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Scot: They say kidney stones are more painful than childbirth, if you can believe that. I suppose people who have had kidney stones would think that. This is "Who Cares About Men's Health," a Men's Health Essentials. We're talking about kidney stones today. Is there anything you can do to prevent them?

And we've got the cast and crew here today. My name is Scot Singpiel. I bring the BS. We've got Dr. Troy Madsen. He is the MD to my BS.

Troy: Hey, Scot. I've never given birth to a child, but I imagine it's painful and I imagine kidney stones are much more painful.

Scot: Producer Mitch is also on the show.

Mitch: Hey. So I'm looking at this pain scale, not to derail too far, but out of 50, a kidney stone says it's 42, and childbirth is a 32, and a really bad tooth break is a 19.

Scot: Oh, wow.

Mitch: I'm excited to hear more.

Scot: Dr. John Smith is a urologist. He's going to help sort us through the kidney stones. How are you doing today?

Dr. Smith: Oh, living the dream, gentlemen. Thanks for having me.

Scot: You ever have kidney stones?

Dr. Smith: I have not, but I've seen enough patients that have that I drink four liters of water a day to make sure I don't have one.

Scot: It's one of those things where when you see somebody that has it, you start doing the things that are going to prevent you from getting them. Is that actually one of the good things to do? Is it caused by not drinking enough water, or can you prevent them by drinking more water?

Dr. Smith: Absolutely. So the old Chinese proverb of the solution to pollution is dilution is correct.

Mitch: I love that.

Scot: Is that a Chinese proverb?

Dr. Smith: I don't know. It was told to me when I was training by one of my mentors and he said it was a Chinese proverb, but it doesn't sound like one to me. It just sounds like good advice.

Scot: Yeah, sure.

Troy: That's funny. So you've heard that in your urologic training, and then I hear it all the time with toxicology, with overdoses. "The secret to pollution is dilution." So, anyway, it crosses multiple specialties

Dr. Smith: And the orthopedic colleagues will say, when they're rinsing out a joint that's infected, that that's the solution.

Troy: Yeah. There you go.

Scot: So, with kidney stones, what's causing those things? Is it because of something I've eaten or something I'm doing, or are they more hereditary? What's the story on that?

Dr. Smith: Yes.

Mitch: Well, no. That's a really good question. I've got a buddy, he's a listener, and I don't want to go too far into it, but I've seen him go through kidney stones. It seems like he gets them every single year. And I know he does a lot to drink all his water, he's done some things to change his diet, but he still gets them. So what could be causing them other than lifestyle, I guess?

Dr. Smith: So I don't know. Troy, do you want to jump in here? I'm happy to go over my spiel that I give my patients who are the chronic kidney stone guys and even the ones who are first-timers.

Scot: I think we want to hear that, don't we, Troy? I mean, I could listen to Troy anytime. I don't always get to listen to Dr. Smith.

Troy: Scot gets tired of listening to me, so please go on.

Dr. Smith: Man, that was some shade, Scot. Wow.

So when I have folks that come in and we talk about kidney stones, there are a couple of different reasons that people get them. And usually, for folks that are first-timers who've never had a kidney stone before, they meet . . .

The other day I had a patient in his mid-40s who came in, never had a kidney stone, and we started discussing stones. Most commonly for folks who aren't predisposed genetically or have some kind of a metabolic issue, it's usually a hydration issue. And so dehydration will put you at risk for stones.

I usually use the analogy of if you ever made those salt crystals or sugar crystal things as a kid where you had that pot of tons of salt or sugar and you dipped a string in and you made those crystal things. You guys ever do that?

Mitch: Yeah.

Scot: Yeah.

Troy: Yep.

Scot: That's what's going on?

Dr. Smith: It's similar to that, because the more concentrated your urine is, the more stuff that's in there that could form a stone. And all a stone is, is a crystal that forms and it's made of different material. The most common ones are calcium-based. A dilute urine will not form a stone the way that a concentrated urine would. So that's the first thing I tell people to do. To drink plenty of fluids is going to keep them from having a concentrated urine. That's number one.

And I usually say there are four things that you can do to prevent a kidney stone regardless of the kind of stone you make, regardless of why you get them.

Number one is hydration. And I usually tell people you want to make at least two to two and a half liters of urine per day. Now, that's a hard one to do because nobody just measures their urine every day. And so that generally means . . .

Scot: Let alone in liters. I mean, what are we doing with the metric system here? We're in America. Come on.

Dr. Smith: Well, but in medicine we use the metric system, unfortunately. But I usually tell folks if you go get those big packs of water at Costco or the supermarket, those are a half a liter each. Those 16.9-ounce bottles are a half a liter each. So you should be drinking four to six of those a day.

Scot: Yeah, or one of those big sodas. Those are two-liter bottles of soda. Now you're talking.

Dr. Smith: Sure. See, now we're talking things. So if you drink at least 6 of those a day, your body uses between 500 and 750 milliliters of fluid a day for metabolic purposes, and so you're not making urine out of that. That's just what you need to be alive. And so anything above and beyond that gets turned into urine. That's why I say you need to drink two to three liters of water per day. To make two liters of urine, you've got to drink around three liters.

Troy: Now, Scot just mentioned he's going to go start drinking those two-liter bottles to measure it. What about drinking soda? Is that going to increase your risk?

Dr. Smith: So it can, depending on the type of stones you make. Obviously, the more stuff you have in your body that your body has to metabolize and break down and put into the urine, the more stuff is in your urine, the more likely you are to make a stone.

