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Yaz Settlement: Both the bladder and the urethra need estrogen in order to stay healthy. Without estrogen, the cells that line the inside of the blad­der and urethra become thinner and less elastic. After menopause, the ovaries make very little estrogen. After months or years with­out adequate amounts of estrogen, these areas generally don’t function as well as they once did. Also, the lining of the bladder can become more easily irritated by substances in the diet that are filtered into the urine, such as from caffeine, alcohol, citrus fruits, carbonated beverages, or spicy foods. Therefore, meno­pausal women who are not taking estrogen replacement may no­tice a worsening of their bladder symptoms over time.

The nerves that carry signals to the bladder also need estrogen to work properly. Without estrogen the nerves may become so sen­sitive that you may experience urgency or have bladder spasms after even partial filling of the bladder. If this condition worsens, spasms can cause leaking. Taking estrogen allows the nerves con­trolling your bladder to function properly and helps prevent these spasms. Sometimes a combination of estrogen and another means of decreasing spasms, as described in this chapter, maybe needed to relieve the symptoms.

There are a number of ways to get estrogen to the tissues of the bladder and urethra. Probably die fastest way to get estrogen to these tissues is to use a vaginal cream with estrogen. The cream is inserted with an applicator at bedtime two to seven times a week, depending on how much estrogen the tissues need. Given in vagi­nal cream form, the estrogen’s effects are focused on the vagina, bladder, and urethra. However, some of the estrogen is absorbed into the bloodstream and will reach the rest of your body. If you use an estrogen cream every day for more tiian a few months, you shoidd also take progesterone to prevent overgrowth of the uterine lining cells (unless you have had a hysterectomy). With a higher dosage and daily use, estrogen in die form of a vaginal cream can afford the same protection to die heart and bones that oral estro­gen does.

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Yaz Settlement: Some women try medications and exercises for relief of inconti­nence but are still plagued by bothersome symptoms. For these women, surgery may provide much-needed relief. Surgery is most effective when stress incontinence is a major part of the problem, and it may help if some urgency accompanies stress incontinence. It is not likely to be effective for pure urgency or urgency inconti­nence. One of the goals of surgery for die treatment of incontinence is restoring the bladder and urethra to their normal position. Most women who have given birth vaginally have some degree of loos­ening, stretching, and even tearing of the supporting ligaments of the vagina, bladder, and rectum (see Chapter 4). This weakening of the supporting ligaments usually begins unnoticed and without any symptoms and remains that way for the majority of women for tiieir entire lives. But for some women, the changes that occur as a result of the lengthening and stretching cause significant incontinence that interferes witii their daily lives.

An abdominal bladder suspension operation is performed in the hospital with anesthesia, either epidural or general (that is, you’re put to sleep). We often find that, in addition to repairing the blad­der, other reparative surgery of the supporting structures of the vagina and rectum may be necessary. Happily, it can all be per­formed at the same time. The bladder suspension procedure itself takes about one hour. Most women spend about two to three days in the hospital, usually because they need pain medication to help with the discomfort from the bikini incision. Most doctors leave a catheter in the bladder for a few days, or even weeks, after surgery to help drain the bladder until you are able to urinate easily.

Since the abdominal incision needs time to heal, some activity is restricted. For die first week, you can get up for meals, go to the bathroom, and take short walks. You will be fatigued, and simple activities will make you tired. After the first week you will feel stronger, be able to take longer walks, and need less rest. After about two weeks, some women begin working again from home. A few who can’t avoid it go to work for a few hours a day. It takes about six weeks for most of the healing to take place. Most doctors recommend that you not do any exercise or lift anything heavier than 15 pounds for three months. This allows the formation of strong scar tissue that will hold the bladder in die proper position. After surgery, you probably should never lift anything heavier than 25 pounds. You don’t want die force of lifting to stretch and weaken the repair work.

The laparoscopic Burch is performed through small incisions and has the advantages of less postoperative dis­comfort and a faster recovery. However, the procedure requires special training and skills on the part of your doctor, and not all gy­necologists perform it. The laparoscope is a small telescope that is passed through a 72-inch incision in the navel . Two or three smaller (74-inch) incisions are made above the pubic hairline and the operating instruments are placed through these incisions. The telescope and operating instruments are placed into the space around the bladder and specialized instruments are used to place the sutures to suspend die bladder to die ligaments near the pubic bone, just as in die Burch procedure.

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