Urogynecology

That's what I've been doing at Penn the last three weeks, and I'm starting my last week tomorrow. It's been a lot of fun, and I'm really glad I came for this rotation. Here's what I learned that YOU should know:

Water is the best thing for your bladder. Caffeine makes you urinate (which you already knew), and can be irritating to the bladder, as well. Acidic or spicy things can irritate your bladder as well. Colas are probably among the worst thing you can drink, bladder-wise, since they are caffeinated, acidic, and full of all sorts of other chemicals. If you're not having any urinary issues, go ahead and drink whatever you want, but if you do have problems peeing, start cutting out all your non-water beverages.

Hot tea is better for you than iced tea. My attending tells her patients that if you think about it, cultures all over the world have been drinking hot tea for thousands of years, and don't seem to have too many problems. In America, we invented iced tea, and she sees women with all sorts of bladder issues because of it. (Note, this is not a proven fact, but an observation of hers over her career.)

Drinking 8 glasses of water a day is, in the words of my attending, "bullshit." You've probably read lots of stuff in the lay press talking about how the 8 glasses thing is a myth, and we're not really sure where it started. Since we also gain fluid from foods we eat, the total fluid intake most of us probably need is somewhere around 4-5 8-oz glasses a day. And that includes non-water beverages, as well. If you're a young woman who can handle getting up to go to the bathroom every hour because you're drinking 8-12 glasses of water a day, that's fine -- you likely won't suffer any negative effects. But if you're 45 and bothered by the fact that you have the urge to urinate every 30 minutes, then for goodness sakes, stop drinking so much! (That's the first thing to do, anyway.)

Wearing Depends is NOT a normal part of aging! So many women think that urinary incontinence is something they just have to deal with, and that is completely untrue. Go see a urogynecologist -- there are many things that can be done for you.

Kegel exercises are your friend. Start doing them now, no matter how old you are! Doing them before you have your first vaginal delivery is great prevention, and doing them throughout your lifetime will help to prevent further pelvic floor problems as you age, and help reverse pelvic floor problems if you already have them. To do them, squeeze the muscles in your pelvis as though you are trying to hold your urine or stop your urine stream. Do 5 "quick flicks" (squeeze and hold for 1 second) and 5 squeeze-and-holds (hold for 3 seconds) each day. Do them in the car, while you're stopped at a light. Do them in a boring meeting. Just do them whenever. Plus, you know, it's good for your sex life, too.

And speaking of sex, everyone should be having it! One of my favorite patients from this month was a 90 year old (who, first of all, looked not a day over 60) who was complaining of pelvic organ prolapse (something "falling down" from her vagina). As part of my normal screening questions, I asked if she was sexually active. She replied, "I've been widowed for 25 years," and I nodded and began to apologize if I had offended her. "But I was in Puerto Rico with my [female] friend last month on vacation and I met a guy, and let me tell you: I COULD have. But I decided not to." And then she laughed. It was great! I love the thought of this 90-year-old picking up a guy in Puerto Rico.

On the other hand, we also see a lot of older women who aren't having sex, and are very frustrated by it. When you question them, there are themes of emotional issues with their husband, or a sense of inadequacy in either the husband or wife that no one has ever had the guts to address, or health issues in the husband that aren't necessarily solved by viagra. From our standpoint, we want everyone to be having sex, and we want to do everything we can to get women to be sexually active again. One of the sadder things I saw was a woman in her 70s who came in with her husband, and when asked if they were sexually active, she quickly replied, "Oh no, honey, we're 75 years old. We don't do that anymore." It was hard to read her, because she clearly didn't want to talk about it any more, and her husband started to say something but didn't want to interrupt after she had made it so clear the subject was closed. They otherwise seemed very emotionally content and apparently had a solid marriage, so it was sad that their sex life had fallen by the wayside. My attending tried to reassure the patient that sex was normal at any age, and that any sort of "fooling around" was completely OK -- oral sex, labial sex (dry rubbing, essentially, if the guy can't achieve an erection), whatever. The patient looked a little uncomfortable at the talk of oral sex, so that was the end of that discussion.

Speaking of uncomfortable, I was also surprised at the number of women who are very uncomfortable with their own bodies. For certain issues, we might prescribe a pessary, which is kind of like a diaphragm but for the purposes of pelvic support. Most pessaries can be worn during intercourse, or can be taken out by the patient before sex if she wants to. Some patients return to the doctor every few months for pessary checks, and one day I saw a woman in her 60s for just such a check. She mentioned that her husband noticed he could feel the pessary during sex, which was new, and she wanted us to check it out. When we asked if she had taken it out herself to check it, she looked mortified and replied that she didn't know how to take it out (directions: stick your finger in your vagina and pull it out). And not only did she not know how, but you could tell that she was completely embarrassed at the thought of taking it out herself. I was shocked. But she -- and many other women of that generation -- have never used a tampon, let alone masturbated, and are really not in touch with their own bodies at all. So the nurse and I taught her how to remove and insert the pessary, and it was so gratifying when she got the hang of it.

Overall, this has been a great rotation, and urogynecology is a very interesting field. I think it's probably not ideal for me, since the patient population is very specific -- middle-aged and older women, almost completely -- and I'd like a little more variation in age. But, urogyns have good hours (no middle-of-the-night deliveries) and do a lot of operating, which I like. So I'll put in the back of my mind and see what happens.