University of Pennsylvania Health System

ObGyn Update | Penn Medicine

Thursday, March 19, 2015

Ignoring Nature's Call

Lori M. Noble, MD, a primary care physician at Spruce Internal Medicine, located at Penn Medicine Washington Square, discusses the health risks of ignoring nature’s call.

Dr. Noble
The long, grueling days of medical school and residency impart many lessons, far beyond those related to patient care. For instance, the mantra of my residency experience was "eat, sleep and pee when you can."

While I always made eating and sleeping a priority, urinating had a tendency to fall off my to-do list during a busy day.

I imagine this is not something unique to a career in medicine; I'm sure any woman who works in a demanding field can recall a time (or several) when she "held it in" a little longer than would have otherwise been comfortable. It's a pretty common sacrifice we make to get that one last thing done, typically without giving much thought to any potential consequence.

I recently came across an interesting article in a popular women's magazine that addressed the potential impact of holding it in and thought I'd share what I read and add my medical opinion.

Bladders are unique like fingerprints.

There is no real agreed upon amount of time that is considered okay to hold in urine. This is because every woman is different in terms of how hydrated she stays, how large her bladder is and how sensitive her bladder is to the stretch that happens as it fills with urine.

Bottom Line: The average woman will feel comfortable holding her urine for between three and six hours, but there's a lot of variability.

So Why Not Hold It In?

The authors downplay any consequence of holding in urine for a prolonged period of time, noting that the "worst case scenario" is a "bit more of a likelihood" of developing a urinary tract infection (UTI). As a physician and a woman, I take issue with this for a couple reasons:

1. UTIs can be dangerous. In some people, the infection can spread from the bladder up to the kidneys and even into the bloodstream if not treated quickly. Pregnant women and those with certain medical conditions that can affect bladder function (i.e., Multiple Sclerosis, Diabetes, etc.) are already at increased risk for UTIs, so they should be extra vigilant about emptying their bladders regularly to prevent infection.

2. Many women struggle as they get older with urinary incontinence (the loss of bladder control). Stress urinary incontinence is leakage when there is increased pressure applied to the bladder, like with coughing, laughing or jogging. Urge urinary incontinence is leakage because of an intense, involuntary contraction of the bladder, often described as the "I gotta go, I gotta go, I gotta go" feeling. Both can be made worse if the bladder fills up beyond a comfortable capacity.

Bottom Line: There are potential consequences of holding in urine for a prolonged period of time. Listen to your body and take time to go when you feel the urge.

Are There Benefits to Holding It In?

There is some evidence that holding urine can "train" the bladder to be less sensitive to the urge to go, and thus allow a woman to wait a bit longer between bathroom trips. In my opinion, the risks of holding it as outlined above, outweigh this potential benefit.

Bottom Line: When it comes to holding in urine, the risks of infection, leakage and pain outweigh the potential benefit of a modest increase in bladder capacity.

So next time you feel the urge to go, try to fight the instinct to just cross your legs and hold it in for a bit longer – your bladder will thank you for it later!

Concerns about bladder and pelvic floor health? Speak to a Penn urogynocologist.

Tuesday, September 30, 2014

Marisa's Story: Defying the Odds in the Intensive Care Nursery

Marisa Mackintosh and her husband were ecstatic to learn they were expecting twins. But when Marisa was three months along, an ultrasound revealed that the babies were having growth problems. Here, she shares the story of her family's difficult journey and the neonatal intensive care team that saved her babies' lives.

When my husband and I learned I was pregnant with twins, we were overwhelmed with surprise, immense joy and anticipation. We dreamt of welcoming them home and introducing them to our beautiful daughter, who was 16 months old at the time. The twins were due August 28, 2013, and we believed we would soon have three healthy and happy children nestled safely under our roof.

Our vision quickly came to a halt at 15 weeks after an emergency ultrasound revealed that one of our babies wasn’t growing well. We were asked to prepare for the unimaginable possibility of losing one or even both babies.

The following weeks were dark and uncertain. Regular ultrasounds were both reassuring and terrifying. 17 weeks became 20 weeks, which became 24 weeks. Of course, we did not want to deliver then, but reaching 24 weeks, we learned, was a milestone. Another ultrasound at 27 weeks showed two babies, growing and defying the odds, though dangerously imbalanced in size and health.

My doctor offered us the opportunity to tour the Intensive Care Nursery (ICN) at Pennsylvania Hospital to get acquainted in the event that we would spend time there. We walked through a door labeled “CHOP Newborn Care at Pennsylvania Hospital” and were greeted warmly by a neonatologist who, with kindness and patience, gave us insight into the world of prematurity. Then a nurse manager gave us a tour, which provided a glimpse of life in the ICN.

One week later, at 28 weeks gestation, the babies decided it was time. On June 7, 2013, we welcomed our miracles William and Daniel (Will and Danny), weighing 2 lbs 12 oz and 1 lb 13 oz, respectively. At this moment, Will and Danny began the fight of their lives. But they – and we – were not alone.

