Pelvic Pain

Pelvic Pain

Tips for Talking to Your Health Care Provider

by Pamela M. Peeke, MD, MPH

woman and doctorWe've talked a lot about all the things health care professionals do wrong when it comes to communicating health information. But what about you? What is your role in the relationship? Well, as with any relationship, health communication is a two-way street. I know that I rely on my patients to tell me about any confusion they may have, or about things they don't understand, just as much as I rely on them to tell me where it hurts.

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Author: HealthyWomen and American Association of Nurse Practitioners
Published by: National Women's Health Resource Center, Inc., December 2010

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Diagnosing and Treating Endometriosis

woman looking off into the distanceIf you've been having painful periods, possibly with pelvic pain that continues even after your period ends, you should talk to your health care provider about evaluating you for endometriosis.

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Surgical Adhesions from Gynecologic Surgery

woman reading somethingWhen you're headed for hysterectomy or other gynecologic surgery, you are probably worried about many things. Will you have any bad reactions to the anesthesia? Will the surgeon find any major problems? Will you be in much pain? Will recovery be fast?

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What is it?

Overview

What Is It?
As you age, the structure of your kidneys can change, reducing their ability to remove wastes. Illness and injury can also affect the filtering ability of the kidneys or block urine's passage.

Your urinary system works with other organs to get rid of wastes and keep chemicals and water in the body balanced. As an adult woman, you eliminate about a quart and a half of urine each day, but the amount can vary depending on the amount of fluid and food you've consumed and how much you lose through sweating and breathing. Some medications can affect the quantity of urine your body eliminates.

When your body uses proteins derived from the foods you eat, it creates a waste product called urea that is carried in the bloodstream to the kidneys, two bean-shaped organs approximately the size of fists. They are located just below the rib cage near the middle of the back. Each kidney has about a million tiny filtering units called nephrons, which remove urea from the blood.

A ball of small blood capillaries (a glomerulus) and a small tube called a renal tubule comprise a nephron. The kidneys remove or return chemicals such as phosphorus, potassium and sodium in quantities needed to maintain optimal blood levels of these substances. Urea, water and other waste products create urine as the substances move through the nephrons and down the kidney's renal tubules.

The kidney also releases three vital hormones: erythropoietin which stimulates production of red blood cells in bones; renin, a blood-pressure regulator; and the active form of vitamin D, which maintains calcium levels in bone.

Urine exits the kidneys through two thin tubes about eight to 10 inches long called ureters, which carry the fluid to the bladder, a hollow muscular organ that stores urine. Ureter muscles tighten and relax to pump urine downward and away from the kidneys. The process is more or less continuous, with minute quantities of urine emptying into the bladder about every 10 to 15 seconds. If the urine gets stuck in the ureters or backs up, a kidney infection can result.

Shaped like a balloon, the bladder sits in the pelvis and stores urine until you are ready to urinate. As it becomes fuller, it swells into a round shape and then shrinks when it is emptied. A healthy urinary system can hold up to 16 ounces of urine for two to five hours. Bladder nerves send signals to let you know when to urinate; the signals grow steadily more urgent as the bladder fills.

To keep urine from leaking, circular muscles called sphincters close tightly around the opening of the bladder. When you decide to urinate, bladder muscles tighten and sphincter muscles relax, and the urine is pushed down the urethra.

As you age, the structure of your kidneys can change, reducing their ability to remove wastes. Illness and injury can also affect the filtering ability of the kidneys or block urine's passage. Urinary system muscles also tend to weaken as you grow older, leading to increased incidence of urinary tract infections and incontinence.

Urinary system disorders are widespread. According to the National Kidney Foundation, approximately 26 million Americans have chronic kidney disease, and most do not know it. Millions more are at risk. Incontinence and overactive bladder are two of the most common health problems among women. And 85,790 Americans died of end-stage renal disease in 2005.

Major Urinary System Disorders

Health care professionals often use the term "renal function" when talking about the kidneys; if both kidneys are healthy, you have 100 percent renal function. If one becomes nonfunctional or is donated for a transplant operation, you will still be healthy, even with only 50 percent of renal function. However, if function slips below 20 percent, serious health problems arise because the kidneys can no longer perform their function of regulating water and chemicals and removing waste. Levels below 10 to 15 percent necessitate dialysis or transplantation.

Renal function levels below 10 to 15 percent necessitate dialysis or transplantation. Unfortunately, symptoms of chronic renal failure (a gradual loss of function) may go undetected for several years and often do not become noticeable before kidney function falls to 25 percent or less.

Acute renal failure denotes a sudden onset of renal failure, such as that caused by an accident, certain drugs or poison. The kidneys may recover or the damage may be permanent. If the kidneys stop working entirely, the result is a condition called uremia, in which the body fills with extra water and waste products, leading to swelling in the hands or feet, fatigue and weakness. End-stage renal disease (ESRD) refers to when the kidneys have lost all or nearly all function.

Specific kidney conditions include:

Analgesic Nephropathy

Improper use of over-the-counter painkillers, or analgesics, can lead to kidney failure. These products include aspirin, acetaminophen, ibuprofen and naproxen sodium, all of which are safe for most people when taken at the recommended dosages. However, combining these drugs or taking them when you have certain conditions boosts your risk of kidney disease. You should avoid these medications if you have an autoimmune disease such as lupus, advanced age, chronic kidney conditions or have recently binged on alcohol.

If you have any of these conditions, make sure your health care professional and pharmacist are consulted before you risk taking an analgesic, since short-term use can cause acute (temporary) kidney failure.

Taking one or more of these products daily for several years can cause analgesic nephropathy, chronic kidney disease leading gradually to end-stage renal disease (ESRD). Combination painkillers (such as aspirin and acetaminophen) are especially dangerous. If you find you need painkillers often, talk to a health care professional about the best options for protecting your kidneys.

Cystocele

A cystocele, occurs when the pelvic floor muscles, which form the wall between the bladder and vagina, weaken, allowing the bladder to drop into the vagina. The consequences are discomfort and voiding difficulties, such as urine leakage or incomplete bladder emptying.

There are three grades of cystocele:

  • Grade 1: the bladder drops a short way into the vagina
  • Grade 2: the bladder sinks to the opening of the vagina
  • Grade 3: the bladder bulges through the vaginal opening

Interstitial Cystitis (IC)

Interstitial cystitis (IC) may also be called painful bladder syndrome, urethral syndrome and frequency-urgency syndrome. It is an inflammatory condition of the lining of the bladder.

The inflammation associated with this chronic bladder disorder can cause diminished bladder capacity or size, glomerulations (pinpoint bleeding) and (rarely) ulcers in the bladder lining. Rarely, in severe cases, scarring and stiffening of the bladder can occur. Although the cause of this disorder is unknown, research shows that it may be associated with other diseases such as vulvodynia (vulvar or vaginal pain), fibromyalgia, irritable bowel syndrome (IBS) and endometriosis. Interstitial cystitis affects an estimated 1.3 million Americans, more than 1 million of whom are women.

Typical IC-associated sensations include discomfort, pressure, tenderness or intense pain in the bladder and surrounding pelvic area. The intensity of pain may shift as the bladder fills or empties. Other symptoms include pain associated with intercourse and frequent and/or urgent need to urinate (women with severe IC may urinate as many as 60 times a day). Symptoms often get worse before or during menstruation and after sexual activity.

No one knows for sure what causes IC; theories point to an autoimmune disease, abnormality in the urine, hereditary condition, infection or allergic condition.

Glomerular diseases

Diseases that damage the glomeruli—the kidney's filtering units—can lead to kidney failure. Two major categories of glomerular diseases are:

  • glomerulonephritis, inflammation of the membrane tissue in the kidney that filters wastes and extra fluid from the blood
  • glomerulosclerosis, scarring or hardening of tiny blood vessels in the kidney

When the glomeruli are damaged, protein and blood can seep into the urine, and waste products can accumulate in the blood. If too much of the protein albumin is lost, the blood is less able to absorb extra fluid.

Glomerular diseases are indicated by:

  • proteinuria
  • hematuria
  • reduced glomerular filtration rate (inefficient waste filtering)
  • hypoproteinemia (low levels of protein in the blood)
  • swelling, or edema

The diseases have many causes, including:

  • Autoimmune diseases, such as lupus. Autoimmune diseases are conditions that develop as a result of the immune system attacking healthy tissue instead of combating invading bacteria or viruses.
  • Hereditary nephritis, also called Alport syndrome. A family history of chronic glomerular disease or impaired vision may stem from this syndrome, and men are more likely to progress to chronic renal failure and/or vision loss.
  • Infection-related glomerular disease, such as strep throat, heart infection (bacterial endocarditis), HIV or skin infection (impetigo). The kidneys usually recover from infection-related damage, but sometimes damage is permanent and ESRD results.

Hematuria

Hematuria is a term used for the presence of red blood cells in the urine. Sometimes hematuria is visible, but in many cases the urine appears normal. Hematuria is not a disease in itself, but a sign of some other condition.

The cause may be a serious one, such as bladder or kidney cancer, but more often the cause is relatively benign. Exercise can cause episodic hematuria, for example. Obvious blood in the urine is often associated with bladder infections or kidney stones. Still, you should check with a health care professional any time you see blood in your urine or follow up if a urinalysis shows red blood cells in your urine.

To identify the cause of hematuria, your doctor may order various tests, such as urinalysis, blood tests, ultrasound, intravenous pyelogram or CT urogram, or may examine your bladder with a cystoscope. If white blood cells are present in the urine, a urinary tract infection or kidney disease may be the cause.

Treatment is tailored to the cause of the hematuria. If it is not caused by a serious condition, no treatment is necessary.

End-Stage Renal Disease (ESDR) and Kidney Failure

The early stages of kidney disease may not cause noticeable symptoms. However, symptoms may include frequent headaches, fatigue or an all-over itch. Worsening disease can cause urination patterns to change (becoming more or less frequent), appetite loss, nausea and vomiting, swelling or numbness in the hands or feet, drowsiness, difficulty concentrating, skin darkening and muscle cramps. Treatment generally requires dialysis or transplant, described in the treatment section.

Diabetes is the leading cause of ESRD.

When diabetes is undiagnosed or poorly controlled, excess sugar circulates in the blood, leading to higher blood flow into the kidney and glomerular scarring. Diabetic nephropathy is the term used for such damage, which can be delayed or prevented by maintaining healthy blood sugar levels. If you have diabetes, high blood pressure or a genetic condition called polycystic kidney disease, your health care team will monitor your condition to prevent or limit the damage to the kidneys. Such damage may lead to renal failure and ESRD.

Bladder Cancer and Kidney Cancer

Signs and symptoms of bladder cancer include blood in the urine (which may be bright red or rusty in appearance or only seen under the microscope), painful or frequent urination or feeling the urge to urinate even though the bladder is empty.

Renal cell cancer is the most common form of kidney cancer. As the cancer grows, it may spread to nearby organs, such as the liver, colon or pancreas, or may disperse (metastasize) to other parts of the body. Cancer cells often spread to lymph nodes, bean-shaped organs that produce infection-fighting cells. Signs and symptoms of renal cell cancer include blood in the urine, back or abdominal pain, or a mass on the kidney. Many kidney cancers are diagnosed by ultrasound or CT examination performed for other medical reasons.

Kidney or Ureter Stones

Stones, or calculi, are usually formed in the kidneys but may be found anywhere in the urinary system. Stones are among the most painful and most common urinary tract disorders—an estimated five to 10 percent of Americans will have a kidney stone at some point in their lives. Men are afflicted with kidney stones more often than women, and Caucasians are more susceptible than African Americans. Stones are most likely to occur between the ages of 20 and 50 in women (later in men) and are more likely to occur in people who have previously had stones.

Kidney stones vary widely in size and in the amount of pain they cause. Most are passed from the body without assistance, but there are a variety of strategies to treat stones that linger.

A kidney stone forms from crystals that separate from urine and accumulate on the kidney's inner surfaces. Urine contains chemicals that prevent crystal formation, but in some people the process doesn't work well and they develop stones. If the stones are small enough, they travel through the urinary tract and leave the body without causing symptoms.

Most stones contain calcium and either oxalate or phosphate—all three are part of a healthy diet. Less common are struvite or infection stones, caused by urinary tract infections. Terms used to describe stones include nephrolithiasis (kidney stones), urolithiasis (urinary tract stones) and ureterolithiasis (ureter stones).

Risk for kidney stones is higher in those with family histories of stones; those who have urinary tract infections, kidney disorders and metabolic disorders such as hyperparathyroidism, cystinuria (too much of an amino acid called cystine) or hyperoxaluria (excess production of oxalate salt); and those with a disease called renal tubular acidosis. High levels of urinary calcium lead to crystals of calcium oxalate or calcium phosphate, which can grow into painful stones.

Other risk factors include:

  • hyperuricosuria—a disorder of uric acid metabolism
  • gout
  • excess intake of vitamin D
  • blockage of the urinary tract
  • use of diuretics or calcium-based antacids
  • chronic bowel inflammation, intestinal bypass surgery or ostomy surgery

The initial symptom is usually sudden, intense pain, provoked by the movement of a stone in the urinary tract. The feeling is usually a sharp, very severe, cramping pain in the back and side in the kidney or lower abdominal region. Nausea and vomiting may occur, and the pain may spread to the groin. A stone too large to pass easily causes continuing pain in the muscles in the ureter as they try to squeeze the stone into the bladder. As the stone approaches the bladder, you may feel compelled to urinate more frequently or feel a burning pain when you urinate.

Note: Fever and chills suggest an infection that warrants a health care professional's immediate attention.

Kidney stones are usually diagnosed via x-ray or sonogram. Urinalysis often shows blood cells. A health care professional may order blood and urine tests to detect abnormal substances that may be stimulating stone production. A type of x-ray called an intravenous pyelogram (IVP) or spiral CT scan may be used to scan the urinary system as well. In addition, to help determine what's causing your kidney stones and, therefore, to plan appropriate prevention measures, your health care professional may ask you to urinate through a strainer designed to catch any stones you pass so the stones can be analyzed for their makeup.

Neurogenic Bladder

The smooth functioning of the urinary system depends on muscles and nerves working properly to store urine in the bladder and release it at the appropriate time. Nerves running between the bladder and the brain tell the brain when the bladder is full and tell the bladder when it's OK to relax and release the urine. When the nerves that carry these messages malfunction, a condition called neurogenic bladder results.

Some possible causes of neurogenic bladder include:

  • diabetes
  • accidents that cause trauma to the brain or spinal cord
  • nerve problems such as multiple sclerosis, strokes, or Parkinsonism
  • congenital nerve problems such as spina bifida

Primary effects of neurogenic bladder are:

  • urine leakage, when muscles holding the urine do not get the message to stay tight to retain the urine
  • urine retention, when the muscles holding in the urine do not get the message that they should let go
  • damage to the tiny blood vessels in the kidneys that results when the bladder gets too full. This prevents good drainage, causing back pressure.
  • bladder infection or infection of the kidneys

Polycystic Kidney Disease (PKD)

This genetic disorder causes multiple cysts to grow in the kidneys and gradually displace functioning parts of the kidney. PKD symptoms sometimes show up in childhood, including frequent headaches and back or side pain. Other symptoms include high blood pressure, urinary tract infections and kidney stones, as well as blood or protein in urine. The disease, however, may exhibit no symptoms for years. There are two forms of PKD :

  • Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most common, affecting one in 400 to one in 1,000 adults. Symptoms include high blood pressure, and the condition can lead to renal failure.
  • Autosomal Recessive Polycystic Kidney Disease (ARPKD), also known as infantile PKD , is far less common, affecting only one in 10,000 to one in 20,000 at a far younger age, including newborns, infants and children. It can be detected during pregnancy through amniocentesis or chorionic villus sampling.

Proteinuria

Proteinuria denotes high levels of protein in the urine. When kidneys are healthy, filtering units called glomeruli remove waste products but leave behind nutrients the body needs, such as proteins, which are usually too large to pass through kidney filters unless the kidneys are damaged. When albumin, a small protein, seeps into the urine, blood vessels lose their capacity to reabsorb fluid from the tissues. The fluid then builds up in hands, feet or ankles, causing swelling.

Symptoms of proteinuria include foamy-appearing urine and swelling in the hands, feet, abdomen or face. But the condition can also be invisible, producing no symptoms. Laboratory testing is the only way to measure proteinuria.

One basic test uses a chemically treated strip of paper to detect protein levels. The paper changes color if dipped in urine with high levels of protein. A more sensitive test, which can detect microalbuminuria, requires urine collection over 24 hours. You may also have to provide a blood sample for creatinine and urea nitrogen testing (see kidney disease and renal failure). If blood levels of these two substances are high, kidney function is impaired.

Proteinuria is a sign of glomerulonephritis, also called nephritis (inflammation of the kidney). Diabetes, hypertension and various kidney diseases can cause the inflammation, which can lead to renal failure and, ultimately, end-stage renal disease (ESRD).

The severity of damage correlates with the level of proteinuria and whether the protein content is entirely albumin or includes other proteins (the more kinds of proteins, the greater the damage).

If you have diabetes, you should be regularly checked for proteinuria. The National Kidney Foundation also recommends that all routine checkups include proteinuria testing, especially for those at high risk.

Small amounts of albumin in the urine—microalbuminuria—is the first sign of declining kidney function in people with diabetes (the leading cause of ESRD). As function continues to slide, the level of albumin rises and the condition becomes proteinuria.

The second most common cause of ESRD is high blood pressure. Proteinuria and high blood pressure together indicate deteriorating kidney function. Medication for hypertension must be started, or renal failure will result. African Americans are at higher risk for high blood pressure and the resulting kidney problems than Caucasians.

Proteinuria also strikes more frequently in Native Americans, Hispanic Americans, Pacific Islanders, older people and overweight people. If you have a family history of kidney disease, you should have your urine tested regularly.

Urinary Incontinence

Many factors can cause urinary incontinence, or a loss of bladder control resulting in the involuntary release of urine. Incontinence is a problem for millions of American women, particularly those aged 65 and older. It is especially common in women who are pregnant or have recently delivered a baby and in elderly women. Incontinence can also affect men.

Bladder control, or continence, is the result of a system of nerves and muscles working together correctly. If the muscles at the bladder neck or in the pelvic floor are weak, laughter, sneezing or heavy lifting can cause leakage.

A condition called urge incontinence arises when the bladder muscle is overactive and contracts involuntarily. Since the occurrence of urge incontinence is unpredictable, it is more devastating to one's quality of life. Overactive bladder (OAB) occurs when you void more than eight times in the day and twice at night, have a strong urge to void, and/or urge incontinence. It affects millions of Americans, both men and women.

Overflow incontinence occurs when your bladder is overly full and leaks urine. You may feel as though you need to empty your bladder but cannot.

Urinary Tract Infection (UTI)

Urinary tract infections are usually caused by bacteria from the bowel that live on the skin near the rectum or near the vagina. Because the openings of the bowel, vagina and urethra are close together, it's easy for the bacteria to spread from the bowel to the urethra and travel up the urinary tract into the bladder, sometimes into the kidneys.

Normal urine is sterile, containing fluid, salts and waste products, but not bacteria. Infections can come from a variety of bacteria that normally live in the digestive system, but infections can also be caused by sexually transmitted microorganisms such as chlamydia and mycoplasma.

Infection can occur when the bacteria cling to the opening of the urethra and multiply, producing an infection of the urethra, called urethritis. Infection can also occur when the bacteria get into the bladder, causing cystitis, or a bladder infection. If the problem is not treated, the infection can continue spreading up the urinary tract, causing infection in the kidneys, called pyelonephritis. A kidney infection that is not treated can result in the kidneys being unable to drain urine, permitting the bacteria to enter the bloodstream, which can cause a life-threatening infection.

The first sign of a UTI is usually a strong urge to urinate. As you release urine, you feel a painful burning sensation, and little urine is eliminated. The urge to urinate returns quickly, and urination may be hard to control. You may have urine leakage during sleep. You may also have soreness in your lower abdomen, in your back, or in the sides of your body. Your urine may look cloudy or have a reddish tinge from blood. It may smell foul or strong. You also may feel tired, shaky and washed out. If the infection has spread to the kidneys, you may have fever, chills, nausea, vomiting and back pain, in addition to the frequent urge to urinate and painful urination.

Vesicoureteral Reflux (VUR)

When urine flows backward from the bladder into the ureters, the condition is called vesicoureteral reflux (VUR). It is most often diagnosed in childhood. If your child develops a urinary tract infection, he or she should be evaluated for VUR because the condition is found in about one-third of children with a UTI .

Primary VUR arises when a child is born with an impaired valve where the ureter joins the bladder. The valve fails to close fully, causing urine to back up from the bladder into the ureters and kidneys. The condition may improve over time as the ureter grows and valve function improves.

Secondary VUR arises due to a blockage in the urinary tract, often the result of an infection that causes the ureter to swell. Again, the result is a backflow of urine into the kidneys.

The leading symptom of VUR is infection. Other symptoms may arise as a child gets older, including high blood pressure, proteinuria and kidney failure.

Diagnosing VUR may involve a voiding cystourethrogram, a test that provides an image of the urinary system to determine if a defect in the urinary tract is causing VUR and infection. Other tests may include a kidney and bladder ultrasound; an intravenous pyelogram (IVP), which involves injecting a liquid that can be seen on x-rays to highlight any obstructions in the kidney or bladder; or nuclear scans, tests that use radioactive material injected into a vein to reveal how well the kidneys and bladder are functioning.

The goal of VUR treatment is to prevent kidney damage. An infection should be treated immediately with antibiotics to prevent it from moving into the kidneys. Antibiotics can also help correct reflux caused by an infection. Sometimes surgery is necessary to repair a physical defect that causes VUR.

Urinary Retention

Sometimes the bladder fails to empty fully, leading to retained urine. Acute urinary retention results in a sudden inability to urinate, accompanied by pain and discomfort. The condition may be caused by a urinary tract obstruction from the prostate gland in men or from pelvic masses in women (fibroid tumors are the most common); stress or neurological factors; infection; and certain medications. Relaxation of the pelvic floor structures resulting in a large bulging cystocele may also result in kinking of the urethra and urinary retention. The cause determines the treatment.

Urinary retention is a relatively common problem after surgery. It occurs as a result of the anesthetic, drugs used for pain control or the type of surgery performed. Chronic urinary retention, by contrast, refers to a persistent condition of urine remaining in the bladder and incomplete emptying. Chronic urinary retention can lead to urinary tract infections.

Evaluation for urinary retention includes a medical history and physical examination (including a prostate examination in men) to find the source of the problem. If an acute nerve problem is suspected, your doctor may order a CT scan or MRI . A urogynecologist or urologist may perform advanced urodynamic testing to help determine the cause of the voiding dysfunction. He or she may also perform a cystoscopic examination.

Diagnosis

Diagnosis

If you are having urinary system symptoms, you may be asked to undergo various tests. Some of the most common are:

Blood tests. Tests for kidney disease include:

  • Serum creatinine. Measures blood levels of a substance called creatinine that is generated when the body breaks down protein and uses it.
  • Creatinine clearance. Measures how effectively your kidneys remove creatinine.
  • Blood urea nitrogen (BUN). A nitrogen-containing substance called urea is a normal byproduct resulting when the body breaks down protein and uses it. Healthy kidneys remove urea from the blood for excretion in urine. Excess urea in the blood is a sign the kidneys are not functioning well. BUN can also be transiently elevated with dehydration.

Dipstick test for proteinuria. When the kidneys are not functioning well, protein may be present in urine. Foamy urine is a strong sign of protein, but usually there are no visible symptoms. The test for proteinuria uses a dipstick that changes color in the presence of protein.

Renal biopsy. In this procedure a health care professional obtains a sample of kidney tissue to examine under a microscope. A needle is inserted through the skin into the back of the kidney to retrieve a tissue sample.

Renal imaging. If blood and urine testing suggests impaired kidney function, your health care professional may recommend renal imaging, a procedure that captures an image of the kidneys using ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI).

Urinalysis. For this test, you urinate into a special container and leave the sample with a nurse or lab technician. The urine is then analyzed for signs of infection, blood cells and abnormal substances such as proteins, glucose or white blood cells and bacteria.

Urine culture. A urine culture is a laboratory test that tests for infection in your urine by allowing any bacteria in the urine sample to grow and multiply. The bacteria are then identified and tested to see which antibiotic will work best to kill the bacteria. Your urine is sent for a culture if infection is suspected on urinalysis.

Urine cytology. A urine cytology involves a check of your urine for cancer cells.

Ultrasound. Lubricating jelly is rubbed on your abdomen and pelvis, and a wand passes over your kidneys and bladder to check for abnormalities in your urinary tract or genitals, as well as residual or leftover urine in your bladder.

Intravenous pyelogram (IVP). This test x-rays the urinary tract to identify a malformation, tumor, kidney or bladder stone or other blockage preventing normal urine flow. A dye containing iodine is administered via a needle into a vein; the dye is then incorporated into the urine, making the urinary tract easier to see on x-rays.

Cystoscopic examination. During this test, a health care professional inserts an instrument called a cystoscope through the urethra and into the bladder. The cystoscope is pencil thin and has a light at the tip to allow a look inside the tract. A cystoscope may have an additional instrument attached to perform a treatment procedure, such as a biopsy. Cystoscopy may be recommended in a variety of circumstances, including frequent urinary tract infections, blood in the urine, incontinence or overactive bladder, presence of unusual cells in the bladder, need for a catheter, chronic pain or interstitial cystitis, urinary tract blockage, kidney stone or an unusual growth. A ureteroscope, which is an even smaller tube, can be inserted into a ureter.

Urodynamic test. This is a series of tests of bladder function. Bladder pressure is measured as the bladder fills, stores and empties urine—in other words, in each phase of bladder activity. For this test, a small tube called a catheter is inserted through the urethra into your bladder. The bladder is then filled with either water or an x-ray dye. Another small tube is inserted into the vagina or rectum to measure abdominal pressure when you strain or cough; if a dye is used, an x-ray is taken. Your doctor may suggest this series of tests if your symptoms suggest muscle or nerve problems in the lower urinary system (bladder, urethra and sphincter muscles).

Treatment

Treatment

A primary care health care professional can treat many urinary disorders, but some conditions may require consultation with a urologist, a surgeon who specializes in the treatment of urinary system disorders and conditions affecting the reproductive system. A urogynecologist is a gynecologist who is trained to treat bladder and pelvic floor disorders in women. For kidney disorders, particularly kidney failure, a nephrologist (a medical specialist in kidney diseases) may be needed.

Treatment for cystocele

A grade 1 or 2 cystocele may require no treatment, except avoidance of heavy lifting or straining. For moderately bothersome cystoceles, a pessary (a plastic or rubber device that fits into your vagina to help support your uterus, vagina, bladder or rectum) may be fitted to the vagina to hold the bladder in place. A pessary must be removed and cleaned regularly to prevent infection and ulcers.

A large cystocele may require surgery to reposition the bladder. The surgery requires a hospital stay of one to several days and four to six weeks for a full recovery.

Treatment for kidney stones

Surgery is usually not necessary to remove kidney stones. Drinking plenty of water—two to three quarts per day––and taking drugs which can relax the ureter may allow for the stone to pass down the tract. A health care professional may recommend that you stay home, drink plenty of fluids and take pain medicine as needed. You may be asked to save the passed stone for tests.

Shockwave lithotripsy. The most common method for removing stones is shockwave lithotripsy (SWL), in which shockwaves initiated outside the body travel through skin and body tissues until they hit the stones. The stones disintegrate into sand-like particles and are passed through the urinary tract. The procedure may be done in a hospital or on an outpatient basis; you typically resume your normal activities within a few days, but it may take months for you to pass all the pieces.

Complications may include blood in the urine for a few days, bruising and discomfort of the back or abdomen. To minimize risk of problems after the treatment, you should avoid medications that reduce blood clotting (such as aspirin) for one to two weeks before treatment.

The stone particles may cause pain as they pass through the urinary tract. Your health care professional may insert a small tube called a stent through the bladder into the ureter to help the fragments pass. Some people may need two or more SWL treatments.

Surgery is generally an option when the stone:

  • does not pass after a reasonable time and causes constant pain

  • is too large to pass on its own or is caught in a difficult place

  • blocks urine flow

  • causes continuing urinary tract infection

  • harms kidney tissue or provokes incessant bleeding

  • is growing (as shown on x-rays)

The two most common surgical techniques for removing stones are:

  • Urethroscopic stone removal. This procedure is used for stones lodged in the ureter or for kidney stones. A small fiber-optic instrument called a ureteroscope is passed through the urethra and bladder and into the ureter or kidney. When the stone is found, the surgeon either removes it or shatters it with an instrument that breaks the stone.
  • Percutaneous nephrolithotomy. This surgical procedure usually requires a hospital stay and is used for large stones or stones in locations not conducive to SWL. The surgeon makes a small incision in the back, creates a tunnel to the kidney and uses a nephroscope to find and remove the stone. A nephrostomy tube may stay in the kidney during the healing process. Large stones may require use of an ultrasound, electrohydraulic energy probe or laser to break up the stone. One advantage over SWL is that percutaneous nephrolithotomy removes the stone particles rather than leaving them to pass through the kidney and out the ureters.
  • Parathyroid gland surgery. In some cases, calcium stones are caused by a small benign tumor in one of the parathyroid glands, four glands located just below your Adam's apple. If this is the case, you may have surgery to remove the tumor or one or more of the parathyroid glands.

Treatment for bladder cancer

Treatment for bladder cancer depends on the size and staging of the tumor. For early-stage tumors, the usual treatment is transurethral resection of the bladder tumor, a procedure during which a lighted tube is inserted through the urethra and into the bladder to remove the cancer for biopsy and to cut or burn away any remaining cancer cells. Chemotherapy and immunotherapy may also be used to prevent cancer recurrence. In extreme cases, a cystectomy, or removal of the bladder, may be performed.

Treatment for interstitial cystitis (IC)

Behavioral therapy. Make sure you get enough water, ideally about two quarts a day. Although no scientific evidence points to dietary factors as the cause of IC, avoiding potential bladder irritants, including coffee, chocolate, carbonated beverages, acidic foods or drinks, may help ease symptoms. Controlling stress can also help.

Medications. Medications are the primary treatment for IC. The only drug specifically approved for IC is pentosan (Elmiron). Pentosan helps restore the normal bladder lining but may take up to six months to work. Several other medications not specifically indicated for IC may also help reduce symptoms, including nonsteroidal anti-inflammatory drugs (NSAIDs), antihistamines and antidepressants, particularly amitriptyline (Elavil) or imipramine (Tofranil). You may require more than one medication.

Bladder instillation. Also called a bladder wash or bath, the bladder is filled with a drug cocktail containing one of several substances including heparin, pentosan, or dimethyl sulfoxide (DMSO, RIMSO-50), which must be held for a specified period of time—usually 10 to 20 minutes––before urinating. This treatment is performed every week or two for six to eight weeks and repeated as needed.

Because DMSO passes into the bladder wall, it reaches tissue more effectively to reduce inflammation and pain. It also appears to prevent the muscle spasms that cause pain and urgent/frequent need to urinate.

Side effects of DMSO include a garlic taste and odor that may last up to three days following treatment. Bladder symptoms may get temporarily worse for a day or so after initial treatments. Blood tests, including a complete blood count and kidney and liver function tests, should be conducted twice a year. Other medications may be added, such as a local anesthetic, to make a DMSO "cocktail."

In addition, a newer approach to bladder instillation involves using a mixture of heparin, lidocaine and sodium bicarbonate. When instilled directly into the bladder, this combination of drugs significantly relieved urinary pain and urgency in the majority of people participating in a clinical trial.

Bladder distention. This treatment arose from the observation that some patients felt better after undergoing cystoscopy, during which the bladder is filled to capacity with liquid. Symptoms often get worse a day or two after distension but return to pre-procedure levels or improve after two to four weeks. No one knows exactly why this treatment is effective, but one theory is that distension increases bladder capacity by interfering with the bladder's transmission of pain signals. This is not an ideal treatment, however. It only helps small numbers of patients and requires anesthesia.

Surgery. All surgical treatments for IC have unpredictable results and most health care professionals turn to surgery only as a last resort. Surgical procedures include:

  • Fulguration, a process in which a cystoscope is inserted through the urethra, and Hunner's ulcers (star-shaped lesions found on the bladder walls of some people with IC) are coagulated with electricity or a laser.
  • Neuromodulation or sacral nerve root stimulation is a newer treatment option that involves stimulating the sacral nerve to help alleviate frequency, urgency and pain. A small electrode is placed under the skin next to the third sacral nerve root in the back. If a test stimulation is effective, a permanent battery is placed under the skin for regular stimulations. Although this can be very helpful in some patients, the results are not always sustained.
  • Augmentation is a surgical procedure that enlarges the bladder by removing damaged and inflamed sections of the bladder and rebuilding it with bowel (small or large intestine) tissue. The effect on pain varies, and IC may recur on the bowel tissue used to enlarge the bladder.

The bladder can also be removed entirely in a procedure called cystectomy. The ureters are then attached to a segment of bowel that opens onto the skin of the abdomen. Urine empties through the opening, called a stoma, into a bag outside the body.

Bear in mind that even a cystectomy does not guarantee the end of IC symptoms; some women experience phantom pain. So make sure you explore other options first.

Treatment for urinary tract infections

Luckily, most infections are not serious and can be easily treated with antibiotic medications. However, a urinary tract infection can be stubborn and sometimes recurs a few weeks after treatment.

Nearly 20 percent of women who have a urinary tract infection will have another, and 30 percent of those who have had two will have a third. About 80 percent of those who have had three will have a fourth. If left untreated, urinary tract infections can lead to other more complicated health problems so they should not be ignored. Prevention includes drinking plenty of liquids, frequent urination and taking vitamin C. Cranberry prevents bacteria from adhering to the bladder wall and may be an effective deterrent to bladder infections. Women who experience recurrent bladder infections often have the bacteria introduced during sexual activity. Treatment prophylactically with a single antibiotic tablet taken just after sex can prevent additional bladder infections.

Treatment for urinary retention

Treatment for urinary retention may include the insertion of a Foley catheter through the urethra into the bladder to relieve urinary retention. Various urethral dilators may be used to open the channel wide enough to pass a catheter through. If a catheter cannot reach your bladder because of an obstruction in the urethra, a suprapubic tube may be placed through the skin, over the pubic bone and through the lower abdominal wall directly into the bladder. The tube provides temporary drainage until the situation can be managed via a cytoscopic procedure.

Treatment for proteinuria

Treatment for proteinuria starts with controlling hypertension and/or diabetes. Those with diabetes should measure blood sugar levels frequently, eat a balanced diet to appropriately manage diabetes, exercise and take prescribed medicines. Those with high blood pressure are usually prescribed ACE (angiotensin-converting enzyme) inhibitors or a similar class of drugs called angiotensin receptor blockers (ARBs) to control the condition. These drugs protect the kidneys more than other blood pressure medicines. People with reduced kidney function and high blood pressure should try to keep their blood pressure below 130/80 mm Hg.

The National Kidney Foundation also recommends limiting salt and protein intake. A consultation with a dietitian may help you develop a kidney-healthy dietary plan.

Treatments for incontinence

A variety of treatments are available to treat incontinence, including:

  • Exercises: Pelvic floor exercises known as Kegel exercises can strengthen the muscles you use to stop urinating so you can hold urine in your bladder longer. To do Kegels, squeeze the muscles you use to stop urinating for a few seconds and then relax. Your health care professional can tell you specifically how often and for how long you should do Kegels.

  • Medications: A variety of drugs can be used to help control incontinence. Some of them relax bladder muscles, helping your bladder to empty more completely, some help prevent bladder contractions and others tighten the muscles in the bladder and urethra to reduce leakage.

  • Biofeedback techniques: These techniques can help you become more aware of signals from your body so you can gain more control over the muscles in your bladder and urethra.

  • Pessary: A vaginal insert that holds up the bladder neck. It may also pinch the urethra closed to help retain urine in the bladder. It is usually not necessary to remove the pessary to urinate. Normal bladder contractions can usually force urine out through the pinched-off urethra.

  • Surgery: Surgery can improve incontinence if the condition is caused by a physical problem such as a change in the bladder position. Common surgery for incontinence involves placing a sling beneath the urethra to help close it during episodes of increased pressure or reducing a bulging bladder or urethra and securing it. Surgery is usually not recommended until you are finished having children because both pregnancy and childbirth can cause damage.

Other Treatments for Kidney Conditions

Hemodialysis is the most common treatment for advanced or permanent kidney failure. In this procedure your blood is circulated out of your body, the wastes filtered out in a machine and the clean blood returned to the body. Removing harmful wastes and extra salt and fluids helps control your blood pressure and maintain proper chemical balance in the body. Treatments are given in a clinic, often called a dialysis center, usually three times a week for three to five hours per visit. The annual survival rate for people on dialysis is about 80 percent.

Peritoneal dialysis allows you to give yourself treatments at home for advanced and permanent kidney failure, but it is important that you work closely with your health team. As with hemodialysis, the treatment filters your blood and returns it to circulate in your body. For this procedure, a soft tube (catheter) is surgically placed in your abdomen and then is used to fill your abdomen with a cleansing liquid. Your body's waste products and extra fluid transfer from your blood into the dialysis solution and then are drained out of the body. The process of actually putting the solution in and out of your abdomen takes about 30 to 40 minutes, but the solution stays in your abdomen for four to six hours. This process is typically done four times a day. There are two forms of peritoneal dialysis: Continuous ambulatory peritoneal dialysis (CAPD) doesn't require a machine and you can walk around with the solution in your abdomen. Continuous cycler-assisted peritoneal dialysis (CCPD), also called automated peritoneal dialysis, uses a machine to fill and drain your abdomen, usually while you sleep.

Infection is the most common problem with peritoneal dialysis. You must understand and follow all instructions from your health team. Keep a close watch for any signs of infection and report them immediately. These include:

  • Fever
  • Nausea or vomiting
  • Redness or pain near the catheter
  • Unusual color or cloudiness in your used dialysis solution
  • A catheter cuff that is out of place

Transplants. For some with kidney failure, transplantation is an option. If the donated kidney is not a close match for your body, your immune system will react against it as if it were a virus or bacteria. Drugs that suppress the immune system are used to help the body accept the transplant. Transplant is more effective than dialysis, with a one-year survival rate of 95 percent and 80 percent at five years for people receiving living-donor kidneys. (Survival rates are slightly lower for people receiving deceased-donor kidneys.)

Prevention

Prevention

Drinking adequate amounts of water is key to a healthy urinary system. The urinary system regulates concentrations of substances such as potassium and sodium. When you don't drink enough water, your body responds by retaining water to maintain the proper concentration.

A good rule of thumb is to drink enough water and other fluids (at least eight glasses a day) to keep the urine clear or straw colored. The fluids also help clear bacteria from the urinary tract. Cranberry juice may help prevent repeat urinary tract infections, but you may want to avoid the beverage during an infection since it contains acid that can exacerbate the painful urination associated with the condition.

Limit your intake of soda because carbonated drinks can make some kidney conditions worse. High levels of calcium and oxalate (a substance found in chocolate, black tea, peanuts, sweet potatoes and leafy green vegetables) can contribute to kidney stones in susceptible people.

Carbonated drinks, coffee and spicy or acidic foods or drinks can cause bladder irritation for some people. Avoiding such foods and drinks can improve bladder symptoms.

Medications, poisons and trauma-related blood loss can also harm the kidneys. In particular, combining over-the-counter painkillers such as aspirin, acetaminophen and ibuprofen can be toxic. Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, can also damage the kidneys. Ask your health care professional or pharmacist about adverse effects of any medications you are taking, including over-the-counter drugs.

High blood pressure can lead to kidney dysfunction. Smoking also elevates bladder cancer risk, and chronic coughing associated with the habit can worsen incontinence.

Preventing kidney stones

If you have had more than one kidney stone, your risk of developing another is high. Fortunately, there are strategies for preventing the recurrence of stones. A good place to start is a medical assessment to determine if you have a known stone-forming condition. Blood and urine tests may be required, and you may be asked to provide urine samples after the initiation of treatment to assess whether the treatment is working.

Medications may also be used to prevent stones, including:

  • Allopurinol (Lupurin, Zyloprim) for some cases of uric acid stones.

  • Diuretics such as hydrochlorothiazide (Esidrix, HydroDIURIL) to control hypercalciuria by reducing levels of urinary calcium.

  • Sodium cellulose phosphate (Calcibind) for severe hypercalciuria associated with recurrent calcium stones. It works by binding to calcium in the intestines and keeping it out of the urine .

  • Tiopronin (Thiola), which reduces the amount of cystine in the urine.

  • Potassium citrate (Urocit-K), which helps make the urine less acidic, reducing formation of uric acid kidney stones.

  • Acetohydroxamic acid (Lithostat) for infection stones (struvite stones) that cannot be removed. Acetohydroxamic acid is used with long-term antibiotic drugs to prevent the infection that provokes stone growth.

You can also make lifestyle changes to reduce your risk:

  • Drink more liquids, especially water. Your total daily urine output should be two to three quarts.

  • Eat foods high in calcium. In the past, susceptible people were told to avoid such foods, but new studies show that high-calcium foods actually help prevent stones. Calcium supplements, however, may increase the risk of stones, so try to get your daily intake from food sources.

  • Based on the results of lab tests, you may be advised to avoid foods with added vitamin D as well as antacids with a calcium base. If your urine is highly acidic, you may be advised to lower your intake of meat, fish and poultry (all of which boost urinary acid concentration).

  • If you tend to form calcium oxalate stones, you may be asked to cut back on the following foods: beets, chocolate, coffee, cola, nuts, rhubarb, spinach, strawberries, tea and wheat bran.

Facts to Know

Facts to Know

  1. Approximately 26 million Americans have kidney disease and millions more are at risk, according to the National Kidney Foundation.

  2. Incontinence and overactive bladder are among the most common health problems in women.

  3. Drinking plenty of water is key to urinary system health. A good rule of thumb is to drink enough water and other fluids (at least eight glasses a day) to keep the urine clear or straw colored.

  4. Combining over-the-counter painkillers such as aspirin, acetaminophen, naproxen sodium and ibuprofen can be toxic to your kidneys. Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen can also damage the kidneys.

  5. Kidney stones are among the most painful and most common urinary tract disorders—about 5 to 10 percent of Americans will have a kidney stone at some point in their lives. Stones are most likely to occur between the ages of 20 and 50 in women and are more likely to occur in people who have previously had stones.

  6. Diabetes accounts for most cases of end-stage renal disease (ESRD). Diabetes-related ESRD can be delayed or prevented by keeping blood sugar levels down.

  7. African Americans are at greater risk than Caucasians for high blood pressure and the resulting kidney problems. African Americans age 25 to 44 are more likely than Caucasians to develop kidney failure related to hypertension.

  8. "Renal function" refers to how well your kidneys are functioning. If both kidneys are healthy, you have 100 percent renal function. If one becomes non-functional or is donated for a transplant, you will still be healthy, even with only 50 percent of renal function. However, if function slips below 20 percent, serious health problems arise, and below 10 to 15 percent dialysis or a transplant may be required.

  9. End-stage renal disease (ESRD) refers to permanent total or nearly total kidney failure, requiring dialysis or transplantation. If untreated, ESRD can cause seizures, coma and death. In the United States , 85,790 died of ESRD in 2005.

  10. The annual survival rate for people on kidney dialysis is about 80 percent. Transplant is more effective than dialysis, with a one-year survival rate of 95 percent and 80 percent at five years for people receiving living-donor kidneys.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about urinary tract conditions so you're prepared to discuss this important health issue with your health care professional.

  1. What possible conditions do my symptoms suggest?

  2. What is involved in the test you want me to take? Will I be uncomfortable?

  3. What are my test results? Please explain them to me. Can I have a copy of those results?

  4. How will my kidneys and the rest of my urinary system be affected?

  5. How might medications I am currently taking affect my urinary system?

  6. What steps can I take to improve the health of my urinary system? Are there foods or drinks I should avoid or seek out?

  7. What are the treatment options available for my condition? Why are you recommending this particular treatment?

  8. What would you estimate my current renal function to be?

  9. How will I know if my treatment is working? Will further tests be needed? When?

  10. Since kidney disease does not produce noticeable symptoms until late in the disease process, how can we monitor the health of my kidneys?

Key Q&A

Key Q&A

  1. What could cause blood in my urine?

    The cause may be a serious one, such as bladder or kidney cancer, but more often the cause is relatively benign. For example, urinary tract infections or exercise can cause episodes of hematuria—the medical term for blood in the urine. Still, you should check with a health care professional any time you see blood in your urine.

