Urogynaecological conditions: prolapse, bladder and pelvic floor problems

Broadly, most of the medicines that we use for-, so if we're thinking about urge incontinence, or that irritability, twitchiness of the-, of the bladder muscle, or mixed incontinence, the medicines that you would think about mostly act to try and tone that down a little bit, and calm it, and they mostly act through a pathway called the cholinergic pathway. So, broadly speaking they're anticholinergics. They're kind of newer ones and older ones, and lots of localities will have a kind of picklist or a guide about the way in which you might work through those. They can interact with other medicines, and actually if people are already on other medicines that act on that pathway, the side effects can add up a little bit, and that’s quite important to think about. Some of those side effects occur in the shorter term, so that’s-, can be things like constipation, or-, or a dry mouth, or sometimes affect the blood pressure, and you need to think about things like risk of falls, which can be important for some of the people you'll be supporting. Some of them also, taken over a very long time, might contribute to a risk of things like cognitive impairment, or memory, in the future, and that’s something that’s really important to some people. For other people the benefit of the symptoms or-, or used over a shorter term, that won’t be a priority, but again it’s about having those conversations and sometimes reflecting a bit of uncertainty there.

In terms of treatments, so if I focus on recurrent urinary tract infection, there are a number of options available to patients, so often what we’ll start with is trying to improve bladder function without antibiotics, and I’m sure a lot of people will be familiar with the concept of anti-microbial resistance which is where when a population uses lots of antibiotics, often inappropriately, we start to get super bugs or bacteria that do not respond. And as an individual that’s not generally a huge risk, but as a population basis individuals can pick up infections that are not treatable but can be life threatening. So we try and avoid unnecessary antibiotics. So when I see a patient with recurrent infection what I’m going to try and do is optimise bladder emptying, optimise fluids, maybe alter their hormonal levels if they’re post-menopausal or around the age of menopause. I may think about treating prolapse, often not surgically, but with things like pessaries to improve bladder function to try and find a way of avoiding the infections coming back without necessarily needing antibiotics. It may be that some patients start antibiotics by themselves, what we call self-start antibiotics and that might be because they get common infections, and it’s just easier to get on top of the infection quickly. Or it might be that they have very obvious triggers so common things like intercourse, or penetrative intercourse can cause infections so patients will take a small antibiotic after intercourse to prevent them getting an infection.

One of the difficulties that a lot of people find is that when they’ve had an infection if there’s a delay to treatment it can really get more deep set, it can go up to the kidneys and cause kidney infection, and the symptoms can take quite a long time to respond or resolve. So for some patients, quick access to antibiotics is really important. Often the first person people see is their GP, and your GP will be great at assessing your symptoms, often taking a urine sample, and hopefully if they feel it’s appropriate, giving you antibiotics. There will be a group of patients for whom antibiotics happen multiple times a year despite optimising all of these, and they’ll have a range of options. It might be that we some more invasive investigations, we might put a camera in the bladder to look for anatomical causes of infection, we may take biopsies of the bladder to look for infection. We might study the rest of the renal tract to look for causes of recurrent infection. If we can’t find anything obvious on those investigations we’ll often talk about prolonged courses of antibiotics in these types of patients, and that’s a controversial area. One of the reasons its controversial is there’s a not a lot of high-quality evidence about the role of long-term antibiotic courses and we’ve already talked about the fact that that may provoke resistance. But there’s an increasing body of evidence that shows that bacteria in the bladder, if they’re not treated properly can form little pods that sit in the bladder wall that then can flare up from a range of triggers. And then more and more we’re using non-antibiotic medications that are good at controlling bacterial infections, so two common things people will hear about is D-Mannose, and that’s an over-the-counter preparation that may come as a tablet or a syrup that prevents or helps prevent infection by making the bladder not a very nice place for bacteria to sit. And then there’s a medication called methenamine hippurate or Hiprex, now that’s another non-antibiotic medication that prevents bacteria. And that’s also got really high-quality evidence that shows that it’s as effective as long-term antibiotics. Now so some people will end up taking antibiotics of a small dose daily for many, many years, but there are a number of things we can try and do to avoid patients getting to that stage. But for some people the risk and benefit ratio means that that’s the right thing for them.

In the last two years, I’ve been doing some research myself. I’ve been on the Internet. I’ve found a couple of good websites. I’ve looked into the many effects of the menopause and the urogynae complications, was there, that was listed so armed with information now I’ve returned to the GP and explained that I feel, I feel this is part of the menopause. There are new types of HRT out now and these are the ones that I would like to try. She was fine with that, prescribed the HRT I’d asked for, and in the last year I feel as if my life has gone back to normal, so intercourse is no longer painful. I no longer have infections and there’s no discomfort or vaginal dryness. I don’t feel any side effects from the HRT apart from maybe breast tenderness and if anything, my libido has returned, so a result.

The trouble is they just throw painkillers at you all the time. Here, have painkillers. But the trouble with a lot of these Pregabalin and other things that morphine and things like that that you get given is they just completely wipe you out. And it’s, you know, I just find that I can’t, I just cannot take them. If I take them that’s the rest of my life gone because I just literally am just lying on the sofa, doing nothing, ‘cos I feel sick all the time. So, I take Zapain I take amitriptyline and every now and again, I’ll have a few glasses of wine just to self-medicate [laughs]. But I try not to take as much, you know. I’ve got a cupboard full of all different prescriptions that I’ve had over the year or so, but, I try really hard not to take them.
 