And so, for some folks, they're really predisposed to that, so it can make a difference for them. And for other people, it may not make a huge difference. That's something where when we get to the diet-related stuff I usually mention, but the first thing is just drinking plenty of fluids.

The second thing that anybody can do would be to decrease the amount of salt in your diet. And so that means soda. Oftentimes diet soda in particular has a ton of salt in it, as well as other processed foods. Pre-made stuff that you buy at the supermarket has a ton of salt in it.

Your body gets rid of excess salt in the urine and oftentimes the other solutes, the things that are going to help make stones, will follow that salt out into the kidneys and make urine. So that's another thing that you can avoid.

The third thing you can do is avoid animal protein. Now, that doesn't mean beef. It means any kind of animal protein -- fish, pork, chicken. Those create a high acid load in your system and decrease the pH of your urine. And when your urine pH is decreased, that increases your risk of stones. Stone formation increases when you have a low pH in your urine.

And that leads into the fourth thing that I usually tell people. Alkalinizing your urine in some way with lemon, lime, fresh fruit, berries, things that have citrate in them will cause a base to form in the urine and increase the pH.

So those are the four things you can do. Without knowing what kind of kidney stone you have if you've never had it analyzed and you have chronic stones, those are the four things you can do to decrease your risk of stones.

Scot: So coming back to our core four, kidney stones are caused by the types of foods that we're eating and drinking. It's totally diet based, right?

Dr. Smith: So not necessarily. Obviously, the dehydration thing is huge, but someone who has . . . So Mitch's buddy probably has a metabolic issue where his urine makeup predisposes him to having stones.

And so oftentimes, for folks in that situation, we'll do a 24-hour urine test and look at what's in the urine and what's spilling into the urine to see what's high level. If there are high levels of calcium or high levels of certain chemicals, high levels of nitrogen from animal protein, high levels of just salt, and different things that can predispose you to having stones, we definitely look at those.

Scot: How much does genetics play into whether somebody develops kidney stones or not? I would imagine that there are plenty of people that aren't drinking water and eating high salty foods and never get stones, or is that not true?

Dr. Smith: No, I think there is definitely a genetic component. How strong it is, is very difficult to kind of put your finger on. The literature shows that there can be some predisposition for folks who have family history.

And I've seen that anecdotally in my practice. Folks who come in at a younger age with stones oftentimes have family members who have chronic kidney stones. So I definitely think there's a correlation for those folks. Absolutely.

Scot: And you talked about the different kinds of stones. What's that about?

Dr. Smith: Well, there are a few different kinds of stone. The most common are calcium-based. There are calcium stones, multiple different kinds of calcium stones, but the important part is they're made with calcium.

Now, that doesn't mean don't drink milk, don't eat calcium. You actually want to have a normal amount of calcium, but not overdo it and not underdo it, which has been a misnomer for people. They're like, "Oh, I'll just stop drinking milk, I'll stop eating calcium, and it'll fix my stone problems." And it actually has been shown to make it worse in some of the literature. So you don't want to cut that out completely, but you also want to make sure that you're not eating other foods that may be problematic.

So calcium oxalate is the most common types of stones. And when you have a high oxalate diet . . . So coffee has oxalate, tea, spinach. Dark green, leafy vegetables have oxalate in them. There are other foods that have oxalate. Some people will say, "Oh, you've got to go on an oxalate-free diet," when in reality if you have calcium and oxalate in your gut, your gut can bind those things and it actually gets put out in the stool instead of going into the system. That's why you don't want to cut out calcium completely.

I mean, there are a lot of dynamics to kidney stones that kind of make it difficult, and knowing what type of stone you have can be helpful. So the calcium stones, we can kind of base things on diet.

The other type of stone that we see in folks is uric acid. Those are probably the second most common that I see. Those ones can actually be "melted" with medication and alkalinizing the urine, making the pH of the urine go up. So that's one where if we know that someone makes those and we keep their urine pH up, we can decrease the size and the amount of the stones that they make with the pH of the urine.

Scot: Which stones are the prettiest stones?

Troy: Calcium, of course.

Dr. Smith: They're all beautiful. They're all terrible.

Troy: Well, the calciums are kind of nice and shiny and it almost looks like a pearl.

Scot: Are you serious, Troy? Do they really?

Troy: I don't know.

Scot: I thought maybe you knew.

Troy: I just know they show up really well on an X-ray.

Dr. Smith: They do. That's the calcium.

Troy: Yeah. I don't know how they look when they come out exactly. But I can say hearing this, though, it sounds like the key is, like you said, John, drink lots of water, try to avoid eating too much meat, avoid salt, fruits and vegetables. Those are the keys. I mean, that just kind of gets back to a lot of what we talk about. Just healthy diet in general.

But hearing this, we talked just a little bit about the pain with kidney stones, but I can tell you when I see someone in the ER with a kidney stone, I don't know that I ever see anyone on a regular basis in the ER who has more pain than a person who's there with a kidney stone. You can tell. You walk in the room, they're writhing. They're pacing around the room, kind of holding their side. It's just incredible pain.

Every time I see them, I kind of have the same feeling you do. It's just like, "Hey, I want to do everything I can to avoid this." And if it means drinking tons of water and just watching my diet, it's well worth it just because that looks absolutely miserable.

Mitch: So what are some of the symptoms, I guess? I mean, we're talking about the pain itself and how to prevent them, but what are the actual symptoms? Is it just, "I've got pain in my stomach"? Or where do we feel it and things?