  2. Why am I having repeated incidences of kidney stones?

    A variety of factors can make a person susceptible to stones in the urinary tract. Risk for stones is higher in those with family histories of stones; those who have urinary tract infections, kidney disorders and metabolic disorders such as hyperparathyroidism, cystinuria (too much of an amino acid called cystine) and hyperoxaluria (excess production an oxalate salt); and those with a disease called renal tubular acidosis. Another risk factor is absorptive hypercalciuria, in which the body absorbs too much calcium from food and dumps the excess into the urine. High levels of urinary calcium lead to crystals of calcium oxalate or calcium phosphate, which can grow into painful stones.

    Various laboratory tests and a family history should allow your health care professional to determine a likely cause. You can then make dietary changes to prevent future stones.

  3. My health care professional is concerned because I have protein in my urine, but I feel fine. Should I worry?

    Yes. Proteinuria is a sign of glomerulonephritis (inflammation of the glomeruli; see below), also called nephritis (inflammation of the kidney). Diabetes, hypertension and various kidney diseases can cause the inflammation, which can lead to renal failure and, ultimately, end-stage renal disease (ESRD).

  4. What is the connection between diabetes and kidney disease?

    Diabetes is the number one cause of end-stage renal disease. If diabetes is undiagnosed or poorly controlled, excess sugar will circulate in the blood, leading to higher blood flow into the kidney and glomerular scarring. Diabetic nephropathy is the term used for such damage, which can be delayed or prevented by keeping blood sugar levels down.

  5. What is the connection between high blood pressure and kidney disease?

    The number two cause of ESRD is high blood pressure. Long-term control of blood pressure is critical to preserving kidney function. ACE (angiotensin-converting enzyme) inhibitors and a similar class of drugs called angiotensin receptor blockers (ARBs) are the best medications for controlling the condition and preventing kidney damage. These drugs protect the kidneys more than other blood pressure medicines. People with reduced kidney function and high blood pressure should try to keep their blood pressure below 130/80 mm Hg.

  6. How can I protect my kidneys if I have diabetes?

    • Have your glycohemoglobin (hbA1c) checked regularly; the test measures your average blood sugar for the previous two to three months.

    • Adhere to your diabetes control regimen, including insulin injections and other medications, diet, exercise and blood sugar monitoring.

    • Have your blood pressure checked several times a year (at every visit to your health care professional) and follow any recommendations for reducing it. Ask your health care professional about ACE inhibitors and ARBs.

    • Have your urine checked yearly for protein and microalbumin (a protein component).

    • Ask your health care professional whether you need to lower your protein intake.

  7. How can I prevent recurrence of a cystocele?

    Avoidance of straining from chronic constipation, avoidance of heavy lifting and learning to contract the pelvic floor muscles to "splint" the pelvic floor during coughing, sneezing and lifting will help to prevent recurrent cystocele. In addition, weight loss in obese women may be helpful. Seeking medical attention to prevent chronic cough is also beneficial.

  8. Is surgery the best option for a painful case of interstitial cystitis (IC)?

    No, the results of the various types of IC surgeries are unpredictable—new ulcers may form after old ones are removed, and IC may afflict bowel tissue used to augment or rebuild the bladder. Even a cystectomy—removal of the bladder—does not guarantee the end of IC symptoms; some patients experience phantom pain. Be sure to explore other options first. Health care professionals should only turn to surgery as a last resort.

  9. What other treatment options are available for IC?

    Sometimes eliminating irritating food and beverages from the diet—such as tomatoes, coffee, spices and acidic foods—reduces symptoms of IC. Nonmedicinal approaches to relief include gentle stretching exercises and bladder training. Bladder training involves working with a health care professional to plan specific times at which to urinate and then using relaxation techniques and distractions to stick to the schedule. Patients keep a diary and over time try to extend the time between scheduled urinations.

    Transcutaneous electrical nerve stimulation (TENS) is a relatively inexpensive treatment that uses mild electrical pulses to relieve pain and reduce frequency of urination. The pulses are administered through wires on the lower back or above the pubic area, although some devices are inserted into the vagina or rectum (in men). Scientists believe TENS works to relieve IC by increasing blood flow to the bladder and triggering pain-relieving substances.

  10. What tests can I expect if I am having urinary system symptoms?

    Urinalysis and blood testing are standard. Depending on your particular symptoms and history, your health care professional may perform a cystoscopy, in which a tiny telescope is inserted through the urethra into the bladder; a biopsy, in which tissue is removed for evaluation; an intravenous pyelogram or a CT urogram, in which an x-ray is taken of the urinary tract enhanced with a radioactive dye; a urodynamic test, in which the bladder is filled with liquid and then emptied to measure function; or imaging using magnetic resonance imaging or computed tomography techniques.

Organizations and Support

Organizations and Support

For information and support on Urinary Tract Conditions, please see the recommended organizations, books and Spanish-language resources listed below.

Organizations

American Urogynecologic Society
Website: http://www.augs.org
Address: 2025 M Street NW, Suite 800
Washington, DC 20036
Phone: 202-367-1167
Email: info@augs.org

American Urological Association
Website: http://www.auanet.org
Address: 1000 Corporate Blvd.
Linthicum, MD 21090
Hotline: 1-800-RING-AUA (1-866-746-4282)
Phone: 410-689-3700
Email: aua@auanet.org

Interstitial Cystitis Association (ICA)
Website: http://www.ichelp.org
Address: 100 Park Avenue, Suite 108A
Rockville, MD 20850
Hotline: 1-800-HELP-ICA (1-800-435-7422)
Phone: 301-610-5300
Email: icamail@ichelp.org

National Kidney and Urologic Diseases Information Clearinghouse
Website: http://kidney.niddk.nih.gov/index.htm
Address: 3 Information Way
Bethesda, MD 20892
Hotline: 1-800-891-5390
Email: nkudic@info.niddk.nih.gov

Society of Urologic Nurses and Associates
Website: http://www.suna.org
Address: East Holly Avenue, Box 56
Pittman, NJ 08071
Hotline: 1-888-827-7862
Email: suna@ajj.com

Books

A Seat on the Aisle, Please! The Essential Guide to Urinary Tract Problems in Women
by Elizabeth Kavaler

Spanish-language Resources

Medline Plus: Urine and Urination
Website: http://www.nlm.nih.gov/medlineplus/spanish/urineandurination.html
Address: US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Kids Health from Nemours Foundation
Website: http://kidshealth.org/parent/en_espanol/general/kidneys_urinary_esp.html
Email: https://secure02.kidshealth.org/teen/kh_misc/send_mail.html

Last date updated: 
Fri, 2010-05-07

What is it?

Overview

What Is It?
Trichomoniasis is the most common curable sexually transmitted disease (STD) in the United States. Infected women may experience a frothy, yellow-green vaginal discharge with a strong odor, discomfort during intercourse and urination, or itching in the genital area.

Maybe you haven't heard of this infection. It is the stepchild of sexually transmitted diseases—one that is hard to pronounce, let alone find information about why it is important.

Ironically, trichomoniasis (trick-o-mon-i-a-sis or "trich") is the most common curable sexually transmitted disease (STD). In recent years, diagnosing and treating this disease has received more attention as new research has shown that it is not as harmless as was once thought.

About 3.7 million people have trichomoniasis, according to the U.S. Centers for Disease Control and Prevention (CDC). Most men infected with the parasite Trichomonas have no symptoms. When symptoms occur, men may experience irritation inside the penis, discharge or slight burning after urination or ejaculation. Most women are also asymptomatic. Some women with the infection experience a frothy, yellow-green vaginal discharge with a strong odor, discomfort during intercourse, pain during urination, itching in the genital area or spotting between periods. In rare cases, pain in the lower abdomen can occur. Women infected with Trichomonas are more at risk of acquiring human immunodeficiency virus (HIV) and other STDs.

Because trichomoniasis is so common and causes significant risks to women's health, you would expect to see more interest in its prevention. There are several reasons why this STD has received so little attention. First, its symptoms—primarily discharge and irritation of the vagina and urethra— are mild and have been seen as troubling but less serious than the side effects of other STDs. Second, the most common treatments—metronidazole and tinidazole—are highly effective in most women, though some difficulties can arise, such as drug allergies or intolerance or Trichomonas becoming resistant to this class of drugs. No other class of drugs is very effective for treatment.

The organisms that cause trichomoniasis are protozoans (the simplest, single-cell organism in the animal kingdom). These protozoans, called trichomonads, can infect other areas of the body, but Trichomonas vaginalis is responsible for genital infection and vaginitis. This parasite resides primarily in the vagina and/or bladder, where body temperature, low oxygen environment and moisture allow it to grow and multiply.

Trichomoniasis is one of the three most common types of vaginitis. The other types are bacterial vaginosis (BV), which is an overgrowth of anaerobic bacteria found in the vagina, and vulvovaginal candidiasis, more commonly known as yeast infection.

As with BV, some research suggests that trichomoniasis is associated with preterm birth. Women infected with Trichomonas during pregnancy are more likely to have low birth weight babies (less than 5.5 pounds).

Studies also link trichomoniasis with an increased risk of HIV transmission (HIV is the virus that leads to AIDS). Studies show that women infected with this STD are at higher risk of acquiring and transmitting HIV.

Trichomoniasis is transmitted through sexual intercourse. It is most common in people who are at their peak of sexual activity (teens and 20s), but it is found in higher rates among older women than other STDs. Having multiple sex partners and infection with other STDs are primary factors that increase a woman's risk of infection.

In very rare cases, trichomoniasis may be transmitted by a pregnant woman to her baby during childbirth. Pregnant women with trichomoniasis are more likely to deliver early and to give birth to a low birth-weight baby (less than 5.5 pounds). Their babies are also more likely to have conjunctivitis.

In the United States, about 3 percent of women are infected. Among women infected with other STDs, such as gonorrhea, the rate of trichomoniasis is higher. For reasons not entirely clear, African American women are 5 to 10 times more likely have trichomoniasis than Hispanic or Caucasian women.

Diagnosis

Diagnosis

A significant number of women infected with trichomoniasis have no noticeable symptoms. If symptoms develop, they usually occur within five to 28 days after exposure to an infected partner. However, in some cases, the symptoms may be delayed for longer. The most common symptoms are vaginal discharge, irritation, itching and burning during urination.

Trichomoniasis most often presents as a yellowish-green vaginal discharge with a strong odor. Itching and soreness of the vagina and vulva are common. Some women experience vague abdominal pain. Trichomoniasis can occur with other infections, particularly pelvic inflammatory disease and bacterial vaginosis.

The majority of men infected with Trichomonas do not have symptoms. The most common symptom is discharge from the penis or burning with urination. When men have symptoms, they often subside without treatment after a week or more.

For both men and women, a diagnosis based on symptoms is inadequate because many of these symptoms are shared with other inflammatory conditions of the vagina and cervix, such as bacterial vaginosis and yeast infections.

For women, the most common way to diagnose trichomoniasis is by physical examination of the pelvic area by a health care professional and by looking at a sample of vaginal fluid under a microscope (called "wet mounts") for the presence of protozoa. A pelvic examination can reveal small red ulcerations on the vaginal wall or cervix. The wet mount technique, however, is accurate only about 60 percent to 70 percent of the time, as protozoa may be hard to find or mistaken for normal cells. It can also yield false positives. There also are several rapid-diagnostic kits available that can diagnose infection in 10 to 45 minutes. These tests also come with the risk of false positives.

More reliable tests have been developed, such as the polymerase chain reaction (PCR) test, a type of nucleic acid test that uses enzymes to better detect the virus in the culture. It is very effective in identifying T. vaginalis in women and is becoming more readily available.

Treatment

Treatment

The standard drugs used for treating trichomoniasis are metronidazole (Flagyl) and tinidazole (Tindamax). In most cases, Trichomonas infection is cured in women with a single oral dose of two grams of either drug. Both of these prescription drugs are in the nitroimidazole class. Metronidazole has been found to be safe in pregnancy.

All sexual partners of an infected person should be treated. An infected person should abstain from sex during treatment and until all symptoms go away, approximately a week or two after treatment. Because of the high rate of reinfection (up to 17 percent within three months), sexually active women may want to consider getting rescreened three months after treatment. This is especially important for HIV-infected women who also have trichomoniasis, because they have an even higher rate of recurrence.

For those who fail treatment, longer courses of metronidazole or tinidazole are recommended by the Centers for Disease Control and Prevention (CDC). Patients who continue to have an infection after a single dose of metronidazole should take 500 milligrams of metronidazole orally twice a day for seven days. If this second course of medication fails, the CDC says to consider treating with two grams daily for five days of either metronidazole or tinidazole. If these therapies fail to cure the infection, further treatment should be discussed with a specialist.

You should take metronidazole or tinidazole with food and avoid drinking alcohol for 24 to 72 hours after taking the drugs.

Prevention

Prevention

Prevention of trichomoniasis is similar to that for other sexually transmitted diseases (STDs). Protective measures include:

  • Use a latex condom every time you have sex.
  • Limit your number of sex partners.
  • Get tested if you think you have an STD and have your partner tested, too.

Facts to Know

Facts to Know

  1. Trichomoniasis is the most common curable sexually transmitted disease in the United States. According to the CDC, about 3.7 million people in the United States have trichomoniasis.

  2. Trichomoniasis is more common among African American women. The reason for this is not clear. Lack of access to medical care in economically challenged communities may play a role.

  3. Trichomoniasis increases a woman's risk of preterm birth or delivery of a low birth weight baby.

  4. It is important that sexual partners of infected women be treated. Although trichomoniasis is often asymptomatic in males, if left untreated it can cause urethral infections, particularly urethritis, and can lead to reinfection of the woman.

  5. Because a test for vaginal infection is not necessarily a part of a routine pelvic exam, you can't assume your health care professional will test you for trichomoniasis. You should request trichomoniasis screening if you have symptoms or if you have been in contact with a high-risk sexual partner.

  6. You can have more than one type of vaginitis at the same time. It is possible to have trichomoniasis and bacterial vaginosis together, each of which can be treated with metronidazole.

  7. If you visit your health care professional to see if you have a vaginal infection, you should schedule your examination when you are not having your period.

  8. It is easy to misdiagnose trichomoniasis or bacterial vaginosis as a yeast infection because yeast infection also causes an unpleasant discharge. Treatment for yeast infections is different than for trichomoniasis or BV, so an accurate diagnosis is important.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about trichomoniasis so you're prepared to discuss this important health issue with your health care professional.

  1. Do over-the-counter products work for treating and preventing trichomoniasis?

  2. Does my partner need to be treated?

  3. What difference does it make whether I have trichomoniasis or a yeast infection?

  4. If I have had trichomoniasis in the past and am pregnant, should I get tested for it even if I have no symptoms?

  5. How do I identify trichomoniasis and avoid it in the future?

  6. Do I need to refrain from sexual contact while I am being treated?

  7. Will poor hygiene increase my risk of trichomoniasis?

  8. Can trichomoniasis be passed on to my baby?

  9. Are the drugs used for treating trichomoniasis safe for pregnant women?

  10. What happens if I am infected with trichomoniasis but never get treated? Will it go away on its own?

Key Q&A

Key Q&A

  1. How do I know if I need to see my health care professional?

    Pay attention to your body. Call your health care professional if you experience any unusual symptoms, such as: a change in the color, odor or consistency of vaginal fluid; vulvar irritation; itching; and burning, frequent or painful urination.

  2. What if I am allergic to the 5-nitroimidazole drugs (metronidazole or tinidazole) or am not responding well to them?

    Up to 10 percent of women do not respond to standard treatment. For those who fail treatment, a longer course of metronidazole is recommended by the Centers for Disease Control and Prevention (CDC). If this second course of medication fails, the CDC recommends two grams daily for five days of either metronidazole or tinidazole.

    If you develop a rash in response to the 5-nitroimidazole drugs, there are other medications you can try, but they have poor cure rates. If you are allergic to tinidazole and metronidazole, your provider may suggest desensitizing you to these medications so you can undergo treatment.

  3. What are my chances of having trichomoniasis reoccur?

    Treatment is successful in most women, and once the organisms are killed they don't come back unless you are exposed again to an infected partner.

  4. What is the relationship between vaginitis and excessive douching?

    The healthy vaginal ecosystem requires just the right balance of bacteria flora. These bacteria make natural acids that keep abnormal bacteria from becoming predominant. Douching may disrupt the pH balance of the vagina and lead to bacterial vaginosis, which may increase a woman's risk of acquiring trichomoniasis.

  5. What about diagnosing and treating trichomoniasis in men?

    The organisms that cause trichomoniasis often don't cause symptoms in males. Consequently, most men never seek treatment because they don't know they are infected. Diagnosis in men is usually made with a urine culture specifically for Trichomonas. If your sexual partners are not treated, it is likely you will become reinfected.

  6. What is considered normal vaginal discharge?

    For uninfected women, vaginal discharge is usually cloudy white in appearance. Discharge often increases in the middle of your menstrual cycle, and during ovulation it changes consistency, appearing similar to egg whites. Symptomatic women with trichomoniasis experience a frothy, yellow-green vaginal discharge with a strong odor, possibly coupled with discomfort during intercourse, painful urination or genital itching.

Organizations and Support

Organizations and Support

For information and support on coping with Trichomoniasis, please see the recommended organizations, books and Spanish-language resources listed below.

American College of Obstetricians and Gynecologists (ACOG)
Website: http://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

American Social Health Association (ASHA)
Website: http://www.ashastd.org
Address: P.O. Box 13827
Research Triangle Park, NC 27709
Hotline: 1-800-227-8922
Phone: 919-361-8400
Email: info@ashastd.org

ASHA's STI Resource Center Hotline
Website: http://www.ashastd.org/herpes/herpes_hotline.cfm
Address: American Social Health Association
P.O. Box 13827
Research Triangle Park, NC 27709
Hotline: 1-800-227-8922
Phone: 919-361-8400

Association of Reproductive Health Professionals (ARHP)
Website: http://www.arhp.org
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Phone: 202-466-3825
Email: arhp@arhp.org

CDC National Prevention Information Network
Website: http://www.cdcnpin.org
Address: P.O. Box 6003
Rockville, MD 20849
Hotline: 1-800-458-5231
Phone: 404-679-3860
Email: info@cdcnpin.org

Guttmacher Institute
Website: http://www.guttmacher.org
Address: 1301 Connecticut Avenue NW, Suite 700
Washington, DC 20036
Hotline: 1-877-823-0262
Phone: 202-296-4012
Email: info@guttmacher.org

National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention
Website: http://www.cdc.gov/nchhstp
Address: Centers for Disease Control and Prevention
1600 Clifton Road
Atlanta, GA 30333
Hotline: 1-800-CDC-INFO (1-800-232-4636)
Email: cdcinfo@cdc.gov

Sexuality Information and Education Council of the United States (SIECUS)
Website: http://www.siecus.org
Address: 90 John Street, Suite 704
New York, NY 10038
Phone: 212-819-9770

Sexual Health Questions You Have...Answers You Need
by Michael V. Reitano and Charles Ebel

Sex: What You Don't Know Can Kill You
by Joe S. McIlhaney and Marion McIlhaney

Meline Plus: Trichomoniasis
Website: http://www.nlm.nih.gov/medlineplus/spanish/trichomoniasis.html
Address: US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Centers for Disease Control and Prevention
Website: http://www.cdc.gov/std/Spanish/STDFact-Trichomoniasis-s.htm
Address: Centers for Disease Control Info
1600 Clifton Road
Atlanta, GA 30333
Hotline: 1-800-232-4636
Email: cdcinfo@cdc.gov

Last date updated: 
Fri, 2013-02-01

What is it?

Overview

What Is It?
Premenstrual syndrome (PMS) describes a wide range of severe, recurrent symptoms that occur from several days to two weeks before your period.

Premenstrual syndrome (PMS) describes a wide range of severe, recurrent symptoms that occur from several days to two weeks before your period. PMS affects up to 75 percent of women in their childbearing years. The symptoms of PMS can appear any time between puberty and menopause, although the most common age for it to start to become a problem is during the late 20s to early 30s.

Symptoms of PMS may get worse with age and stress, although the underlying causes are not well understood. Even women who have had hysterectomies can have PMS if at least one functional ovary is left. Women who are vulnerable to depressive illness, panic disorder, other psychiatric disorders or chronic medical conditions may also be susceptible to PMS, although these conditions may occur in women without PMS as well. Heredity may also play a role: if your mother or sister suffers from PMS, you may find you experience it, too.

As many as 150 physical and behavioral symptoms have been assigned to PMS, but the number of PMS symptoms that most women experience is much more limited. The most common symptoms include irritability, bloating, mood swings, anxiety, depressed mood, fatigue, appetite changes, water retention and breast tenderness, among others.

Menstrual cramps, or dysmenorrhea, are not considered a PMS symptom, although women with PMS may experience cramps.

PMS appears to be caused by rising and falling levels of the hormones estrogen and progesterone, which may influence brain chemicals, including serotonin, a substance that has a strong affect on mood. It's not clear why some women develop PMS or PMDD and others do not, but researchers suspect that some women are more sensitive than others to changes in hormone levels.

Calcium may play a role in PMS. In one study, women who took 600 mg of calcium twice a day experienced fewer PMS symptoms than women who took a placebo.

Dietary changes and exercise may also help relieve the discomfort of PMS symptoms. When symptoms are severe, serotonergic antidepressant medication may be prescribed. It is thought that increased serotonin reduces PMS symptoms.

One of the most important strategies for coping with premenstrual discomfort is to be aware of any pattern your symptoms follow. The more aware you are of your symptoms—when they start and stop and what works best to relieve them, for example—the better you can develop strategies to recognize and cope with them—whatever they may be.

Premenstrual Dysphoric Disorder

Approximately three to eight percent of women experience premenstrual dysphoric disorder (PMDD), a condition that, like PMS, is associated with the menstrual cycle. The symptoms of PMDD are the same as PMS symptoms, although women with PMDD may experience more dysphoric (depressive) symptoms and more severe symptoms. In fact, to be diagnosed with PMDD, symptoms must be severe enough to disrupt a woman's daily function. Symptoms must also meet diagnostic criteria specific to PMDD developed by the American Psychiatric Association.

The most important criteria for a PMDD diagnosis are mood symptoms. Physical symptoms may also be present but aren't as critical to the diagnosis. The difference between PMDD and mild PMS is like the difference between a mild tension headache and a migraine, experts say.

Women who have a history of depression are at higher risk for PMDD than other women. Treatment for PMDD includes serotonergic antidepressant medications and a particular brand of birth control pills, called Yaz. Yaz contains drospirenone (a progestin) and ethinyl estradiol (a form of estrogen) and has been shown to be clinically effective at treating the emotional and physical symptoms of PMDD. A newer form of Yaz, called Beyaz, which contains an additional daily dose of folic acid, is also FDA approved to treat PMDD.

Diagnosis

Diagnosis

There is no specific laboratory test to determine if you suffer from PMS, and diagnosis can take some time because symptoms are so varied. But there are certain characteristics that health care professionals consider. To qualify as PMS, symptoms must follow this general pattern:

  • They tend to increase in severity as your cycle progresses.
  • They improve within a few days of your menstrual period starting.
  • They are present for at least two to three consecutive menstrual cycles.

More than 150 physical and behavioral symptoms may be associated with PMS. The most common are irritability and anxiety/tension. Other symptoms include:

  • Sudden mood swings
  • Depression
  • Headaches
  • Joint and muscle aches
  • Food cravings
  • Fluid retention
  • Forgetfulness
  • Clumsiness
  • Sleep disturbances
  • Breast swelling and tenderness

The timing and severity of these symptoms are key to a PMS diagnosis. An average menstrual cycle spans 21 to 35 days. The follicular phase extends from menses to ovulation, and the luteal phase extends from ovulation to menses. PMS occurs during the luteal phase—approximately the last 14 days of your cycle, usually during the five to seven days before you get your period.

A premenstrual symptom chart or checklist (also called a menstrual cycle diary) is the most common method used to evaluate menstrual cycle symptoms. With this tool, you and your health care professional can track the type and severity of your symptoms, as well as when they occur, to identify a pattern that may indicate PMS.

Follow these simple steps to determine if your symptoms fit the PMS pattern:

  1. Track your symptoms using the first day of menstrual flow as Day 1. (Note: Don't be surprised if you do not have any symptoms to record before day 18 or so.)

  2. Have a person close to you (your partner, roommate, friend) chart his or her impression of your symptoms, when they occur and their severity.

  3. Chart your symptoms for at least three consecutive months to help you and your health care professional identify a pattern that may indicate PMS.

  4. Record the date when/if any of the following symptoms occur over three consecutive months and note their severity (1 = mild; 2 = moderate; 3 = severe)

Physical Symptoms

  • Abdominal bloating
  • Breast tenderness
  • Constipation
  • Diarrhea
  • Dizziness
  • Fatigue
  • Headache
  • Swelling of hands/feet

Emotional Symptoms

  • Anger
  • Anxiety
  • Depressed mood
  • Irritability
  • Mood swings
  • Tension

Behavioral Symptoms

  • Crying spells and tearfulness
  • Decreased or increased appetite
  • Difficulty concentrating
  • Difficulty sleeping
  • Forgetfulness
  • Hostility

In addition to suggesting that you keep a menstrual cycle diary, your health care professional likely will ask about your personal and family medical history and will give you a physical exam.

Laboratory tests are not routine but may be obtained to rule out other conditions with similar symptoms, such as low blood sugar (hypoglycemia), mania, depression, thyroid disorders, anemia, endometriosis, allergies, fibroids, dysmenorrhea, lupus, endocrine abnormalities, neurological problems such as brain tumors and heart problems.

Menopause and PMS share some of the same symptoms, so depending on your age and health history, your health care professional may want to make sure that you are indeed ovulating and therefore experiencing PMS, not menopausal symptoms.

To do this, you will probably be asked to use an over-the-counter ovulation testing kit. This is a simple test that you can do at home. The results tell you when ovulation is likely.

If you are approaching menopause (the average age is about 51 for U.S. women, but ranges from 42 to 60 years), blood hormone tests may also be used to confirm if you are menopausal. However, a single blood test is not informative because hormone levels change often.

Treatment

Treatment

Many premenstrual syndrome (PMS) symptoms improve with treatment. Treatment options range from medication therapy to birth control pills to diet modification, including vitamin and mineral supplementation, herbal medicines and exercise.

Antidepressant drugs called selective serotonin reuptake inhibitors (SSRIs) are typically recommended to women with severe mood-related symptoms such as anxiety, depression or mood swings.

Overall, common treatment options include:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs). These medications are used to relieve premenstrual headache and other menstrual-cycle related pain. A variety of NSAIDs are available including over-the-counter ibuprofen products (Motrin) and others or naproxen sodium (Aleve). They usually cost less and have fewer side effects than other treatments. Prescription NSAIDs also are available.

    Note: NSAIDS carry some risks, such as an increased risk of serious cardiovascular (CV) events, including heart attack and stroke. As a result, the FDA has issued a "black box" warning highlighting this risk, as well as the risk of potentially life-threatening stomach bleeding. If you've recently had heart surgery, you shouldn't take NSAIDS. All other women considering NSAIDS to ease PMS or any other condition should discuss these potential risks with their health care professional.

  • Contraceptive hormones. Some women with PMS or PMDD experience relief of their symptoms after they start taking birth control pills. (Other women, however, feel worse on birth control pills.) You can take the pill continuously to avoid having a menstrual period, thus preventing the hormonal changes that can lead to PMS/PMDD. The combination birth control pills Yaz (containing 3 mg of drospirenone, a progestin, and 20 mcg ethinyl estradiol, a form of estrogen) and Beyaz (containing 3 mg of drospirenone, 20 mcg ethinyl estradiol and a daily dose of folic acid) are FDA approved for the treatment of PMDD.

  • GnRH agonists (gonadotropin-releasing hormone). These medications include leuprolide (Lupron), among others. They belong to a class of hormones used to temporarily shrink fibroids and relieve endometriosis. They also may be recommended to treat PMS because they "turn off" the menstrual cycle by blocking estrogen production. Side effects may include menopausal symptoms like hot flashes, vaginal dryness and bone loss. That's why low-dose hormone therapy, a combination of estrogen and progestin hormones, is typically prescribed along with GnRH agonists. Some women may experience a return of their PMS symptoms with the additional hormone therapy. GnRH agonists are usually considered only as a short-term treatment option (given for no longer than six months) because of the increased health risks such as osteoporosis associated with low estrogen levels.

  • Antidepressant medications. Antidepressant medications called selective serotonin reuptake inhibitors (SSRIs) are the preferred antidepressants for treating severe PMS and PMDD symptoms, including depression. SSRIs include sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), and fluoxetine (Prozac). Other types of antidepressants may also be prescribed to treat PMS and PMDD, including venlafaxine (Effexor) and clomipramine (Anafranil). The U.S. Food and Drug Administration warns that women taking antidepressants should monitor their symptoms closely, with the help of their health care professional, for signs that their condition is getting worse or that they are becoming suicidal, especially when they first start therapy or when their dose is increased or decreased.

  • Danazol. Danazol (Danocrine) is a medication that works similarly to GnRH agonists to prevent ovulation. Danocrine works to improve PMS symptoms in some women, but it has some unpleasant side effects, such as acne and facial hair growth, so it is usually only used in women who do not respond to other treatments.

  • Anti-anxiety medications such as alprazolam (Xanax) are sometimes prescribed when anxiety is the main symptom associated with PMS or PMDD. These drugs can be taken during the 14 days between ovulation and menstruation (the luteal phase) when symptoms occur (rather than daily). Dependence and serious withdrawal reactions can occur with Xanax, so its dosage and discontinuation should be carefully monitored.

  • Calcium supplements (1,200 mg daily). Additional calcium in any form may help relieve some PMS symptoms. Low-fat dairy products (milk, yogurt and cheese) are a primary source of calcium, but you can also gain calcium from the following:

    • Tofu and other soy products
    • Rice milk
    • Broccoli
    • Dark greens, like turnip greens
    • Green or red cabbage (raw)
    • Salmon and sardines
  • Taking an over-the-counter calcium supplement can also help. In one study, women who took 600 mg of calcium twice a day experienced fewer PMS symptoms than women who took a placebo. But be patient; it may take two to three months to relieve PMS symptoms with calcium supplementation. If symptoms persist, have your vitamin D levels checked or change the type of calcium supplement you're using. Low levels of vitamin D can affect how the body absorbs calcium, and some generic supplements may not have enough calcium available for absorption.

  • Exercise. Regular exercise can also help relieve and possibly prevent PMS symptoms. You will get the greatest benefits if you exercise for at least 30 minutes, at least five days a week. But even taking a 20- to 30-minute walk three times a week can improve your mood.

  • Chasteberry. The extract of the fruit of the chasteberry tree is shown to be a safe and effective treatment for PMS. This therapy is used primarily outside the United States. It may be obtained over the counter, but the dose and purity may be uncertain.

In addition, there's some evidence that some nutritional supplements such as vitamin E, magnesium and vitamin B-6 may help ease symptoms of PMS. Discuss these and other strategies with your health care professional before taking any dietary supplement.

There is no single treatment that works well for every woman who experiences PMS. Typically, it's wise to try the most conservative treatment options first, which include lifestyle changes such as modifying your diet and exercising more. Discuss your symptoms with your health care professional if strategies you've tried don't work, so he or she can recommend other treatment options.

Prevention

Prevention

Can premenstrual syndrome (PMS) be prevented? Many women report benefits from a variety of lifestyle change including dietary changes, exercise and stress management. Dietary changes may include:

  • Increasing calcium intake.

  • Decreasing consumption of refined sugar.

  • Decreasing or avoiding caffeine and nicotine, which act as stimulants and can increase tension and anxiety as well as interfere with sleep patterns. For some women, the severity of PMS symptoms increases as caffeine consumption increases.

  • Decreasing alcohol consumption, which can act as a depressant. If you experience PMS, you may have an increased sensitivity to alcohol at certain points during your cycle.

  • Decreasing salt intake and increasing water consumption to avoid water retention and bloating.

  • Avoiding sodas, which may contain high levels of caffeine, salt, sugar and/or artificial sweeteners.

  • Drinking natural diuretics, such as herbal teas.

Ironically, some PMS symptoms, such as mood swings, irritability, bloating, hunger, carbohydrate cravings and fatigue, may lead you to consume foods that aggravate the condition.

Premenstrually, you may crave either refined sugar (usually combined with chocolate) or fat (combined with salt). Generally, foods high in refined sugars and fat temporarily raise energy levels. But within several hours or less, as your body metabolizes these foods, you may "crash," meaning you'll feel worse than before you ate them. Foods high in sugar content can also leave you feeling jittery.

To alleviate mood swings and fatigue, try adding more high-quality, complex carbohydrates to your diet such as:

  • Whole grain breads, pastas and cereals
  • Potatoes (white or sweet)
  • Rice (preferably brown or wild)
  • Fresh vegetables, particularly corn and peas, such as chickpeas and lentils
  • Fresh fruits

These complex carbohydrates help keep blood sugar levels even while providing your body with a long-lasting source of energy.

It's not uncommon for your appetite to increase just before your period begins. To combat the munchies and extra weight gain, try eating smaller, low-fat healthful meals using the food choices listed above.

Make sure you include adequate calcium in your diet; calcium may help prevent irritability, anxiety and other PMS symptoms. Good sources of calcium include:

  • Low-fat milk and milk products like yogurt, ice cream and cheese
  • Broccoli
  • Dark greens (like turnip greens)
  • Green or red cabbage (raw)
  • Cooked collards
  • Salmon and sardines
  • Soy products, such as tofu and soy milk
  • Calcium-fortified orange and grapefruit juices

Another good way to prevent PMS symptoms is through regular exercise in the form of aerobic activities such as brisk walking, jogging, biking or swimming. You will get the greatest benefits from exercise if you do it for at least 30 minutes, five or more days a week. But even taking a 20- to 30-minute walk three times a week can:

  • Increase endorphin and serotonin production, brain chemicals that may help decrease pain and discomfort and improve mood, respectively
  • Decrease stress and anxiety
  • Increase REM sleep

Other lifestyle changes that will help you control PMS include:

  • Sleeping consistent hours
  • Establishing a bedtime routine to help cue body and mind for sleeping
  • Keeping a PMS symptom checklist, also called a menstrual cycle diary, to identify when symptoms and which symptoms occur so you can be prepared for them

Facts to Know

Facts to Know

  1. An estimated 75 percent of women of childbearing age suffer from PMS in some form.

  2. Approximately 3 to 8 percent of women experience premenstrual symptoms severe enough to disrupt their daily function and meet criteria for premenstrual dysphoric disorder (PMDD)––a severe form of PMS.

  3. Taking additional calcium in any form may help improve or even prevent PMS symptoms. Ideally, increase daily amounts of low-fat dairy products and other calcium-containing foods to reach the 1,200 mg of calcium daily health care professionals recommend. If you have trouble reaching this goal from your diet alone, consider using over-the counter calcium supplements.

  4. Symptoms of PMS may get worse with age.

  5. If you experience PMS, you may experience an increased sensitivity to alcohol at certain points in your menstrual cycle.

  6. Some evidence suggests that women who are vulnerable to depressive illness, panic disorder or other psychiatric or chronic medical disorders may be particularly susceptible to PMS.

  7. Strategies for PMS symptom relief include medication, dietary changes, exercise and stress management.

  8. Dietary changes to relieve PMS symptoms include increasing daily amounts of dietary or supplemental calcium, drinking more water and adding more complex carbohydrates (fruits, vegetables and grains) to your meals. Decreasing foods in your diet that contain refined sugar, limiting or avoiding caffeine and nicotine, decreasing alcohol consumption, decreasing salt intake and avoiding sodas may also help.

  9. Some of the PMS symptoms you may experience, such as mood swings, irritability, bloating, hunger, carbohydrate cravings and fatigue, may lead you to consume high-fat foods and/or foods high in refined sugar, which actually aggravate these symptoms. Try to avoid them.

  10. Even women who have had hysterectomies can have symptoms of PMS if at least one functional ovary is left intact following the hysterectomy.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about premenstrual syndrome (PMS) so you're prepared to discuss this important health issue with your health care professional.

  1. What causes PMS?

  2. Are my symptoms characteristic of PMS?

  3. What other illnesses could be causing these symptoms?

  4. Which tests, if any, should I have to rule out other illnesses?

  5. How is PMS treated?

  6. What treatment may work best for me?

  7. I've heard that not getting enough calcium can cause PMS. How can I add calcium to my diet?

  8. What tests are available to determine calcium deficiency, and where can I get tested?

  9. What's premenstrual dysphoric disorder (PMDD)?

  10. How do you treat PMDD?

Key Q&A

Key Q&A

  1. What exactly is premenstrual syndrome (PMS)?

    There are more than 150 documented symptoms of PMS, but the number of symptoms seen in the vast majority of patients is much more limited. Some of the most common PMS symptoms include bloating, fatigue, sudden mood swings, irritability,anxiety, depression, weight gain, headaches, joint and muscle aches, food cravings and fluid retention. To be considered PMS symptoms, they must occur exclusively in the last 14 days of your menstrual cycle (usually about five to seven days before your period begins). True PMS symptoms tend to increase in severity as the cycle progresses, are relieved within a few days after the start of the menstrual flow and are present for at least two to three consecutive menstrual cycles. Cramps are not considered a symptom of PMS, but they can occur in women with PMS.

  2. What causes PMS?

    PMS appears to be caused by rising and falling levels of the hormones estrogen and progesterone, which may influence brain chemicals, including serotonin, a substance that has a strong affect on mood. It's not clear why some women develop PMS or PMDD and others do not, but researchers suspect that some women are more sensitive than others to changes in hormone levels.

  3. How is PMS diagnosed?

    There is no single laboratory test for PMS, but one of the most common ways to diagnosis PMS is by keeping a daily checklist, chart or "menstrual cycle diary" that tracks when your premenstrual symptoms occurs for at least three months. Your health care professional should rule out other disorders or diseases that mimic or are identical to the symptoms caused by PMS before diagnosing you with the condition. These conditions include thyroid disorders, depression, endocrine abnormalities, menopause, heart problems, allergies and low blood sugar, among other conditions. Laboratory tests, personal and family medical histories and a physical exam are also part of the diagnostic process.

  4. Is PMS treatable?

    Yes! Many women experience some relief from PMS symptoms if they make diet and lifestyle changes, particularly increasing consumption of calcium, complex carbohydrates (fruits, vegetables, grains and beans) and water, and decreasing caffeine, alcohol, salt and refined sugar intake. Regular exercise and sleep may also help relieve symptoms. Certain medications can provide relief.

  5. When does PMS typically appear?

    PMS symptoms can appear any time between puberty and menopause, though the most common age for PMS to start to become a problem is during your late 20s to mid-30s.

  6. Will my PMS symptoms get better as I age?

    Probably not until you reach menopause. In some women, symptoms of PMS worsen with age and stress. Even women who have had hysterectomies can have PMS if at least one functional ovary is left intact following the hysterectomy. Once you reach menopause, your PMS symptoms will end with the end of menstruation.

  7. If I regularly take the recommended steps to relieve my PMS symptoms, how long before I may see results?

    It may take two to three months to experience relief from PMS symptoms. If you don't see any improvements by then, check with your health care professional for a new action plan.

  8. Are menstrual cramps a symptom of PMS?

    Cramps are not considered a symptom of PMS, although they may occur in women who have PMS. Called dysmenorrhea, cramps typically begin just before (24 to 48 hours) the onset of menstruation and disappear by the end of flow.

Lifestyle Tips

Lifestyle Tips

  1. Lifestyle changes for PMS sufferers

    Some of the lifestyles changes recommended to treat premenstrual syndrome (PMS) may also be useful in preventing symptoms. Performing aerobic activity such as brisk walking, jogging, biking or swimming for a minimum of 20 to 30 minutes at least three times a week or ideally, for at least 30 minutes, five or more days a week, coupled with a balanced diet (with increased whole grains, vegetables, fruit, and decreased or no salt, sugar, alcohol and caffeine) can help. It's also important to get adequate rest; the body may have different sleep requirements at different times during the menstrual cycle.

  2. Eating right to fight PMS

    To reduce your PMS symptoms, spread your normal caloric intake over three small meals and three small snacks per day, and avoid going for long periods of time without eating. Avoid or wean yourself off caffeine. Caffeine can worsen breast tenderness, and many women report that irritability and headaches decrease when they cut their caffeine intake. Reducing salt intake can relieve fluid retention. Snack suggestions: Plain yogurt; unsalted nuts, seeds and popcorn; whole-wheat bread with peanut butter; pumpkin or banana bread; graham crackers; unsalted whole-grain crackers; bran or oatmeal muffins; raw vegetables; and raw or dried fruits.

  3. Calcium can help alleviate PMS symptoms

    If you suffer from the physical and psychological symptoms typical in premenstrual syndrome (PMS), calcium may help solve your problem. In one study, women who took 600 mg of calcium twice a day experienced fewer PMS symptoms than women who took a placebo. Calcium can be obtained through the diet or in the form of nutritional supplements or antacids. Remember to talk to your health care professional before taking calcium supplements.

  4. Medications for PMS

    If a healthy diet, regular exercise and calcium supplements fail to improve mood swings or other emotional symptoms of PMS, you may want to talk to your health care professional about a serotonin reuptake inhibitor (SSRI) antidepressant medication. Other prescription medications sometimes prescribed for severe PMS include the anti-anxiety drug alprazolam (Xanax) and gonadotropin-releasing hormone (GnRH) agonist treatments that suppress estrogen production. Two "combination" oral contraceptives containing drospirenone, a progestin, and ethinyl estradiol, a form of estrogen—Yaz and Beyaz (which contains added folic acid)—are FDA approved for both the prevention of pregnancy and for the emotional and physical symptoms associated with PMDD. Be sure to ask your health care professional about short- and long-term side effects of any medications recommended to relieve symptoms of PMS/PMDD, including the potential for dependence with the use of certain anti-anxiety medications.

  5. Is it PMS or PMDD?

    If your premenstrual symptoms are bothersome , you may have PMS. If the symptoms are primarily emotional or behavioral and are severe enough to interfere significantly with work or relationships, you may have a more serious form of PMS, premenstrual dysphoric disorder (PMDD), which affects about 3 to 8 percent of women of childbearing age. PMDD symptoms can include a markedly depressed mood, severe anxiety or tension and wild mood shifts, as well as significant physical symptoms. However, severe mood-related symptoms are key to PMDD. If you suspect you have PMDD or PMS, consult your health care professional.

Organizations and Support

Organizations and Support

For information and support on coping with Premenstrual Syndrome, please see the recommended organizations, books and Spanish-language resources listed below.

American College of Obstetricians and Gynecologists (ACOG)
Website: http://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

Association of Reproductive Health Professionals (ARHP)
Website: http://www.arhp.org
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Phone: 202-466-3825
Email: arhp@arhp.org

MGH Center for Women's Mental Health
Website: http://www.womensmentalhealth.org
Address: Perinatal and Reproductive Psychiatry Program Simches Research Builiding
185 Cambridge St Suite 2200
Boston, MA 02114
Phone: 617-724-7792

National Family Planning and Reproductive Health Association (NFPRHA)
Website: http://www.nfprha.org
Address: 1627 K Street, NW, 12th Floor
Washington, DC 20006
Phone: 202-293-3114
Email: info@nfprha.org

A Gynecologist's Second Opinion
by William H. Parker and Rachel L. Parker

Bitchin' in the Kitchen: The PMS Survival Cookbook
by Jennifer Evans

Curing PMS Naturally with Chinese Medicine
by Bob Flaws

Natural Medicine for PMS
by Deborah R. Mitchell

Once a Month: Understanding and Treating PMS
by Katharina Dalton

PMS & Perimenopause Sourcebook: A Guide to the Emotional, Mental, and Physical Patterns of a Woman's Life
by Lori Futterman and John E. Jones

PMS Relief: Natural Approaches to Treating Symptoms
by J. Marshall

PMS: Women Tell Women How to Control Premenstrual Syndrome
by Stephanie Degraff Bender and Kathleen Kelleher

Self-Help for Premenstrual Syndrome
by Marla Ahlgrimm R.Ph.

SOS for PMS: Whole Food Solutions for Premenstrual Syndrome
by Lissa Deangelis and Molly Siple

Medline Plus: Premenstrual Syndrome
Website: http://www.nlm.nih.gov/medlineplus/spanish/premenstrualsyndrome.html
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Womenshealth.gov
Website: http://www.womenshealth.gov/espanol/preguntas/pms.cfm
Hotline: 1-800-994-9662

Last date updated: 
Mon, 2011-10-03

What is it?

Overview

What Is It?
Chronic pelvic pain (CPP) is characterized by pain in the lower abdomen and pelvic area that has been present for at least six months. Sometimes the pain may travel downward into the legs or around to the lower back. The pain may be felt all of the time or it may come and go, perhaps recurring or intensifying each month with your menstrual period.