I kind of wish my healthcare provider had mentioned more options the first time it was, it’s so called diagnosed over the phone and I thought it would have done no harm to have mentioned the oestrogen ointment because that’s, as I understand it, completely safe to take and really because after menopause that has such an effect, lack of oestrogen has quite a lot of effect I think on the, in that region, in the pelvic floor region, in the organs there so I think there’s be no harm in offering that kind of almost routinely to someone who have, who mentioned prolapse but that wasn’t mentioned to me, I had to bring it up and ask for it. So, perhaps if they were, it was suggested to healthcare providers that they could mention a, a range of options to patients and that could be one of the options perhaps.

And I think now when I, when I look back at the letter I think he had said to me as well, when I’ve looked at the letter as well in the past that, that if it carried on happening, if I-, to do that five times and then for it, if it then carried on after that then I should go back to him but he hoped that it would settle. And I think I was at a stage of my life where I was like ‘Oh well it’s working,’ and so I kept-, you know, I would, I had sex and then it’d work and then I got into a long, a kind of a long-term relationship and it seemed okay. I would have sex, I’d take the tablet and I thought ‘Okay well there’s no, it’s working for me, there’s no reason for me to do anything differently, I don’t need to go back’. And I had in my head, I thought, ‘Okay well once I’d been with this partner for a while it will settle down and I won’t get them anymore.’
 
So, I sort of self-medicated looking back on it which is a regret I think really but at the time I never even knew that chronic UTI existed, so I never knew that it was possible for something to turn from a recurrent UTI to chronic UTI. And I suppose, I don’t know if it would have been managed any differently if I’d have gone back at the time because I’m not sure whether he would have been able to manage the condition differently or prescribe what I needed on the NHS at that point. And I don’t like to beat myself up about it, but yeah I think it probably was a mistake to just carry on using the medication in that way but I was just so happy it was enabling me to have sex without getting the UTIs that I just carried on with it at the time.
 

So that’s how I was going on until maybe two or three years ago I got called into the surgery by another GP, and he said he had grave concerns about me being on these antibiotics and wanted to stop prescribing them. And I think I went into shock because I’d been, all the time I was having those low dose antibiotics I was having no UTI’s and I thought they’re taking away the only thing that’s helped me. And he, you know he explained about becoming resistant to antibiotics and I kept saying, actually if it shortens my life I’m not bothered, it’s quality of life really that I’m interested in. Well he said “I can’t really let you carry on, so you’re gonna have to wean off them.” He said, “But I promise you I won’t leave you ever in pain.” So I thought, “Well I’ll just see how this works.”

They obviously are a very specialist unit and they’re operating slightly outside of standard procedures because the concept of you having, y'know, an embedded or chronic infection is not that widely accepted. I mean, for me, I feel really comfortable that it, I am being treated on the NHS because I know, you know, sometimes I worry with some of the private doctors, there, it’s in their interest to carry on treating you. I know that sounds bad. But you do pay them. So, but with this, I know that it’s on the NHS it must be, y'know, they’re not going to do it if it’s wildly different. But they, they, they are following different protocol because they, they keep you on high dose antibiotics pretty long term until all your symptoms have gone. So I am on, I don’t want to be, but I am on antibiotics that I’ve been on for nine months and y'know, I desperately hope that I can get off them at some point, but y'know, when I started this, I y'know, I was struggling to live any form of daily life and now, whilst I’m uncomfortable a lot of the time, y'know, I’m working, looking after the kids and exercising every, most days. So, the difference is enormous.

I think first and foremost it was, it was around weight gain so I read amitriptyline can make you put weight on, it has lots of not very [nice] side effects, makes you have a dry mouth. It makes you drowsy, so it kind of, you know, limits you in the evening in terms of what you can do and it makes you groggy in the morning. All of those symptoms though, the longer you’re on it, they do improve. And actually, sorry I’m jumping around a bit, but actually getting to the point where I’d taken enough amitriptyline that I had been able to start walking, start swimming, I’ve actually then been able to manage the weight gain better. So, the fears that I had to start, yeah, I mean I have put, I did put weight on definitely, I put quite a lot of weight on. But I suppose over the last year since I’ve been able to start walking and then more recently start swimming, I’ve been able to manage that a lot more and have very healthily, very slowly been, been able to lose some weight in a safe way. So yeah I suppose no-, no one really kind of really talked me through it, I just had, I kind of came to that realisation.

She was seeing me every two weeks, every fortnight, which was fine. Keeping an eye on, changing drugs because the drugs were making me so ill because I was on such a cocktail of them. I, I mean I, altogether I was on gabapentin, tramadol, amitriptyline, and codeine. So I was on all of those drugs at once. And they made me so ill, so ill that I mean I was just green, I was vomiting, diarrhoea, I, the pain from the back was horrendous, so I was trying to cope with everything and every time that I wanted to be sick or think I had to get up to go to the toilet.