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Dr. Michael Smith (Host): The pelvic floor includes the muscles, ligaments, and connective tissue in the lowest part of the pelvis. When things go wrong there, a whole host of symptoms can develop. This is The GW HealthCast. I'm Dr. Mike. Let’s talk with Dr. Charelle Carter-Brooks. She is the assistant professor of obstetrics and gynecology at GW Hospital and is affiliated with The George Washington University Hospital. Dr. Carter-Brooks, welcome to the show.

Charelle Carter-Brooks, MD, MSC (Guest): Thanks so much for having me.

Host: So how about first we just have a nice anatomy lesson? How’s that? Let’s start with what exactly is the pelvic floor.

Dr. Carter-Brooks: That’s a great question because I think it’s something that women don’t commonly know until they're having an issue. So we think of the pelvic floor basically as like a bowl of muscles that attaches to your pubic bone in the front and then your tailbone, or sacrum, in the back. Those muscles hold up the bladder, the vagina and uterus, and the rectum. When there’s an injury to those muscles—such as from child birth or changes that happen to the muscles with age, menopause or just genetics—then you can develop a pelvic floor disorder, which includes urinary symptoms like urinary incontinence; or pelvic organ prolapse, which is actually when the pelvic organs distend or drop down through the vagina; and fecal incontinence, which is leaking of stools.

Host: How common is this? How many patients do you see with a pelvic floor issue?

Dr. Carter-Brooks: So all the patients that I see have pelvic floor issues. What’s commonly reported is that one in four women will experience a pelvic floor disorder, which, again, is urinary leakage, fecal leakage, or pelvic organ prolapse in their lifetime. That number actually is increased in women who have had children or women who are obese or women who’ve had family members that actually have that issue as well. By the time a woman is 80 years old, she has a 50% chance of having a pelvic floor disorder. So it’s very, very common. More common than things like hypertension and diabetes.

Host: You mentioned a few things or reasons why there might be a pelvic floor disorder. Can we go over that again? Who’s at risk for this type of condition and why is that?

Dr. Carter-Brooks: Right. So really because it’s so common in all women, we say that being a woman puts you at risk. But beyond that it is childbirth. So actually being pregnant, carrying a pregnancy, having a vaginal delivery, having a vaginal delivery where you use forceps, or a vacuum also increases that risk. Your genetic makeup. So your family members—your mother, your aunts, your grandmother—if they’ve had issues with their pelvic floor then you are more at risk. If you have a connective tissue disorder like Ehlers-Danlos you can also be at risk. Obesity, smoking because those effect the tissue and the muscle strength. Then actually going through menopause and no longer making estrogen anymore weakens the pelvic floor as well.

Host: So you mentioned that you only see women with pelvic floor conditions. So tell us a little bit about your role and your specialty when it comes to this type of condition.

Dr. Carter-Brooks: That’s a really great question because I think a lot of women don’t know that there are physicians who specialize in these conditions that they can see. So my approach is to have whenever a woman comes in with any complaint is to make sure we assess bladder symptoms, vaginal symptoms, and rectum symptoms. We really have a multidisciplinary approach here at GW. I work with urologists and colorectal surgeons, gastroenterologists, pelvic floor physical therapists, and general OBGYNs to provide the most comprehensive care for the patient and making sure that we’re addressing all issues and not just one issue. I think that makes us unique here.

Host: So most of the patients that you do see, are they being referred from their primary care physician or can patients reach out to your clinic directly?

Dr. Carter-Brooks: So both happen. Many patients are referred form their primary care or their OBGYN because they have those symptoms that are brought up during an annual exam for a physical or for a pelvic exam. Patients can also directly come in to see me and don’t need a referral if they're having any of those symptoms. I also get referrals from the pelvic floor physical therapists as well if patients have done physical therapy and are not seeing the improvement that they desire.

Host: I would love for you to walk us through a typical workup. When you see a patient, what kind of tests can she expect to undergo to be diagnosed correctly? Then what are some of the treatment options?

Dr. Carter-Brooks: Great. So that will vary kind of based on what the patient’s presenting symptoms are, but let’s say somebody comes in that reports they're leaking urine or having urinary incontinence. So really a large part of what we’ll do is talk about your symptoms. When you're leaking, how often you're leaking, what you're using. Are you using pads? Are you using incontinence diapers? What you're drinking, how often you're going to the bathroom, medications, past medical history. So a very thorough history of what’s been going on. Then we always perform a pelvic exam, which is kind of a standard pelvic exam that women will have with a gynecologist, but we look for things like pelvic organ prolapse, changes in the vagina from not having enough estrogen—which is called atrophy. We would want to measure after urination the amount of urine that’s left in the bladder to make sure that you're not holding on to too much urine. Then we also measure the prolapse if there is any. That’s kind of a standard exam that we’ll do in the office.

Depending on symptoms from that point and what we find, if we see leaking on the examination then we move forward to talk about treatment options. If we don’t see any leaking, sometimes we have to move forward with special testing called urodynamics, which is basically where we fill the bladder with water very slowly and ask the woman about sensation. What she’s feeling, to cough, bare down so we can try to see the leaking as well. That gives us more information. Every once in a while, if the woman’s had previous pelvic surgeries or issues with blood in the urine, we’ll have to perform a cystoscopy, which is a camera in the bladder which we can do in the office to assess the bladder and the urethra to make sure there’s nothing there that could be causing the symptoms of urinary leakage.

After that we talk about treatment options. So the treatment options usually start with behavioral things. So cutting back on caffeine, drinking 60 to 80 ounces of water a day. Not drinking two to three hours before bedtime, time voiding. So putting your bladder on a schedule and not letting your bladder tell you when it’s time to go to the bathroom. Those are behavioral interventions that we start with and then physical therapy. We have specialized pelvic floor physical therapists here at GW that we work very closely with that help women regain strength and muscle coordination in their pelvic floor. Just behavioral interventions along with pelvic floor physical therapy can actually improve symptoms substantially, upwards of 50%.

Then depending on the type of urinary incontinence or urinary leakage the woman has. If it’s stress incontinence—which is leaking with coughing, laughing, sneezing, sometimes lifting heavy objects, running, jumping jacks. Treatments for that beyond pelvic floor physical therapy would include a pessary, which is a silicone vaginal insert. Or moving on to procedure, which include a mid-urethral sling, which is kind of the gold standard for stress incontinence. If the urinary leakage is from bladder spasms, so that strong urge to go to the bathroom. We think of you put the key in the door, you can't hold your bladder. You're already starting to leak. Or your hands are in running water, you have to go to the bathroom. That got to go, got to go. We usually will start with medications after physical therapy and behavioral things.

Then there’s third line treatments for women who fail medications which include bladder Botox, sacral neuromodulation, and PTNS, or percutaneous tibial nerve simulation which is acupuncture for the bladder. That’s kind of in a nutshell. There’s a lot of information there. Just know that there are treat options for pelvic floor disorders. We have many, many, many treatments. We tailor it to the patient’s goals for their life.

Host: Okay doc. I really appreciate that. A lot of great information. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Carter-Brooks or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment.. I'm Dr. Mike Smith. Thanks for listening.