Guest: Dr. Steven Swift – Obstetrics and Gynecology
Host: Dr. Linda Austin
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. Steven Swift who is professor of OB/GYN and co-director of the Bladder and Pelvic Health Center. Dr. Swift, you are a surgeon and your expertise is in a number of areas including the surgical treatment of urinary incontinence. What are some of the symptoms of women who become candidates for this type of surgery?
Dr. Steven Swift: There are several reasons why women may develop incontinence and there are several treatments for incontinence, not all of which are surgical. I think that is one of the most important things that we get through to patients because a lot of times they are a little bit frightened of coming to the office, thinking that they can only have surgical options. There was a very nice podcast done by Lynette Franklin where she talks about several of the other treatment options available. But, a woman who develops stress incontinence is the classic indication for surgical management. Stress incontinence is classically described as women who leak with activity, such as coughing, sneezing, jumping, running and laughing, things of that nature, anything that puts stress on the abdominal cavity, not stress like my job is bothering me and I am frustrated with my children. It is abdominal stress which is the stress we are considering here.
Dr. Linda Austin: Now, a lot of women will have that once in awhile. Are there guidelines about how severe or frequent or troubling that symptom has to be before a woman qualifies for surgery?
Dr. Steven Swift: For years, the various societies involved in standardizing terminology tried to come up with a number, tried to come up with a frequency. But, really, at the end of the day, what they decided is that incontinence that presents a problem to the patient. Once a patient comes to you and says the incontinence is bothering me, that is when it becomes a diagnosis of incontinence. You are exactly right, the patient that leaks once every six or seven months when her bladder is very, very full and she is tickled pink and is just laughing out loud, that is really not a patient with incontinence. It is more the patient who is leaking generally several times a day, may now be wearing pads because that certainly is a sign of changing your hygiene as far as a measure of bother. But, any patient that comes in to me and says her incontinence is causing her to interrupt activities or is causing her to change her hygiene, that is how we define it.
Dr. Linda Austin: Before we get to talking about the surgery, if a woman is beginning to have those symptoms, are there things that she can do to prevent this becoming more severe so quickly?
Dr. Steven Swift: Yes, there are: Kegel exercises as they are often referred to. We now really refer to them as pelvic floor muscle rehabilitation. I think, although I do not have any data to prove this, but I think that if you practice Kegels and if you keep your pelvic floor tone increased, that will decrease your likelihood of developing incontinence. Again, we do not have any research for that, and the biggest problem with Kegels is that it is a very difficult thing to learn. When I send patients for Kegel exercises, which we do frequently, generally I send them to a physical therapist. You can really teach them how to strengthen that muscle and if it is done through a physical therapist, the success rates tend to be very good. Therefore, I would say a woman who has early onset and if she is interested in avoiding further problems down the road and doing something to help herself, going to see a physical therapist, trying to get a referral to a physical therapist through her physician is an excellent place to start.
Dr. Linda Austin: Anything else? For example, overweight, is that a contributing factor?
Dr. Steven Swift: There actually are a couple of recent studies looking at bariatric surgery and its effect on incontinence. Now, these are patients that are obviously very morbidly overweight. When they lose 20, 30 percent of their body mass, incontinence rates drop substantially. We do not have as good of data looking at women who are doing small, 10, 15, 20 pounds of weight loss. But, there is one study out of a group in England that showed that even with as little as 10 pounds of weight loss, that reduced the incidents of incontinence.
Dr. Linda Austin: If a woman comes to see you with these symptoms, what should she expect from the evaluation?
Dr. Steven Swift: A good pelvic exam, defining if there is any relaxation. At the very least, a urinalysis to make sure that the patient does not have a urinary tract infection which can sometimes mask as incontinence or certainly make very minimal incontinence much more problematic. If we deem that she has stress incontinence, at the very least we need to see it, and what does that mean? Well, it means that we would fill her bladder through a catheter and then have her cough and bear down in our presence. You want to see urine coming out of the urethral meatus, and that is a demonstrating stress incontinence. That is how we diagnose the disease or the process and those are the patients who then would go onto to possibly be surgical candidates to treat stress incontinence. There are many types of incontinence and it is really only stress incontinence that is surgically managed. All the other forms of incontinence are managed with behavioral therapy, medication, sometimes use of catheters, all sorts of things.
Dr. Linda Austin: What are some examples of the other types of incontinence?
Dr. Steven Swift: Well, in females, the most common form of other incontinence is overactive bladder or urge incontinence. That is where the bladder is having a spasm. So, in other words, the patient gets the urge to void. Most of us can keep the bladder relaxed using our cortex, our cerebral cortex, until we can find a socially acceptable time and place to evacuate our bladder. Patients with urge incontinence, however, when they get that first urge, often it is preceded almost immediately by a very strong bladder contraction that they cannot resist and so they will start to leak. That is not a problem that is treated surgically. That is a problem that is treated with behavioral therapy or potty training for adults, or medical management.