Dr. Smith: Well, I think Troy could probably answer that because he has them come in, but usually it's a pain in the flank, which is kind of the upper outer portion of your back on either side. And as the stone kind of travels down the ureter, that pain can migrate to the low back, even into the groin.

And I usually tell folks when stones are sitting in the kidney, they don't usually cause pain because they're not obstructing. They're not bothering you. But when they start blocking the flow of urine and they get into the ureter, the small tube, your body tries to get rid of that by peristalsing, just the way it does when it moves food through your intestines.

And so at that time, the stone, once it gets into the tube is where you start to have the pain and it usually starts in the flank and then moves down.

Troy: Yeah, and that's exactly what I see. People are kind of holding their sides. So if you were to kind of reach around, hold your sides of your abdomen, that's typically where they're feeling the pain. I push on their stomach, their belly doesn't hurt, they're not really tender, but it's just a deep, severe pain. And they'll tell me it comes and goes, it's sharp, sometimes it's better, sometimes it's worse. John, it's exactly like you mentioned, that spasm where that ureter is spasming. That's when they really seem to have severe pain.

Scot: And then is the treatment painful too? I mean, is this the double whammy of not only does the thing hurt, but the treatment is going to hurt bad as well?

Dr. Smith: Well, what Troy does for people doesn't hurt. They really love Troy. They don't like it when they come and see me after they've seen Troy.

Scot: Okay. Because Troy gives them . . .

Troy: I just give them pain meds.

Scot: And then you send them to John.

Troy: Exactly. But it's great, though, because there is a non-narcotic and non-steroidal anti-inflammatory medication that we give intravenously. And it just works beautifully for kidney stones. So it's not like we're just knocking people out with narcotics. Some people need narcotics, but so many people, I give that medication and they're just like, "Wow. I feel better."

Scot: What's the treatment then, Dr. Smith?

Dr. Smith: So there are a couple of different treatments depending on where the stone is at and different things. I mean, there's a little bit more to it here, some nuance. But if it's moving down and it's relatively small, oftentimes we'll offer people to pass it on their own. We call it medical expulsive therapy. It's not pretty, but it gets rid of the stone.

And so we give them some medication to help the stone pass. And after we do that, we let them kind of do their thing and pass the stone on their own for a couple of weeks. And if it doesn't pass, well, then we bring them back and we offer them surgery. Stones can be . . .

Scot: Ugh.

Dr. Smith: Go ahead.

Scot: No. I just went, "Ugh."

Mitch: Yeah, ugh.

Troy: Two weeks of that. Yeah.

Scot: Yeah. I don't have to say anything other than ugh.

Dr. Smith: I mean, I'll give them a little bit more than two weeks if they're really confident that they're passing it and they're not wanting to do anything surgically.

But the other options that we have are if the stone is visible on an X-ray, just like Troy alluded to earlier, sometimes we can do what's called an extracorporeal shock wave lithotripsy. Some people just refer to it as lithotripsy, where we use an external shock wave beam to break up the stone, and then you still have to pass the fragments. And that's only if we can see it on an X-ray to target and hit it.

Scot: So those are my two options? Either give birth to that stone myself or . . .

Dr. Smith: No, there are other options. I'm just saying those are the two . . .

Scot: Oh, okay.

Dr. Smith: I'm going from least invasive to most invasive here.

Scot: All right. Get them busted into shards or have surgery. Yeah, that's more reasons why to drink more water, I guess.

Dr. Smith: Exactly. So the third option that I offer folks is called a ureteroscopy laser lithotripsy, where we go up with a small, thin, flexible camera and we find the stone and we blast it with a laser.

Scot: Oh, that sounds badass.

Dr. Smith: It's pretty cool.

Mitch: It's all pretty cool, but miserable.

Dr. Smith: Yeah. And usually, with that, they have to put what's called a stent, which is a small, thin, flexible plastic tube from the kidney to the bladder. And they are miserable. I always tell patients, "It's miserable. You keep it in for about a week to let things heal and then you take it out in the office."

Troy: And I think Scot, when he thought that was really cool, I think it's probably worth telling him how you get the laser up to the stone.

Scot: Oh, no.

Mitch: Oh!

Scot: No, I'm good.

Troy: You're good? Okay.

Dr. Smith: Well, there's no cutting, Scot, so you can use your imagination.

Scot: Yeah. Just thread that thing right up there, huh?

Dr. Smith: Yep. Just like throwing darts.

And then the last thing that we do for stones if they've gotten too large to pass and they're in the actual kidney, we can do what's called a percutaneous nephrolithotomy. They use the term PCNL because it's way easier to say. And that's where we make a small incision in the back and we go into the kidney and we actually are able to remove the stone in larger pieces that way.

That's obviously the most invasive way to do it, and we do that for much larger stones. You've got to have a stone that's a centimeter and a half or larger, or at least that much volume of stone in the kidney before we would contemplate doing that.

Scot: Troy, can these stones get so bad that you're going to see somebody in the emergency room that has to have an emergency surgery because they just can't urinate anymore?

Troy: I can't say I see them where they can't urinate, because usually it's just in one of the ureters and so the other kidney is working, although you could have it, I guess. I've rarely seen it where it's so bad that you can really see it's impacted their overall kidney function.

The more concerning thing I see is when you get an infection along with the stone, and those are the cases where they're definitely admitted to the hospital.

But yeah, if it's a really large stone, like John mentioned . . . Usually the cutoff we use is six millimeters, but even there, I think sometimes our urologists will say, "Give it a little time. Let's see what happens." But if they've got a big, centimeter and a half stone just lodged in there, yeah, those are cases where the urologists will admit them and do something sooner rather than later.

Dr. Smith: Good point, Troy. When you have an infection above the stone blockage, those folks can get real sick real quick. And those are the people that emergently get surgery. And oftentimes we don't treat the stone immediately. We treat the infection. We put a stent in and give them antibiotics and come back another day to take the stone out. They're just so fragile as far as their health goes at that point that oftentimes they need antibiotics to clear out that infection before we're able to treat the stone.

But Troy is right. Anything 5 millimeters and under have a 75% to 80% chance of passing on their own. Now, that to be said, I have folks who come in with two-millimeter stones who are unable to pass them and folks with seven-millimeter stones that pass them and they said it wasn't a big deal. So, again, it's all relative to the patient. But once you get these larger stones, definitely surgery is much more frequent for those folks with larger stones.

Scot: Hey, Mitch, we're wrapping this up. Do you have anything you'd like to share?

Mitch: I'm just very uncomfortable and trying to drink my water off camera. That's what I'm doing right here right now.

Scot: You went and got some more water.

Mitch: I did. And I'm saving everyone from the sipping noises, but yeah, a refill was necessary.

Scot: These lifestyle changes that we make, Dr. Smith, is there a percentage of reduction of risk that they will do that we know about?

Dr. Smith: That's a tough one. I don't know that there's an actual percentage of risk. I would say when you do it, if you are a chronic kidney stone patient, we usually follow your 24-hour urines to check your risk assessment. But folks who have a stone and pass a stone and then hydrate themselves can really reduce their risks just by doing those things.

The numbers that I know and usually quote people is if you have a kidney stone that requires surgery, 50% of folks who have that issue will have another episode of a kidney stone within a year. And so that's why I usually tell folks the more you can do to drink and keep them away, the better off you are.

Scot: Well, it was a fun topic. I still don't know which stones are the prettiest stones, which makes me a little bit sad, but that's okay.

Dr. Smith, thank you so much for being on the show, and educating us on kidney stones, and telling us what to do. Would you like to summarize, Mitch? What are you going to do? You're going to drink water. What else?

Mitch: I'm going to just drink all the water and I'm going to make sure that I'm not having too much salt in my diet.

Scot: Watch the processed foods.

Mitch: And watch the processed foods. I need to eat less taquitos.

Scot: And maybe a little lime in your water, it sounds like. Is that right, Dr. Smith?

Dr. Smith: Yeah.

Scot: Get that pH down. Is that what that . . .

Dr. Smith: It won't hurt you.

Scot: No, that's getting that pH up, isn't it?

Dr. Smith: Yeah, pH up. Correct.

Scot: Yeah.

Mitch: Okay. So preventing scurvy and rocks in places I don't want rocks. Got you.

Scot: Dr. Smith, thanks for being on the podcast. Thanks for caring about men's health.

Dr. Smith: Troy, Scot, Mitch, it's always a pleasure. Thanks for having me.

A baby that is wanted and planned for, a child by choice and not by chance, that is what modern contraception offers men and women. But you have to know what's out there, how it works, and where to get it. This is really important now more than ever.

This is Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah Health, and this is the "7 Domains of Women's Health" on The Scope.

Women and men all over the world have wanted to plan their families for thousands and thousands of years, but methods used in Cleopatra's time in ancient Egypt probably weren't as effective as what is available now. If no method of contraception is used, women in sexual relationships that would make them pregnant could expect to have more than 11 babies. That's in these days of good obstetrical and pediatric care, where women are less likely to die in childbirth and babies are much less likely to die in the first five years of life. Eleven babies sound like too much? One more baby sounds like too much right now?

Let's talk about contraception. It's an egg and a sperm problem. You need to stop egg production, stop sperm production, or stop the sperm from getting to the eggs. These are the main ways that modern contraception works.

About 50% of unplanned pregnancies happen to people who are "using" contraception but using it incorrectly. This is the most common reason that methods like abstinence or periodic abstinence, think natural family planning, or methods like barrier methods like condoms or diaphragms actually fail. They weren't used correctly or at all. Methods that you have to think about at the time of sex are more likely to fail because you're more likely to fail to use them. If you combine two methods, abstain during your fertile period and use condoms all the rest of the time, your chance of getting pregnant by accident is much lower. Two methods are better than one, and this is a combo where men can be the important user. You can get condoms most anywhere, and anyone with some smarts and gumption can figure out their fertile period.

So let's talk about hormonal pills, patches, and rings. They are considered moderately effective methods or ones that have an annual failure rate between 1 in 10 to 1 in 100. That means if women use them, the chance of getting pregnant is about 1 in 10 to 1 in 100 per year. Of course, you might be at risk for pregnancy for multiple years, so these chances literally add up. Considering a lifetime of contraception using these methods, it was calculated that women would have about two unplanned pregnancies. These methods work by blocking ovulation and by changing cervical mucus so sperm cannot get to the eggs, but women don't always take the pills, or patches or rings correctly. They miss some days or they stop for a week as directed, but they stop for longer than seven days, and they are very likely to ovulate. But you could team up with your sex partner and use a moderately effective method and condoms and get much more bang for your buck birth control-wise.

