University of Pennsylvania Health System

ObGyn Update | Penn Medicine

Wednesday, July 8, 2015

How to Do Kegel Exercises Correctly

Kegel exercises: If you’re a woman, chances are just hearing someone mention those two words causes you to involuntarily start doing them yourself.

But are you doing them correctly?

If you are, your pelvic floor muscles all relax and contract together, not separately. So when you do a kegel exercise, you’re contracting a whole group of muscles.

Pamela Levin, MD, assistant professor of Clinical Obstetrics and Gynecology, knows firsthand that a lot of women think they’re doing kegel exercises correctly. But they’re not.

Here are some of the most common mistakes her patients have made and some tips on how to do them correctly.

Three Common Kegel Mistakes

1. You’re squeezing the wrong muscles.

“It’s not your abdomen, and it’s not your butt cheeks,” explains Dr. Levin. “If you put your hand on your abdomen and you feel your belly muscles clenching, you’re not squeezing the right place. If you feel your butt cheeks tightening and coming up off the chair, then you’re not squeezing the right place.”

2. You’re not contracting your muscles. 

Dr. Levin says, “Some people who think they’re doing kegels correctly are actually pushing, not squeezing.”

3. You’re trying to practice at the wrong time. 

One of the main misconceptions about kegel exercises is that you should try to stop your urine mid-stream when you’re on the toilet.

“I think at some point we’ve all heard that advice,” says Dr. Levin. But, she warns, “Practicing that way sets you up for trouble.” That trouble may include difficulty urinating in the future.

Instead, practice them when you have a spare moment, like when you’re sitting in traffic waiting for a red light to change. Here’s how:

Doing Your Kegels the Right Way

“Envision you have a straw in your vagina, and you’re trying to pull fluid up through the straw,” suggests Dr. Levin.

It may help to insert a finger into your vagina and tighten the muscles like you’re trying to hold your urine in, says the NIH. If you’re doing your kegel exercises correctly, you should feel your muscles tighten as you do this.

As with all muscle training exercises, practice makes perfect.

“Often you can squeeze the muscles for a quick second but then the muscles fatigue really fast,” explains Dr. Levin. “With practice, focus, and training you can actually learn to do kegels that you can sustain for a few seconds before releasing. Being able to do both the quick squeezes and the longer, stronger Kegel exercises is the best-case."

As for how often you should practice, Dr. Levin says, “I suggest you do them a couple of times a day.”

You’re doing them right now, aren’t you?

Wednesday, July 1, 2015

What on Earth Is Urogynecology?

Picture this: You’re out with your friends and someone says something so hilarious that you all burst out laughing. But your good mood plummets to embarrassment: You’ve started to leak urine. You dash to the nearest restroom, hoping you’ll make it in time.

Over the next few months, you’re plagued by more embarrassing leaks and close calls. Finally, you mention it to your primary care physician. She recommends you see a urogynecologist.

A what...? You heard right—urogynecologist.

No, it’s not a European gynecologist. Urogynecology is a hybrid specialty: Urology plus gynecology.

“I see a lot of women who are postpartum—just had babies. I see women who are in or approaching menopause. I see women who are postmenopausal.  I also see women at other times in their life who are simply bothered by their symptoms,” explains Pamela Levin, MD, assistant professor of Clinical Obstetrics and Gynecology.

Here's what you should know about the specialty.

What exactly does a urogynecologist do?

Urogynecologists help women who have pelvic floor conditions. They handle everything from evaluation and diagnosis to treatment and management.

“The beauty of urogynecology is that it is a collaboration between you and your doctor. It’s all aimed at meeting your goals,” says Dr. Levin. “The primary focus is on quality of life.”

Treatment for pelvic floor conditions include:
  • Behavioral therapy—relaxation techniques, muscle training, dietary changes can help manage symptoms
  • Pessaries—after receiving doctor instruction on proper use, this device that fits into the vagina to support the bladder, uterus, etc. can be removed for cleaning and reinserted
  • Medications—depending on the condition, this may be an option for treatment  
  • Surgery—options vary from minimally invasive and laparoscopic procedures to reconstructive surgery, depending on the condition

What are some common pelvic floor conditions that urogynecologists treat?

