Authored by Amy Rosenman, MD
A Resounding YES! Many gynecologists feel the best way to treat a falling uterus is to remove it, with a surgery called a hysterectomy, and then attach the apex of the vagina to healthy portions of the ligaments up inside the body. Other gynecologists, on the other hand, feel that hysterectomy is a major operation and should only be done if there is a condition of the uterus that requires it. Along those lines, there has been some debate among gynecologists regarding the need for hysterectomy to treat uterine prolapse.
Some gynecologists have expressed the opinion that proper repair of the ligaments is all that is needed to correct uterine prolapse, and that the lengthier, more involved and riskier hysterectomy is not medically necessary. To that end, an operation has been recently developed that uses the laparoscope to repair those supporting ligaments and preserve the uterus. The ligaments, called the uterosacral ligaments, are most often damaged in the middle, while the lower and upper portions are usually intact. With this laparoscopic procedure, the surgeon attaches the intact lower portion of the ligaments to the strong upper portion of the ligaments with strong, permanent sutures. This accomplishes the repair without removing the uterus. This procedure requires just a short hospital stay and quick recovery. A recent study from Australia found this operation, that they named laparoscopic suture hysteropexy, has excellent results. Our practice began performing this new procedure in 2000, and our results have, likewise, been very good. However, as is the case with all reparative procedures, the goal is the success of the procedure over the long-term. Since long-term evaluations are ongoing, ask your doctor his or her opinion about this operation and be sure you understand the reasons for their recommendation.
This same uterine preserving procedure may also be accomplished though the vagina making a small entry into the abdomen behind the cervix and reattaching the ligaments to the uterus and cervix. This would be called a vaginal-uterosacral hysteropexy and leaves no abdominal scars. We have had excellent experience with this approach as well since 2000 especially if other vaginal procedures are needed at the same time for cystocele, rectocele, or vaginal narrowing.
Our sex lives are sometimes hard for us to talk about. We struggle to tell our children "the facts of life," and we struggle to tell our partners what pleases us.
Sex is personal, and, at its best, is an intimate treasure savored privately. We each want to please and be pleased, to feel warm, safe, and desired. For many women, perceived problems with their weight, overall appearance and desirability can cause enormous anxiety. When a woman chooses to have sex, oftentimes her worries and insecurities get right into bed with her. Does he like my body? Am I pretty? Are my thighs too big? As you age, those issues may make you more ill at ease. Add prolapse or incontinence to the mix, and things can get pretty complicated. Incontinence may turn that little voice of insecurity into a roar.
The good news is that a recent study tells us women with incontinence or prolapse report the same amount of sexual activity, comfort, and enjoyment with sex as women without incontinence. There's more: 80% of the women with either prolapse or incontinence felt their partners were also satisfied with their sexual relationship. Naturally the woman's feeling about her partner and the relationship has a lot to do with whether she is satisfied sexually or otherwise. But the incontinence and the prolapse turned out to be less important than expected. Incontinent or not, many women stay sexually active well into their seventies and eighties.
However, the same study stated that women with the most severe prolapse or most frequent incontinence did report that their physical condition interfered with their sex lives. As a result, these women were more distressed about their medical situations and were less content. While the women with less severe incontinence did not have a significant problem with sexual satisfaction, those with severe problems found it was a detriment to their sex lives.
Incontinence makes some women feel unclean and, consequently, undesirable. They may consequently avoid sex or feel less pleasure and freedom when they do have sex. The type of incontinence a woman has can greatly affect how much it troubles her. Women with stress incontinence usually have fewer problems with sex than women with urgency incontinence. Stress incontinence often happens at predictable times, most often right at the beginning of intercourse when penetration alters the angle of the bladder and urethra. Urinating just before having sex will usually prevent this problem.
Urge incontinence, the result of an overactive bladder, causes more distress because it is unpredictable and unavoidable. Women with urge incontinence often lose urine during an orgasm, which may be particularly upsetting. Also, the amount of urine leaked because of an overactive bladder is usually greater than with stress incontinence. One study found that almost 70% of women with urgency or urge incontinence had unsatisfying sexual relations while only 20% of women with stress incontinence had this complaint.
Prolapse does not usually cause problems with sex. If prolapse results in bulging of the bladder or rectum into the vagina, the bulge can be easily pushed back into place before intercourse, and most women with prolapse say they don't notice it during intercourse. Also, if you have a prolapse, you should know that intercourse will not cause any harm to whatever is bulging: your bladder, vagina, uterus or rectum.
Incontinence can undeniably complicate life in an unpleasant way. Many women modify what they wear and how they live as a result. Some tell us they feel less feminine and less independent. However, as we hope readers will learn from this website, there are now many ways to prevent incontinence. The social and physical isolation that incontinence sometimes brings is unnecessary.
