It’s the part of our bodies whose name we can hardly bear to even utter. We may refer vaguely to our “waterworks” or even more vaguely to “down below.” But to actually talk about problems with our bladders or vaginas is to enter a whole new world of embarrassment.
As a urologist, Dr Seema Sheth deals with those “embarrassing” problems every day as part of an all-woman team at the new Female Urology Program at Cleveland Clinic Abu Dhabi. They provide dedicated care for women with urological issues, including pelvic floor disorders, incontinence and pelvic organ prolapse. A graduate of Cornell University in the US, Dr Sheth is an expert in female urological conditions and as a woman, a rarity in her field.
Dr Sheth talked to Livehealthy about the urological problems that can afflict women.
Why are women so reluctant to talk to a doctor about urological problems?
Urinary incontinence affects about one in five women between 18 and 44 years of age and about 50 percent of all women over the age of 65, but women don’t want to talk about it or else they normalize it. They think it’s normal to have some leakage after having a few kids or they consider it to be just a normal part of ageing. But just because it’s common doesn’t mean it’s normal and it doesn’t mean they have to live with it.
If women don’t want to talk about incontinence or things falling out of their vagina in general, then they certainly don’t want to talk about those issues with a male physician. The problem is there are only a small number of female urologists in the UAE, but at Cleveland Clinic Abu Dhabi we have an all-female team to deal with and treat these problems.
The patients I see are mostly male, actually, but urological problems are split 50-50 between the genders. Half of kidney stones occur in women. Leakage is more common in women.
Why does leakage occur?
Lifestyle, obesity, constipation, pregnancy and childbirth – that is, if you’ve delivered your babies vaginally – and ageing are some of the common factors that can cause incontinence in women but first, we have to determine what type of incontinence you have because there’s more than one.
Stress incontinence is leaking when you cough or sneeze or when exercising. Urge incontinence is when you really, really need to go to the bathroom, right away. Those two are the most common. Then there’s overflow incontinence, where the bladder gets overfilled, and there’s functional incontinence where a patient might have had a stroke or be in a wheelchair and can’t physically get to the bathroom.
Overall, it’s more common in women.
What about prolapse? What causes it and what can be done about it?
Prolapse is when things fall out of your vagina that shouldn’t. Sometimes we see prolapse without incontinence, but most often we see both together because they stem from the same problem. It’s when the muscle layers loosen so there isn’t the support mechanism there to hold everything up.
Patients usually come to me when they’re sick of the situation and the first thing I tell them is that it’s very common, they’re not alone and most importantly, I can heal them. It’s not a lost cause and we can offer many treatment options and you, the patient, get to pick. Most times I can get you to the point where you’re happy.
If a woman gets leakage only during exercise, I’d say put in a tampon. For women who say they leak during the day but they’re fine at night, there are silicone devices called pessaries which they can put in during the day when they need something.
There’s minimally invasive surgery which uses fillers to bulk up the urethra and narrow the opening, and sling surgery, which involves creating a ‘sling’ out of mesh or your own tissue. It goes under the urethra (the tube that urine passes through) and it’s like a hammock that lifts and supports your urethra and the neck of your bladder to help prevent leaks. It’s actually the gold standard for stress incontinence.
For urge incontinence, some lifestyle changes will help, like cutting down on coffee, or losing weight, physiotherapy and medications. If all else fails we put botox in the bladder every six months.
There are nerve stimulation devices too.
What about pelvic floor physiotherapy?
I love this option because there’s no downside. It will never hurt you. You strengthen the core and there are deep breathing exercises, which can give you that extra 10 seconds you need to undo your pants.
Studies show that just doing only Kegel exercises [tightening the pelvic floor muscles and holding for five five to 10 seconds] doesn’t work, but they do work wonderfully in conjunction with physiotherapy.
Using vaginal weights really does work. They come in different weights, like dumbbells, and you can order them from Amazon. You put one inside your vagina and hold it in while you’re having your shower. If it falls out, rinse it off and try again. When you can keep it in for the whole shower, move on to the next weight.
But you mustn’t push the weight in too far, all the way up, as it will just sit there with no effort from you to make it stay there. Just insert it at the opening of the vagina, so that it’s three-quarters in and a quarter out.
The only problem is you have to keep doing it. It’s like working out – you have to do it regularly.
What about urinary tract infections?
UTIs are really painful and they can leave you incapable of doing anything until they’re treated. They occur in babies and children, or when a woman begins to be sexually active – what they call honeymoon cystitis – and in menopausal women. We don’t see it much in the age group in between and we have no real idea why.
A urinary tract infection in, say, a 10-year-old is more likely to be caused by urine reflux, where urine is going back up into the kidneys and coming back to settle in the bladder. The most common reason for this is that the patient is constipated, even if they are having bowel movements every day.
There’s no clear consensus on treating honeymoon cystitis, but I try to treat patients with vaginal probiotics rather than medications and in 85 percent of cases, they’ll be fine.
With post-menopausal women, estrogen will change everything. It’s a really easy fix.
How do we prevent UTIs?
There’s emerging data that says you can get rid of them without antibiotics, even by just drinking a lot of water. I like probiotics. Lactobacillus is a probiotic found in yogurt. Like the gut, the vagina has a microbiome and lactobacillus is the good bacteria that should be living in there, so I flood the vagina with lactobacillus.
You can get probiotics over the counter but I would recommend taking an oral pill and inserting it in the vagina because they work better vaginally. Use a capsule, which will dissolve more easily than a tablet.
A good intake of water helps. To pass 1.5 liters of urine daily you need to be drinking two liters of fluid. Some people swear by cranberry juice but it has to be in extremely concentrated form. Just drinking the sweetened cranberry juice you can buy in a shop won’t help.
But, as I tell every patient, getting a UTI is not your fault. It’s got nothing to do with how you wipe or whether you go pee after intercourse.
However, some infections can spread to the kidneys and even become life-threatening. Seek medical attention if you have back pain or a fever. You should not get a fever with a simple UTI.
We’re hearing more about GSM lately — what is it?
It stands for Genitourinary Syndrome of Menopause and not that many physicians are familiar with it. The symptoms are burning when peeing, dryness and pain during sex and extremely tender, thinned-out vaginal tissues. If there are no other issues, that’s GSM and it’s cured with vaginal estrogen. This poses absolutely no increase in risk of breast cancer.
A good examination is very important. Unfortunately this is not taught as well as it should be to doctors. But if done right, it saves the patient from having a battery of unnecessary tests.
This is where urology crosses over a bit into gynecology. As a urologist, I look at anything that can affect the vagina.
Why do we get kidney stones?
They are extremely painful – in fact the pain has been compared to labor. We don’t know why some people are susceptible to them. It could be hormonal. I’m sure there’s a genetic factor. Some people have high levels of uric acid or oxalates, which are natural compounds found in foods which are generally good for you, like spinach, strawberries, peanuts and chocolate, but too much can lead to kidney stones.
But the biggest culprit is not drinking enough fluid, so my general advice is to drink a lot and avoid red meat.
What symptoms should we beware of?
Fever for sure, blood in the urine and difficulty in urinating. See someone before you get to the point where you can’t pee at all. Don’t wait more than one or two days to see a doctor and get tested.
• Dr Seema Sheth, urologist at Cleveland Clinic Abu Dhabi, was a guest on the Livehealthy podcast on April 7, 2021