In either case, the pain is felt internally, not externally as in another common pain disorder in women called vulvodynia. In vulvodynia (or burning vulva syndrome), the external genital area stings, itches, becomes irritated or hurts when any kind of pressure, from tight clothing to intercourse, is experienced. Chronic pelvic pain and vulvodynia sometimes occur together.

Symptoms of Chronic Pelvic Pain
Women with CPP have one or more of the following symptoms:

  • constant or intermittent pelvic pain
  • low backache for several days before menstrual period, subsiding once period starts
  • pain during intercourse (rarely, some vaginal bleeding after intercourse)
  • pain on urination and/or during bowel movements (rarely, blood in urine or stool)
  • painful menstrual periods (dysmenorrhea)
  • severe cramps or sharp pains

The course of CPP is unpredictable and different in every woman. Symptoms may stay constant, disappear without treatment or suddenly increase. They sometimes decrease during pregnancy and improve after menopause.

The severity of pain is also unpredictable. It may range—even in the same woman—from mild and tolerable to so severe it interferes with your normal activities. Your physical or mental state can also cause the level of pain to fluctuate, so you may experience fatigue, stress and depression. Moderate to severe pain generally requires medical or surgical treatment, although such therapies are sometimes unsuccessful at relieving pain entirely.

Chronic Pelvic Pain Syndrome
Unrelieved, unrelenting pelvic pain may affect your sense of well-being, as well as your work, recreation and personal relationships. You may begin to limit your physical activities and show signs of depression (including sleep problems, eating disorders and constipation), and your sex life and role in the family may change.

When pelvic pain leads to such emotional and behavioral changes, the International Pelvic Pain Society (IPPS) calls the condition "chronic pelvic pain syndrome" and says that the "pain itself has become the disease." In other words, the pain is more of a problem than the original cause. In fact, a medical examination may find nothing physically wrong with the area that hurts. Nonetheless, the nerve signals in that area continue to fire off pain messages to the brain, and you continue to hurt.

Causes of Chronic Pelvic Pain
There are two kinds of pain. Acute pain typically occurs with an injury, illness or infection. A warning signal that something is wrong, it lasts only as long as it takes for the injured tissue to recover. In contrast, chronic pain lasts long after recovery from the initial injury or infection and is often associated with a chronic disorder or underlying condition.

Endometriosis
The most common cause of pelvic pain is endometriosis, in which pieces of the lining of the uterus attach to other organs or structures within the abdomen and grow outside the uterus. In practices specializing in the treatment of endometriosis, a significant number of patients with CPP are diagnosed with endometriosis. Two disorders that sometimes accompany endometriosis and are also linked to CPP are adhesions (scar tissue resulting from previous abdominal or pelvic surgery) and fibroids (benign, smooth muscle tumors that grow inside, in the wall of, or on the surface of the uterus). Fibroids often occur in the absence of endometriosis, without any pain at all, and are not a common source of chronic pelvic pain.

Pelvic Inflammatory Disease (PID)
Another common cause of CPP is pelvic inflammatory disease (PID). PID is one of the most common gynecologic conditions, usually related to a sexually transmitted disease. However, many women recuperate fully from STD-related PID, and we don't know exactly why PID sometimes leads to CPP.

One of the most common contributors to pelvic pain is dysfunction of the pelvic floor and hip muscles. This problem often accompanies pain originating from the reproductive organs but can occur on its own or persist after other sources are successfully treated.

Other Causes of Chronic Pelvic Pain
Other causes of CPP are diagnosed more frequently by other kinds of clinical care specialists, such as urologists, gastroenterologists, neurologists, orthopedic surgeons, psychiatrists and pain management physicians. They include diseases of the urinary tract or bowel as well as hernias, slipped discs, drug abuse, fibromyalgia and psychological problems.

In fact, many women with CPP collect a different diagnosis from each specialist they see. What is going on here? It is likely that CPP represents a general abnormality in the way the nervous system processes pain signals from the pelvic nerves, producing pain that involves the genital organs, the bladder, the intestine, pelvic and hip muscles and the wall of the abdomen, as well as pain involving the back and legs.

Characteristics of Pelvic Pain Patients
Despite the number of possible causes, many women with chronic pelvic pain receive no diagnosis. These are often the women who make the rounds of various specialists seeking relief, only to be told the pain is "all in their heads." They may also be subjected to multiple tests or even unnecessary surgery. These women may feel that the pain is somehow their fault, when, in fact, the lack of a diagnosis represents the limitations of medical science.

Simply put, there is no simple answer to the question, "What causes chronic pelvic pain?" and no "typical patient." Still, a woman with pelvic pain is more likely to:

  • have been sexually or physically abused
  • have a history of drug and alcohol abuse
  • have sexual dysfunction
  • have a mother or sister with chronic pelvic pain
  • have history of pelvic inflammatory disease (PID)
  • have had abdominal or pelvic surgery or radiation therapy
  • have previous or current diagnosis of depression
  • have a structural abnormality of the uterus, cervix or vagina
  • be of reproductive age, especially aged 26 to 30 years.

Some of these, like family history, surgery and PID, are obvious risk factors; others (drug abuse, depression) may be risk factors or may result from having chronic pain.

Impact of Chronic Pelvic Pain

An estimated 4 to 25 percent of women have chronic pelvic pain, but only about a third of them seek medical care. It is also one of the most common reasons American women see a physician, accounting for 10 percent of gynecologic office visits, up to 40 percent of laparoscopies and 20 percent of hysterectomies in the United States.

The cost to the patient is also enormous. Studies and surveys show that a quarter of affected women are incapacitated by pain two to three days each month. More than twice that many are forced to curtail their normal activities one or two days each month. Many women with chronic pelvic pain have pain during intercourse, and some have significant emotional changes. For many, the pain and underlying conditions lead to fertility problems, just at the age when they want children.

Diagnosis

Diagnosis

As with many pain conditions, chronic pelvic pain (CPP) can be difficult to diagnose. For one thing there is no screening test. For another, because symptoms may be variable, it can be difficult for a woman to define and localize her pain. Finally, there are all those possible causes and associated conditions to investigate.

Conditions that can cause pelvic pain may be divided into several categories:

Gynecologic conditions

  • Endometriosis is a condition in which tissue that makes up the lining of the uterus (endometrium), exits the uterus and attaches to the ovaries, fallopian tubes, bowels or other organs in the abdomen. Because endometrial tissue responds to hormonal changes during a woman's menstrual cycle, the abnormally located tissue swells and bleeds, sometimes causing pain.

    Endometriosis pain is not always restricted to the menstrual cycle. Many women with endometriosis have pain at other times of the month. Endometriosis can also scar and bind organs together, cause tubal (ectopic) pregnancies and lead to infertility, although these outcomes are unusual.

  • Fibroids are benign (noncancerous) tumors that grow inside, in the wall of or on the outside surface of the uterus. Many women don't know they have fibroids because often they have no symptoms. However, depending on their location and size, fibroids may cause pelvic pain, backaches, heavy menstrual bleeding, pain during intercourse and such urinary problems as incontinence and frequent urination. They can interfere with fertility or pregnancy if they distort the shape of the inside of the uterus, but this is unusual. Pain with fibroids is uncommon; heavy bleeding is more common.

  • Adenomyosis, like endometriosis, involves the abnormal growth of cells from the uterine lining. In this case the cells grow into the wall of the uterus, growing into the muscle fibers there. The result is painful cramps and heavy menstrual bleeding.

  • Adhesions are fibrous bands of scar tissue that are caused by endometriosis or pelvic infection, or they may form after surgery. When these bands tie organs and tissues together inappropriately, even normal movements and sex may stretch the scar tissue and cause pain. When adhesions block the fallopian tubes or ovaries, infertility can result. If they wrap around the bowel, they may cause bowel obstruction.

  • Pelvic inflammatory disease (PID) includes any infection or inflammation of the fallopian tubes, uterine lining and ovaries. It often begins as a sexually transmitted infection, most commonly chlamydia or gonorrhea. Many women with PID have no symptoms or only mild symptoms (abnormal vaginal bleeding or discharge or pain with intercourse) and may not seek treatment. However, left untreated, PID may cause scar tissue to form that can lead to chronic pelvic pain, abscesses, tubal pregnancies and infertility.

  • Ovarian remnants can sometimes cause pelvic pain. After a hysterectomy with bilateral salpingo-oophorectomy, where the uterus, ovaries and fallopian tubes are removed, a small piece of ovary may be left behind, which can later develop a painful cyst.

Urinary Tract Disorders

  • Interstitial cystitis (IC) is an inflammatory condition in which the bladder wall becomes chronically inflamed. The lining of the bladder that protects the wall from irritation seems to break down. In its most severe form, ulcers form in the bladder lining. The resulting discomfort ranges from annoying constant sensations of bladder fullness, even immediately after voiding, to intense bladder pain with associated cramping and spasm of the pelvic floor muscles. Symptoms include frequent urination that does not relieve the sensation of bladder fullness, pain or pressure. Ninety percent of IC sufferers are women, and symptoms may flare during menstruation. IC pain often gets worse during or after intercourse. Many women with IC are treated repeatedly for bladder infections, because symptoms overlap. With IC, however, antibiotics provide no relief, and urine testing for infection is negative.

  • Chronic urethritis is inflammation and irritation of the urethra (the tube through which urine is eliminated from the bladder) caused by either an infection or noninfectious inflammation. Most urethritis occurs in men, and this rare female condition rarely responds to oral antibiotics and is often also diagnosed as bladder infection, again with negative urine infection test results and minimal or no response to oral antibiotics. Symptoms include a burning pain that may radiate into the vulva or groin, exacerbated by sex or activities that put direct pressure on the groin area, such as biking or horseback riding.

Intestinal disorders

  • Irritable bowel syndrome (IBS) symptoms include abdominal discomfort or painful cramping, bloating and gas and constipation or diarrhea (or bouts of both). Stress and depression can increase the symptoms, as can particular foods and beverages. Women are more than twice as likely to have IBS as men, and their symptoms are often worse during their periods.

  • Diverticulosis occurs when small pockets develop in the wall of the large intestine. When these pockets get plugged with undigested food, an infection can develop in the bowel wall causing diverticulitis. Usual symptoms are pain in the lower left abdomen, fever, constipation or bloody diarrhea. Diverticulosis is uncommon under the age of 50.

Musculoskeletal disorders

  • Pain and tension in the pelvic nerves, pelvic and hip bones and attached pelvic floor muscles are often the primary site of musculoskeletal chronic pelvic pain. Pain from these sources, including sciatica, pudendal neuropathy, sacroiliac inflammation, pelvic asymmetry and psoas muscle spasm, among others, may cause chronic low back, deep pelvic and lower abdominal wall pain symptoms.

  • Scoliosis (curvature of the spine), herniated disks in the lower region of the back, spinal stenosis, spine or hip arthritis and other disorders of the bones, nerves and muscles in the pelvic region can result in chronic pelvic pain.

Psychological disorders

  • Depression is a common and treatable illness; chronic pain is a common symptom of depression.

Other conditions

  • Hernias, which occur when the intestine pushes through the abdominal wall, can cause pelvic pain when the intestines become intermittently or permanently trapped in the hernia defect, effectively obstructing the small intestine. Although they are more common in men, hernias do occur in women. Hernias rarely occur more than once in any individual.

  • After abdominal surgery, nerves may get entrapped in the tissue layers of the healed wound, causing pain.

Diagnostic Tests for Pelvic Pain

When you first seek medical help for pelvic pain, you may see either your internist (primary care physician) or gynecologist. In either case, your doctor will consider every possible source of pain. Each may require different diagnostic tests and distinct treatments, including referral to specialists for evaluation of specific organ systems. If you have more than one diagnosis, each can be diagnosed and treated accordingly. Depending on the problem(s) involved, your initial doctor may recommend evaluation with other specialists.

Your doctor, nurse practitioner, midwife or physician assistant will begin by asking you specific questions about your past and present health, your menstrual cycle, sexual history, previous abdominal surgeries, accidents and injuries and your symptoms. You may be asked to describe the kind and severity of your pain (aching, burning, stabbing), where it is and how it affects your life, including activities that worsen or relieve the symptoms.

You should tell your health care professional if the pain is constant or intermittent, related to your period, or worse during urination, bowel movements or sex. Also discuss any urinary or intestinal problems you may be having. Do you have constipation or diarrhea? Can you associate the start of your pain with a bladder infection or backache? Do certain movements or physical activities affect the pain intensity or duration? All information about your pain and other symptoms can help your physician with your diagnosis. Keep a pain diary with detailed information about the pain and associated activities and symptoms.

Because pelvic pain appears to run in families, the clinician will also inquire about related illnesses and problems in your parents and siblings, especially your mother and sisters. You must be prepared to report and, if possible, provide documentation about any tests, treatments and therapies you've already undergone for the pain and what the outcomes were.

Following the medical history, your health care professional will conduct a general physical examination, including a pelvic and rectal exam to determine areas of tenderness and find such potential problems as fibroids, pain trigger points, pelvic masses and abdominal wall hernias. If you have muscle pain, skeletal problems or backache, your health care professional may check your posture and gait and look for relations between those problems and your pelvic pain.

Depending on what he or she finds, these simple, standard tests may be ordered:

  • blood tests to check for infection (complete blood count or CBC) and inflammation (sedimentation rate or ESR)

  • pregnancy test

  • urinalysis and other urinary tests

  • tests for sexually transmitted diseases

  • imaging tests, such as pelvic or abdominal sonography, MRI defecography, spinal imaging, CAT scan of the abdomen and pelvis or other imaging tests

If certain conditions are suspected, endoscopic evaluations or surgery may be recommended. These include:

  • cystoscopy (look in the bladder)

  • sigmoidoscopy or colonoscopy (partial or complete look in the colon)

  • laparoscopy (minimally invasive endoscopic look into the abdomen and pelvis)

Treatment

Treatment

A diagnosis provides a starting point for treatment. The type of treatment your health care professional recommends depends on you, your reproductive health stage (childbearing years vs. menopause, for example), your condition and your level of pain.

The goals of CPP treatment focus on creating self-management strategies that allow you to manage your pain, restore your normal activities, improve your quality of life and prevent symptoms from recurring. These goals may be difficult to achieve.

The fact is that managing any kind of chronic pain is one of the most difficult jobs in medicine. You may find that your health care professional recommends a "watchful waiting" period using nonmedical therapies such as exercise, relaxation techniques and yoga to see how your symptoms develop or whether they decrease on their own. As hard as this approach may seem at first, it may provide more information about your symptoms and prevent rushing into surgery. It is also important to see a gynecologic specialist with specific experience and training in chronic pelvic pain.

If and when you decide on a specific treatment, a team approach involving specialists in several medical fields often offers the best results. This is especially true if you've been diagnosed with several conditions, all of which may represent a single pain-processing problem.

Medications

  • Pain-relieving nonsteroidal anti-inflammatory drugs, or NSAIDs, such as ibuprofen (Motrin) and naproxen (Aleve), are available over the counter (OTC) and by prescription.

    Because they reduce the amount of the hormone prostaglandin, which is involved in producing inflammation, these drugs reduce swelling and relieve menstrual cramps and pain. Studies have shown that women with painful periods produce higher than normal levels of prostaglandin. To be most effective, NSAIDs must be taken regularly, but long-term use can lead to serious side effects, including stomach ulcers and intestinal bleeding; discuss these risks with your health care professional.

  • Hormonal therapies, like birth control pills and Depo-Provera injections, regulate ovulation and menstruation. These medications help menstrual-related pelvic pain. High-dose progestin and GnRH agonists (gonadotropin-releasing hormone drugs) completely stop menstruation. Danazol, an androgen, helps ease pelvic pain related to endometriosis. Androgenizing side effects, such as increased hair growth, clitoral enlargement, deepening of voice and weight gain are common side effects of danazol therapy, however; as a result, it is usually a therapy of last resort. These drugs all work by stabilizing or reducing the production of estrogen, which causes endometrial tissue to grow. To avoid laparoscopic surgery, which is the only secure way to diagnose endometriosis, clinicians often opt to diagnose endometriosis indirectly, based on clinical response to treatment with leuprolide (Lupron), a GnRH agonist. If leuprolide relieves the pain, a presumptive diagnosis of endometriosis may be made. This conclusion may still be incorrect because other causes for pain, such as adenomyosis or painful uterine fibroids, also tend to improve with Lupron.

  • Pain medication may be injected into abdominal or pelvic trigger points, tender areas in the abdominal wall or pelvic muscles to block pain.

  • Elmiron (pentosan polysulfate sodium) is an oral drug approved to treat interstitial cystitis. How this drug relieves interstitial cystitis is not completely understood, but it is believed to work by gradually helping repair and restore the damaged bladder lining. While some women find their symptoms improve in as little as four weeks, studies show that it usually take three months to see a significant benefit, and some women never experience a benefit.

  • Antibiotics may be prescribed for underlying infections such as PID. However, there is no substantial evidence showing that antibiotics improve residual CPP.

  • Antidepressant drugs are often prescribed for chronic pain. They seem to affect pain transmission signals to the brain as well as help relieve any underlying depression.

Surgery

Surgery may be recommended to remove endometriosis, adhesions and fibroids, correct physical abnormalities or remove a diseased or damaged uterus and ovaries that may be contributing to the pain.

  • Laparoscopy may be used for both diagnosis and treatment. During the procedure, sites of endometriosis and adhesions may be destroyed by laser beam or electric current or cut out with a specially designed laparoscopic micro-scissor. In experienced hands, even advanced stages of endometriosis can be treated laparoscopically.

  • A laparotomy is a more invasive surgical procedure that involves an abdominal incision. It's used to remove endometriosis, adhesions or ovarian cysts that can't be removed laparoscopically.

  • A hysterectomy is the surgical removal of the uterus. It may be a reasonable treatment for chronic pelvic pain after other options have been considered. Hysterectomies may be performed laparoscopically, vaginally or by laparotomy.

Other Therapies

Various other therapies may be helpful alone or in combination with medical and surgical treatment:

  • relaxation and breathing techniques to reduce stress and anxiety

  • stretching exercises, massage therapy and biofeedback to reduce muscle tension in the pelvic floor, hips and low back that can cause or enhance pelvic pain

  • physical therapy to improve posture, gait and muscle tone and to work with painful muscle groups, especially pelvic floor and hip muscles.

  • cognitive behavioral therapy that includes various pain-coping strategies

  • counseling to treat depression and associated pain symptoms

The chronic nature and complexity of pelvic pain may require multiple treatment strategies, and the right combination may take some time to discover. Often, a combination of medical, surgical and alternative therapies works best. Counseling and support groups can help you to keep a positive attitude during treatment. Meanwhile, as research continues on the possible causes of chronic pelvic pain, improved drug treatments and less invasive surgical techniques are being developed.

Prevention

Prevention

Many conditions that cause chronic pelvic pain (CPP) cannot be prevented. However, reducing your risks for developing sexually transmitted infection such as chlamydia or gonorrhea can reduce your chances of developing pelvic inflammatory disease (PID), a common cause of CPP. Regular pelvic exams—once a year after commencing sexual activity or for all women age 18 and older—are also important. Regular pelvic health checkups give you the opportunity to discuss any concerns or symptoms with your physician and help identify health conditions, such as CPP, early in their development. If you experience pelvic pain, don't wait; make an appointment to discuss your symptoms with your physician.

Facts to Know

Facts to Know

  1. Chronic pelvic pain (CPP) may be either constant or intermittent pain in the lower abdomen and pelvic area that has been present for six months or more. The exact symptoms and course of disease are unique for each woman. CPP tends to improve after menopause. According to various studies, CPP affects 4 percent to 25 percent of women.

  2. Pelvic pain symptoms may include severe menstrual cramps; pain during sex, urination or bowel movement; low backache right before your menstrual period and rectal pain.

  3. As with other chronic pain conditions, the unrelenting nature of pelvic pain and the difficulties encountered in its diagnosis and treatment may lead to depression, anxiety, fatigue, behavioral changes and impaired mobility.

  4. Common causes of pelvic pain include fibromyalgia, endometriosis, fibroids, adenomyosis, pelvic adhesions related to prior pelvic surgery, endometriosis or sexually transmitted infections, pelvic inflammatory disease, interstitial cystitis, chronic urethritis, irritable bowel syndrome, diverticulitis, spinal problems, muscular dysfunction, hernias and psychological problems.

  5. Risk factors associated with CPP include past sexual and physical abuse; sexual dysfunction; a mother or sister with chronic pelvic pain; history of pelvic inflammatory disease; abdominal or pelvic surgery; depression; and congenital structural abnormalities of the uterus, cervix or vagina.

  6. The process of diagnosing chronic pelvic pain may take time, involving various tests. The goal is to identify all underlying causes of pain. In some women, no clear diagnosis or underlying cause for chronic pain is established, which can be frustrating for both the patient and physician.

  7. The goal of treatment is to manage pain, restore normal activities, improve quality of life and prevent recurrence of symptoms.

  8. Treatment may involve a combination of medications, surgery, alternative therapies and counseling. The approach used depends on the individual's condition(s), level of pain and age.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about chronic pelvic pain (CPP) so you're prepared to discuss this important health issue with your health care professional.

  1. Why am I having pain? Do I have a condition causing the pain?

  2. I've tried over-the-counter pain relievers but they're not enough. What drugs can you prescribe that will relieve my pain? What are their side effects? Will they interact with other drugs I'm taking?

  3. Do I need surgery? What kind? What is its success rate in reducing pain or curing the condition? What will happen if I choose not to have surgery?

  4. If I have surgery, will that increase my chances of developing adhesions that can cause pelvic pain in the future? What methods do you use during surgery to reduce the chance of adhesions developing?

  5. Is there a specialist in laparoscopic surgery you could refer me to?

  6. Are there nondrug, nonsurgical therapies that can help reduce my pain and improve my condition? What can I do to cope with the pain and continue my normal activities?

  7. Is there a pain management specialist you could refer me to?

  8. Are there support groups for chronic pelvic pain? Where can I get more information?

Key Q&A

Key Q&A

  1. When should I consult a health care professional about pelvic pain?

    Make an appointment with your physician or alternate pelvic health clinician if your periods are painful, if you have vaginal bleeding at times other than during your normal menstrual cycle, if you have pain during intercourse, urination or bowel movements or if you have blood in your urine or stool. If severe pelvic pain suddenly appears, see a health care professional immediately. Generally, a woman with pelvic pain and symptoms will see her primary care physician or gynecologist first. Depending on his or her findings, you may be referred to other specialists such as a urologist, for example, if there is a urinary tract condition contributing to your pain syndrome. Or it may be best to undergo treatment with a gynecologist who specializes in chronic pelvic pain or a colorectal surgeon or rheumatologist, if gastrointestinal or rheumatologic conditions are contributing to your pain. In addition, you may require physical therapy.