Over the next four months, we witnessed neonatal intensive care at Pennsylvania Hospital's ICN and the Children's Hospital of Philadelphia at its absolute finest. The doctors made decisions that were simultaneously life-saving and delicately mindful of long-term health. The nurses were by our boys’ sides, 24 hours a day, 7 days a week, providing expert care and love when we – with terrible pain – had to leave at night.

It is immensely difficult to think about those days. It conjures up images of our tiny sons connected to devices, separated from us – and each other – by technology. But when reflecting on that time, it is impossible to forget that we were part of something truly incredible. The team at Pennsylvania Hospital became our family, who hugged us, cried with us, answered our endless questions, loved our children – and who celebrated with us when we finally brought our two babies home after 81 and 116 days.

In honor of Neonatal Intensive Care Awareness Month, we want to thank the very special people at Penn Medicine’s ICNs. They give themselves to our babies, and they provide hope to parents. For that we are truly grateful, this month and forever.

Thursday, September 5, 2013


The Department of Obstetrics and Gynecology at the University of Pennsylvania
hosted the annual NICHD Women’s Reproductive Health Research (WRHR) Symposium in
October 2012. Over 80 scholars, Ob/Gyn chairs and research program directors from 17
programs across the country attended this two-day event. Highlights included research
presentations by former and current scholars, career development panel, workshop on NIH
funding and grantsmanship and a keynote lecture by Dr. Alan Guttmacher, director of the Eunice
Kennedy Shriver National Institute of Child Health and Development (NICHD).

The WRHR program, initiated in 1998 by the NICHD, provides obstetrician-gynecologists
who recently completed postgraduate clinical training to further their education and
experience in basic, translational, and clinical research under the guidance of a senior
investigator and mentor. The goal is to create a talented pool of investigators with expertise
in women’s health. Chair of the Department of Obstetrics and Gynecology at the University of
Pennsylvania Health System, Deborah A. Driscoll, MD, is the principal investigator for the WRHR

“The WRHR program is a prestigious award, with our department being one of only 17 universities
nationwide chosen to participate,” says Dr. Driscoll. “But most importantly it enables us to
leverage our strong research infrastructure and provide research training to promising junior
faculty to prepare them for a career in academic medicine.”

Samuel Parry, MD, director of the maternal-fetal medicine division and a former WRHR scholar
explains: “Depending on their experience, scholars are chosen for two to five-year awards
and are required to devote at least 75 percent of their effort to their research program under
the guidance of an assigned mentor.”

A scholar’s research may be spent in the basic sciences, translational or clinical investigation
in a variety of fields including gamete biology, imprinting, preterm birth, maternal fetal
health and development, and gynecologic oncology.

The rest of the scholar’s time is spent in clinical and teaching activities.

The research program director, Dr. Christos Coutifaris, works with the mentor to
monitor the scholar’s academic progress and assist with future grant applications and
the transition to independent funding.

Michal Elovitz, MD, associate professor of obstetrics and gynecology, director of the
Maternal and Child Health Research Program in the Center for Research on Reproduction
and Women’s Health, is a former WRHR scholar who is currently mentoring Jamie Bastek, MD, MSCE.

“My own work as a WRHR scholar helped me obtain NIH funding, as well as the necessary research
time, resources and mentorship to be able to pursue a career in maternal-fetal medicine,” says
Dr. Elovitz. “Now, as a mentor myself, I can guide scholars to target a specific research interest,
and work with them to nurture their own research careers.”

Current Penn WRHR scholar, Dr. Bastek agrees. She is currently working on a project in
conjunction with the Penn cartographic modeling lab to research environmental exposures
within Philadelphia that may affect pre-term
birth rates.

“Being a WRHR scholar has afforded me the opportunity to perform grant-funded research, to focus my research interests with the guidance of mentors who have been successful in research, and to pursue a research-based career in maternal-fetal medicine,” says Dr. Bastek. “It’s also
given me the opportunity to make sure
I am in a place where I can do my own grant-funded research at the end of my WRHR scholarship.”

Wednesday, August 28, 2013


The Basser Research Center for BRCA 1 and 2 at the University of Pennsylvania focuses on the
prevention and treatment of cancers associated with the BRCA gene mutation. The BRCA mutation
increases a person’s lifetime risk for developing breast and ovarian cancer, as well as other types of cancer. “Our mission is to advance the research and the clinical care for BRCA1 and 2 using the resources available through the Basser Center,” says Executive Director of the Basser Research Center for BRCA, Susan Domchek, MD. “We want to create better choices for individuals  with these gene mutations and to eliminate the development of cancer in these individuals altogether.” Clarisa Gracia, MD, director of the Fertility Preservation Program at Penn Fertility Care, is currently working on a research project with the Basser Center to assess ovarian reserve and  attitudes toward parenthood in BRCA mutation carriers.“For women with a BRCA 1 or 2 mutations, their risk for ovarian cancer is up to 45 percent compared to two percent in women without the mutation,” says Dr. Gracia. “Risk reducing strategies, such as oophorectomy, shorten the reproductive lifespan, and part of this study will investigate how knowledge of BRCA carrier status impacts a woman’s reproductive decisions and attitudes about parenthood.”For example, a 35-year-old single woman with a BRCA mutation may decrease her chances of getting ovarian cancer by having her ovaries removed. If she is not yet prepared to have a child, then  oocyte or embryo cryopreservation may allow her the opportunity to have biological children even after her ovaries are removed.

