Nearly 30 percent of all women will develop a pelvic floor disorder in their lifetime, but many don't seek help. They may be too uncomfortable talking about their symptoms, think it's just a normal part of aging, assume these kinds of problems can't be corrected, or just aren't sure what kind of specialist to see.
At The Christ Hospital, we specialize in treating these disorders and have specialists in female bladder and bowel dysfunction, pelvic organ prolapse, female sexual dysfunction, chronic pelvic pain and other disorders of the pelvic floor, as well as a dedicated Pelvic Floor Center and a physician training program that offers comprehensive training in all areas of urogynecology and reconstructive pelvic surgery.
Dr. Mickey Karram discusses treatment options for pelvic floor disorders available at The Christ Hospital Pelvic Floor Center.
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Treatments for Pelvic Floor Disorders
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Learn more about Mickey Karram, MD
Mickey Karram, MD
Mickey Karram, MD is an internationally-renowned urogynecologist and pelvic surgeon. He is board certified in obstetrics and gynecology and completed his fellowship training in urogynecology and reconstructive surgery at Harbor UCLA School of Medicine. He is currently the Director of Urogynecology and Reconstructive Surgery at The Christ Hospital; medical director of The Christ Hospital Pelvic Floor Center and Clinical Professor of Obstetrics and Gynecology at the University of Cincinnati School of Medicine.Learn more about Mickey Karram, MD
Transcription:
Treatments for Pelvic Floor Disorders
Melanie Cole (Host): Nearly 30% of all women will develop a pelvic floor disorder in their lifetime, but many don’t seek help. They may be too uncomfortable talking about their symptoms, think it’s just a normal part of aging, assume these kinds of problems can’t be corrected or just aren’t sure what kind of specialist to see. My guest today is Dr. Mickey Karram. He’s an internationally renowned urogynecologist and pelvic surgeon, the director of Urogynecology and Reconstructive Surgery at the Christ Hospital Health Network and the Medical Director of the Christ Hospital Pelvic Floor Center. Welcome to the show Dr. Karram. Explain a little bit about pelvic floor disorders and the types and conditions that you see.
Dr. Mickey Karram, MD (Guest): Sure, good morning. Pelvic floor disorders are very common quality of life problems that the majority of women sometime in their life suffer from. I like to categorize it into five separate therapeutic areas. The first would be problems with bladder dysfunction. Most of that is going to be around bladder control and the problem of urinary incontinence in women is huge. We spend in excess of three billion dollars a year on adult protective wear and there’s a variety of medicines and surgeries that we do.
The second category is problems with pelvic organ support, something called pelvic organ prolapse and this is a problem that again, is very, very common but not talked about much and women basically develop a problem where the tissues in the vaginal canal basically loose their support and protrude to the opening, beyond the opening and sometimes quite a ways beyond the opening and that can be the bladder pushing the vagina out, the uterus itself can fall out, the rectum can push the vagina out, the rectum itself can fall out; so a variety of problems like this that we deal with.
The third category would be problems with defecation or bowel dysfunction. Again, loss of bowel control, very, very common and obviously devastating from a quality of life problem as well as a variety of problems with bowel evacuation.
The fourth category would be female sexual dysfunction and again, this can range from anything from pain with intercourse to a variety of issues with libido and stimulation etc., etc. And again, this is a very common area, somewhat complicated but a very prevalent problem in women.
And the fifth would be a variety of pelvic pain syndromes related to bladder pain, vaginal pain, vulvar pain, pain around the rectum. Again, very common and a problem that women never really know who to reach out to. So, those are the categories that we in this subspecialty deal with.
Melanie: So, what are some common conditions and factors that lead to some of these pelvic floor disorders? Are they a normal part of aging?
Dr. Karram: So, that’s good question. Unfortunately, we have not been really good at understanding the pathophysiology or the causes of these. They are multifactorial. And that’s the sad thing is there is really nothing on the horizon for prevention but, certainly things like delivering babies through the vaginal canal put women at higher risk, especially if they have had a long labor, a big baby, an issue with a tear or some sort of an operative delivery. Aging contributes. Loss of estrogen or the menopause contributes. There is probably even some genetic and cultural factors that play into it. But there is really not one etiologic or causative factor we can hang our hat on.
Melanie: Dr. Karram, speak about treatment options, based on the quality of life of the patient, starting with things like physical therapy and behavioral modification, medicational intervention and when does it become surgical.
Dr. Karram: So, the first thing even before you think about any treatment is to really appreciate from a quality of life standpoint, the impact that the condition is having. So, you’ll have – at the far end of the spectrum you may have a woman that for the first-time coughs real hard or doesn’t make it to the bathroom in time and has a little bit of leakage of urine and thinks the world is coming to an end. And that could have been a very, very erratic experience that she had and there’s – it may not be truly a big problem to her. The flip side of that, you have women that are living in pads or not socially - basically socially isolating themselves and in denial that the problem doesn’t bother them. So, you really need to dive in and let patients know that there’s a lot of treatment options and appreciate the quality of life impact it is having. And then education. Simply explaining to a patient, the way things are supposed to function, behavioral therapy, timing their voids, identifying if they are able to appropriately utilize and contract their pelvic floor muscles.
Those are all things that we do initially and then when we get into medicines, there are medicines that can prevent the bladder from having too much spasm, there are medicines that we can give to for example, bulk up the stools and help them with bowel evacuation problems. There is hormone therapy can be very, very successful in patients that have developed changes in their vaginal canal related to loss of estrogen. And so, our first line therapy is usually behavioral and pharmacologic with pelvic floor rehabilitation.
Melanie: And people have heard about pelvic floor rehabilitation and Kegel exercises and that sort of thing. Do you feel that they work pretty well for some women?
Dr. Karram: So, the issue is that patients don’t understand these are not your typical muscles. They are very deep muscles that are hard to isolate, irregardless of the intelligence level of a patient. So, many women, most women I would even say that think they are appropriately contracting their pelvic floor muscles really aren’t because they are recruiting musculature from either the buttocks area, the abdominal area, the inner thighs. Again, they are deep muscles and for that reason, biofeedback techniques and there is new technology that even allows the placement of a device that has sensors in it that blue tooth’s to a patient’s iPhone to let her know that she is appropriately contracting the muscle and also quantitate the strength of that muscle. So, you need biofeedback, pelvic floor physical therapy. The patients need help with appropriate – and if they do that, absolutely. Very, very successful in certain conditions.
Melanie: Speak about surgical interventions and even laser, the MonaLisa Touch, what are you doing there to help women?
Dr. Karram: So, we were fortunate enough to be the first center in the United States to study this fractional CO2 laser technology. It is very, very successful in basically treating the vaginal skin in a way that estrogen would treat it in a postmenopausal woman. When a woman goes through menopause, she basically loses her circulating estrogen and over a time frame of 1-4 years, basically the pelvic floor dries up. The vagina becomes thin, very, very sensitive, and patients have difficulty with intercourse, they have a lot of irritation, they develop recurrent bladder infections and the only therapy prior to this was hormonal therapy. Well, hormonal therapy locally, is difficult because patients have to put creams or tablets or devices in their vaginal canal, so compliance is an issue and there are a lot of contraindications to hormones, i.e., breast cancer. And so, to have a non-hormonal solution with this very, very simple laser treatment has really been game changing and it’s an office procedure, it takes five minutes. It’s three treatments in the session usually give patients relief for a year at least with usually a touch up once a year after that. So, that’s been a very nice addition to our armamentarium. When we get to surgical interventions, when non-surgical treatments don’t work; surgeries are available and there’s a whole array of surgeries that we do. There are surgeries for bladder leakage called synthetic sling procedures which are very safe and work very well. There are surgeries for overactive bladder which can be anything from injection of Botox in the bladder to neuromodulator devices such as the InterStim device. We have a multitude of surgeries that we utilize for prolapse in which we re-support things and narrow down the caliber of the vaginal canal. And then there is a variety of different less common surgeries that we utilize in specific indications.