Both women and men with incontinence may suffer from feelings of isolation. Embarrassment and fear of humiliation often keep them from talking to their partners about the subject. Usually the fear is worse than the reality. Unnecessary tension and emotional distancing hurts both people in the relationship. We know that good communication between lovers helps to make sex more joyful, under any circumstance. If you have incontinence, talking to your partner about it may be the most important thing you can do. Good communication will lead to greater affection and trust. Talking about any kind of problem is usually easier in a long-term, intimate relationship, but even in a new relationship, getting things out in the open often brings relief.
If you have incontinence with intercourse, discussing this with your partner before having sex might help you both. Many women, although embarrassed at first, are surprised at how easily the conversation goes. Oftentimes mentioning that there might be a bit of dribbling is all that is needed. Some men worry about getting a bladder infection from an incontinent partner. Although loss of urine may feel unclean, urine is entirely sterile. Your partner can be reassured that no risk of transmitting infection exists. Others worry needlessly about hurting a woman with a prolapse when all that is needed is to push the prolapse back and use a lubricant. The bottom line is very clear. Incontinence does not need to get in the way of sexuality.
If many women have problems talking to their partners about sex, isn't it even more difficult for them to broach the subject with their doctors? To complicate things even further, doctors are often uncomfortable about discussing sex and are rarely well trained to do so. Adding incontinence to a conversation may make both a woman and her doctor even more reluctant to pursue further discussion.
To illustrate what a significant problem this is, interviews with 324 sexually active women found that only 2 women had volunteered information about having incontinence during sex. However, when specifically asked about this symptom, 77 additional women acknowledged that they had incontinence during intercourse.
Patients and doctors need to do a better job communicating about incontinence and sexuality. If your doctor doesn't ask about incontinence, it is important for you to bring it up if there is a problem. If your doctor seems uncomfortable with the subject, ask for a referral to someone who regularly deals with incontinence. If you are having a problem with incontinence and sexuality, more than likely you will need to bring this up as well. If your doctor is not equipped to discuss this with you, ask for the name of a knowledgeable therapist who can help.
If your doctor doesn't know such specialists, make an effort to find someone on your own. The important thing is to get what you need. You're not alone with this problem.
Kegel exercises can certainly help. Women who learn to do Kegels correctly and do them regularly have less leaking during intercourse. A recent study from Norway found that women who were taught by a physical therapist the correct way of performing Kegels were more likely to have more satisfying sex than a group of women who were not properly taught these exercises. These women had fewer problems with their sex life and less discomfort with intercourse. We encourage you to do Kegel exercises on a regular basis.
Another way to prevent leaking during sex is to keep your bladder reasonably empty during intercourse. Try to avoid drinking fluids for an hour or so before you expect to have intercourse. This will keep the bladder from filling up too quickly once you get into bed. If you empty your bladder just before you begin lovemaking, leaking is much less likely.
Some positions make leaking much less likely. A woman on top has control over penetration and better control of her pelvic muscles. Some women find more control in positions they find less tiring. Intercourse on your side is usually less strenuous. Rear entry will keep pressure directed away from the bladder and urethra. However, everyone is different so you should experiment with different positions until you find the ones that work for you.
To answer this, a recent American study questioned a group of women before and after surgery to repair a prolapse or incontinence. About half of these women were sexually active. Before surgery, 82% of the sexually active women reported being happy with their sex lives, and after surgery, 89% of the women felt happy with their sexual relationship.
However, a study brought out a number of interesting findings. For one, the frequency of intercourse did not change following surgery. And two, while only 8% of the women had pain with intercourse before surgery, 19% noted pain with intercourse after surgery. About one quarter of the women who had a repair of a bulging rectum (rectocele) developed pain with intercourse. About one third of the women who had repair of a rectocele and a bladder suspension had painful intercourse. Unfortunately, the researchers did not ask these women why they were more satisfied with their sex lives even though more of them had painful intercourse.
Another study performed in Sweden may shed some light. This study found that one third of women noted an increased interest in sex after incontinence surgery, and one half of their male partners were more interested in sex. It could be that knowing the repair for the prolapse or incontinence had been addressed was enough to make the couples feel better about sex.
One way to reduce discomfort during intercourse is to use a lubricant. Ask the pharmacist to recommend a good lubricant or try a few to see which one works well for you. Try to avoid using Vaseline or hand lotion, as these tend to dry out quickly. If vaginal dryness is a longstanding problem, consider asking your doctor about vaginal estrogen. Estrogen makes the vagina more elastic and increases natural lubrication. Local forms of estrogen, available as creams, estrogen-containing silastic rings or small pills inserted into the vagina can improve vaginal health without any significant absorption of the estrogen into the bloodstream and the body.
Here are bits of information our patients with incontinence have told us helped them improve their sex lives: