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The first antibiotic was arsphenamine Salvarsan discovered by Paul Ehrlich in after he observed that bacteria took up toxic dyes that human cells did not. This is used by lobby groups to push their own agendas, in this case, the minimalist approach.

Pelvic Health & Childbirth

And much more...

If you're on a stimulant while having some cocktails, you may not notice your body's natural cues that it's time to stop. You could risk alcohol poisoning or a drinking-related accident. Having both booze and a stimulant in your system also raises the risk of heart-related issues.

The amount of alcohol that would give a person not on medication a minor "buzz" could make someone taking these meds drunk. The medicines affect how booze is broken down in the body and can lead to higher blood alcohol levels. You need to factor in when you last took your medication, and how long the stimulant works in your system.

Short-acting immediate release medications, which are taken a few times a day, usually last about 4 hours. Long-acting extended release medications are meant to last the whole day, and are usually taken in the morning. With a long-acting stimulant, I would recommend they wait at least 12 hours," Leung says.

Goodman MD, an assistant psychiatry professor at Johns Hopkins School of Medicine, says he'd tell his patients to have no more than two drinks. But he warns, "Some patients tell me they feel more hung over in the morning than usual, even if they've separated their stimulant and alcohol use by several hours. You may be more likely to feel the effects of alcohol while on nonstimulants.

It can take a higher toll on your motor skills, and it may heighten symptoms of depression. The person I had an affair with became my support and I was able to gain strength, courage and not feel alone. I was able to leave! And my husband did kidnap me and attempt to murder me but I was rescued by a team of law enforcement just in time. I am not with the person I had an affair with today and I don't regret our time in the affair.

I am now the happiest I have ever been with my ex out of my life. Also, on the flip side, I would rather survive the pain of an affair than be with someone I think is just as committed to me. Interesting that those yelling the loudest in response to this article are women. You'd probably never hear a man saying those same things with the same intensity. Obviously, marriage is a construct for the benefit of women. And you know what people do when you try to take away their benefits.

Meanwhile, I had an affair five years ago with my rediscovered high school sweetheart. I was going to make the switch and get divorced, but I couldn't handle or live with the hatred coming towards me from my children late teens and to a lesser extent my wife.

So I gave up what I'd really wanted all my life, and went back to take care of my family. Because I couldn't be happy with my children hating me. If I had my life to live over, I'd never ever get married. Having children is overrated also. Not bitter, just realistic. Getting married was my decision. So was who I picked to be my wife. But turning that into a life sentence and not being allowed to make any further decisions of that type truly sucks. Is the marriage to the benefit of the women?

Because I am too weak to be on my own and need protection from a strong male? I spent 29 years taking care of 5 people, giving them the best of me and the benefit was mostly theirs. Now I know it was a mistake.

But then, what is this fabled benefit? That I reproduced myself? Looking back I would've made different choices. After learning of my H's 5 year long affair with his assistant all the life we had before lost any meaning to me. It feels like it evaporated into nothingness. I know it sounds extreme, but that's how I feel and in truth I am deeply disturbed by my own reaction. What was the point?

I should've asked myself 29 years earlier and never go this silly road of love, trust and devotion to someone else. Instead, go for what is good for me, like everybody else should. We do get caught up in the dicta of society with being committed, devoted, faithful, putting on a brave face when you're unhappy and soldiering on in a marriage that dried up and went sour long ago. What we so often forget is "To thine own self be true".

It does no one any good to stay in a marriage because of obligation or feeling sorry for the other spouse. There are no gold stars given out for being a doormat either. Honesty is still the best policy primarily with yourself and then share that with your partner. Sure, you might make some ripples in the waters but they will be a lot less than the stormy outcome of an affair uncovered. Marriage is not for sissies. You still have to have guts.

Women might be more demonstrative about it, but men hurt just as deeply, even if they don't express it as strongly. I congratulate you for not breaking up your marriage because of the way your children would see you. My father had no such compunctions. He lives an hour and a half away from me, but for the past ten years we have spoken once a year or so, and most of that conversation is taken up with his telling me about what he and the woman for whom he left my mother have been doing.

He is desperate for my approval and acceptance of her and their relationship. I can't give him those things because of the hurt he caused my mother and the disrespect he showed for his daughters by implying that it's perfectly acceptable for their husbands to replace them with newer models.

You congratulate this man for caving into his childrens needs and ignoring his own? I have also stayed in a relationship that is less than desirable for my children. What a load of crap. Women are in most danger when they try to leave men, men who feel betrayed often react much more extremely than women do, they're the ones who turn to stalking, violence, murder, family annihilation. Study after study shows that men benefit more from marriage than women do.