Melanie: Doctor, what does current research indicate for future developments and treatments do you think and are there some treatments or research that you are doing at the Christ Hospital Health Network that other physicians may not be aware of?
Dr. Karram: Yeah so, in general, historically, we have basically utilized the modalities as I have talked about and if they don’t work, we go to surgery and all surgery can do is really alter anatomy. And there’s a significant neurologic aspect of the functional derangements that occur related to bladder, bowel and sex. And so, there are more – there is a lot of research around modulation devices that can be done locally. We are now using other energy sources besides the CO2 laser. We are doing a study utilizing radiofrequency energy which is again, very simple to deliver in the vaginal canal. For bladder dysfunction, there’s a lot of research now around various treatments for fecal incontinence again, a devastating problem. That’s the involuntary loss of stool. So, there’s a lot on the horizon that’s fortunately very minimally invasive that I think will be coming to fruition in the next five to ten years.
Melanie: So, in summary, doctor, please tell other physicians what you would like them to know about pelvic floor disorders and when to refer to a specialist.
Dr. Karram: So, pelvic floor disorders are very, very prevalent and you said at the onset of the program, impacting about 30% of women. The number is probably higher than that. The largest segment of our population, growth wise, is the female above the age of 60. They are living a longer, expecting a better quality of life. So, I would first of all, like physicians to know, if they are not asking about these problems on their patients with their either at their annual visits because patients historically are very reluctant, shy, difficult for them to initiate a conversation about pain with intercourse or about bladder control, etc. But I think if they are asked about it; they are much more willing to talk about it. And I think that many primary care and certainly OB-GYNs can initiate the evaluation and therapy without much difficulty by just again, asking patients, initiating behavioral therapy, assessing their pelvic floor musculature, something that is certainly within the realm of all of these physicians and doctors should take a patient as far along as their comfort level allows. There are not enough specialists, no where near enough specialists to deal with all these problems, so there has to be a significant interaction with general OB-GYNs and primary care docs in this regard.
Melanie: Thank you so much Dr. Karram, for being with us today. It is such important information for so many women in this country. You’re listening to Expert Insights Physician Views and News with the Christ Hospital Health Network. More information on Dr. Karram and all of the Christ hospital physicians is available at www.tchpconnect.org , that’s www.tchpconnect.org . This is Melanie Cole. Thanks so much for listening.
Treatments for Pelvic Floor Disorders
Melanie Cole (Host): Nearly 30% of all women will develop a pelvic floor disorder in their lifetime, but many don’t seek help. They may be too uncomfortable talking about their symptoms, think it’s just a normal part of aging, assume these kinds of problems can’t be corrected or just aren’t sure what kind of specialist to see. My guest today is Dr. Mickey Karram. He’s an internationally renowned urogynecologist and pelvic surgeon, the director of Urogynecology and Reconstructive Surgery at the Christ Hospital Health Network and the Medical Director of the Christ Hospital Pelvic Floor Center. Welcome to the show Dr. Karram. Explain a little bit about pelvic floor disorders and the types and conditions that you see.
Dr. Mickey Karram, MD (Guest): Sure, good morning. Pelvic floor disorders are very common quality of life problems that the majority of women sometime in their life suffer from. I like to categorize it into five separate therapeutic areas. The first would be problems with bladder dysfunction. Most of that is going to be around bladder control and the problem of urinary incontinence in women is huge. We spend in excess of three billion dollars a year on adult protective wear and there’s a variety of medicines and surgeries that we do.