Hormonal methods aren't right for everyone, and you should know by reading up or asking knowledgeable clinicians if they're right for you. Now, there may be immense hormonal contraception on the horizon, transdermal hormones to block sperm production. If it has about a 10% failure rate per year, and women taking the pill as they will, not perfectly, have a failure rate of about 10% per year, if both members of the sexually active couple use the method not perfectly, the failure rate would be about 1 in 100 per year. The two methods multiply in terms of their effectiveness. If they both used effectively, if they both, men and women used hormonal methods effectively, it would be about 1 in 10,000 women per year, and that is effective contraception.

Now for highly effective methods, these methods have failure rates of about 1 per 1,000 women per year. They are so good because you don't have to think about them and using them correctly almost always happens. These include copper IUDs, hormonal IUDs, and hormonal implants under the skin. The hormonal implants' primary method of action is to work by blocking ovulation. The IUDs' primary method of action is by blocking sperm. Copper in the copper IUD kills sperm on their way up to the egg, and the hormonal IUD blocks sperm from getting through the cervix. The IUDs and implants are highly successful at preventing pregnancy but require a trained clinician to put them in. They last a long time, the copper IUD for 12 years, the hormonal IUD for 5, and the implant for 3, but they are immediately reversible as soon as they come out.

Now, all contraceptive methods have some side effects and risks, but none have as many risks and side effects as an unwanted pregnancy. Uh-oh, did you just say, "Oops?" Did you forget to take your pills? Did the condom slip off or stay in his back pocket? Was sex forced on you and you weren't using anything? Emergency contraception is for people who had unprotected or under-protected sex. They are pills over the counter or by prescription, that must be used in the first three to five days after the unprotected sex act, and the earlier, meaning the next day or the day after, the better. The copper IUD and hormonal IUD can also be used for emergency contraception, but they aren't FDA approved for that use, and you have to find a clinician to place one in a timely manner.

Using contraception means some work on your part. You have to know what you can use and want to use. You need to know where you can get them. You need to know how you can pay for them. All this information is available from many sources, but an overall good resource is bedsider.org. Many clinics around the country provide contraception on a sliding fee scale based on the ability to pay. Most insurance plans pay for a significant amount of the cost of contraception. There's a national family planning grant called Title X, that provides low-cost contraception to anyone who needs it, and it's available in most states. But you have to lace up your boots or put on your flip-flops and do it. Children deserve to be by choice and not by chance now more than ever. Thanks for joining us on The Scope.

Dr. Jones: Today, in The Scope studio, we're talking with Dr. Audra Jo Hill. Dr. Hill is a urogynecologist, who specializes in problems with the pelvic floor, the down there that isn't always the same after childbirth. She started a new clinic for postpartum pelvic floor problems. Welcome to The Scope, Dr. Hill. So help us understand a little about this specialty clinic. What made you decide to start this clinic?

Dr. Hill: I think I was going through training and treating patients, I started to recognize unvalidated problem, an unspoken problem that a lot of women experience following childbirth. There's small specialty clinics across the country that really focus on postpartum pelvic floor disorders, but we didn't have anything here in the state of Utah, and helping fix some other problems following deliveries has really motivated me to start the clinic. I find ways to help these women who previously had gone untreated.

Dr. Jones: And they've come to you. They probably came to you even before you formally started this clinic. Is there a story? Is there . . . Not without using anybody's name, but someone who's come, who's had a baby, is overwhelmed, and she can't talk about the fact that either it hurts or she leaks or . . . And it's kind of overwhelming. She's just trying to be a happy mom, but she's not so happy. Is there something that's common?

Dr. Hill: Yes. So following delivery, some women can experience different levels of vaginal tears that can occur. And one story that really sticks out in my mind was a woman who sustained a fourth-degree laceration.

Dr. Jones: That's where the tear went all the way through the muscles around the rectum and into the rectum.

Dr. Hill: Correct. And she was repaired appropriately at the time of her delivery. But about one week later, she called in complaining of increased pain and symptoms of discharge and starting to leak stool through her vagina. And so she presented to my clinic as a new time mom, trying to handle breastfeeding, juggling life, new baby, lack of sleep, but also these problems that were not exactly on her list of following delivery.

Dr. Jones: No.

Dr. Hill: And so we were successfully able to, based on her tissue quality and her examination, to take her back to the operating room on Christmas Eve, and we repaired her vaginal tissues and her rectal tissue so that she was able to be continent. And she now is successfully able to ride her horses, and take care of her baby, and is very pleased that she doesn't have to deal with this as part of her postpartum adventures in motherhood.

Dr. Jones: Wow. You gave her a new year, a brand-new year. We've heard all over the world about the trauma of childbirth that goes untreated. We hear about women with fistulas and leaking urine all their life in Africa or in Bangladesh. But we don't really think about this happening here. And because, of course, we take care of that stuff here, or it doesn't happen here. But it does happen here.

Dr. Hill: Definitely, I think with our more differences is that we have more modern medicine, opportunities to intervene in the vaginal birth process, but the same trauma still occurs. And so women can have, you know, urinary leakage, prolapse or a vaginal bulge after delivery, fecal leakage. And just, you know, those muscles and nerves have had a lot of trauma. And how to help new moms even just understand what happened is a huge part that I think can be very reassuring.

Dr. Jones: Right. It isn't something you usually share with your girlfriends, right?

Dr. Hill: No, this is one of those things that once you start talking about it, it's amazing how many people say, "Oh, yeah, me too. I've experienced that." But it doesn't come up. And, you know, everybody wants to know how their baby is doing after delivery.

Dr. Jones: Right. Well, everybody would share their labor story, how long it was, their pain. They'll talk about how hard they pushed. They'll talk about their breastfeeding problems. But when it comes to down there, they don't talk about it.

Dr. Hill: No. And some people feel it's their price they have to pay for having children, and it's a common thing, and they just have to live with it.

Dr. Jones: Well, you mentioned, as we were talking before we got started, that the resident that was in clinic with you said there are a lot of tears in your clinic. So talk to me about that, about, you know, women who are . . . they're hormonal, they've had a new baby, they just are overwhelmed. Talk about the tears around this difficult issue.

Dr. Hill: As you were saying, it's not necessarily tears of . . .

Dr. Jones: Despair.

Dr. Hill: Yeah. Despair or fear. I think it's a validation and acceptance to tell them this is what happened to you, educating them on their pelvic floor, what this means for future childbearing. Does this change any of their options? Also looking at that telling them, "You're not broken. You're not damaged. You're just different because a baby's been there. And that doesn't mean that this is something that means you're abnormal. You're just differently from your prior normal."

Dr. Jones: That's a lovely way to put it because I always think of a vaginal birth as being a moderately traumatic process from an evolutionary perspective, but I think you've a much healthier way of bringing this process of getting a baby out. That's a good way to put it. Well, can a woman who has these problems call your clinic directly, or do they need a referral from their OB or midwife or a family physician?

Dr. Hill: So I think, though, how we're starting to work on this and, again, there's many bugs as you start to start a clinic is to give our offices a call. And we are currently looking through them to make sure (a) it's one, the appropriate provider for you. Because, again, if it's been three or four years after the delivery, there may be somebody better suited to help treat some of your symptoms. But for right now, it doesn't require referrals because I do not want to hinder patients being able to come in and see us. But primarily, always going back to your delivery and provider addressing these symptoms and concerns and asking, is there anything else that can be done is very helpful because you may not need to come to a specialty clinic. And a lot of these things can be taken care of with your own provider. But if things aren't improving, if there's complications, we are always here to help.

Dr. Jones: Right. There are a lot of women who have either bladder leakage or not being able to empty or your bladder is just not the same, and luckily, sometimes time can help. If women . . . I think women in Idaho who may be far from their own OB and farther from you, but if their own OB can help them understand that things get better. Or they could always call you and say, "This is what I got, you know. What could we do from here?" And sometimes time and things tighten back up a little bit.

Dr. Hill: You are absolutely correct. I think those first six months following a vaginal delivery, there's so much remodeling of the muscles and the tissues, and fluid shifts in the body. And if you're breastfeeding or not, the hormonal status, lots of things can change. And majority of the symptoms actually get better and go away. But I think if they're not getting better, and if you are really bothered and your quality of life is suffering, talk to your provider.

Dr. Jones: Right. Exactly.

Dr. Jones: The normal vaginal birth of a baby can be a joyful time, but most women will say that nothing is ever the same down there.

Humans are not the only species that can have trouble getting their babies out, but we seem to have the most trouble. Our babies' heads have evolved to get bigger and bigger, and good nutrition have made babies get bigger and bigger. And the baby has to pass by muscles and tissue and bowel and bladder on the way out, and often there are long-term consequences.

Today in The Scope studio we're talking with Dr. Audra Jo Hill. Dr. Hill is a urogynecologist, a gynecologist who specializes in problems with the pelvic floor, the "down there" that isn't always the same after childbirth. Welcome to The Scope, Dr. Hill.

So what are the reasons that those happen? How come women who, having just vaginal birth . . . we populated the planet with vaginal births, even though people think C-section is the most common. In fact, it's not. But what are kinds of things that happened during a birth that can lead to these kinds of problems?

Dr. Hill: So some of the risk factors that we've identified have to do with having a larger baby, sometimes an older mom and just how their tissues are different than younger moms, also genetics.

Dr. Jones: Not so stretchy or tear . . . I mean, I'm way too past older mom. I mean, what do you mean by older mom?

Dr. Hill: I think after the age of 35, just the complications of pregnancy in general, albeit still small, do increase. I think more medical comorbidities also increase. And I would say that the recovery of the tissues after the normal birthing event sometimes is slower.

Dr. Jones: Right. Well, we were engineered to get to 35, to get one generation of children to childbearing age. And so we're over-engineered, but everything starts to . . . You know, our eyes, our bones, our everything tends to be a little less resilient after 35. Oh, dear. Okay, well, I'm way after that, but that's . . . Well, let's go back to babies being bigger and mom's tissues maybe not so stretchy. What other kinds of things can make these problems happen?

Dr. Hill: We find an increased risk of these complications or disorders, such as prolapse, incontinence, or higher-level tears are associated with operative deliveries, which kind of means if we used forceps or a vacuum versus just a spontaneous vaginal delivery.

Dr. Jones: Okay. So if the baby needed some help coming out, and the obstetrician, or midwife, or family doc used something to help the baby through, that usually means that the baby was bigger anyway. So we don't know. They might have torn even if you didn't put those things on.

Dr. Hill: Correct.

Dr. Jones: It's just those things just help out. I don't want people to say, "Oh, I'm never going to have any equipment to help my baby out." Okay, that would be one too.

And then we stopped doing episiotomies routinely. That used to be pretty much commonplace, meaning to cut the opening so it got a little bit bigger. Our fear back not that long ago was, "If it tore, it would tear irregularly. If we just cut it, it would be easier to repair." I think that that's kind of old science and wrong medicine now. But people do tear.

