Can We Talk About What We Don’t Talk About?

Whether you are in Sub-Saharan Africa or in New York City, the trauma and embarrassment of experiencing urinary incontinence and/or a vaginal bulge are no different. Having traveled to many parts of Africa, Latin America, and Asia to perform and teach female pelvic reconstructive surgeries for over a decade, I can relate that the stories are similar and the shame of living with these problems like constantly smelling of urine is no different for women from all over the world, including right here at home.

The story below is typical of the American equivalent of these Congolese women. Fortunately for them, I can see them in my office and ultimately treat them, although the disturbing histories I hear too frequently from them are roughly the same as those women in the developing world.  

Elinor, a 45-year old account executive with 3 children delivered vaginally, was escorted into my consultation room a bit reticent to tell me her story. She related the following. “I have waited a long time to see a doctor to address my problems with urinary incontinence. I have waited for decades as I was too embarrassed and did not feel that there was a “fix”. Thus, I decided to live with it until I could no longer tolerate the negative impact on my quality of my life.  I have been wearing more than 10 pads per day and I was too ashamed to discuss with my husband. I was also too embarrassed to have sex since I was afraid of leaking urine while having intercourse. This all began since having children. I would like to be able to exercise, play with my kids and enjoy having intercourse without fearing leakage. Sometimes, I have to push up my vagina before having sex. I heard from one of my friends that surgical repair is not effective and I should learn to live with the problem”. However, I then heard of you and the possibility of a better life……….”

When evaluating Elinor, or any other woman with similar problems, it was extremely important to identify the reason she had incontinence, as there are multiple possibilities. Urinary incontinence affects 30-50% of all women over the age of 20. Although the prevalence rises with age, it is not uncommon for young women to experience urinary leakage. More importantly, urinary incontinence is NOT normal at any age.

We know that there are various types of urinary incontinence including: 

- Incontinence with physical activities with coughing, laughing, exercising, and intercourse (stress urinary incontinence, SUI)

- Incontinence with urgency, frequency of urination during the day and/or night (urgency urinary incontinence, UUI)

- Difficulty with voiding and leaking after bladder emptying (overflow incontinence)

- Combination of the above

Every patient is questioned about the risk factors that contribute to urinary incontinence including:

- Pregnancy & Childbirth

- Menopause/aging

- Chronic constipation

- Repetitive impact of heavy lifting or running

- Obesity

- Chronic coughing

- Diabetes

- Neurologic conditions

- Dementia

- Certain medications

- Genetics

- Bladder infections

- Bladder stones

- Certain food/liquid products

Once your risk factors have been established and proper evaluation has been completed, and importantly any underlying medical condition excluded, the patient’s handling of her problem has to be addressed. In order to deal with the leakage, many women start using sanitary pads. It is not a treatment and NEVER a sexy alternative. 

Another alternative is vaginal inserts, which are inconvenient, and costly. Lifestyle and behavior therapy may be good conservative treatment options for some patients. Other non-surgical treatments are pelvic floor physical therapy and anti-incontinence pessary. They are safe and often effective.

Medical therapy often is helpful for the treatment of overactive bladder and urgency urinary incontinence. It is NOT effective for the treatment of stress urinary incontinence. That is why identifying the actual nature of an individual patient’s incontinence is so important.

For those women who are looking for more effective treatment & possible cure, surgery should be considered. For treatment of overactive bladder and/or urgency urinary incontinence who have not responded to medical therapy, intravesical Botox injection should be considered. Botox, which is FDA approved for the treatment of OAB and has been used for more than 10 years, has been proven to be effective and shown to last for 6-12 months. This quick procedure can be repeated when the symptoms recur. Electrical stimulation is offered to those who have not responded to the above-mentioned conservative treatment.

For treatment of bothersome SUI, the most common surgical procedure is mid-urethral sling (MUS) with a thin, synthetic mesh that has been approved by the FDA as safe and effective. It is considered to be the gold standard and has been studied for greater than 20 years. It is performed as a same-day procedure, placed trans-vaginally, and offers 80-90 % long-term efficacy with minimal complications. Also, the surgery can be done with one’s own tissue, if one is not comfortable with the insertion of mesh. However, harvesting of one’s own tissue takes longer recovery and less long-term efficacy and leaves a noticeable scar.

After evaluation, Elinor was found to have stress urinary incontinence. A mid-urethral sling procedure was performed without incident and Elinor no longer needs the pads or pullups she once used just to get through the day. Needless to say, she is grateful, as is her now smiling husband. They both agree that had she discussed her problem, they both would have had a better quality of life………sooner.

The takeaway is, don’t be afraid to see a doctor when you are suffering from urinary incontinence and/or vaginal bulge. Your doctor can refer you to a Urogynecologist (a Female Pelvic Medicine & Reconstructive Surgeon). Urogynecology is a medical specialty that is dedicated to treating women with pelvic floor disorders. Urogynecologists are trained in a fellowship program for additional 3-years after their obstetrics/gynecology residencies. They specifically treat women with pelvic floor disorders, not only with urinary incontinence or prolapse but also with all female pelvic floor issues. 

Dr. Kwon's Bio 

Dr. Kwon’s acclaimed career in medicine began after completing her undergraduate degree at The University of Chicago; she earned her MD degree from the University of Illinois College of Medicine. She then went on to her residency in Obstetrics & Gynecology at the University of Cincinnati followed by a prestigious 3-year fellowship in Female Pelvic Medicine & Reconstructive Surgery at the University of North Carolina at Chapel Hill. Specializing in women’s health, Dr. Kwon is board-certified in Obstetrics & Gynecology and Female Pelvic Medicine & Reconstructive Surgery by the American Board of Obstetrics & Gynecology (ABOG). The mission of the ABOG is to define standards, certify and facilitate continuous learning to advance knowledge, practice, and professionalism in women’s health. 

Dr. Kwon is a Fellow of the American College of Obstetrics & Gynecologists (FACOG), she is a member of the American Urogynecologuc Society, an elected member of The Society of Gynecologic Surgeons, the International Continence Society, and the International Urogynecological Association. She has served as the Director of the Training Program in Ghana through the Foundation of International Urogynecological Society and was appointed as the Vice President of Foundation of International Urogynecological Society. Dr. Kwon also was appointed as the Chief of her Division both at Rush University Medical Center in Chicago and Lenox Hill Hospital in New York City. Dr. Kwon's passion for medicine and Global Health reflects her concern for women worldwide. Having traveled to Africa, Asia, and Latin America, to perform much-needed surgeries; she brings the same compassion and care to those right here in New York. After serving as the Chief of her Division in Chicago and New York City medical centers, Dr. Kwon is now beginning a new practice for the purpose of providing unencumbered personal care for her patients. This will allow quality time for each patient in order to understand and treat female pelvic health concerns as a patient/physician partnership.

Dr. Kwon has received numerous awards including:

• Super Doctor NY
• Top Female Pelvic Reconstructive Surgeon
• Top Doctor of NY
• New York Times Super Doctor
• Castle Connolly Top Doctors
• Patients’ Choice Award
• APGO/CREOG National Teaching Award
• Northwell Resident Teaching Award