Couples who know one of them has the BRCA mutation may feel a sense of urgency to have children faster, or wish to pursue IVF with preimplantation genetic diagnosis in order to avoid passing the gene mutation to their offspring. The study will also aim to learn more about how a BRCA mutation can influence a woman’s ovarian  reserve. “A study recently found that breast cancer patients with BRCA1 mutations undergoing IVF do not respond as well to ovarian stimulation as non-carriers,” says  Lauren Johnson, MD, a fellow in reproductive endocrinology at the Hospital of the University of Pennylvania and co-investigator of the study. “That finding suggests BRCA1 carriers may be at risk for ovarian insufficiency.” The Penn Medicine study will assess ovarian reserve of BRCA carriers and non-carriers using standard laboratory tests and ultrasonography.“This finding may have significant implications for the  application of assisted reproductive technologies in BRCA carriers,” says Dr. Johnson.  BRCA research through the Basser Center, as well as the advances in fertility technologies is providing more options for women with a BRCA mutation than ever before. “Knowledge really is power, and research on the reproductive issues associated with BRCA mutations may provide important information to help women make decisions about their reproductive future,” says Dr. Gracia. “As fertility preservation strategies and reproductive technologies have improved over the past decade, more women with BRCA mutations are pursuing technologies such as embryo and oocyte cryopreservation, and preimplantation genetic diagnosis.”

Tuesday, August 27, 2013


Chief of Gynecologic Oncology Mark A. Morgan, MD, says now more than ever, it’s important
for women with cancer to receive their care within an organization that facilitates the continuum
of care across all disciplines. “It’s important to care for the whole person – especially when
we are treating cancer. This means integrating services that treat diabetes, obesity,
hypertension and cardiovascular disease, as well as providing preventative services and genetic
counseling,” says Dr. Morgan. “No institution in the Philadelphia region is better prepared to
take care of women like this than Penn Medicine.”

Gynecologist and Director of Minimally Invasive Surgery at Pennsylvania Hospital
Sarah H. Kim, MD, agrees: “Women may have co-morbidities, other malignancies, or require a
 level of care not all hospitals are equipped to handle. At Penn, women can come here knowing
 they have the full support of the entire health care system.” Drs. Morgan and Kim have recently
joined Penn’s gynecologic oncology program. “Gynecologic oncology is a bit of a hybrid,”
explains Dr. Morgan. “Technically, we are surgeons, but we give chemotherapy and work closely
with radiation therapists.” Dr. Morgan says in his new role, he plans to continue the collaboration
with the Abramson Cancer Center and the Basser Research Center for BRCA to provide the ultimate
continuum of care for women.

Dr. Kim, who completed her residency and fellowship at Penn, specializes in minimally
invasive robotic surgery for gynecologic cancers such as uterine and ovarian cancer.
“Today, the majority of surgery I perform for cancer is minimally invasive, robotic surgery,”
she says. “Women who have this type of surgery benefit from less blood loss, shorter hospital stays
and fewer incisions.” Dr. Kim, who trains residents and fellows in robotic surgery, says with
robotic surgery, she can “push the envelope” a little further to remove cancer.

“We can take out more lymph nodes, and get better biopsy samples, so staging cancer is easier
and more accurate,” says Dr. Kim. “We can even remove more ovarian masses laparoscopiclly,
when in the past it would have required a bigger incision.” Dr. Kim adds, at Penn, her patients
will benefit from the exciting research from an academic institution on the cutting edge of new
therapies. “Teaching and furthering research is a big part of my clinical philosophy,” says Dr. Kim.
“At Penn, I feel like I can make more of an impact not only with the exciting translational research happening right here, but also with the patients I work with who can benefit from the latest and greatest techniques and treatment modalities.”

“Because of our expanded network, and our presence in the surrounding Philadelphia communities,
we can offer a strong core of services within an academic institution throughout the entire
Philadelphia region,” says Dr. Morgan. “Women at Penn receive exceptional cancer care, as well
as access to innovative therapies and clinical research not available anywhere else.”
Those innovative therapies include immunotherapy, which uses a patient’s own tumor cells to
fight cancer and prevent recurrence.

“Between genetic research like the BRCA research happening at the Basser Center, research in
Mark Morgan, MD & Sarah Kim, MD
immunotherapy and the already strong established clinical centers like the Jordan Center for Gynecologic Cancer, Penn has all the pieces of the cancer puzzle to complete,” says Dr. Morgan.
“I think these are the things that make Penn stand out — newer approaches to cancer care and more and more targeted therapies individually designed to work with each woman’s body.”