to help restore normal bowel movements.
  • Stool softeners. To prevent stool impaction, your doctor may recommend a stool-softening medication.
  • Other medications. If diarrhea is the cause of your fecal incontinence, your doctor may recommend drugs that decrease the spontaneous motion of your bowel (bowel motility) or medications that decrease the water content of your stool.

Bowel training
If fecal incontinence is due to a lack of anal sphincter control or decreased awareness of the urge to defecate, you may benefit from a bowel training program and exercise therapies aimed at helping you restore muscle strength.

In some cases, bowel training means learning to go to the toilet at a specific time of day. For example, your doctor may recommend that you make a conscious effort to have a bowel movement after eating. This helps you gain greater control by establishing with some predictability when you need to use the toilet. This technique can work well for children who have constipation and fecal incontinence because they forget to use the toilet. Children can learn to use the toilet at scheduled times.

In other cases, bowel training involves an exercise therapy called biofeedback. Biofeedback as a treatment for fecal incontinence involves inserting a pressure-sensitive probe into your anus. This probe registers muscle strength and activity of your anal sphincter as it contracts around the probe. You can practice sphincter contractions and learn to strengthen your own muscles by viewing the scale's readout as a visual aid. These exercises can strengthen your rectal muscles.

Treatment for stool impaction
Your doctor may have to remove an impacted stool if taking laxatives or using enemas doesn't help you pass the hardened mass. To remove an impacted stool, your doctor inserts one or two fingers into your rectum to break apart the impacted stool. These smaller pieces are easier to expel.

Surgical options
For some people, treatment of fecal incontinence requires surgery to correct an underlying problem. Surgical procedures to treat fecal incontinence aren't necessarily easy or free of complications. But, certain causes of fecal incontinence — anal sphincter damage caused by childbirth or rectal prolapse, for example — can often be effectively treated with surgery. Surgical options include:

  • Sphincteroplasty. This is surgery to repair a damaged or weakened anal sphincter. In this procedure, an injured area of muscle is identified and its edges are freed from the surrounding tissue. The muscle edges are then brought back and sewn together in an overlapping fashion. This strengthens the muscle, tightening the sphincter.
  • Operations to treat rectal prolapse, a rectocele or hemorrhoids. Rectal prolapse, a condition in which a portion of your rectum protrudes through your anus, weakens the anal sphincter. In certain circumstances, such as chronic constipation and straining, the ligaments to the rectum can become stretched and lose their ability to hold the rectum in place. Surgical correction of the rectal prolapse may be needed along with sphincter muscle repair. In women, a protrusion of the rectum into the vaginal wall (rectocele) may need to be treated surgically to correct fecal incontinence. Prolapsed internal hemorrhoids may prevent complete closure of the anal sphincter, leading to fecal incontinence. Hemorrhoids may be near the upper part or beginning of the anal canal (internal hemorrhoids) or at the lower portion or anal opening (external hemorrhoids). Hemorrhoids can be treated by conventional hemorrhoidectomy, a surgical procedure to remove the hemorrhoidal tissue.
  • Sphincter replacement. An artificial anal sphincter can be used to replace a damaged anal sphincter. The device is essentially an inflatable cuff, which is implanted around your anal canal. When inflated, the device keeps your anal sphincter shut tight until you're ready to defecate. To go to the toilet, you use a small external pump to deflate the device and allow stool to be released. It then reinflates itself about 10 minutes later.
  • Sphincter repair. During a surgical procedure called a gracilis muscle transplant, a muscle is taken from your inner thigh and wrapped around your sphincter. This restores muscle tone to your sphincter.
  • Colostomy. As a last resort, a colostomy may be the most definitive way to correct fecal incontinence. Colostomy is generally considered only after other treatments have failed. A colostomy is an operation that diverts stool through an opening in the abdomen instead of through the rectum. A special bag is attached to this opening to collect the stool.

Sacral nerve stimulation
Another possible treatment for fecal incontinence is sacral nerve stimulation. The sacral nerves run from your spinal cord to muscles in your pelvis. These nerves regulate the sensation and strength of your rectal and anal sphincter muscles. Direct electrical stimulation of these nerves is a promising treatment option for fecal incontinence caused by nerve damage.

Sacral nerve stimulation is carried out in stages. First, four to six small needles are positioned in the muscles of your lower bowel, and these muscles are stimulated by an external pulse generator. The muscle response to the stimulation generally isn't uncomfortable. After a successful response, you may have a permanent pulse generator implanted in your abdomen.

A wire from the small, battery-driven device is connected to the sacral nerves. Through the wire, the device generates electrical impulses that stimulate the nerves, helping you regain continence.