Dr. Hill: They do. And so, again, an episiotomy, they're still performed for appropriate indications. That does increase the risk of some of these symptoms after birth. But, at the same time, it's just because you maybe had all of these, a big baby, and an operative delivery. That doesn't necessarily mean you're going to experience any of these symptoms. And so, sometimes, that's how all these risk factors are joined together with your genetics, and how your body repairs after injury, and things that we can't control for.

Dr. Jones: Well, having a new baby can be a wonderful turning point in a woman's life. But, if your body isn't getting back to normal, and you're having problems down there after your vaginal birth, you don't have to grin and bear it. We're here to help. And thanks for joining us on The Scope.

Dr. Jones: Every year, tens of millions of Chinese women observe a practice of staying inside for a month after giving birth. This custom is called, "Sitting the Month." Is it a strange custom? What do we recommend? This is Dr. Kirtly Jones from obstetrics and gynecology at the University of Utah Health and this is about the rituals we practice after having a baby on the Scope.

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones, on The Scope.

Dr. Jones: All over the world, for the hundreds of thousands of years that we have been humans, giving birth has been a very risky business. Until 100 years ago, 1 in 10 women died in childbirth. Of all the ways women met their death, giving birth was one of the most common. If they survived a difficult birth, they were often left weakened and anemic with trauma to their pelvic tissues. If their babies survived, they needed to successfully breastfeed, as there was no formula for babies. Mothers who found themselves barely alive had to also provide the milk for their babies to survive.

All over the world, there are cultural practices around this very delicate time after childbirth for the mom and the baby. In fact, we still use the word EDC, estimated date of confinement, as the term for the due date. But what is this confinement business? What do Chinese woman do? I trained in obstetrics and gynecology at the Boston Lying-In. Lying in was the term for the rest period for woman after giving birth, and many obstetrical hospitals have that phrase in their name.

The laying in period in the US was anywhere from two weeks to two months, even for healthy woman and it was their confinement. Of course, this was the luxury for woman of some financial means. Many women in the 1800s had no choice but to get up shortly after birth, and take care of the baby, all the other children, and help out on the farm. Although, most women were attended by other women in their family, or church community, and hopefully, a skilled birth attendant, they didn't have two weeks or two months to stay in bed.

Until World War I and World War II, women who gave birth in a hospital stayed in bed at the hospital for a week or so, recovering from the delivery. When hospital beds were needed for wounded soldiers, the time in the hospital was decreased from two weeks to one week, to four days, to our present 48 hours. The good news is that the frequency of a condition called Milk Leg, or blood clots in the leg from lying around that might have progressed to blood clots in the lungs, dramatically decreased when women got up out of bed after birth.

So what about those Chinese women in the practice of, quote, "sitting the month?" Women cannot go out. Family cannot come in. The guidelines are set to help women restore their energy balance to their bodies and protect their babies. Women are not allowed to bath or shower or go outside, drink cold fluid, or eat spicy foods. They cannot eat raw vegetables or fruits or drink coffee. No coffee.

All fluids have to go between room temperature or hot, and they have to bundle up and stay very warm. These practices have been noted in documents going back 2000 years. Today's affluent Chinese women can go to special confinement center, there's that word confinement again, and have all their ritual needs met for $500 a day. So we know that women are often exhausted and beat up after the birth of a child, especially the first one.

They're often exhausted, bruised, and battered down there. Their bladders don't work. And their hemorrhoids hurt. And breastfeeding every two hours doesn't help with the sleep problems. About 70 percent of women have the baby blues in the first couple weeks postpartum, and about five percent of women will develop postpartum depression. So what is good medical practice?

The first two weeks are rocky. That's the time that moms are establishing their milk production and their feeding schedule. They need to drink a lot of fluids, and eat a balanced diet of whole grains, lots of fiber for that beat up bum, fruits, vegetables, and protein. They may continue taking their prenatal vitamins several weeks for iron replacement if they had significant blood loss, iron rich foods or iron replacement can be recommended.

Ladies need a lot of rest. But as soon as they're comfortable, after the cesarean or difficult delivery, they need to get up and walk around. This is important by, in decreasing the risk of blood clots. Family can help by taking on the cooking and cleaning responsibilities in the home for the first two weeks or maybe the first two months or maybe two years. Well, two weeks at least.

In the US women are often given an appointment to see their OB six weeks after the birth of a child. That six-week idea was made up as the time by which women should have her pelvic organs back to normal. This is a totally ridiculous plan. By six weeks, new moms have either sunk or swum on their own. If they're suffering postpartum depression, they're already well into it. If they have a bladder problem, they've been suffering for over a month. If they're not breastfeeding, they may by already pregnant because they can ovulate at four weeks. And 50 percent of women resume intercourse before their, postpartum visit.

In Europe and Great Britain, it's common for home nurse visit by a midwife, or a nurse, at about a week after discharge from the hospital. This offers support and answers questions for the new mom. A randomized trial of a midwife home visit at 10 days and three weeks, instead of a physician's six weeks visit, found women were more likely to be using contraception, more likely to be breastfeeding successfully for longer, more likely to have their babies immunized, and less likely to be depressed, if they had a home midwife visit on that schedule.

So what's the six-week postpartum visit for? We used to do a pap smear and start contraception at that visit. But now, pap smears are done every two to three years, and women should have started contraception or had a plan before they left the hospital.