Married men live longer than single ones, not so women. Married women stick with men when they have serious illnesses, men more often abandon their spouses. You've sentenced yourself to loveless intimacy, held hostage to the possibility of children and spouse withholding a positive relationship. From what you've written, it doesn't sound as if it was worth it. The older the children, the better able they are to understand divorce.

You can't throw a baseball without hitting a child of divorce. I've gone out with many. The ones who were in the latter part of high school when it happened are the most emotionally healthy. It's possible it's because they were old enough to have dated, been on both ends of being the instigator or the recipient of a breakup. They are old enough to have a heart to heart appropriate for their age , with the parent instigating the divorce.

One thing which might be going on in your home is your children internalizing your marriage as a blueprint for their future relationships.

I can't tell you how many friends and partners have told me that their parents, even their home s are much happier since their parents divorced. No yelling, no meanness, no coming home to a house where the tension is so thick that you can't breathe.

If you do decide you want more for your life than living as a hostage, it will initially be tough. But children want to know what the divorce will mean to them. Where will they live? Are they being divorced from you too? Maybe their mother is using the children as a weapon, telling them that they will be broke if you leave, that you'll have no time for them.

Sadly, you might find a child taking sides. I know one guy who with his coworkers , caught his wife cheating. He divorced her and their daughter decided to side with the wealthy mother.

On the other hand, he can and does see his son whenever he can. He is sorry about his daughter but doesn't regret his actions. A neighbor told me about a couple who live next door to their summer soon to be full time home. They have been married for 50 years. Note I didn't say "happy". Their children are grown and gone, rarely visit. The neighbor said that they used to have loud fights but this passed with time. Now, like many old people, they like to sit outside in the sun.

But she sits outside in the back yard, and he sits outside in the front. They will likely go on this way until they die.

That's just so sad. Do you want to end up like this? Find your friend, and if she isn't married, maybe there's a future for you both together. Even if she's moved on, you've got or more years of life left. Would living alone, dating, maybe even getting remarried, be a way you could see yourself living?

Wouldn't it be better than a life sentence in a failed relationship? Your wife might even find someone who could make her happy, once she let go of something which sounds as if it died long ago but nobody called the undertaker. I hope you choose life.

Not all marriages should be saved. Many marriages should end. I just don't think breaking a promise, lying, intimate betrayal and sneaking around right for anyone involved.

If it takes being with someone else to leave an unhealthy relationship, that's your choice. I am not a fanatic. I know men and women who have been devastated and I would hate for someone looking for an ego boost to read this article and jump in. Once you pull that trigger, there's no erasing it.

Lily, please excuse yourself from your bubble and look at both sides of the story. There can be are "successful" affairs in the same numbers as your "traumatic" affairs. There are so many more mature people in this world than you give credit.

UGH, society is so holier than thou anymore. I am so tired of hearing about the trauma associated with infidelity. Try living through real trauma Hurt feelings are not trauma. Feeling betrayed is not trauma. Shattered illusions about how life is suppose to be is not trauma.

How about some perspective. How about having some coping skills to deal with the inevitable losses and difficulties of life and love. Marrying for love is risky. If you believe that the people who love you will never hurt or leave you, you're living in a fantasy world. Get married if you must, but always have a plan B. There are no guarantees. Your the one who needs perspective. Trauma doesn't have to be physical. Such narrow mindedness is very reckless. Try living trough betrayal and see how 'traumatizing' it is.

How would you feel is someone betrayed your privacy and tell nasty things about you to your friends? How would you feel if your friend betrayed you borrowing large amount of money then disappearing? How would you feel if someone raped you? Life is risky always is. You can't be sure if you could graduate in college. You can't be sure if you can drive and stay accident free. You can't be sure that you won't just drop from heart attack few moments from now.

Life is risky but does not mean you downplay it. Many experiences, like infidelity, sickness, or bankruptcy, turns life upside down, just as war do but in different manner. Making little of this experiences is a great disrespect to the strength of people who had overcome it. Either you never experience trauma or you are very weak as to turn your back to them.

You like to immunize your heart rather than face the harsh reality your so proud of talking about. You are so right! I left my war ravaged native country 15 years ago and, believe me, I know about trauma When I learned of my husband's short affair I did suffer, but it wouldn't call it "traumatic" I recovered, we reconciled, and now are happier than ever with each other.

Ask any soldier coming from deployment, any survivor of a natural disaster, anyone who have lost a son or a daughter in an accident or even an illness Those are the really traumatic experiences of life. You never recover from that Your experience with severe trauma does not give you the right to invalidate anyone else's feelings and experience of trauma.

Each person gets to choose whether an experience is traumatizing for them; it is not for you to pass judgment on their suffering.