Dr. Linda Austin: Describe, if you would Steve, the surgical approach to treating incontinence.
Dr. Steven Swift: That is one of the areas in urogynecology, or the treatment of pelvic floor disorders, that has actually come a long way in about the last five years, maybe the last ten years. It is kind of a very exciting new field because we have discovered ways of treating incontinence surgically that are very minimally invasive. What you do for the vast majority of patients is, you take a small piece of a permanent mesh, and it looks like a piece of ribbon. It is about half an inch wide and usually about seven or eight inches in length. You put that through the tissues and then you string it right under the bladder neck. So, what happens is, when the patient bears down and coughs, her urethra drops down and literally kinks on that piece of permanent sling or mesh material that is underneath the urethra. So, every time she has an abdominal strain, the urethra drops down a little bit, catches or kinks against that little sling. That basically fixes incontinence in about 85 to 90 percent of patients. It is fairly easy to put these slings, or these tapes, in. We can do it through minimally invasive, usually two small little pokes in the skin either above the pubic bone or in the groin. Then, we just thread this little piece of mesh on a needle through those incisions and place it under the bladder neck. The patients usually go home the following morning and in some cases that same day.
Dr. Linda Austin: You make it sound very easy.
Dr. Steven Swift: It is a technique. I mean, every technique in the operating room has its risks and every technique requires a little bit of training in order to make it appear easy. But, once the technique is learned, and in a properly selected patient, it is a fairly straight forward operation. As we have gotten farther along, it is become less and less risky. We have learned to avoid the various structures in the pelvis that we don not want to damage. So, you never want to say something is easy but it is a lot less invasive than the abdominal incisions and the dissection that we did even 10 years ago.
Dr. Linda Austin: What are some of the risks of that surgery?
Dr. Steven Swift: The biggest long term risk is that it does not work. As I just said, we have very nice success rates in the 85 to 90 percent. But, that means that 10 to 15 percent of patients do not get all the relief they are looking for from the operation. The nice part is that, once we have the sling in place, there are some office things that can be done to help that other 10 to 15 percent. So, it is not always a trip back to the operating room. The other risks of the surgery involve the classic risks of bleeding, damage to other organs. Although, in all honesty, with the minimally invasive technique that we are using, that is one of the things that we are really avoiding now, damaging the bladder or the urethra and, then, infection. An infection probably is the second biggest bugaboo we have with this surgery because about two to three percent will develop an erosion such that the mesh becomes exposed in the vagina. Often times, those patients do have to go back to the operating room for a small operation to close the vagina over the top of that mesh. We think that is because there is a slight infection that occurs at the time of surgery.
Dr. Linda Austin: In order for a woman to get her insurance to pay for that, typically does she have to show that she has tried some of the other less expensive methods, like a pessary or Kegel exercises, those sorts of things?
Dr. Steven Swift: Not really. I mean, if you look at stress incontinence, it was actually getting insurance companies to pay for physical therapy that was the difficult part. Insurance companies have always been very happy to pay for the surgery and it actually took lobbying by several national organizations to get them, only in the last five years, to pay for physical therapy.
Dr. Linda Austin: How long does it take to recover from the surgery?
Dr. Steven Swift: Well, the short term recovery in the hospital stay generally is less than 24 hours. We do like patients to avoid a lot of lifting because, since we are not attaching this sling to anything in the body, it is an open weave mesh as I mentioned earlier and, so, the body has to kind of scar it down in place so that the sling does not move around too much. We generally like patients to avoid a lot of heavy lifting; heavy lifting is defined as anything greater than 10 pounds, for at least six to eight weeks after surgery, so not a lot of housework. We recommend that patients do not do a lot of yard work. We recommend that they do not go to the gym for that eight weeks. We recommend that if they go to the grocery store, they do not carry their grocery bags, etc.
Dr. Linda Austin: I am curious what the youngest and the oldest patients you have had undergo this surgery have been.
Dr. Steven Swift: I cannot recall ever operating on a patient in their 20s but I have certainly operated on a few in their 30s. The oldest, I would have to say, in late 80s. So, again, it gets down to the relatively minimally invasive nature of the procedure. It is a very straight forward operation, patients tolerate it well, and it is a short anesthesia time. So, what that has done, is that has given elderly patients, who in the past might not have been considered ideal surgical candidates, that has kind of brought them into the surgical consideration.
Dr. Linda Austin: Dr. Swift, thanks so much talking with us today.
Dr. Steven Swift: You are welcome, Linda. Thank you for having me.
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