 

Question:

HUMAN RIGHTS

Women have the right to reproductive self-determination.  They have the right to control their own reproductive functions, the right to privacy and the right to protection from gender-based harm.  They have the right to make decisions concerning reproduction free of discrimination, coercion and violence.  They have the right not to be subjected to torture or other cruel, inhuman or degrading treatment or punishment.  They have the right to share in scientific advancement and its benefits.  They have the right to life, liberty and security of person.  They have the right to health, reproductive health and family planning.  Obstetrical care providers do not have the right to deny these universal human rights to women.  They are basic human rights that the majority of countries around the world have ratified.  They were established in 1968 when Reproductive Rights were added to the Universal Declaration of Human Rights established in December, 1948 by the General Assembly of the United Nations.  As I read your website it is clear that Canada talks the talk but doesn’t walk the walk.  Check out the universally accepted charter of Reproductive Rights at the Centre for Reproductive Rights www.reproductiverights.org/pdf/rr2k-1.pdf

Answer:  Now I know that this isn’t technically a question but we did want to comment on this.  Our response is you are absolutely right.  Denying fundamental human rights to women during pregnancy, childbirth and the postpartum is endemic and the stories and comments we hear everyday highlight this.  This can’t always be blamed on patriarchal misogyny.  A large percentage of human rights abuses we hear about are woman on woman abuse.  Unfortunately having the UN talk about non-negotiable and obvious human rights doesn’t mean that people respect them.  It doesn’t even mean the UN respects them. I wish we could take human rights for women for granted but the sad truth is that we have to fight for them just as we have always had to fight for them and we have to keep fighting for them.  I’ve lived on this planet for over half a century and, for the life of me, I can’t understand why women making their own decisions about their sexuality and reproduction scares so many people and why controlling women in this manner is something anyone would want to spend any of their precious time on this earth doing.  There are so many things to see and do and think about that it boggles my mind that anyone would have any time left over to make other peoples decisions for them.  But they do and many are pathological about it.  Obstetrics and motherhood are referred to as the only area of female life that has been forgotten by feminism.  This is true.  Your life is easier and your human rights are respected if you avoid pregnancy altogether.  This is an inescapable conclusion and it explains the low and ever decreasing birth rate.  It isn’t right and it isn’t fair and we would like that to change.  When mothers are respected in the same way as CEOs by their own families (including their own children), the medical profession, the justice system and other segments of society we will know we have accomplished that.  Motherhood is the hardest job in the world and the most thankless.  Young girls today look at their mother’s lives and say they want no part of that.  And who can blame them?  Any mother who has watched someone’s eyes glaze over when they tell people at a cocktail party that they are a mother or has applied for a job after years of raising children and running a household only to find herself slotted into low paying, meaningless positions because she lacks ‘skills’ knows we have a long way to go.   Changing obstetrical attitudes, respecting maternal autonomy, making childbirth less barbaric and making maternal experience the priority instead of an incidental (if that) are important first steps in that transformation.

 

Question:  Is it possible to develop PTSD when your baby is several months old?

Answer:  Yes it is.  PTSD can develop days, weeks, months and even years after the original traumatic experience.  Same with any other trauma disorder (like depression and obsessive/compulsive behaviours for instance).  This is true for traumatized women, men and children.

Question:  I had a very traumatizing vaginal birth that involved a vacuum extractor.  My baby is four months old and inconsolable.  Do you think babies can be traumatized by the mother’s birth experience?

Answer:  Most definitely we do.  What you do to the mother you also do to the baby.  Events after birth can also be traumatizing to both mother and baby.   There is evidence that trauma to the baby can have both short term and long lasting detrimental effects just like it does for the mother.  Traumatized babies show many of the same symptoms as any other traumatized person.  They are often inconsolable, they startle easily, they have problems getting to sleep and staying asleep.  They can have feeding problems and are irritable.  Traumatic births are linked to learning disabilities, mental illness and suicide in children and adults.  This is one more obstetrical topic that invites concealment and won’t be remedied until it is looked at honestly. 

Question:  Why do some women develop PTSD and others develop depression?

Answer:  I don’t know why some develop different trauma disorders after childbirth.  It has everything to do with the fact that every human body is different.  They have different genetic, environmental and chemical physiologies but the meat and potatoes of that difference is something none of us understands.

Question:  Do you think women are superhuman?  Do you think they should be expected to cope with stuff others wouldn’t be expected to?  It sure seems like this is true.

Answer:  Women are heroic but they aren’t superhuman.  They are subjected to so many unreasonable demands by the medical profession and by every other sector of society.  How I wish mothers were allowed to be human and respected and valued for that. 

Question:  I had a terrible problem with hemorrhoids after my second.  They were the size of a large grapefruit and it was impossible to sit or walk for several weeks without pain.  The postpartum nurse thought they were hilarious. It was more than I could bear on top of everything else.  I didn’t suffer like that after my first.  Have you heard about this problem being worst after a second baby? 

Answer:  Hemorrhoids are a very common problem associated with pregnancy and childbirth.  They are considerably worse after a vaginal delivery than a cesarean although women who have cesareans can still develop this problem.  They can range from uncomfortable to painful.  They can bleed and, like anything that heals, can be intensely itchy.  Defecation becomes an ordeal.  Surgery is sometimes necessary to fix them.  As you well know they can make sitting and walking very difficult and sometimes impossible.  Once you develop hemorrhoids you are far more likely to develop them again through exercise, weight gain, lifting and a subsequent pregnancy.  So, yes, you are right that women usually suffer more from hemorrhoids with subsequent pregnancies.  There are a number of medicated wipes and ointments that are prescribed but all have limited or no effect on your suffering.  As you found, time and rest are the only effective remedy and that can take awhile.  Some women never have these swollen veins go away completely and many others have skin tabs where the hemorrhoids used to be.   There is no good reason for anyone to think that any of this is funny and I’m truly sorry you were subjected to this ridicule from someone who should know better.

Question:  Is there any way to prevent stretch marks?

Answer:  No, but there are no shortage of snake oil salesmen out there that say there are.  Stretch marks occur when the connective tissue of the skin stretches past its ability to stretch.  It is like an elastic band that you stretch too far and it breaks.  It can’t be put back together again.  Most women get stretch marks.  It depends on the elasticity of your connective tissue and how much (and how rapidly) you grow during your pregnancy.  Creams and lotions keep the top layer of the skin (which is dead cells) moist and smooth but they have no effect on connective tissue.  Women have gone for macro-dermabrasion (like sandblasting) followed by topical retinol treatments and this will diminish the appearance of stretch marks but it is, as you can imagine, quite painful, takes several treatments and is very costly.  Women are often told not to worry about the appearance of these marks.  They will turn from purple red to silvery white given time.  As if the world thinks silvery white stretch marks are somehow more attractive than purple red ones.  They don’t of course.  There are no fashion magazines with models that have flabby bellies and stretch marks nor is it likely there will ever be, despite the well meaning attempts to change that.

Question:  I’ve decided I want an elective cesarean.  When I told my co-worker she got so angry with me.  Her face was red and there was spit coming out of her mouth.  I couldn’t believe she would go off her rocker like that.  Please, please tell me how to handle her.  I still have to show up at work for three more months.

Answer:  It would be nice if people would work at improving their objective abilities and ridding themselves of bias before they opened their mouths.  Asking themselves about all the reasons they could be wrong never occurs to many people.  There is so much irrational emotion, propaganda and bizarre hatred leveled at women who want to decide delivery options.  At this point in time most of it is leveled at women who choose elective cesareans but some is leveled at women who want a vaginal delivery instead of a cesarean.  It isn’t the first time this has happened during women’s struggle for reproductive self-determination.  We’ve seen the same thing with the fight for contraception and abortion.  It is the same story no matter what aspect of women’s rights you consider.  Remember how hard the Famous Five had to fight to get women recognized as ‘persons’ and how long it took for women to get the right to vote.   It is also a shameful fact that much of the inflammatory rhetoric and barriers in each of these struggles came from other women.  Madeleine Albright, former U.S. Secretary of State, feels there is a special place in hell for women who behave this badly toward other women.  I may not accept her religious ideology but I do share that sentiment. 

Tell your obnoxious co-worker that she has the right to decide how she gives birth.  BTCanada will support her as well if she runs into any problems.  She does not have the right to tell you how you will give birth.  That right is yours and only yours.  What is true for her isn’t true for other people.  Celebrate how diverse each woman is.  No two are the same and why would anyone think they should be?  No one expects all men to think the same.

If you are too frightened to talk to this bully you can print this answer and drop it on her desk.  Sometimes when people are confronted by their own bad behaviour, and have a chance to see what they look like to the rest of the world, they feel guilty enough to change.  You can get her to read this website.   You can tell her that, in private hospitals in Brazil, women choose elective cesareans 90% of the time.   In Italy it is illegal to deny women the right to decide which delivery option they want.  Planned cesareans are done in several more countries around the world that are far more obstetrically progressive than Canada is at respecting a woman’s autonomy.  These facts usually shut up those with anti-cesarean biases.  If she still feels like fighting and spitting tell her to contact me.  I’d rather have me putting up with her than you.  Pregnancy should be a wonderful time.  It shouldn’t be a stressful time putting up with vicious people and I’m truly sorry you’ve had to deal with this.

Question:  Do you know that cash registers can sound just like the machines they hook you up to in the hospital?  When I hear them I get dizzy and feel like I’m smothering. Has anyone else said that to you?

Answer:  Yes, we definitely know that and we hear it from other women too.  A lot. What you are describing is a panic attack.  Panic attacks occur suddenly, peak in about 10 minutes but symptoms can last for considerably longer and they are very distressing.  For some, like yourself, there is a known trigger like the sound of machines or a person’s face.  For others these attacks seem to come out of the blue.  They can be so debilitating people won’t leave their homes, can’t hold jobs or function productively in any other way because they never know when the next one will strike.  Other symptoms, aside from feeling dizzy and having difficulty breathing, can include a pounding heart, chest pains, upset stomach, nausea, dreamlike sensations, tingling or numbness, flushes or chills and absolute terror where you feel like something horrible is going to happen and you can’t stop it.  People also report a fear of dying and a fear of doing something embarrassing during these attacks.     

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