Family practice docs, who do obstetrics and will also be taking care of the baby, see the mom and the baby at two weeks, a great idea. Combined group care with the pediatrician and an OB or midwife at two weeks would make a lot easier for new moms to, not only have to pile all that stuff in the cart once, but do it over and over again. So we're thinking about that here at the university and it's a great idea.

What are the cultural practices around the postpartum period in your cultural background? We certainly should celebrate the birth of a new citizen of the planet, and the woman who put her body and her life at risk to accomplish this miracle. As obstetrics practitioners, we should give up the arcane and useless rituals like the six weeks postpartum visit, and see women and their babies in a more evident space timing and do a more family friendly combination of services.

And if you can get your family to take over the cooking and cleaning for two years after the birth of a child, more power to you.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: May 29, 2018
originally published: December 10, 2015

Dr. Kirtly Parker Jones: America is not the best place in the world to become a mother. Fifteen years ago, the U.S. was number four in the world in terms of newborn and maternal safety, and now we're 31st in the world. The risk of dying in childbirth in the U.S. is now equal to that of Iran. What's happening to mother's and newborns and what could we be doing about this? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Healthcare. Today we're going to talk about save motherhood, the scope of the problem. Today on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Dr. Kirtly Parker Jones: New reports on women and children show that the U.S. has increasing rates of death and complications due to pregnancy and childbirth especially compared to European countries. The U.S. is among just eight countries in the world to have an increase in maternal mortality, death during pregnancy, delivery, or in the six weeks after delivery. Of course many countries are doing better because they were doing so poorly ten years ago. When you're doing pretty well it's hard to do better, but we are doing worse.
It's very dangerous to be a mother in Somalia. The lifetime chance of a woman dying in childbirth is 1 in 7. Put another way, looking at how women die in Somalia, 1 in 7 die in complications relating to pregnancy. In Finland which is number 1 in the world as the safest place to get through pregnancies, the chance is 1 in 12,000. Somalia 1 in 7. Finland 1 in 12,000. In the U.S. the lifetime risk of dying in pregnancy was 1 in 3700 in 2000, and today it's 1 in 2400. That is 50% higher. Ten years later, 50% higher. That means a woman today is more likely to die from a pregnancy than she is from breast cancer.
So let's look at some reasons, there's been a dramatic increase in the rate of cesarean section in the U.S. Now 30% of babies are born by Cesarean Section, the third highest rate in the world. Having a baby by Cesarean increases the risk of hemorrhage and infection and pulmonary embolism, blood clot to the lungs. It increases the risk of problems in future pregnancies. It also affects the risk of newborn mortality but more about that later. You can see one of my previous blogs on decreasing the rate of cesareans.
More women are having babies later and they may not be in such great health, but that's not where the biggest increase in maternal mortality is noted. The biggest increase in the U.S. is in deaths in women 20 to 24. There are very large disparities in health outcomes in the U.S. compared to countries in the top performers for safety, that's Finland, Norway, Sweden, Iceland, Denmark, Switzerland, you know, those cold places. The U.S. has the largest income disparity in the industrialized nations and the most disparities in access to healthcare.
Now not all moms in the U.S. are getting equal treatment. In Scandinavia where healthcare is universal and almost everyone has access, moms fare very well. That's not the same in the U.S. What's really heartbreaking about being a mother in the U.S. is inequality. In the U.S., 18 mothers died for every 100,000 live births in 2013 which is double the rate of Saudi Arabia and Canada where 7 mothers died per 100,000 live births. The number more than triples for black women in urban America.
Now the rise in obesity in the U.S., in particular morbid obesity, increases the risk of dying in pregnancy, are greater risk of cesarean, greater risk of infection, greater risk of blood clots, and of diabetes.
Lastly but not leastly, at least to me, the U.S. has the highest rate of unplanned pregnancies in the industrialized world. Planning pregnancies gives mom a chance to get medical problems under control and seek healthcare. You can read my bit on cleaning out the incubator. So unplanned pregnancies and pregnancies that happen close together, less than 18 months apart, are more likely to have problems for the mom, and of course, low income women and women with little access to healthcare are more likely to have unplanned pregnancies.
What about the babies? We've made progress in newborn mortality in the past ten years but not much, not nearly as much as other countries. We haven't really made a dent in prematurity which is the biggest cause of newborn mortality. Repeat Cesareans, obesity, and unplanned pregnancy are all risk factors for prematurity and some of the same risk factors for maternal mortality.
We as women, as doctors and citizens have a responsibility to our most vulnerable member society, pregnant women and children. If we had the will, we do have the resources, and we could do more.
Number one, all women should space their babies, plan their pregnancies, make sure they're in good health prior to conception or under medical care, and seek prenatal care.
Number two, all OB/GYNs should take care in not delivering babies too soon unless there's a very good reason and should only do Cesarean Sections for very good reasons.
Number three, all healthcare systems should dictate good practices for deliveries and reach out to their most vulnerable moms.
Number four, the affordable care act had as a goal to get coverage for more women and mandates that insurance cover 100% of prenatal care, maternity care, and contraception, but there's been a lot of push back from industry and political groups. I hope that they're taking a long, hard look at our track record for maternal mortality. A lot of women still don't have healthcare. There is a white ribbon pin for safe motherhood. Check out the White Ribbon Alliance for safe motherhood. We should do better. We can do better.
This is Dr. Kirtly Jones, and thank you for joining us on The Scope.

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