The second category is problems with pelvic organ support, something called pelvic organ prolapse and this is a problem that again, is very, very common but not talked about much and women basically develop a problem where the tissues in the vaginal canal basically loose their support and protrude to the opening, beyond the opening and sometimes quite a ways beyond the opening and that can be the bladder pushing the vagina out, the uterus itself can fall out, the rectum can push the vagina out, the rectum itself can fall out; so a variety of problems like this that we deal with.
The third category would be problems with defecation or bowel dysfunction. Again, loss of bowel control, very, very common and obviously devastating from a quality of life problem as well as a variety of problems with bowel evacuation.
The fourth category would be female sexual dysfunction and again, this can range from anything from pain with intercourse to a variety of issues with libido and stimulation etc., etc. And again, this is a very common area, somewhat complicated but a very prevalent problem in women.
And the fifth would be a variety of pelvic pain syndromes related to bladder pain, vaginal pain, vulvar pain, pain around the rectum. Again, very common and a problem that women never really know who to reach out to. So, those are the categories that we in this subspecialty deal with.
Melanie: So, what are some common conditions and factors that lead to some of these pelvic floor disorders? Are they a normal part of aging?
Dr. Karram: So, that’s good question. Unfortunately, we have not been really good at understanding the pathophysiology or the causes of these. They are multifactorial. And that’s the sad thing is there is really nothing on the horizon for prevention but, certainly things like delivering babies through the vaginal canal put women at higher risk, especially if they have had a long labor, a big baby, an issue with a tear or some sort of an operative delivery. Aging contributes. Loss of estrogen or the menopause contributes. There is probably even some genetic and cultural factors that play into it. But there is really not one etiologic or causative factor we can hang our hat on.
Melanie: Dr. Karram, speak about treatment options, based on the quality of life of the patient, starting with things like physical therapy and behavioral modification, medicational intervention and when does it become surgical.
Dr. Karram: So, the first thing even before you think about any treatment is to really appreciate from a quality of life standpoint, the impact that the condition is having. So, you’ll have – at the far end of the spectrum you may have a woman that for the first-time coughs real hard or doesn’t make it to the bathroom in time and has a little bit of leakage of urine and thinks the world is coming to an end. And that could have been a very, very erratic experience that she had and there’s – it may not be truly a big problem to her. The flip side of that, you have women that are living in pads or not socially - basically socially isolating themselves and in denial that the problem doesn’t bother them. So, you really need to dive in and let patients know that there’s a lot of treatment options and appreciate the quality of life impact it is having. And then education. Simply explaining to a patient, the way things are supposed to function, behavioral therapy, timing their voids, identifying if they are able to appropriately utilize and contract their pelvic floor muscles.
Those are all things that we do initially and then when we get into medicines, there are medicines that can prevent the bladder from having too much spasm, there are medicines that we can give to for example, bulk up the stools and help them with bowel evacuation problems. There is hormone therapy can be very, very successful in patients that have developed changes in their vaginal canal related to loss of estrogen. And so, our first line therapy is usually behavioral and pharmacologic with pelvic floor rehabilitation.
Melanie: And people have heard about pelvic floor rehabilitation and Kegel exercises and that sort of thing. Do you feel that they work pretty well for some women?
Dr. Karram: So, the issue is that patients don’t understand these are not your typical muscles. They are very deep muscles that are hard to isolate, irregardless of the intelligence level of a patient. So, many women, most women I would even say that think they are appropriately contracting their pelvic floor muscles really aren’t because they are recruiting musculature from either the buttocks area, the abdominal area, the inner thighs. Again, they are deep muscles and for that reason, biofeedback techniques and there is new technology that even allows the placement of a device that has sensors in it that blue tooth’s to a patient’s iPhone to let her know that she is appropriately contracting the muscle and also quantitate the strength of that muscle. So, you need biofeedback, pelvic floor physical therapy. The patients need help with appropriate – and if they do that, absolutely. Very, very successful in certain conditions.