Urinary Incontinence

Urinary incontinence is the clinical term for urine leakage. The American Urogynecologic Society (AUGS) found that it's twice as common in women than in men. Risk factors include:
  • Vaginal childbirth
  • Genetics
  • Diuretic medications
  • Chronic constipation
  • Obesity
  • Smoking

Overactive Bladder

People with overactive bladder have urine leakage as well as a frequent, intense urges to urinate.

Some women have an obvious underlying medical condition—usually a neurological or inflammatory illness—that causes overactive bladder. But for most women, the cause is unknown.

Pelvic Organ Prolapse

Pelvic organ prolapse occurs when the pelvic organs—like the uterus or bladder—drop because of weakened vaginal muscles, says the AUGS.

Risk factors for pelvic organ prolapse include:
  • Vaginal childbirth
  • Genetics
  • Smoking
  • Pelvic floor injuries
  • Chronic constipation
  • Chronic coughing
  • Obesity
Obese women are 40 to 75 percent more likely to have pelvic organ prolapse.

Is urogynecology a new field of medicine?

Yes and no. The health issues that urogynecologists deal with are not new.

But the American Board of Medical Specialties (ABMS)—the organization that oversees certification standards—added urogynecology as a subspecialty in 2011, according to AUGS.

Urogynecology is also known as Female Pelvic Medicine and Reconstructive Surgery. Doctors began receiving board certification for it in 2013.

What should you look for in a urogynecologist?

Your primary care physician or gynecologist can refer you to a urogynecologist if you're dealing with pelvic floor issues.

If you’re looking at prospective doctors on your own, keep in mind a few key factors: Experience and certification are important. But, so is the doctor’s personality and how comfortable you feel with him or her.

“You have to make sure you feel like this person is someone you can share intimate details of your life with," says Dr. Levin "Someone that you feel comfortable with, that you trust and that you know is listening to you."

Do you want to learn more about urogynecology services? Ready to see a specialist about your pelvic floor issues? Sign up for an appointment with a Penn urogynecologist.

Friday, May 8, 2015

Feeling Well, Healing Well After Pregnancy

The bra that fit perfectly before the baby might not be as flattering now. And your bathroom habits? Well, they may be different, too.

“Urinary incontinence during pregnancy is not uncommon. and makes sense given the changes that take place during pregnancy,” says Uduak Andy, MD. Dr. Andy is a urogynecologist at Penn Medicine, an ob/gyn that specializes in treating women with pelvic floor disorders.

“You have this baby growing in your uterus pushing down on your bladder and urethra. For some women, incontinence will increase as the pregnancy progresses.”

Childbirth can lead to urinary incontinence, too. As your baby makes its way down the birth canal, your pelvic floor muscles may be stretched and, in some cases, even damaged. Even women who have a C-section are not without risk.

Dr. Andy says that because of all the changes a woman may experience throughout her pregnancy and childbirth, it may take anywhere from six weeks to a year to fully recover.

“If a woman is still experiencing pain, painful sex, or urinary incontinence six months after she’s given birth, she may want to see a urogynecologist, who can offer her treatment options and exercises to improve the pelvic floor,” says Dr. Andy. 

Bladder and Pelvic Floor Issues

Women with stress urinary incontinence may leak urine while coughing, sneezing, laughing or exercising.

According to urogynecologist Pam Levin, stress incontinence occurs when the urethra and surrounding muscles of the bladder lose their strength and support.

“Urinary incontinence and pelvic floor disorders don’t have to be a rite of passage for women, or something we just have to deal with as we age," she says.

That's why she created the Feeling Well, Healing Well Program.

Treatments for Urinary Incontinence

Penn's Feeling Well, Healing Well Program focuses on pelvic floor disorders women may experience as a result of pregnancy and childbirth.

“The post-partum time period can be challenging for new moms,” says Dr. Levin. “They might not feel comfortable talking about the issues they are experiencing. We want them to know that we specialize in these disorders and are here to help.”