I seriously doubt that I would rate my experience and trauma as a betrayed spouse anywhere near your experience in war. But I'm unusually resilient and I had very little past experiences that made me susceptible to PTSD an continuing anxiety. I've communicated with some who say that they've been through severe traumas such as you and they say that the infidelity was still that hardest or most painful for them.

To each their own. The good point of the article in my mind was that the author brought some nuances into this subject matter.

We tend to be very black and white and the author reminded us that nothing is that simple. As a woman, I guess I am more unusual in that I was the unfaithful one. I had a very long term affair more than 10 years with a married man, and I think it kept both of us married to our spouses, in that we had an escape valve from our own unhappy marriages.

Neither of us wanted to get divorced because we were very invested in our families. We would periodically break it off to try to work on our own marriages, but inevitably got back together, probably just out of inertia.

I finally did break it off more than two years ago, but ended up in another affair. That one was more of the "mind-body" type, which was my big wake-up call to 1 go to counseling to figure out what the hell was wrong with me and my marriage to cause me to stray from my husband 2 be brave enough to separate, and ask my husband for the things I needed from him in order to stay married and really work out our problems, and 3 finally ask for a divorce when he refused to do any of the three things I asked.

I am not with either of those two men anymore, although I remain friends with the last one. We ceased sexual relations when I separated from my husband, because we both thought I needed the time and space to think things through.

My friend helped me through many difficult times and continues to do so, but he is not my boyfriend anymore. Although I miss that aspect very much, I am grateful to him because he helped me be brave enough to get out of an emotionally abusive marriage and completely change my life, grow, change, evolve, and become a much better and stronger person, a better mother, a more authentic person.

My husband never acknowledged that he had a part in the disintegration of our family or that perhaps my affairs had more to do with my unhappiness instead of me just being a slut.

He currently refuses to make contact with the children, which hurts them and me very much, but with God's help, we are struggling through this difficult time. I never wanted to hurt my husband, but I did not know how to confront him about our problems, or even know exactly what the cause of my unhappiness was for many years.

The infidelity was an escape hatch that allowed me to continue to live an apparently normal grade-A family life until I absolutely could not cover up the problems any more. Please, commenters, have some compassion for the cheating spouse Thanks for sharing your story. Life is indeed complex, with many conflicting issues that we have to struggle through, assess, and hopefully learn from as we "evolve.

It's been a very long and desperately difficult journey to get healthy enough to make the changes I needed to make I'm so happy to hear that you managed to leave a terrible situation and find the real you in the process.

Your story is very similiar to mine. I've done a lot of research to find out more about women having affairs and there is very little out there. I had several affairs and dalliances which began at about 13 years of happy marriage. All the while, I looking at myself from the outside trying to figure out why I was behaving that way. I never knew I was unsatisfied in the marriage, but I finally diagnosed myself as being frustrated because my social creativity was thrwarted.

I know that sounds flippant, but I can't fully explain my behavior because my marriage was comfortable. I did recently pick up the 's book "Passages" which has given me a lot to think about adult developmental phases.

I left my husband about 3 months ago because I cannot seem to remain faithful. Like yours, my husband never acknowledges any part in our disentigration I'm just a slut. I have been in a 2 year long "mind-body" affair and find myself even more conflicted about my feelings since I left home. I miss my husband and I hurt him deeply. I have young children. I love my lover. I don't think I can recover my marriage. The best book defending this view I read is: Whatever view one holds however, one cannot escape the fact that the delivery of a healthy infant, without significant damage to the mother, is a high stakes competitive and astonishingly finely balanced process.

This same process is responsible for our survival as a species, but things can and do sometimes go wrong. Lewontin, who holds the Alezander Agassiz professorship at Harvard University, is a leader in research on the genetic basis of evolution. The easiest way to visualize the pelvic floor is to imagine a trampoline see illustration.

Think of one of those small round framed trampolines found in many neighborhood gardens. Now, imagine this trampoline's frame to be slightly bent, so that it is somewhat wider from side to side than from front to back. Imagine that it is bent a second time, so that the front end is slightly more pointed than the back, and that the black canvas webbing is somewhat sagging.

Now picture three holes cut into the canvas one behind the other, in the fore and aft plane. The front hole is the smallest. The other two holes behind it are almost equal in size to one another and a bit larger than the little one in front. Got it so far? Our pelvic floor picture is almost complete, but a few details still have to be sketched. Now imagine a sling made of car seat-belt material sutured onto the canvas and looping around all three holes.

It originates just off-center on each side of the front of the trampoline frame where it is strongly attached. This seat belt loop is tightened so as to pull the canvas slightly forward and in the process closes the holes in it off.

Lastly, imagine a piece of very strong white sheet on top of the black trampoline canvas. This sheet is sewn onto the canvas, but is only attached to the frame at the front. Along the rest of the way it is attached to the canvas, especially on the sides. The same holes cut into the canvas permeate the white sheet. This, very simply, is the pelvic floor. The trampoline frame represents the pelvic bones and the black canvas the pelvic floor muscles.