Melanie: Speak about surgical interventions and even laser, the MonaLisa Touch, what are you doing there to help women?
Dr. Karram: So, we were fortunate enough to be the first center in the United States to study this fractional CO2 laser technology. It is very, very successful in basically treating the vaginal skin in a way that estrogen would treat it in a postmenopausal woman. When a woman goes through menopause, she basically loses her circulating estrogen and over a time frame of 1-4 years, basically the pelvic floor dries up. The vagina becomes thin, very, very sensitive, and patients have difficulty with intercourse, they have a lot of irritation, they develop recurrent bladder infections and the only therapy prior to this was hormonal therapy. Well, hormonal therapy locally, is difficult because patients have to put creams or tablets or devices in their vaginal canal, so compliance is an issue and there are a lot of contraindications to hormones, i.e., breast cancer. And so, to have a non-hormonal solution with this very, very simple laser treatment has really been game changing and it’s an office procedure, it takes five minutes. It’s three treatments in the session usually give patients relief for a year at least with usually a touch up once a year after that. So, that’s been a very nice addition to our armamentarium. When we get to surgical interventions, when non-surgical treatments don’t work; surgeries are available and there’s a whole array of surgeries that we do. There are surgeries for bladder leakage called synthetic sling procedures which are very safe and work very well. There are surgeries for overactive bladder which can be anything from injection of Botox in the bladder to neuromodulator devices such as the InterStim device. We have a multitude of surgeries that we utilize for prolapse in which we re-support things and narrow down the caliber of the vaginal canal. And then there is a variety of different less common surgeries that we utilize in specific indications.
Melanie: Doctor, what does current research indicate for future developments and treatments do you think and are there some treatments or research that you are doing at the Christ Hospital Health Network that other physicians may not be aware of?
Dr. Karram: Yeah so, in general, historically, we have basically utilized the modalities as I have talked about and if they don’t work, we go to surgery and all surgery can do is really alter anatomy. And there’s a significant neurologic aspect of the functional derangements that occur related to bladder, bowel and sex. And so, there are more – there is a lot of research around modulation devices that can be done locally. We are now using other energy sources besides the CO2 laser. We are doing a study utilizing radiofrequency energy which is again, very simple to deliver in the vaginal canal. For bladder dysfunction, there’s a lot of research now around various treatments for fecal incontinence again, a devastating problem. That’s the involuntary loss of stool. So, there’s a lot on the horizon that’s fortunately very minimally invasive that I think will be coming to fruition in the next five to ten years.
Melanie: So, in summary, doctor, please tell other physicians what you would like them to know about pelvic floor disorders and when to refer to a specialist.
Dr. Karram: So, pelvic floor disorders are very, very prevalent and you said at the onset of the program, impacting about 30% of women. The number is probably higher than that. The largest segment of our population, growth wise, is the female above the age of 60. They are living a longer, expecting a better quality of life. So, I would first of all, like physicians to know, if they are not asking about these problems on their patients with their either at their annual visits because patients historically are very reluctant, shy, difficult for them to initiate a conversation about pain with intercourse or about bladder control, etc. But I think if they are asked about it; they are much more willing to talk about it. And I think that many primary care and certainly OB-GYNs can initiate the evaluation and therapy without much difficulty by just again, asking patients, initiating behavioral therapy, assessing their pelvic floor musculature, something that is certainly within the realm of all of these physicians and doctors should take a patient as far along as their comfort level allows. There are not enough specialists, no where near enough specialists to deal with all these problems, so there has to be a significant interaction with general OB-GYNs and primary care docs in this regard.
Melanie: Thank you so much Dr. Karram, for being with us today. It is such important information for so many women in this country. You’re listening to Expert Insights Physician Views and News with the Christ Hospital Health Network. More information on Dr. Karram and all of the Christ hospital physicians is available at www.tchpconnect.org , that’s www.tchpconnect.org . This is Melanie Cole. Thanks so much for listening.