It’s estimated that nearly 50 percent of women suffer from bladder and pelvic floor disorders at some point in their lifetime; however, there are options so that women don't have to live with their symptoms.

Stress incontinence can be treated with physical therapy, including Kegel exercises, physical therapy, or the use of a pessary, a removable appliance similar to a diaphragm that is inserted into the vagina or rectum to strengthen the pelvic muscles. Collagen injections may also be used to help minimize urine leakage from the bladder.

“In some cases, we recommend surgery during which a hammock or sling is placed under the urethra to provide more permanent support,” says Dr. Levin. During the operation, a sling created from FDA-approved mesh is inserted behind the urethra to support the weakened pelvic muscles.

Women who have vaginal pain after delivery or pain with intercourse may experience muscle spasms or have painful scar tissue that narrows the opening of the vagina.

“Once we learn what is causing the pain, we can determine if a woman needs surgery, physical therapy or both to address the issue,” says Dr. Andy.

Depending on the issue, surgery may be deferred until a woman decides not to have any more children. This decision would be made in collaboration with the patient after a full consultation and discussion about the risks and benefits.

Friday, April 24, 2015

When Should You See a Doctor for Irregular Periods?

Maybe you’re in your mid-to-late 20s and and suddenly—after having regular periods for more than a decade—your cycle suddenly stops behaving like clockwork. You’re not pregnant, and you’re nowhere near menopause, so what’s the deal?

Here’s what you should know about how to identify irregular periods, what causes them and when to see a doctor.

What Are Irregular Periods, Anyway?

During a normal menstrual cycle, an egg is released from one of your ovaries during ovulation. If the egg is not fertilized by a sperm, then changing hormone levels signal for your body to shed the blood and tissues that line your uterus, says the Office on Women’s Health (OWH).

This bleeding typically lasts about five days. Then, the monthly cycle repeats itself.

But some women have what is called abnormal uterine bleeding—another term for irregular periods, the OWH explains.

What is abnormal uterine bleeding?
  • Bleeding or spotting between periods
  • Bleeding after sexual intercourse
  • Heavy bleeding during your period
  • Menstrual bleeding that lasts longer than normal
  • Bleeding after you’ve reached menopause
According to the American Academy of Family Physicians (AAFP), between nine and 14 percent of women who have already gotten their first period but haven’t yet reached menopause have irregular periods.

What Causes Irregular Periods?

There are a number of reasons why a woman has irregular periods, says the National Institute of Child Health and Human Development (NICHD). 

When a girl first starts menstruating, it may take some time time before her periods become regular. And periods may stop becoming regular up to eight years before menopause.

Common causes of irregular periods include:

Uncontrolled diabetes—Women with unmanaged diabetes may have irregular periods because the interaction between blood sugar levels and hormones can disrupt a woman’s menstrual cycle, says the American Diabetes Association.

Eating disorders—Women with conditions like anorexia or bulimia may have irregular or missed periods because their bodies are not producing and circulating enough hormones to control the menstrual cycle, according to the Hormone Health Network.

Hyperprolactinemia—Women who have too much of a protein hormone called prolactin in their blood can have irregular periods.

Medications—
Certain medications, including anti-epileptics and antipsychotics—can cause irregular periods.

Polycystic ovary syndrome—PCOS is caused by imbalanced sex hormones, which can disrupt regular menstruation.

Premature ovarian failure—The ovaries of women with POF stop working before the age of 40, says the National Institutes of Health. Some women with this condition continue to have periods occasionally, however.

When Should You See A Doctor For Irregular Periods?

It may be time to talk to your doctor if:
  • You haven’t had a period for 90 days
  • Your period suddenly becomes irregular
  • You have a period more often than every 21 days
  • You have a period less often than every 35 days
  • Your period lasts for more than a week
  • Your period becomes unusually heavy
  • You bleed between periods
  • Your periods are extremely painful
Source: Office on Women’s Health

A gynecologist will be able to determine the cause of your irregular periods and help you figure out a treatment course. This may include oral contraceptives to regulate your cycle.

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.