  2. What kinds of tests will I need for a diagnosis?

    Your physician will first conduct a medical history followed by a comprehensive physical exam, including a pelvic and rectal exam, to locate your pain and find such potential contributing problems as arthritis, pelvic inflammatory disease, endometriosis, colitis, urinary tract conditions, fibroids, pelvic masses and lower abdominal hernias. The doctor may also examine the muscles of the pelvic floor and hips. Your posture and gait may be evaluated to look for relations between musculoskeletal imbalances and your pain. You may also undergo blood tests, urine tests and tests for sexually transmitted diseases. If your doctor suspects certain conditions, he or she may order an exploratory or diagnostic laparoscopy, abdominal or pelvic ultrasound, X-ray, CT scan or MRI.

  3. Why can't I get complete pain relief?

    Complete relief from chronic pain, whether from chronic pelvic pain or other chronic conditions like backache, arthritis and fibromyalgia, can be difficult to achieve. No one medication works on all women with pain symptoms. A personalized combination of therapies that may include medication, surgery, physical therapy, alternative therapies and lifestyle changes will be formulated to manage your chronic pain symptoms.

  4. Why did I get this disease? What causes it?

    Although there are risk factors that may have increased your chances for developing chronic pelvic pain, most are not things you could have prevented or controlled. The most common causes of chronic pelvic pain are endometriosis, adenomyosis, PID, muscular problems, interstitial cystitis, irritable bowel syndrome and depression.

  5. Why are my symptoms different from a friend's, who also has chronic pelvic pain?

    Because of the wide range of conditions that can cause or contribute to chronic pelvic pain, symptoms vary from woman to woman. You may find that your own symptoms vary during your monthly cycle or over time.

  6. What can I expect from medical treatments?

    Your pain symptoms may not be totally relieved by taking medications. However, by working closely with your team of health care providers and using some self-care techniques, you may be able to reduce the impact your pain symptoms have on your lifestyle.

  7. Should I have surgery? When should I consider surgery?

    The recommendation for surgery to diagnose or treat CPP varies from patient to patient, based on the evaluation test results and responses to medical therapies. In general, surgery to relieve pelvic pain succeeds when the cause of the pain is structural, for example adhesions, ovarian cysts, endometriosis or a congenital or acquired abnormality in the uterus that may be treated with surgery. For other conditions that cause chronic pelvic pain, surgery may not be an option. In either case, surgery should be carefully discussed with your physician(s) to determine whether the risks involved in surgery are outweighed by the likelihood that surgery will relieve your pain.

Lifestyle Tips

Lifestyle Tips

  1. A combination of therapies works best

    Over-the-counter (OTC) or prescription analgesics may not be adequate to relieve your pain. Complementing drug therapy with one or more alternative therapies, including physical therapy, massage and psychological counseling, may also improve pain relief.

  2. Pay attention to posture

    Bad posture, lumbar spine disorders and hip problems can all contribute to pelvic pain, as can muscle strength and length imbalances, leg length discrepancy and foot problems. If you have chronic pelvic pain, be sure to get a complete evaluation of your musculoskeletal system from a doctor or physical therapist. If such musculoskeletal problems are detected, range of motion exercises to increase flexibility of the spine, strengthening exercises for certain muscle groups or an orthotic for your shoe may be recommended.

  3. Relax to reduce stress

    Stress exacerbates many recurrent and chronic conditions, including chronic pelvic pain. Stress increases blood pressure, reduces the immune system's ability to fight infection and affects hormone production, increasing cortisone production in the adrenal glands and upsetting the balance of female hormones. Managing stress by learning to relax daily through meditation or other established therapeutic relaxation techniques is an important part of any pain relief program. Relaxation techniques include focused breathing (as women in labor are advised to do), meditation, deep breathing, progressive muscle relaxation and listening to classical music or nature relaxation recordings. Biofeedback techniques require formal instruction and training but can help you improve your ability to recognize which muscles are tense and how to relax them.

  4. Heat and hot water relaxes muscles

    Any kind of heat improves blood flow and relaxes tense muscles. A heating pad or hot water bottle applied to the lower abdomen can help relieve menstrual cramps or pain associated with trigger points; use one on your lower back if that is where your pain originates. Treat yourself to a warm bath with relaxing ingredients, such as Epsom salts, added to it.

  5. Exercise and eat right

    Regular exercise improves circulation and increases the production of natural pain-relieving substances (endorphins) in your body. By staying fit and active, you will also reduce your chances of increasing pain due to tight muscles. It may also help you to stay positive and ward off depression. Good nutrition and getting enough rest also help you manage pain.

Organizations and Support

Organizations and Support

For information and support on coping with Pelvic Pain, please see the recommended organizations, books and Spanish-language resources listed below.

American Association of Gynecologic Laparoscopists (AAGL)
Web Site: http://www.aagl.org
Address: 6757 Katella Avenue
Cypress, CA 90630
Hotline: 1-800-554-AAGL (1-800-554-2245)
Phone: 714-503-6200

American College of Obstetricians and Gynecologists (ACOG)
Web Site: http://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

American Society for Reproductive Medicine (ASRM)
Web Site: http://www.asrm.org
Address: 1209 Montgomery Highway
Birmingham, AL 35216
Phone: 205-978-5000
Email: asrm@asrm.org

American Urogynecologic Society
Web Site: http://www.augs.org
Address: 2025 M Street NW, Suite 800
Washington, DC 20036
Phone: 202-367-1167
Email: info@augs.org

American Urological Association
Web Site: http://www.auanet.org
Address: 1000 Corporate Blvd.
Linthicum, MD 21090
Hotline: 1-800-RING-AUA (1-866-746-4282)
Phone: 410-689-3700
Email: aua@auanet.org

Association of Reproductive Health Professionals (ARHP)
Website: http://www.arhp.org
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Phone: 202-466-3825
Email: arhp@arhp.org

National Association for Continence (NAFC)
Web Site: http://www.nafc.org
Address: P.O. Box 1019
Charleston, SC 29402
Hotline: 1-800-BLADDER (1-800-252-3337)
Phone: 843-377-0900
Email: memberservices@nafc.org

National Uterine Fibroids Foundation
Web Site: http://www.nuff.org
Address: P.O. Box 9688
Colorado Springs, CO 80932
Hotline: 1-800-874-7247
Phone: 719-633-3454
Email: info@nuff.org

Society of Interventional Radiology
Web Site: http://www.sirweb.org
Address: 3975 Fair Ridge Drive, Suite 400 North
Fairfax, VA 22033
Hotline: 1-800-488-7284
Phone: 703-691-1805
Email: info@sirweb.org


A Gynecologist's Second Opinion: The Questions & Answers You Need to Take Charge of Your Health
by William H. Parker and Rachel L. Parker

A Seat on the Aisle, Please! The Essential Guide to Urinary Tract Problems in Women
by Elizabeth Kavaler

A Break in Your Cycle: The Medical and Emotional Causes and Effects of Amenorrhea
by Theresa Francis-Cheung

Coping With Endometriosis: A Practical Guide
by Robert Phillips and Glenda Motta

The Curse: Confronting the Last Unmentionable Taboo: Menstruation
by Karen Houppert

Endometriosis Sourcebook
by Mary Lou Ballweg and The Endometriosis Association

Endometriosis Survival Guide: Your Guide to the Latest Treatment Options and the Best Coping Strategies
by Margot Fromer

Endometriosis: The Complete Reference for Taking Charge of Your Health
by Mary Lou Ballweg

Honoring Menstruation: A Time of Self-Renewal
by Lara Owen

Uterine Fibroids: What Every Woman Needs to Know
by Nelson Stringer, M.D.

What Your Doctor May Not Tell You About Fibroids: New Techniques and Therapies--Including Breakthrough Alternatives to Hysterectomy
by Scott C. Goodwin, David Drum, and Michael Broder

Yale Guide to Women's Reproductive Health: From Menarche to Menopause
by Mary Jane Minkin and Carol V. Wright

Internation Association for the Study of Pain
Website: http://www.iasp-pain.org/AM/Template.cfm?Section=Fact_Sheets&Template=/CM/ContentDisplay.cfm&ContentID=4575
Address: IASP Secretariat
111 Queen Anne Ave N, Suite 501
Seattle, WA 98109
Phone: 206-283-0311

University of Maryland Medical Center: Prostatitis Chronic Overview
Website: http://www.umm.edu/esp_ency/article/000523.htm
Address: University of Maryland Medical Center
22 S. Greene St.
Baltimore, MD 21201
Hotline: 1-800-492-5538
Phone: 410-328-8667

Last date updated: 
Thu, 2012-02-09

What is it?

Overview

What Is It?
Pelvic organ prolapse (POP) occurs when one or more organs in your pelvis—your uterus, vagina, urethra, bladder or rectum—shifts downward and bulges into or even out of your vaginal canal.

Pelvic organ prolapse (POP) occurs when one or more organs in your pelvis—your uterus, vagina, urethra, bladder or rectum—shifts downward and bulges into or even out of your vaginal canal. In the United States, 24 percent of women have some sort of POP.

Just one symptom that can be associated with the condition—urinary incontinence—costs the country more than $20 billion annually in direct and indirect medical costs, while surgeries to correct POP cost more than $1 billion annually. Approximately 200,000 surgeries are done each year in the United States to correct POP.

The condition is poised to become much more common in the United States and other Western countries with the aging of the Baby Boomers (women ages 45-63). In fact, an estimated 11 to 19 percent of women will undergo surgery for POP or urinary incontinence by age 80 to 85, and 30 percent of them will require an additional surgery to correct the problem.

Many women don't have any symptoms of POP. Those who do may experience a feeling of vaginal or pelvic fullness or pressure or feel as if a tampon is falling out. They may also experience incontinence, uncomfortable intercourse, pain in the pelvic area unrelated to menstruation, lower back pain and difficulty getting stools out.. Some women also complain of not being able to fully void stools and of fecal soiling of their underwear.

Treatments include lifestyle options, such as exercises to strengthen the pelvic floor, devices designed to support the pelvic organs, physical therapy and surgery to repair damaged ligaments and reposition the prolapsed organs. For women not planning to have sex, obliterative surgeries, which close off the vaginal opening, are also an option.

Risk factors for POP include pregnancy (particularly pregnancies that have ended with a vaginal birth, especially a forceps-assisted birth), genetic predisposition, aging, obesity, estrogen deficiency, connective tissue disorders, prior pelvic surgery and chronically increased intra-abdominal pressure from strenuous physical activity, coughing or constipation. In many cases, women with POP have at least two or more risk factors.

Having been pregnant with and given birth to a child—particularly two or more children—is a significant risk factor. According to the National Association for Continence, as many as 50 percent of women who have ever given birth have some degree of POP.

While cesarean section delivery reduces the risk of POP and urinary incontinence, there is still no good evidence to support elective cesarean sections for preventing POP. Having a hysterectomy may also increase your risk of POP, depending on how the surgery was performed and how well the surgeon reattached the ligaments that typically hold up the uterus to the top of the vagina, where the cervix used to be.

Genetic factors also contribute to your risk of POP. If possible, talk to your mother, grandmother, aunts and sisters about any pelvic organ problems they've had. Also ask about urinary and fecal incontinence; although it's embarrassing to talk about, both are often associated with POP.

Diagnosis

Diagnosis

The most common symptoms associated with pelvic organ prolapse (POP) are related to urination. You may have feelings of urgency, in which you suddenly have to urinate, find yourself urinating more often than normal, experience urinary incontinence or have difficulty urinating and completely emptying your bladder.

Some women experience painful intercourse, problems reaching orgasm and reduced sexual desire or libido. Although prolapse does not directly interfere with sexuality, it may affect self-image. Data shows that women with urge incontinence have the most problems with sexuality and that POP interferes with sexuality more than any other form of incontinence. Some women avoid sex because they are embarrassed about the changes in their pelvic anatomy, and some worry that having sex will "hurt" something or cause more damage.

You may also experience problems in the rectal area. Some women with POP have pain and/or straining during bowel movements, and some experience anal incontinence, in which they inadvertently release stool.

Other symptoms include feeling as if a tampon is falling out. In fact, if the cervix has descended into the vagina, you may find you can't use a tampon at all.

However, doctors may have trouble diagnosing the condition because many symptoms can be related to situations and medical conditions unrelated to POP. The following questions can help alert your doctor to the possibility that you may have POP:

  • Do you ever have to push tissue back in the vagina to urinate?
  • Do you have to use your fingers in the vagina, on the perineum (the area between the anus and vagina) or in the rectum to have a bowel movement?
  • Do you ever feel a bulge or that something is "falling out" of your vagina? Or do you feel like you're sitting on an egg?

Let your doctor know if you answered yes to any of these questions.

Diagnosing POP begins with a complete medical history and physical examination. The doctor will carefully examine your vulva and vagina for any lesions or ulcers and will perform an internal examination to identify any prolapsed organs. The doctor will also conduct a rectal examination to test for the resting tone and contraction of the anal muscle and to look for any abnormalities in that region. The doctor may also examine you while you're standing (to see if gravity brings the organs down) and may ask you to strain as if you were urinating or having a bowel movement. A check of the nerves and reflexes in this area may be included.

POP refers to a displacement of one of the pelvic organs (uterus, vagina, bladder or rectum). These displacements are typically graded on a scale of 0 to 4, with 0 being no prolapse and 4 being total prolapse (called procidentia). Your doctor will determine which type of prolapse you have. The different types include the following:

  • Bladder prolapse (cystocele). In this form, the bladder falls toward the vagina, creating a bulge in the vaginal wall. Usually the urethra also prolapses with the bladder, called urethrocele. The two together are called cystourethrocele. Symptoms include stress incontinence (when you urinate a little when you sneeze, cough, jump, etc.) or problems urinating.
  • Rectal prolapse (rectocele). In this form, the bladder falls toward the vagina, creating a bulge in the vaginal wall. Usually the urethra also prolapses with the bladder, called urethrocele. The two together are called cystourethrocele. Symptoms include stress incontinence (when you urinate a little when you sneeze, cough, jump, etc.) or problems urinating.
  • Uterine prolapse (uterine descensus). This is a very common form of POP. It occurs when the ligaments that hold the uterus in place weaken, like a rubber band that's been stretched too often. This causes the uterus to fall, weakening the back walls of the vagina.
  • Vaginal vault prolapse. This form occurs when the vaginal supports weaken and the vagina drops into the vaginal canal after a hysterectomy. It may also occur when the front and back walls of the vagina separate, allowing the intestines to push against the vaginal wall in a form of prolapse called enterocele. Enterocele may occur with a uterus in place, but vaginal vault prolapse occurs only after hysterectomy when the uterus no longer supports the top of the vagina.

Tests

Your doctor may order several tests to confirm a diagnosis of POP. These include:

  • Urinary tract infection screening. You pee in a cup and your urine is evaluated for the presence of bacteria.
  • Postvoid residual urine volume test. This determines if any urine remains in your bladder after voiding. After urinating, the doctor or nurse inserts a catheter, or thin tube, into the urethra to measure any remaining urine or uses an ultrasound to identify any urine remaining in the bladder.
  • Urodynamic testing. This test uses special sensors placed in the bladder and rectum or vagina to measure nerve and muscle response.

If you have problems with bowel movements, your doctor will likely refer you to a gastroenterologist for a thorough evaluation, including a colonoscopy to rule out colon cancer, which can cause constipation and straining. You may also have pressure testing of the rectum known as manometry.

Treatment

Treatment

Pelvic organ prolapse (POP) is not a dangerous medical condition. Treatment options range from doing nothing and observing your condition over time to surgery to correct the prolapse. The choice of treatment typically depends on how your POP affects your quality of life, on your overall health and on your physician's expertise.

Nonsurgical options

  • Observation. If you're not having symptoms, or your symptoms are not interfering with your quality of life, you should choose a wait-and-see approach. Every year, you undergo a complete examination to evaluate your POP. Just make sure you contact your health care professional if your condition changes during the year. If you have no symptoms, treatment cannot improve your quality of life and should be avoided.

  • Addressing symptoms. Another option is to address any symptoms you have without actually "fixing" the underlying prolapse. For instance, if you're experiencing urinary or fecal incontinence, your doctor may recommend Kegel exercises (described below) or medication. If you are constipated and straining with bowel movements, then changing your diet, adding fiber supplements or taking medications such as laxatives may help.
    • Kegel exercises. These exercises strengthen your pelvic floor, which can help strengthen your organs in the pelvic region and may relieve pressure from prolapse. To make sure you know how to contract your pelvic floor muscles correctly, try to stop the flow of urine while you're going to the bathroom. If you can do this, you've found the right muscles. But do not do the actual exercises while stopping the stream of urine or you may develop a voiding dysfunction.

      To do Kegel exercises, empty your bladder and sit or lie down. Contract your pelvic floor muscles for three seconds, then relax for three seconds. Repeat 10 times. Once you've perfected the three-second contractions, try doing the exercise for four seconds at a time and then resting for four seconds, repeating 10 times. Gradually work up to keeping your pelvic floor muscles contracted for 10 seconds at a time, relaxing for 10 seconds in between. Aim to complete a set of 10 exercises, three times a day.
  • Pessaries. Pessaries are diaphragm-like devices placed in the vagina to support the pelvic organs. They are commonly used in women with POP to reduce the frequency and severity of symptoms, delay or avoid surgery and prevent the condition from worsening.

    Most pessaries are made from silicone, plastic or medical-grade rubber. Silicone is probably best, since it is nonallergenic, doesn't absorb odors or secretions, can be repeatedly cleaned and is pliable and soft. You typically remove the pessary at bedtime and replace it in the morning, although you can arrange to remove it less often or have it removed and cleaned at your doctor's office. Most doctors prescribe vaginal estrogen with a pessary in postmenopausal women to prevent any irritation of the vaginal walls.

Surgery

An estimated 11 to 19 percent of women will undergo surgery for POP or urinary incontinence by age 80 to 85. The goal of surgery for POP is to improve your symptoms by addressing the underlying cause. Surgery can be reconstructive, which corrects the prolapsed vagina while maintaining or improving sexual function and relieving symptoms, or obliterative, which moves the organs back into the pelvis and partially or totally closes the vaginal canal.

Surgery may involve repairs to any pelvic organs, including the various parts of the vagina, the perineum (the region between your vagina and anus), bladder neck and anal sphincter (anus). The goal of surgery is to reposition the prolapsed organs and secure them to the surrounding tissues and ligaments. Sometimes synthetic mesh is used to hold the organs in place.

Although hysterectomy is still commonly performed in women with symptomatic POP, several other surgical procedures are available. Which your doctor recommends depends on your condition and the specific type of prolapse. Surgeries can be performed through an abdominal incision, vaginally or laparoscopically, with or without robotic assistance, through small incisions in your belly.

Studies find that the vaginal or laparoscopic approach results in fewer wound complications, less postoperative pain and shorter hospital stays than with open abdominal surgery. Today, a large number of POP surgeries are performed vaginally, laparoscopically or robotically. However, all forms carry a risk of relapse.

In terms of the surgery itself, procedures vary depending on the type of prolapse. In most cases, surgery for POP is performed under general or regional anesthesia (epidural or spinal), and patients may stay in the hospital overnight.

Here's an overview of the surgical procedures used to treat the various forms of POP:

  • Rectal prolapse (rectocele). Surgery to repair a rectocele, or prolapse of the rectum, is performed through the vagina. The surgeon makes an incision in the wall of the vagina and secures the rectovaginal septum, the tissue between the rectum and the vagina, in its proper position using the patient's connective tissue. The opening of the vagina is tailored to the appropriate dimension, and extra support is reinforced between the anal opening and the vaginal opening.
  • Bladder prolapse (cystocele). Surgery to correct bladder prolapse, or cystocele, is usually performed through the vagina. The surgeon makes an incision in the vaginal wall and pushes the bladder up. He or she then uses the connective tissue between the bladder and the vagina to secure the bladder in its proper place. If urinary incontinence is also a factor, the surgeon may support the urethra with a sling made out of a special nylon like material.
  • Prolapse of the uterus (uterine descensus).In postmenopausal women or women who do not want more children, prolapse of the uterus is often corrected with a hysterectomy. In women who want more children, a procedure called uterine suspension may be an option. Some doctors now use laparoscopic surgery or vaginal surgery to repair the ligaments supporting the uterus so that hysterectomy is not necessary. This operation requires only a short hospital stay, has a quicker recovery time and involves less risk than a hysterectomy. The long-term results, however, are still being studied, so talk to your health care professional about what's right for you. If you have heavy bleeding or other uterine problems, you may want to consider hysterectomy, but if there are no other problems than prolapse, the ligament repair may be preferable. Generally, surgery for prolapse is not recommended until after you have completed childbearing because pregnancy can make it worse.
  • Vaginal vault prolapse and herniated small bowel (Enterocele). Vaginal vault prolapse and herniated small bowel often occur high in the vagina, so surgery to correct the problems may be done through the vagina or the abdomen. There are a number of surgical procedures used to treat these forms of POP. The most common involves vaginal vault suspension, in which the surgeon attaches the vagina to the sacrum. This can be done through an incision in the abdomen, by laparoscopy (belly button surgery) or via robotic surgery. Robotic surgery takes many hours but accomplishes the surgery without a big incision. In the past, these surgeries have sometimes involved the placement of nylon mesh to suspend the vagina.

    However, in July 2011, the FDA issued a warning concerning the use of vaginally placed mesh to repair POP, stating that the surgical vaginal placement of mesh may expose patients to greater risk than other surgical methods including the abdominal placement of mesh, and that there is no evidence that surgeries involving mesh lead to better outcomes. Be sure to talk with your health care professional about the best approach for you.

Prevention

Prevention

Preventing pelvic organ prolapse (POP) begins in your teens. Get in the habit of practicing Kegels or pelvic tilts as done in yoga several times a day, until doing them becomes as routine as brushing your teeth.

When you get pregnant, make sure you're aware of the risks and benefits of a forceps delivery in case one is necessary. A forceps delivery creates a very high risk for incontinence and prolapse. Talk to your health care professional about the options of a vacuum delivery or a cesarean section.

Maintaining a healthy weight and quitting smoking may also help prevent pelvic floor problems, including POP.

You should also avoid straining during bowel movements and when lifting heavy items, and if you have a chronic cough, get it checked out. Chronic coughing creates the kind of straining that can lead to POP.