The white sheet represents the pelvic fascia, which will be discussed and explained later, and the sling represents the puborectalis part of the pubococcygeus muscle don't worry, we'll get to it.

The three holes represent the openings where the pelvic floor is penetrated by three tubular structures, namely, the urethra, vagina and rectum, in that order. The pelvic floor is not really horizontal or even flat. Instead, the muscles usually form a concave shape, just like our imaginary loose canvas, but since it is an active organ it can also contract to a convex shape, thus creating active lift.

The most important muscles include the pubococcygeus, iliococcygeus, coccygeus and ischiococcygeus muscles that together form the levator ani muscles one each side meeting in the midline. Although considered different muscles, they form a single unit in one plane and function in unity.

The levator ani are mostly made up of fibers of the so-called slow-twitch type. Such muscles are designed to provide constant and prolonged contraction even though the person is not aware of it. They do not tire easily and, unlike ordinary skeletal muscle, they are able to provide constant support. We are usually not conscious of them, which is somewhat different than most other skeletal muscles, but they are, however, also under our voluntary control.

This is mainly because they also contain so-called fast-twitch fibers. These allow quick responses to messages from the brain during episodes of involuntary and increased intraabdominal pressure, as occurs when we cough, sneeze, or laugh.

The resultant contraction then serves to counteract the downward pressure that is generated. There are a few other muscles we should be familiar with if pelvic floor defects are to be understood. These are the various sphincter clamping muscles of the tubular hollow organs perforating the pelvic floor and whose dysfunction may cause fecal or urinary incontinence leakage. Although much more complex than the descriptions here, the main point to understand is that both the bladder neck as well as the lower rectum have strong sphincter muscles that are under voluntary control.

This control is needed to overcome those sudden urges we all know, to urinate, to pass gas or to defecate at inappropriate times or under unacceptable circumstances. The sphincter muscles can also contract reflexively, however, to counteract involuntary episodes of increased intraabdominal pressure.

It is obvious that the weakness caused by direct damage to the muscle tissue itself or to its nervous supply will lead to poor function and to the danger of incontinence. Everyone is aware, at least, of his or her rectal sphincter muscles. If one does not actively relax this sphincter, one just cannot defecate. The flip side is immediately obvious. If the rectal sphincter relaxes when it should not, or if it cannot contract or maintain the necessary tonic contraction, involuntary defecation or incontinence is a high probability.

Sphincter muscles are in effect our safety clamps. They give us control over our bodily functions, and without them we would be at the mercy of every bowel and bladder contraction. This would have made civilization, as we know it, impossible. I worked for a few months as a medical officer in the Kaokoland of northwestern Namibia then called "South-West Africa".

This is the traditional area of the Himba tribe. The Himba are, to this day, one of the most isolated nomadic peoples in the world. They wear basically only loincloths, beads and a mixture of fat and clay, which they paint on their bodies.

They wash only a few times a year, accompanied by celebrations, and because they are nomadic, they possess few belongings.

Most of their rituals and habits are easy to appreciate as very appropriate and practical adaptations to a very harsh environment. The Kaokoland is an extremely dry and desolate region. During the few rainy months, when very little rain actually falls, malaria is rampant.

Fresh water for washing is not available for most of the year, and the fat and clay effectively keeps the mosquitoes at bay. The two things that I remember most about the Himba people, however, are the following: They are a fiercely proud people, distinguished by their erect bearing and aura of great dignity.

There was no question of embarrassment about their almost naked bodies. The first thing usually done by hospital staff after Himba people were admitted to hospital was to wash off from their bodies the rancid mixture of fat and clay.

This was necessary of course to preserve conditions of asepsis, but also the white hospital linen. Immediately after this washing, however, the women whom I usually treated felt suddenly shy and felt naked.

My second distinct memory was the tribe's completely uninhibited attitude to normal bodily functions. I vividly remember groups of Himba women walking in the town of Opuwo, who would suddenly stop, spread their legs and urinate in the middle of the street before walking on as if nothing untoward had happened.

Our western sensibilities and culture find this behavior almost incomprehensible, but this example illustrates how much our attitudes and taboos about bodily functions, have helped to shape our civilization and cultural psyche. It is interesting to think that our civilization is partly built upon intact sphincter muscles and our ability to control them! For a muscle to work efficiently and properly there are a few basic prerequisites.

Think about a rope that is used to pull something. It obviously has to be attached securely at both ends to enable efficient transfer of the forces created. Secondly , the muscle needs to be innervated by nerves that would enable it to receive messages from the brain or spinal column. The return loop of the nerves is equally important since nerves have to return information to the spinal column or brain about the status of contraction and the position of the muscle.

The brain has to know when to stop the contraction, or how to modify the contraction to exert just the right amount of force. It is amazing to realize the intricate control we have over our muscles under normal conditions. Thirdly , for a muscle to contract effectively, the muscle tissue has to be healthy and free of unnecessary scar formation or connective tissue non-muscle tissue which keeps tissues together. The sphincters we are concerned with here are under both conscious as well as involuntary control.

This means that we can consciously and purposefully contract them, but that they also have the ability to contract as a reflex reaction without the need for us to consciously think about it. In our imaginary picture the white sheet on top of the pelvic muscle trampoline represents the pelvic fascia.

Fascial tissue is connective tissue, which basically is the soft tissue framework which holds our various body parts together, or apart, depending on their location. Without connective tissue we would literally fall apart in separate clumps of muscle, brain and various specialized tissues which would lack a recognizable form.

Connective tissue is formed mainly by combinations of different types of collagen, especially type 3, but this is not important for an understanding of its function. In the pelvis the fascial layers which surround the muscles of the pelvic floor not only provide a framework for the implantation of these muscles, but also surround the various pelvic organs and keep them each in a proper position. As an example, the recto-vaginal septum is a fascial layer, which separates the vagina from the rectum and prevents collapse of the front of the rectum wall into the vagina during straining, for instance when a bowel movement is passed.

The pelvic fascia not only surrounds each tubular organ as it perforates the pelvic floor, but is integrally embedded in the wall of each organ. Tears or damage to this fascia can thus have significant consequences for both the normal functions of these organs, their position, as well as for the strength and integrity of their sidewalls. The recto-vaginal fascia has been the subject of much controversy.

Only very recently has it generally become accepted that there is such a thing in females. This is especially interesting since it has always been known to exist in the male. How about that for some rectal gender discrimination!? This recto-vaginal septum a septum is basically a fascia layer between two closely related organs is currently thought to be important to establish the integrity of the vagina and rectal walls, and, to anchor the perineal body.

The perineal body is the thickened part between the anal and vaginal openings. It is that part which would be in direct contact with a bicycle seat. The perineal body is basically formed by the insertion of multiple small muscles and strong connective tissue units, including the anchored recto-vaginal septum. Most of the muscles involved surround the lower vagina and can be clearly felt during a voluntary contraction when placing two fingers in the lower vagina.

The external anal sphincter is also attached to the perineal body. Any disruption or dysfunction which results for instance from a tear through this area which is extremely common during childbirth could destroy the insertion point of multiple muscles, connective tissue structural units and the attachment of the recto-vaginal septum.

This could have severe consequences for the integrity of the wall between the vagina and the rectum. Furthermore, as we now know, an intact insertion is one of the prerequisites for effective muscle action. A tear in the recto-vaginal septum can cause the perineal body to lose its anchor and to fall downwards.

This effect will be especially great during episodes of increased intraabdominal pressure straining thus causing the whole perineum to bulge downwards. This,, in turn, can cause branches of the pudendal nerves to stretch, which could potentially lead to further damage and set in motion a vicious circle which will worsen over time.

In the absence of adequate muscular support to the pelvic and abdominal contents, the full brunt of their weight and pressure falls on the fascial layer. In cases of muscular atrophy weakening from loss of bulk , injury or weakness from other reasons, this fascial layer has the burdensome task of providing the only support.

Unfortunately, some of the same causes of muscle deterioration cause tears or stretching of the fascia, so that even if initially intact, the absence of the pelvic floor muscle support, causes the fascial layer to stretch out over time or eventually to tear. Certain inherited disorders of connective tissue cause a propensity to develop hernias and other tissue support problems. Unfortunately, there has been little research into the possible pelvic floor dysfunction of these patients, so we have little knowledge about the contribution of genetically abnormal connective tissue to the development of pelvic floor disorders and urogenital prolapse.

Nevertheless, it is probably safe to state that there is a range of genetically determined connective tissue disorders, which might be highly prognostic predictive of possible future problems. It has also been suggested by numerous authors and researchers that there might be racially based differences in connective tissue strength, possibly related to differences in the collagen type mix in the connective tissues of the various races.

It is known from experience my own included that pelvic prolapse is more common in certain races, but I have yet to see a large study confirming this or a definitive explanation for this phenomenon. An interesting theory about acquired pelvic fascia weakness is that it is hormone dependent and, specifically, estrogen dependent. It is well known that many of the urogenital tissues are extremely sensitive to estrogens and rapidly become weaker in its absence, for instance in the postmenopausal phase.

The theory states that a deficiency in estrogen would lead to a change in the composition of the connective tissue collagen types that form the pelvic fascia. Thus a strong collagen type would be displaced by a weaker type which is then unable to provide the support needed.