Facts to Know

Facts to Know

  1. Pelvic organ prolapse (POP) occurs when one or more organs in your pelvis—your uterus, urethra, bladder urethra bladder or rectum—shifts downward and bulges into your vagina. In the United States, about 24 percent of women have some for of POP.

  2. Pelvic organ prolapse is poised to become much more common in the United States and other Western countries with the aging of the Baby Boomers.

  3. Symptoms of POP include a feeling of pelvic fullness or pressure; feeling as if a tampon were falling out; incontinence; uncomfortable intercourse; pelvic pain (not menstrually related); lower back pain; and difficulty getting stools out. However, many women don't have any symptoms.

  4. Causes of POP include pregnancy, childbirth, aging, obesity and menopause. Straining with bowel movements, lifting heavy items and chronic cough can also contribute to POP. In some cases, hysterectomy can increase the risk, while a cesarean section may reduce it. The condition also has a genetic component.

  5. Urinary symptoms are the most common symptoms associated with POP. These include feelings of urgency, frequent urination, urinary incontinence or difficulty urinating.

  6. Diagnosing POP begins with a complete medical history and physical examination, including an internal exam and an anal examination. Tests to evaluate the health of your urinary system and bladder may be performed.

  7. There are four stages of POP, ranging from 0 (no prolapse) to 4 (total prolapse).

  8. There are several types of POP, including bladder prolapse, or cystocele; rectal prolapse, or rectocele; uterine prolapse, or uterine descensus; and vaginal vault prolapse.

  9. Treatment for POP depends on the type of prolapse. Treatment options range from doing nothing and observing your condition over time to surgery to correct the prolapse.

  10. Kegel exercises help strengthen your pelvic floor and may relieve pressure from prolapse. They are an excellent way to treat and prevent POP.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about pelvic organ prolapse (POP) so you're prepared to discuss this important health issue with your health care professional.

  1. What type of POP do I have? Do I have more than one type?

  2. What treatment do you recommend to treat my prolapse?

  3. What is the success rate of the treatment you recommend? What are the benefits and potential risks?

  4. Can you treat my prolapse, or do I need a referral to a physician who regularly treats patients with my condition, such as a urogynecologist?

  5. How many patients with prolapse do you see a month?

  6. How many procedures do you perform monthly to treat prolapse?

  7. What are my treatment options if I still want to have children?

  8. Will treatment affect my sexual function?

  9. Where is this procedure usually performed and how?

  10. How soon after treatment can I return to my daily activities?

Key Q&A

Key Q&A

  1. If I have stress incontinence, does that mean I have pelvic organ prolapse (POP)?

    No, you can have stress incontinence without having POP. However, stress incontinence is usually related to some weakness in the pelvic floor. It often occurs in conjunction with POP.

  2. My doctor says I have some bladder prolapse, but I don't have any symptoms. How is that possible?

    Pelvic organ prolapse can be mild to severe and often doesn't have any symptoms. If you don't have any symptoms, you don't have to do anything if you don't want to, although incorporating pelvic floor exercises into your daily routine to strengthen your pelvic region is a good idea.

  3. I've been diagnosed with POP. Do I need surgery?

    That depends on your personal condition. If you don't have any symptoms and your condition is manageable with lifestyle changes, then you don't need surgery. Surgery is not foolproof; the prolapse could recur. So try to avoid surgery until your activities of daily living are affected. If you are scheduling your life around your prolapse symptoms, it is time to address them.

  4. I'm not sure if I'm doing Kegel exercises properly. How can I tell?

    A physical therapist or biofeedback expert is your best option when it comes to ensuring that you're doing Kegels properly. Physical therapists can give you vaginal cones that you place in your vagina. The squeezing pressure you use to keep the cone in the vagina teaches you which muscles to use for Kegels. Biofeedback can also be used to teach you which muscles to exercise. Talk to your health care practitioner about a referral to a physical therapist or a nurse practitioner with this expertise. There also are electrical stimulators that can help to identify and contract the correct muscles.

  5. I think I might have vaginal prolapse. Which doctor should I see?

    While your gynecologist can most likely manage your condition, you might also consider seeing a urogynecologist, a gynecologist who specializes in the care of women with pelvic floor dysfunction.

  6. What is the best type of surgery for POP?

    Again, that depends on the type of prolapse you have and your surgeon's comfort level with various surgical techniques.

  7. Is there any way to prevent POP?

    Maintaining a healthy weight is important, since there is evidence that being overweight significantly increases your risk of POP. Also, straining when you go to the bathroom, lifting heavy items and chronic cough can contribute to POP.

  8. What are the risks involved in not repairing POP?

    Generally, none. POP won't shorten your life or lead to other health conditions. In some situations, the prolapsed organs can irritate the vaginal wall, creating ulcers. The greatest risk is that it creates genital, urinary and rectal problems that significantly affect your quality of life. The only emergency situation is if the uterus descends to such a degree that the bladder cannot empty and acute urinary retention occurs. This is rare but requires immediate medical attention.

Organizations and Support

Organizations and Support

For information and support on coping with Pelvic Organ Prolapse, please see the recommended organizations, books and Spanish-language resources listed below.

American Association of Gynecologic Laparoscopists (AAGL)
Website: http://www.aagl.org
Address: 6757 Katella Avenue
Cypress, CA 90630
Hotline: 1-800-554-AAGL (1-800-554-2245)
Phone: 714-503-6200

American College of Obstetricians and Gynecologists (ACOG)
Website: http://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

American Society for Reproductive Medicine (ASRM)
Website: http://www.asrm.org
Address: 1209 Montgomery Highway
Birmingham, AL 35216
Phone: 205-978-5000
Email: asrm@asrm.org

American Urogynecologic Society
Website: http://www.augs.org
Address: 2025 M Street NW, Suite 800
Washington, DC 20036
Phone: 202-367-1167
Email: info@augs.org

American Urological Association
Website: http://www.auanet.org
Address: 1000 Corporate Blvd.
Linthicum, MD 21090
Hotline: 1-800-RING-AUA (1-866-746-4282)
Phone: 410-689-3700
Email: aua@auanet.org

Association of Reproductive Health Professionals (ARHP)
Website: http://www.arhp.org
Address: 1901 L Street, NW, Suite 300
Washington, DC 20036
Phone: 202-466-3825
Email: arhp@arhp.org

National Association for Continence (NAFC)
Website: http://www.nafc.org
Address: P.O. Box 1019
Charleston, SC 29402
Hotline: 1-800-BLADDER (1-800-252-3337)
Phone: 843-377-0900
Email: memberservices@nafc.org

Society of Interventional Radiology
Website: http://www.sirweb.org
Address: 3975 Fair Ridge Drive, Suite 400 North
Fairfax, VA 22033
Hotline: 1-800-488-7284
Phone: 703-691-1805
Email: info@sirweb.org

The Incontinence Solution: Answers for Women of All Ages
by William Parker, Amy Rosenman, and Rachel Parker

Pelvic Organ Prolapse: The Silent Epidemic
by Sherrie Palm

Medline Plus: Pelvic Support Problems
Website: http://www.nlm.nih.gov/medlineplus/spanish/pelvicsupportproblems.html
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Last date updated: 
Tue, 2011-11-15

What is it?

Overview

What Is It?
Colon cancer is cancer of the large intestine or the rectum, and is often called colorectal cancer.

Colorectal cancer is one of the most common cancers in the United States. About one in 20 people will develop cancer of the colon or rectum in their lifetimes. It also is the second leading cause of cancer deaths when men and women are considered together and is the third leading cause of cancer death among women.

There are regional differences in colorectal cancer's incidence and mortality throughout the country, with the lowest rates occurring among those living in Western states, and survival rates lowest among African Americans.

The good news is that the disease is not only highly beatable and treatable, but also highly preventable. Regular screening and removal of polyps can reduce colorectal cancer risk by up to 90 percent. But unfortunately, fear, denial and embarrassment keep many people from being screened.

When colon cancer is caught and treated in stage I, there is a 74 percent chance of survival at five years. Once the cancer is larger and has spread to the lymph nodes, however, the five-year survival rate drops to 46 percent. If the cancer has already spread to distant parts of the body such as the liver or lungs, the five-year survival rate goes down to 6 percent.

The large intestine is the last section of the digestive tract and consists of the colon and rectum. The colon is four to six feet long, and the last seven to nine inches of it is called the rectum. After food is digested in the stomach and nutrients are absorbed in the small intestine, waste from this process moves into the colon, where it solidifies and remains for one or two days until it passes out of the body.

Sometimes the body produces too much tissue, ultimately forming a tumor. These tumors can be benign (not cancerous) or malignant (cancerous). In the large intestine, these tumors are called polyps. Polyps are found in about 30 percent to 50 percent of adults. People with polyps in their colon tend to continue producing new polyps even after existing polyps are removed.

There are several types of polyps, the most common being hyperplastic polyps, adenomatous polyps, sessile serrated polyps and malignant polyps. Hyperplastic polyps are typically not precancerous. Adenomatous polyps (also called "adenomas") and sessile serrated polyps may undergo cancerous changes, becoming adenocarcinomas. Malignant polyps are already cancerous.

Colon cancers develop from precancerous polyps that grow larger and eventually transform into cancer. It is believed to take about 10 years for a small precancerous polyp to grow into cancer. Therefore, if appropriate colorectal cancer screening is performed, most of these polyps can be removed before they turn into cancer, effectively preventing the development of colon cancer.

Besides adenocarcinomas, there are other rare types of cancers of the large intestine, including carcinoid tumors typically found in the appendix and rectum; gastrointestinal stromal tumors found in the connective tissue of the colonic or rectal wall; and lymphomas, which are malignancies of immune cells that can involve the colon, rectum and lymph nodes.

Risk Factors

The exact cause of colon cancer is unknown, but it appears to be influenced both by hereditary and environmental factors. People at an increased risk of colon cancer include those with either a personal or family history of colorectal cancer or polyps, individuals with a long-standing history of inflammatory bowel disease and people with familial colorectal cancer syndromes. Some of those at high risk may have a 100 percent chance of developing colorectal cancer.

Specific risk factors include:

  • Personal History: A personal history of colorectal cancer, benign colorectal polyps which are adenomas or sessile serrated polyps, or chronic inflammatory bowel disease (e.g., ulcerative colitis and Crohn's disease) puts you at increased risk for colorectal cancer. In fact, people who have had colorectal cancer are more likely to develop new cancers in other areas of the colon and rectum, despite previous removal of cancer.
  • Heredity: If one of your parents, siblings or children has had colorectal cancer or a benign adenoma, you have a higher risk of developing colorectal cancer. If two or more close relatives have had the disease, you also have an increased risk; approximately 20 percent of all people with colorectal cancer fall into this category. Your risk is even greater if your relatives were affected before age 60 or if more than one close relative is affected.

    Additionally, there are two genetic conditions—familial adenomatous polyposis (FAP) and hereditary nonpolyposis colorectal cancer (HNPCC)—that lead to colorectal cancer in about 5 percent of patients.

    • Familial adenomatous polyposis (FAP). People who have inherited the FAP syndrome may develop hundreds to thousands of polyps in their colon and rectum at a young age, usually in their teens or early adulthood. These polyps are all adenomas. By age 40, almost all patients with FAP will develop colon cancer if they don't have preventive surgery. Most people who have this syndrome begin annual colon examinations while in elementary school, and many choose to have their colon and rectum removed before cancer develops. FAP is rare, accounting for about 1 percent of all cases of colorectal cancer.
    • Hereditary non-polyposis colon cancer (HNPCC). Also known as Lynch Syndrome, HNPCC is a more common form of inherited colon cancer, accounting for about 3 percent to 5 percent of all colorectal cancer cases. While it is not associated with thousands of polyps, polyps are present and grow more quickly into cancer than in patients without HNPCC. Colon cancer in people with HNPCC also develops at a younger age than sporadic colon cancer, although not as young as in those with FAP.

      Cancers in patients with HNPCC tend to be fast growing and respond less to chemotherapy. The lifetime risk of colon cancer in people with HNPCC may be as high as 80 percent. People with HNPCC are also at an increased risk for other types of cancer, including cancer of the ovary, uterus, stomach, kidney and bladder.

    • MUTYH-associated polyposis (MAP): People with this syndrome, which is caused by mutations in the gene MUTYH, develop colon polyps that are destined to become cancerous if they are not removed. Their colonoscopy findings may be similar to FAP with hundreds to thousands of polyps or not. People with MUTYH are also at increased risk of cancers of the small intestine, skin, ovary and bladder.

There are some additional rare genetic mutations associated with colon cancer. These include Turcot syndrome, an inherited condition in which people are at an increased risk of adenomatous polyps (and thus, colon cancer) and brain tumors, and Peutz-Jeghers syndrome, a condition that leads to freckles around the mouth and sometimes on the hands and feet, as well as large polyps in the digestive tract and an increased risk of colon and other cancers at a young age.

In addition, there are several gene mutations found in Jews of Eastern European descent (Ashkenazi Jews) that increase colon cancer risk. The most common mutation, which is called the I1307K APC mutation, is found in 6 percent of American Jews.

If you have a history of adenomas or colon cancer or suspect you have a family history of the disease, you should discuss this with your health care professional because you may need to begin screening for the disease at a relatively young age. In some cases, you may wish to undergo genetic testing.

  • Age: The risk of colorectal cancer increases with age. Ninety percent of new cases of colorectal cancer in the United States are in people over 50. Clinical studies indicate that when screened for the disease, African Americans tend to be diagnosed with colorectal cancer at a younger age than Caucasians.
  • Race: African Americans are more likely to get colorectal cancer than any other ethnic group. Compared to Caucasians, African Americans are about 10 percent more likely to develop colorectal cancer. Unfortunately, they also are more likely to be diagnosed in advanced stages. As a result, African Americans are more likely to die from colon cancer than Caucasians. In 2007, the rate of death from colon cancer among African Americans was 44 percent greater than that among whites.
  • Diet: Eating a diet high in processed meats (hot dogs and some lunch meats) and red meats (lamb, beef or liver) may increase your risk of developing the disease. Avoiding red meat and eating a low-fat diet rich in vegetables, fruit and fiber (e.g., broccoli, whole grains and beans) may reduce your risk of developing colorectal cancer. Some studies suggest that boosting calcium intake helps prevent colon cancer. Until further studies are done, men should keep their intake below 1,500 milligrams because of the increased risk of prostate cancer associated with high levels of calcium. Some research has also shown that vitamin D, which you can get from foods, sun exposure or a pill, can help lower colon cancer risk, but because of the increased risk of skin cancer with sun exposure, most health care professionals don't advocate getting more sun to reduce colorectal cancer at this time. Other studies suggest that taking a multivitamin that contains folic acid may lower colon cancer risk, but more study is needed in this area. There is some research suggesting that a diet high in magnesium may decrease colon cancer risk, especially in women. More research is necessary to find out if this link exists.
  • Lifestyle: Regular exercise is a key weapon in the fight against colorectal cancer. Another significant risk factor in colorectal cancer is smoking. Get help quitting if you can't do it on your own. And keep your alcohol intake to one drink a day or less (two drinks a day or less for men).
  • Obesity: Obesity is an epidemic in the United States and has been associated with many types of cancers, including colorectal cancer. There is a strong link between higher BMI (body mass index) and waist circumference and colon cancer risk in men and a weaker association seen in women. High levels of insulin and insulin-like growth factor may play a role in development of colon cancer in obese people. Weight loss has been shown to reduce the risk of colon cancer.

Screening Tests

The American Cancer Society recommends all women and men over the age of 50 who are at average risk of colorectal cancer undergo one of the following:

  • A fecal occult blood test once a year. This test detects microscopic amounts of blood in the stool and only detects tumors that are bleeding. This must be performed on three separate bowel movements, and you should avoid nonsteroidal anti-inflammatory medications (NSAIDS) for seven days and vitamin C and red meat for three days before collecting the stool samples. Your health care professional provides the necessary materials to collect the stool specimens for simple testing at home or in the office. The stool should be collected before it is in the toilet water. A wooden stick is used to smear a small sample of stool onto the slots in the test card. You will get three test cards, which, when completed, you return to your health care professional. Your health care professional may recommend this test earlier than age 50 or more frequently if you are at high risk for colon cancer and/or polyps.
  • A flexible sigmoidoscopy every five years. This examination allows the health care professional to inspect the rectum and lining of the left colon with a thin tube with a light and camera on the end. To prepare for the test, you may be asked to follow a special diet (such as drinking only clear liquids) for a day before the exam and to use enemas or laxatives to clean out your colon. The sigmoidoscope is inserted into the rectum while you lie on your left side. Sedative medication is not usually given for this procedure. This test is both diagnostic and therapeutic. However, it can only detect polyps or cancer accurately in the last two feet of the large intestine. Unfortunately, the sigmoidoscopy visualizes less than half the colon and misses about half of cancers and polyps that are close to becoming cancer in the first two to three feet of the colon.
  • Fecal Immunochemical Test (FIT) every year. Similar to FOBT, FIT is a stool test that also detects hidden blood (occult) in the stool and must be performed every year. However, it tests for hidden blood in a different way than FOBT and has fewer false positive results. Some forms of FIT only require two stool specimens versus three for the FOBT, and neither vitamins nor foods will affect FIT results (these things can affect results of a FOBT); therefore, no dietary restrictions are necessary prior to collecting the stool samples. You perform the test in a similar manner as the FOBT. Similar to FOBT, the FIT test will not detect a tumor that is not bleeding, so a colonoscopy may be necessary for further screening or if cancer is suspected.
  • Stool DNA at an uncertain frequency (manufacturer recommends every five years). A new screening approach, this test is available but not yet certified by the FDA. This test detects abnormal DNA shed by tumor cells into the stool and requires an entire stool sample. Studies are under way to determine how often the test should be done and how to increase its accuracy.
  • A double contrast barium enema every five years. This test involves injecting barium (a liquid imaging agent that shows up during an X-ray) through the rectum into the colon, then taking X-rays of the colon. A health care professional injects the thick, chalky liquid through a small tube inserted into your anus. You may feel an urge to move your bowels, but should hold on while the X-rays are taken. After the X-rays finish, you can expel the liquid. To avoid becoming constipated afterward, you should drink plenty of fluids to flush the barium from your system. While the procedure can be uncomfortable, it is not usually painful. This test is only a diagnostic test. If abnormalities show up, a colonoscopy must be performed. The barium enema is not a very sensitive test and misses half of polyps that are larger than 1 centimeter.
  • A colonoscopy every 10 years. Similar to the flexible sigmoidoscope, the colonoscope is a longer thin black tube that allows the health care professional to examine the entire large intestine. Preparation for the procedure requires drinking a laxative the day before the colonoscopy. Adequate preparation is critically important to enable the physician to visualize the entire lining of the colon. Leftover stool obscures the view of that portion of the colon and could lead to missing lesions. The ACS recommends getting a colonoscopy starting at age 50 for the average-risk person or if a FOBT or FIT shows blood in the stool. You typically receive a mild sedative during the procedure, so you should experience minimal discomfort. The procedure itself typically lasts 20 to 30 minutes.

    This test is both diagnostic and therapeutic. It detects polyps and cancers found anywhere in the colon. Any polyps or other growths found during this examination are usually removed and sent to a laboratory for examination. Medicare now covers this procedure every 10 years for people over 50 who are considered average risk for developing colon cancer and every two years for people at high risk. Women and men over 50 should have a colonoscopy at least every 10 years. The American College of Gastroenterology recommends that African Americans, who tend to develop the disease at a younger age than other races, begin getting screening colonoscopies at age 45.

  • CT colonography (virtual colonoscopy) every five years. This is a relatively new technique that uses a CT scan to create a three-dimensional image to evaluate the colon. It does not allow for a biopsy (tissue sampling) or polyp removal if any abnormalities are found. You must take a laxative the day before this test, similar to a colonoscopy, and if any abnormalities are found, you must undergo a colonoscopy. Most insurance companies do not cover virtual colonography as screening for colorectal cancer.

Most women find sigmoidoscopies and colonoscopies much more tolerable than they expect. Worrying about the process and undergoing the necessary preparation beforehand are often more unpleasant than the exam itself. Of the above-mentioned tests, colonoscopy is the preferred screening/prevention test, and FIT is the preferred test for patients who decline invasive cancer prevention tests.

Other tests that your health care provider might perform include:

  • Digital rectal examination (DRE). Your health care professional inserts a gloved finger into the rectum to feel for any abnormalities. This simple test, which may be uncomfortable but usually is not painful, can detect many rectal cancers. However, even the longest of fingers are far too short to examine the full length of the large intestine. For this reason, other tests and examinations, such as the FOBT, flexible sigmoidoscopy and colonoscopy must be used. The rectal exam is not sufficient to screen for colon cancer.
  • Genetic testing. The few hereditary cancer syndromes mentioned here are rare but are associated with mutations in specific genes. These mutations can be passed on to other family members. Thus, if your family is affected or may be affected by one of these syndromes, you may need to undergo genetic testing. If genetic testing and counseling are done properly, lives can be changed dramatically, both in terms of preventing colon cancer and lessening the psychological impact of knowing you are predisposed to the disease.

    Genetic testing for colon cancer raises many scientific and ethical issues. Although tests are available to identify the mutations that may predispose you to colon cancer, they are not absolutely positive predictors. Additionally, some health care professionals are not yet fully educated about the tests and may misinterpret the results.

    Thus, if you have a strong family history of colon cancer, you should be seen at a genetic screening center. Talk to your health care professional about the genetic screening process and how to locate such a center.

If there is a reason to suspect that you have colorectal cancer, your health care professional will take a complete medical history and perform a physical examination as part of an initial evaluation.

Symptoms

Symptoms of colorectal cancer include:

  • Change in bowel habits (diarrhea, constipation or narrow stools for more than a few days)
  • Urgency for a bowel movement or feeling like you need to move your bowels even if you just did
  • Blood in the stool
  • Stomach pain
  • Weakness and/or fatigue

Contact your health care professional if you experience one or more of these symptoms.

Diagnosis

Diagnosis

Because the symptoms of colon cancer are vague and typically occur late in the development of the cancer, a variety of tests are used to both screen and diagnose the disease. Screening tests look for disease in those who look and feel healthy, ideally catching the disease as early as possible or, in the case of colon cancer, even before the precancerous lesion has turned into cancer. Diagnostic tests look for the cause and determine the extent of the disease in someone who has obvious symptoms.

A bowel preparation is often required before many of these tests, especially a colonoscopy. This involves cleaning out your bowel the night before the test with a laxative solution. It is important that the bowel be clean so the physician performing the colonoscopy gets the best look at your colon. Since some preparations can affect your blood level for certain electrolytes, your health care professional will tell you which preparation to use for your procedure.