Secondary prolapse and other problems might, as a result, develop with time. It follows, therefore, that hormone replacement therapy has a useful role to play in the prevention and possible improvement of such disorders. It is also believed that some of the muscles of the pelvic floor are also sensitive to estrogen and is negatively influenced by its absence or with lowered estrogen levels. Estrogen deficiency, moreover, leads to decreased vascularization blood flow of the urethra and to decreased coaptation of the urethral walls.

This basically means that the internal walls of the urethra will press less tightly together, and this can lead to urinary leakage. The atrophy and decreased vascularization lead to loss of thickness of the interior walls of the urethra, with the above-mentioned urinary leakage as the unfortunate result.

Although estrogen deficiency is a common contributing factor, it would seldom be the sole cause for incontinence in the absence of pelvic floor weakness. Another female hormone that is important to the health of fascia, is progesterone. This is the hormone that is secreted by the ovaries after ovulation to prepare the endometrial lining lining of the uterus for implantation by the embryo.

This occurs every month in ovulating women during the latter half of the menstrual cycle, with a tremendous rise in progesterone levels when pregnancy ensues.

The placenta eventually takes over the production of progesterone for the duration of the pregnancy, which in turn supports the placenta and causes changes in the mother's body to prepare her for the pregnancy as well as the delivery.

The fetus in this case in reality the placental half of the fetal-placental duet has to do some work too!!

If no pregnancy occurs, a drop in progesterone levels signals the onset of menstrual bleeding. It is very well known that progesterone causes laxity of the body's ligaments, which is an important adaptation attempting to make the birth process easier.

This laxity of one of the body's important connective tissue types ligaments might also be associated with weakness or laxity in others. Although not generally recognized as a direct cause for later problems, this might be one more important reason to refrain from activities such as heavy lifting during pregnancy and for about six weeks after birth.

Unfortunately, the pelvic fascia is susceptible to tearing. This commonly happens during childbirth and we will discuss that in more detail later on. It is also susceptible to stretching, and unlike the muscles on our pelvic trampoline, it cannot bounce back to its normal shape.

This is as a result of its particular collagen composition. Possible further causes of fascia damage include chronic straining during heavy lifting; chronic lung disease which causes chronic coughing including smoking, which also decreases estrogen levels ; or chronic constipation with repeated and constant straining in attempts to evacuate the bowel.

As will be seen later, chronic straining from constipation can potentially lead to pelvic muscle damage too, but by another route. Another well-known cause for connective tissue weakness is vitamin deficiencies, especially vitamin C. It is conceivable that subclinical nutritional disorders could lead to degradation in the quality of the body's connective tissue and in that way contribute to genital prolapse and the other disorders of pelvic dysfunction.

It is interesting to speculate whether nutritional disorders, for instance that found in many young women, might not through this route lead to later connective tissue including pelvic floor disorders. As mentioned previously, muscles can only function if nerves innervate them. Damage to nerves can take many forms, and does not necessarily have to be permanent or complete.

Nerves can be damaged by overstretching, by being crushed against a hard object for instance a bony point , by tearing or by being cut during an episiotomy, for instance. If the nerve is not completely severed, the term used is neuropraxia. Such injuries can usually repair themselves in time, although deficits often remain.

More severe injuries can lead to the death of nerve fibers and subsequent dysfunction of the particular muscle innervated by that nerve fiber. As we know, effective muscle action requires that the nerve supply be intact. Without this essential element, muscles degenerate and waste away atrophy. The same is true for muscles which are not used for other reasons. Just think of someone whose leg is in a cast.

During vaginal childbirth there are multiple possibilities for nerve damage within the pelvic area. During descent of the fetus's head through the pelvis, the pelvic nerve plexuses and individual nerves are compressed against the bony pelvis. One of the very important nerves that supply the pelvic floor, namely the pudendal nerve, is very vulnerable to a combination of crushing and stretching forces.

These nerves, one on each side, supply most of the voluntary muscles of the pelvic floor and perineum and are essential to normal pelvic muscle action. During their course through the pelvis, they angle sharply around bony points called the ischial spines. It is apt to think of the Latin root of the words "ischial spine" which can be translated as "thorn of the hip joint". The ischial spines again one each side are part of the ischial bones of which there are of course two.

These are the lateral side bones of the pelvis. Since the inter-spinal distance is the narrowest part of the mid-pelvis, the fetal head invariably applies significant force to the pudendal nerves in these areas. Since the nerves are relatively unable to move because of their sharp angulation around these bony points, they are especially vulnerable to crushing, stretching and tearing forces.