Diagnostic Tests

  • Flexible sigmoidoscopy or colonoscopy. Sigmoidoscopy is a procedure that allows a physician to view the lining of the rectum and the lower part of the colon. This area accounts for less than one-half the total area of the rectum and colon. If a mass or any other types of abnormalities are seen through the flexible sigmoidoscope or colonoscope, a sample (biopsy) is taken for further examination by a pathologist to determine if it is cancerous or benign.

  • Complete blood count (CBC) and blood chemistry. The CBC determines whether you are anemic because many people with colorectal cancer become anemic due to prolonged bleeding from the tumor.

  • Computed tomography (CT). In this test, a rotating X-ray beam creates a series of pictures of the body from many angles, helping visualize any masses that may indicate that the colon cancer has spread to your liver or other organs.

  • Magnetic resonance imaging (MRI): Like CT, magnetic resonance imaging displays a cross-section of the body. However, MRI uses powerful magnetic fields and radio waves instead of radiation.

  • Chest x-ray. This familiar imaging test detects if colorectal cancer has spread to the lungs.

  • PET scanning: This test can determine if certain cells are using glucose more than other cells. Cancer cells, which are actively dividing, use more glucose so they light up on a PET scan. This test is used to follow cancer and can be combined with a CT scan to better localize a possible recurrence. It is important to remember that not all tumors will be responsive to PET/CT imaging.

Colorectal Cancer Stages

As with all cancers, there are various stages of colon cancer:

  • Stage 0: Abnormal (dysplastic) cells have been found in the innermost lining (mucosa) of the colon. This stage is also known as carcinoma in situ or intramucosal carcinoma, and there is a very small chance these cells have spread, so this stage is not considered to be invasive cancer.

  • Stage I: Cancer has spread to the inside lining of the colon but hasn't spread beyond the colon wall or rectum.

  • Stage II: Cancer has spread through the colon or rectum and may invade surrounding tissue, but no lymph nodes are involved.

  • Stage III: Cancer has spread to the lymph nodes, but not to distant sites.

  • Stage IV: Cancer has spread to other distant parts of the body, such as the liver or the lung.

Treatment

Treatment

Surgery is often required to treat colorectal cancer. The surgical procedure used depends on where the cancer is located. Most patients who undergo surgery for colon cancer have an open abdominal operation, where the surgeon makes an incision in the abdomen and removes the tumor and any affected lymph nodes. In some cases, however, a procedure called laparoscopic colon cancer resection may be used. Like open abdominal surgery, laparoscopic surgery is performed under general anesthesia, but multiple, much smaller incisions are made, which leads to a shorter recovery time. Studies have shown similar results when open abdominal and laparoscopic techniques are used to remove colon cancer. A surgeon experienced at laparoscopic surgery should perform these surgeries.

Occasionally, early cancerous changes may be limited to a portion of an otherwise noncancerous polyp. In these cases, it is sometimes possible to remove some very early colon cancers during a colonoscopy.

If part of the colon needs to be removed due to a larger cancerous tumor, the surgeon will remove the affected portion and leave as much of the healthy colon behind as possible. In rectal cancer, the rectum is removed.

In many cases, the surgeon will be able to reconnect the healthy portions of the colon and rectum, which allows waste to flow through the colon to the rectum. If this is not possible, you may need to have a colostomy. A colostomy (stoma) involves creating a hole in the wall of abdomen to which an end of your colon is attached so you can eliminate waste into a special bag. Depending on the situation, a colostomy may be temporary or permanent.

You may be referred to an enterostomal therapist (a health care professional, often a nurse, trained to help people with their colostomies) as part of your initial workup. The enterostomal therapist can address concerns about how a colostomy might affect your daily activities.

Even after colon cancer has been completely removed with surgery, cancer cells can remain in the body and cause relapse. To kill these cells and decrease the chances of a relapse, health care professionals use chemotherapy. Not all people need chemotherapy after surgery. Those most likely to receive chemotherapy are people at risk for recurrence, namely, those with stage III colon cancer or high risk stage II.

For some rectal cancers, chemotherapy is given along with radiation therapy in an attempt to shrink the tumor before surgery. This is called neoadjuvant chemotherapy.

Several chemotherapy drugs are used to treat colon cancer. In many cases, two or more of these drugs are combined for more effective treatment:

  • 5-Fluorouracil (5-FU): 5-FU is part of most chemotherapy treatments for colorectal cancer, and it is often given together with another chemotherapy drug called leucovorin (folinic acid). 5-FU may be given through a vein over two hours or as a quick injection followed by continuous infusion via a battery-operated pump over the following one or two days. In most cases, patients get 5-FU every two weeks for six months to a year. Side effects include nausea, loss of appetite, diarrhea, low blood cell counts and sensitivity to sunlight.
  • Capecitabine (Xeloda): A chemotherapy drug in pill form, Xeloda changes to 5-FU once it reaches the tumor and is about as effective as continuous intravenous 5-FU. Patients taking capecitabine usually get it twice a day for two weeks, followed by a week off. Capecitabine is a convenient option to 5-FU because it can be taken at home, but it still has similar side effects.
  • Irinotecan (Camptosar): This drug is often combined with 5-FU and leucovorin in a regimen called FOLFIRI. Irinotecan may also be used by itself as a second-line therapy if other chemotherapy drugs are not effective. It is given intravenously over 30 minutes to two hours. Some people cannot break down irinotecan, which leads to severe side effects like diarrhea and low blood counts. This inability to break down the drug is due to an inherited gene variation that can be tested for, so it is possible to predict how you will react. If you are taking irinotecan and experience severe side effects, call your doctor right away.
  • Oxaliplatin (Eloxatin): For the treatment of advanced colorectal cancer, oxaliplatin is usually given together with 5-FU and leucovorin (known as the FOLFOX regimen) or with capecitabine (known as the CapeOX regimen) as a first- or second-line treatment. It may also be used as adjuvant therapy after surgery for colorectal cancers at earlier stages. Patients take oxaliplatin intravenously over two hours, usually once every two or three weeks. Oxaliplatin may affect peripheral nerves, leading to numbness, tingling and heightened sensitivity to temperature, especially in the hands and feet. In most cases, these side effects go away once patients stop taking the medication, but they can persist. Talk to your doctor about potential side effects before you start taking oxaliplatin.

Individuals with advanced colon cancer may receive targeted drugs that help stop cancerous tumors from growing. These drugs include bevacizumab (Avastin), cetuximab (Erbitux) and panitumumab (Vectibix). They may be given alone or together with chemotherapy.

Not all people benefit from targeted medications. Researchers are currently examining who are most likely to respond. Until then, health care professionals will continue to weigh the risks and benefits of targeted drugs before they prescribe them for people with advanced disease.

Radiation therapy may benefit some people with rectal cancer, but it is not usually used in the treatment of early stage colon cancer. Like chemotherapy, radiation may be helpful for patients who are at high risk of cancer recurrence, for instance if the cancer has spread to nearby organs. In general, the goal of radiation is to reduce chances of colon cancer recurrence rather than to improve survival.

For those whose colorectal cancer has metastasized to a few areas in the liver, lungs or elsewhere in the abdomen, surgically removing or destroying these metastases can increase survival.

If the cancer comes back in only one part of the body, you may need surgery again. If it has spread to several parts of the body, you may receive chemotherapy and/or radiation therapy.

Prevention

Prevention

The most important line of defense against colorectal cancer is screening for colorectal cancer. You should follow the established guidelines for screening procedures so that any precancerous polyps can be removed before they turn into cancer and, if cancer exists, it can be detected at the earliest possible stage. If you are at average risk of colorectal cancer, the American Cancer Society recommends that all women and men over the age of 50 undergo one of the following:

  • annual fecal occult blood test
  • flexible sigmoidoscopy every five years
  • double contrast barium enema every five years
  • colonoscopy every 10 years unless you are African American, in which case your screening can begin at age 45
  • virtual colonoscopy (CT colonography) every five years
  • stool DNA testing, interval uncertain (a new screening approach, this test is available but not yet certified by the FDA)

Any positive screening test should be followed by an appropriate and complete diagnostic evaluation of the colon including a colonoscopy with biopsies, if necessary.

If you are at an increased risk of colorectal cancer or adenomas because of a family history of cancer or polyps, you should follow the above recommendations and also:

  • Begin colorectal screening at age 40, or 10 years before the youngest case of colon cancer in the immediate family.

  • Discuss genetic counseling and/or testing with your health care professional.

If you are at an increased risk for colorectal cancer for a reason other than family history, such as a personal history of inflammatory bowel disease, you may also need to begin screening before age 50. Screening recommendations vary based on your particular risk factors; discuss your individual screening schedule with your health care professional.

Modifying your diet and exercise may help decrease your risk of forming colon polyps and/or colon cancer. A diet rich in vegetables, fruit and fiber and low in fat may reduce the risk of developing colon cancer. Some suggest that increasing intakes of calcium and vitamin D can help prevent colon cancer. (Men should keep their intake below 1,500 milligrams because of the increased risk of prostate cancer associated with high levels of calcium.) Calcium can be found in dairy products, calcium-fortified products such as orange juice, soy and dark green vegetables. Other research has shown that taking a multivitamin containing folic acid (a B complex vitamin) decreases the risk of colon cancer, but more study is needed. There is some research suggesting that a diet high in magnesium may decrease colon cancer risk, especially in women. More research is necessary to find out if this link exists.

Regular exercise is important in preventing colon cancer. Experts say that vigorous exercise is not necessary. Instead, just incorporate more activity into your daily routine, such as taking the steps instead of the elevator or parking your car farther from the building you are entering. Overall, the American Cancer Society recommends 30 minutes of physical activity at least five days per week and says that 45 minutes or more of moderate to vigorous activity five or more days a week may further reduce the risk of colon, breast, uterine and prostate cancers.

It is also advisable to drink alcohol only in moderation (no more than one alcoholic beverage per day for women, for a total of less than seven drinks per week, and no more than two alcoholic beverages for men, for a total of less than 14 drinks per week) and abstain from tobacco use.

Results from multiple studies show that people who regularly take aspirin and other non-steroidal anti-inflammatory medications (NSAIDS) have a lower risk of colorectal cancer and adenomatous polyps. An August 2009 study published in the Journal of the American Medical Association found that aspirin can help prevent colorectal cancer deaths as well. The study looked at 1,279 men and women with colon cancer and found that those who took aspirin regularly after their diagnoses were 30 percent less likely to die from the disease than people who didn't take aspirin. However, the risk of stomach ulcers and other side effects associated with aspirin and NSAIDS may outweigh the benefits. Therefore, experts do not recommend people at average risk of colorectal cancer take NSAIDS as a prevention strategy. Discuss the potential risks and benefits of taking NSAIDS with your health care professional.

Facts to Know

Facts to Know

  1. The American Cancer Society estimates that about 103,170 new cases of colon cancer and 40,290 new cases of rectal cancer will be diagnosed in 2012. Combined, these cancers are predicted to cause about 51,690 deaths during 2012.

  2. While colorectal cancer is the second leading cause of cancer deaths when men and women are considered together and is the third leading cause of cancer death among women, incidence among Caucasians in the United States has been decreasing, perhaps due to improved screening methods. Among African Americans, however, incidence rates have remained relatively stable.

  3. The risk of developing colorectal cancer is highest among those with a family history of colorectal cancer or adenomatous polyps and those who have inflammatory bowel disease.

  4. Except for those with hereditary conditions that may predispose them to developing colorectal cancer relatively early in life, 90 percent of all cases occur after the age of 50.

  5. Tumors that grow in the large intestine are called polyps. A biopsy determines if the polyp is benign (not cancerous) or malignant. Benign polyps can be precancerous (adenomatous and sessile serrated) or not precancerous (hyperplastic). Thirty percent to 50 percent of the population has polyps. Over the course of about 10 years, adenomatous polyps can become cancerous if they are not removed.

  6. Undergoing appropriate screening for colorectal cancer can decrease death rates from this cancer by up to 90 percent. Colorectal cancer screening is designed to detect and remove precancerous polyps (adenomas and sessile serrated polyps) before they turn into cancer and to diagnose cancer at the earliest stages.

  7. If you or a close relative were diagnosed with colon cancer at age 45, then other members of your family should begin screening around age 35. If you have a close relative with colorectal cancer, you should begin screening at the age of 40 or 10 years before the age at which the youngest relative was diagnosed with cancer.

  8. Cancer specialists are using more aggressive strategies to make sure cancer does not return after surgery. You may receive both chemotherapy and radiation therapy to increase your chances of a complete cure. These treatments destroy microscopic accumulations of cancer cells that cannot be seen or removed during surgery.

  9. When colon cancer is caught and treated in stage I, there is a 74 percent chance of survival at five years. Once the cancer is larger and has spread to lymph nodes, the five-year survival rate drops to 46 percent. If the cancer has already spread to distant parts of the body such as the liver or lungs, the five-year survival rate goes down to 6 percent.

  10. You may be able to reduce your risk for colorectal cancer by eating a diet high in fiber and low in fat, getting plenty of exercise, limiting your alcohol intake to one drink or less a day, losing weight if you are obese, taking calcium and having regular colorectal cancer screenings.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about colon cancer so you're prepared to discuss this important health issue with your health care professional.

  1. What causes colorectal cancer?

  2. How can I reduce my risk for colorectal cancer?

  3. What are the signs and symptoms of colorectal cancer?

  4. What exams or tests will you do during my regular physical to screen for colorectal cancer?

  5. What is the "stage" of my cancer? What does that mean? What does it tell me about how severe my cancer is?

  6. Will treatment be needed before I have surgery?

  7. How long will I be in the hospital?

  8. If I'm in pain, what medication will you give me to make me feel better?

  9. Will I need more treatment after surgery?

  10. If I need chemotherapy after surgery, how soon after my surgery would I start?

  11. What kind of chemotherapy is used for colon cancer?

  12. When is radiation therapy used for colon cancer?

Key Q&A

Key Q&A

  1. My health care professional told me I have polyps. What are these and how will they be treated?

    Colorectal polyps are excess growths of tissue in the lining of your colon or rectum. They can be noncancerous (hyperplastic), precancerous (adenomas or sessile serrated polyps) or malignant (cancerous). All colorectal cancers develop from precancerous polyps. Therefore, if these precancerous polyps are removed during colonoscopy or sigmoidoscopy, they will no longer be able to grow into cancer. Most colorectal polyps are easily removed during colonoscopy without the need for surgery. Once you have polyps, you are at increased risk for developing more polyps in the future and need repeated screening to detect and remove them.

  2. My father and grandmother both had colon cancer. What are my risks and what should I do?

    First, realize the disease is highly curable when diagnosed early. When the cancer spreads to other distant places like the lung or liver, however, the survival rate is less than 10 percent. A family history of colon cancer or adenomatous polyps significantly increases your chances of developing the disease, and the more family members you have with colon cancer, the higher your risk. Make an appointment with your health care professional now to discuss your personal and family health history and to determine the next steps you should take. You will need to have colorectal cancer screening starting at the age of 40 or 10 years before the age at which the youngest relative was diagnosed with cancer. You will probably have regular surveillance of your colon by colonoscopy.

  3. Is there any way to reduce my risks for colon cancer?

    Most important is to ask your health care professional about colorectal cancer screening beginning at age 50 (45 for African Americans) if you are at average risk or earlier if you have family members (such as your father, mother, sister or brother) who had colorectal polyps or cancer. If you undergo appropriate screening for colorectal cancer, you may decrease your risk of death from colorectal cancer by 90 percent. This is because physicians can detect and remove precancerous polyps before they turn into cancer, most effectively by colonoscopy. Research increasingly suggests that a diet high in fiber, fruits and vegetables and low in fat may help reduce your risk for colon cancer. Losing weight if you are obese may decrease your risk of colorectal cancer. Taking calcium and vitamin D may prevent formation of precancerous polyps and colon cancer. And getting regular exercise may help, too.

  4. My health care professional told me my cancer had metastasized and that I had a "met" in another place besides the colon. What does that mean?

    "Met" is short for metastasis, which means the cancer has spread to other parts of the body. Any time your health care professional uses a word you don't understand, stop him or her right there and ask what that word means.

  5. What are my chances of a cure?

    No one really knows if cancer is totally cured. But it is sometimes pushed back so far it never grows again, which is called achieving remission or long-term survival. Your chances of surviving for a long time largely depend on the stage of your cancer at the time of diagnosis and the success of treatments you receive. The earlier the cancer is detected, the higher your chances for long-term survival.

  6. My cancer is pretty advanced. How long have I got?

    Any number that a health care professional gives you is based on estimates derived from experiences with other patients. No one can tell you what your specific chances are. Survival averages are just that: averages.

  7. What can I do about this ongoing pain?

    One of the worst things that cancer patients do is to suffer pain when they do not have to! Discuss your pain with your health care professional so that you can get the relief you need. It might be necessary to see a pain specialist. Most health care professionals can refer you to someone who specifically handles chronic pain problems. If you have severe pain, narcotics may be the best type of medicine.

  8. What caused this? Was it something I did? How long did it take to grow?

    No one is really sure what causes colorectal cancer. It's very unlikely that it was something you did. The tendency to get the disease may be hereditary, that is, it may run in families. A polyp in your colon can take as many as 10 years to become cancerous. Colorectal cancer is difficult to find without regular screening and often does not cause symptoms until it's already well developed. So don't beat yourself up that you didn't "catch" it a few months ago.

Organizations and Support

Organizations and Support

For information and support on coping with Colon Cancer, please see the recommended organizations, books and Spanish-language resources listed below.

American Cancer Society (ACS)
Website: http://www.cancer.org
Address: 250 Williams Street
Atlanta, GA 30303
Hotline: 1-800-ACS-2345 (1-800-227-2345)
Phone: 404-315-1123

American College of Gastroenterology
Website: http://www.acg.gi.org
Address: P.O. Box 342260
Bethesda, MD 20827
Phone: 301-263-9000

American Institute for Cancer Research
Website: http://www.aicr.org
Address: 1759 R Street, NW
Washington, DC 20009
Hotline: 1-800-843-8114
Phone: 202-328-7744
Email: aicrweb@aicr.org

Association of Cancer Online Resources, Inc.
Website: http://www.acor.org
Address: 173 Duane Street, Suite 3A
New York, NY 10013-3334
Phone: 212-226-5525

Cancer Care, Inc.
Website: http://www.cancercare.org
Address: 275 Seventh Ave., Floor 22
New York, NY 10001
Hotline: 1-800-813-HOPE (1-800-813-4673)
Phone: 212-712-8400
Email: info@cancercare.org

Cancer Information and Counseling Line (CICL)
Address: AMC Cancer Research Center
1600 Pierce Street
Denver, CO 80214
Hotline: 1-800-525-3777
Email: contactus@amc.org

Cancer Support Community
Website: http://www.gildasclub.org/
Address: Gilda's Club Worldwide
48 Wall Street, 11th Floor
New York, NY 10005
Phone: 888-GILDA-4-U
Email: info@gildasclub.org

Corporate Angel Network
Website: http://www.corpangelnetwork.org
Address: Westchester County Airport
One Loop Road
White Plains, NY 10604-1215
Hotline: 1-866-328-1313
Phone: 914-328-1313
Email: info@corpangelnetwork.org

Gathering Place
Website: http://www.touchedbycancer.org
Address: The Arnold & Sydell Miller Family Campus 23300 Commerce Park
Beachwood, OH 44122
Phone: 216-595-9546
Email: info@touchedbycancer.org

Mautner Project - The National Lesbian Health Organization
Website: http://www.mautnerproject.org
Address: 1875 Connecticut Ave., NW Suite 710
Washington, DC 20009
Hotline: 1-866-MAUTNER (1-866-628-8637)
Phone: 202-332-5536
Email: info@mautnerproject.org

Memorial Sloan-Kettering Cancer Center, New York
Website: http://www.mskcc.org
Address: 1275 York Ave
New York, NY 10065
Phone: 212-639-2000
Email: publicaffairs@mskcc.org

National Cancer Institute (NCI)
Website: http://www.nci.nih.gov
Address: NCI Public Inquiries Office
6116 Executive Boulevard, Room 3036A
Bethesda, MD 20892
Hotline: 1-800-4-CANCER (1-800-422-6237)
Phone: TTY: 1-800-332-8615

National Coalition for Cancer Survivorship (NCCS)
Website: http://www.canceradvocacy.org
Address: 1010 Wayne Ave., Suite 770
Silver Spring, MD 20910
Hotline: 1-877-NCCS-YES (1-877-622-7937)
Phone: 301-650-9127
Email: info@canceradvocacy.org

National Comprehensive Cancer Network
Website: http://www.nccn.org
Address: 275 Commerce Dr, Suite 300
Fort Washington, PA 19034
Phone: 215-690-0300

Native American Cancer Research
Website: http://www.natamcancer.org
Address: 3022 South Nova Rd.
Pine, CO 80470
Phone: 303-838-9359
Email: info@natamcancer.net

Prevent Cancer Foundation
Website: http://www.preventcancer.org
Address: 1600 Duke Street, Suite 500
Alexandria, VA 22314
Hotline: 1-800-227-2732
Phone: 703-836-4412

Women's Cancer Resource Center
Website: http://www.wcrc.org
Address: 5741 Telegraph Avenue
Oakland, CA 94609
Hotline: 1-888-421-7900
Phone: 510-420-7900
Email: info@wcrc.org

The Colon Cancer Survivors' Guide, Second Edition: Living Stronger, Longer
by Curtis Pesmen

Understanding Colon Cancer
by A. Richard M.D. F.A.C.P. Adrouny

Living With Colon Cancer: Beating the Odds
by Eliza Wood Livingston, David, M.D. Spiegel

Intimacy After Cancer: A Woman's Guide
by Dr. Sally Kydd, Dana Rowett

What to Do If You Get Colon Cancer: A Colon Cancer Specialist Helps You Take Charge and Make Informed Choices
by Paul Miskovitz, Marian Betancourt

National Cancer Institute
Website: http://www.cancer.gov/espanol/pdq/tratamiento/colon/patient
Hotline: 1-800-422-6237
Emails: nciespanol@mail.nih.gov

Medline Plus: Colon Cancer
Website: http://www.nlm.nih.gov/medlineplus/spanish/ency/article/000262.htm
Address: Customer Service
US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Family Doctor
Website: http://familydoctor.org/online/famdoces/home/common/cancer/treatment/026.html

Last date updated: 
Tue, 2012-05-15