Many investigators have proven, beyond reasonable doubt, that pelvic nerve injuries are extremely common during vaginal childbirth. A cervix that is fully opened with the fetal head ready to come out defines the second stage of labor. During this stage the mother is usually actively pushing, the fetal head is deep in the pelvis, and the vagina as well as the pelvic muscles and fascial layers are maximally stretched.

All the factors to cause compression and shearing forces on the pelvic nerves are thus in play. Researchers have found no nerve damage after elective cesarean births. With elective cesarean births the fetal head is usually still high in the pelvis, or even above the pelvis, and at any rate the tremendous compression and stretching forces have not been applied. The pudendal nerves are, in addition, the main nerves of the pelvic organ sphincter muscles voluntary component.

These, mainly, include the external anal sphincter, the bladder neck sphincter and certain small muscles surrounding the lower part of the vagina. Other nerves that might be damaged include the sympathetic and parasympathetic nerve chains, and this can lead to the dysfunction and weakening of the levator ani muscles which help support the pelvic floor. Acta Obstet Gynecol Scan ; Operative vaginal deliveries and nerve damage: It is now well accepted that operative vaginal delivery has the potential to increase the risk for pelvic damage.

Forceps delivery, especially, has been shown to carry this risk. The vacuum extractor, is associated with a lower risk for this complication. The dilemma is that these operative procedures are, in some cases, essential to expedite delivery, or to make vaginal delivery possible at all. In those cases where labor has already reached the second stage often after prolonged pushing , and vaginal operative procedures are considered, it is to a large degree probably already too late to do a cesarean section in preference to operative vaginal delivery to make a meaningful difference to the protection of the pelvic floor.

As mentioned, some of this damage heals with enough time. There are, however, disturbing studies which show that significant nerve damage persists in a large percentage of women after vaginal delivery. The pelvic fascia can usually overcome the resultant weakness in the levator ani muscles for a while only. This is of course only true if the fascia is intact and attached to begin with.

With aging, natural processes and the increasing stretching of the fascia under the influence of the intraabdominal weight it now solely has to bear, the fascia eventually cannot support its burden effectively anymore and prolapse develops.

As will be seen later, this can manifest as overt genital prolapse, or urinary or fecal incontinence. Weak sphincter muscles usually lead to incontinence problems. Sphincter defects can arise from the above-mentioned neurological damage or from more direct damage, which will be discussed next. Urinary incontinence can be devastating physically, economically, and psychologically. It often leads to curtailment of enjoyable activities, social embarrassment, depression, and even isolation.

The typical scenario is that any activity that would increase the pressure inside the abdominal cavity of women suffering from urinary incontinence could precipitate an uncontrolled squirt of urine. This typically occurs as a result of damage to the pelvic floor, the bladder sphincters or the integrity of some finer control mechanisms, and is called genuine stress incontinence. These unfortunate women often tell me that whenever they leave their houses, they have to plan their trip or visit around the availability of washrooms.

They are intimate with the exact location of every toilet in the immediate vicinity. By going to the toilet at every possible opportunity, they attempt to keep their bladders completely empty to avoid embarrassment and physical discomfort.

Since this problem, of course, also intrudes upon their professional lives, many women have an all-encompassing fear of public embarrassment. I have seen young women with major clinical depression as a result. It is therefore surprising and disconcerting that only an estimated 25 to 50 percent of women with incontinence seek medical help. Incontinence can also become a problem during the most intimate of all acts, namely, sexual intercourse. I once browsed through a book in a respected bookshop, which describes how to reach sexual ecstasy.

One of the main points of this book was the phenomenon of female ejaculation. The author describes how a woman at the top of her excitement would and should ejaculate a large volume of clear fluid. Well — I'm sorry to disappoint, but…. This figure is even higher in institutionalized elders.

The figures vary widely from study to study. Even if given a conservative overall figure, the incidence of urinary incontinence is absolutely shocking.

A stress urinary incontinence has been found to be the most prevalent, making up 77 percent of the incontinence in women in some studies. The figures vary according to the definitions used in the different studies as well as whether the studies used self-reporting or objective investigative results.

Some women report incontinence but do not necessarily have significant problems with it since it might occasional, for instance, during a severe cold. The great tragedy, however, is the numbers of young woman that are inhibited from participating in ordinary activities that they enjoy or must do on a daily basis. An understanding of urinary incontinence is complicated by the fact that there are different types of incontinence, and that not all types of incontinence are related to pelvic floor damage.

The most common type is stress urinary incontinence, also called genuine stress urinary incontinence and which usually is a consequence of pelvic floor damage or dysfunction. The typical case history is that a squirt of urine occurs in the event of increased intra-abdominal pressure coughing, sneezing and the other triggers already mentioned. The great majority of women suffering from this have had vaginal childbirth, a fact that has been known since early times.

In fact, in , Howard A. Kelly, the first professor of gynecology at the Johns Hopkins Medical School, co-authored a text entitled " Disease of the Kidney, Ureters and Bladder".

It is usually progressive, beginning with an occasional dribble, later becoming more frequent and occurring on slight provocation.

In its incipiency, a strain, cough, sneeze or stepping up to get on a tram car starts a little spurt of urine which, in the course of time, initiates the act which empties the Bladder". Most studies have found a high incidence of urinary incontinence in pregnancy in healthy young women even during the first pregnancy.

Prevalence rates as high as 50 percent have been reported. Most of these women recover urine control after the pregnancy, but not all. Unfortunately, a great many of those who recover control have sustained sufficient pelvic floor damage to destine them for future renewed urinary incontinence, with or without genital prolapse and anal incontinence. One of the other relatively common causes of incontinence is so-called bladder instability. This would typically cause the feeling of urgency "I have to gorightnow!

Triggers for this kind of incontinence often include things such as hearing water running, feeling cold water on your hands, or seen a washroom. Regrettably, it is usually impossible to determine which of the two causes predominate without further testing, since patients' histories alone are notoriously inaccurate. These two main causes of incontinence often occur together in the same patient, which makes it difficult to determine what therapeutic approach would be most effective or likely to succeed.

Obvious pelvic floor prolapse, especially a prolapse of the bladder into the vagina so called cystocele , in the setting of a typical history, together with urine leakage during coughing make genuine stress incontinence the likely diagnosis.

The price of being wrong however is so high that one would seldom resort to surgical intervention in the absence of corroborative information. This information can be obtained from a cystometrogram. This basically involves measuring the pressures inside the bladder during different activities, and during bladder filling with sterile water.

Typically, urgency incontinence occurs after a rise in pressure inside the bladder related to a bladder muscle contraction. Somewhat simplistically, it is abnormal for the pressure inside the bladder to rise except when purposely voiding. Such abnormal pressure increases is the result of bladder instability, the causes of which will be shortly discussed later.

More sophisticated cystometrogram instruments also measure contractions of the pelvic floor muscles and the bladder sphincters, as well as the pressure differentials between the bladder, the urethra, and the intra-abdominal cavity. The main purpose of a cystometrogram is to diagnose or exclude bladder instability, the presence of which has to be known to plan an intelligent therapeutic approach to the incontinence.

The reason that it is important to rule out bladder instability is that surgery, in the setting of bladder instability, has a high risk of increasing the instability. Bladder instability the medical term is "detrusor instability" means that the bladder muscle contracts when it is not supposed to. Under normal circumstances the bladder has the ability to distend enormously without any increase in pressure inside the bladder. This occurs as a result of passive distention without the occurrence of any detrusor contractions.

The unstable detrusor, however, contracts with bladder filling or other external stimuli, for instance, to see or to hear running water, certain body movements and sometimes for no discernible reason that all. This then causes an intense feeling of the need to urinate even if there is only a little urine. This is sometimes the result of infection or interstitial cystitis at a relatively common and extremely frustrating urological condition , and may also be caused by diabetes or other medical diseases.

Very commonly, however, no obvious cause is found. The presence of detrusor instability does not necessarily contraindicate surgery. Although this seems to contradict what I said before, I will try to explain. One of the worst mistakes a surgeon can make is to attempt surgical treatment on a patient who hasonlydetrusor instability.

Surgery in this setting is very unlikely to be of any benefit to the patient and, ironically, can lead to a significant increase in the problem. With pure, or so-called genuine stress incontinence in the absence of detrusor instability surgery does have a definite role to play. Alternatives to surgery will be discussed a bit later. More complicated are the cases where both types of incontinence occur together. It is well known that detrusor instability can sometimes be the result of pelvic floor damage and the resultant abnormal position of the bladder base.

In such a case, surgery often cures not only the stress incontinence, but also the detrusor instability. It is a highly unpredictable outcome, nonetheless, and there is a risk that the instability will persist or increase postoperatively. Fortunately, postoperative instability is commonly transient and there are strong drugs available to suppress the abnormal detrusor contractions, which usually leads to significant improvement. It has to be noted however that this is a potential complication that might render a technically perfect operation a failure.

Unfortunately women are anatomically at much higher risk than men for the development of urinary incontinence. This is not only related to childbirth, but also in some degree, to the short urethra and it's anatomical relationship to the vagina. As a result of this, a significant number of perfectly young women suffer from the occasional urinary leak, but fortunately usually not to any serious degree.

Clinically important, so-called genuine stress incontinence, on the other hand, usually occurs in the setting of pelvic floor defects. The normal control mechanisms of urinary continence are very complicated processes, which I will greatly simplify. An understanding of the main concepts is however necessary to understand why the intact pelvic floor is so important in this regard.

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