Maggie McKay (Host): When it comes to your pelvic floor, how much do you know? Today, Dr. James Raders, board-certified urogynecologist, will discuss how to know the signs and find solutions to a weak pelvic floor.

Welcome to Putting Your Health First, a podcast from Health First. I'm your host, Maggie McKay. Thank you so much for being here today, Dr. Raders.

Jim Raders, MD: Thank you very much for having me, Maggie.

Host: Just to begin, can you start by explaining what Urogynecology is and what a urogynecologist does?

Jim Raders, MD: Yes. Actually, Urogynecology is very obscure still to this day, even though we have over 2,000 members of our parent society. Urogynecology became the fourth board-certified subspecialty of OB-GYN in 2011. However, the Urogynecologic Society was founded in 1979. They changed their name to the Urogynecologic Society in 1986, and now we have over 2,000 members. And what we do is we take care of women with pelvic floor disorders, which are primarily incontinence of urine, incontinence of bowel, voiding dysfunction, and pelvic organ prolapse among other things.

Host: And you mentioned a little bit, but let's just get into it a little more detailed. What exactly is the pelvic floor, and what crucial roles does it play in the body's overall function?

Jim Raders, MD: I think the pelvic floor has been used as a general term, not just to talk about what is actually the pelvic floor. The actual pelvic floor is a set of muscles that form sort of the upside down diaphragm, so to speak, of the abdominal cavity. And it supports, as we went from four legged creatures to two, everything in the abdomen. But the pelvic floor also contains not only these muscles, but fascial connections or connections of the muscles and all of the pelvic organs. When I took anatomy in medical school, I thought neuroanatomy was hard until I got to pelvic floor anatomy, because mother nature put a whole lot of stuff in the way, like a bladder and bowel and reproductive organs and all kinds of nerves and all sorts of other things in there.

Host: Wow. That is a lot. So, what are some common signs and symptoms of a weakened pelvic floor? How do these affect a person's daily life and overall health?

Jim Raders, MD: The disorders we take care of that are only partially caused by weakness of the actual muscles are things like starting to leak urine. There are several types of leaking, but most of what we see is either stress incontinence, which isn't mental stress, but the stress of sudden increases in pressure on the bladder in the abdomen, coughing, sneezing, running, working out, that sort of thing. And then, urge incontinence happens later in life, and urgency is defined as the sudden need to run to the bathroom, and I don't make it. You see commercials on TV like that all the time. And then there's a mixture of those two, most of the urinary incontinence we see.

We also see patients with bowel incontinence, which we now call accidental bowel leakage, to make it a little kinder so people will actually talk about it. And then, there's pelvic organ prolapse, things that are coming through the vaginal opening that don't really belong coming through the vaginal opening. And that's most of what we do.

Host: How do these affect a person's daily life and overall health? I mean, I imagine, for one thing, it kind of ties you to maybe being home, you know, not so mobile if you're leaking and don't know when that's going to happen.

Jim Raders, MD: There is no question. It affects life, quality of life. These are quality of life issues, and it can profoundly affect a woman's quality of life, her self image, her function at work, her sexual function. All of those things are affected by that. In fact, there's something called the SF-36 questionnaire, which is the short form 36 of how chronic medical conditions affect overall quality of life in different domains and pelvic floor disorders are second to the bottom in terms of affecting quality of life. There's only one thing that more profoundly affects quality of life than pelvic floor disorders, and that's major depression and pelvic floor disorders can lead to that as well.

Host: Wow. So, you mentioned pelvic organ prolapse. What causes that and what is it?

Jim Raders, MD: It's a multifactorial problem. So, I always tell patients that, unfortunately, most of the things that cause this are non-modifiable. In other words, you can't change them. Genetics is a big part of this. You inherit your connective tissue from your ancestors. Vaginal childbirth is probably the major precipitating cause that injures the structures in the pelvic floor and weakens the muscles and ruins the nerves there, as well as aging and menopause, those sorts of things, and none of those can be undone. There are some modifiable risk factors like being overweight, smoking, chronic constipation, those kinds of things.

Host: Are there different types of prolapse? How do they differ like in terms of symptoms and severity?

Jim Raders, MD: Oh, they absolutely differ. The major symptom is common, feeling a bulge in the vagina. However, if you think of the vagina, forgive me for this analogy, like a room has a ceiling, a floor, a back wall, two sidewalls, and an opening, any part of that can fall. The ceiling can fall, which we used to call a cystocele. The back wall can fall, and if you have a uterus, that's called uterine prolapse. And the floor can fall, which is called a rectocele. And those affect those organ systems differently. So if the bladder falls, you may have bladder symptoms, such as not being able to void without manually pushing the bulge up. If the floor is involved, you may not be able to empty your rectum without actually using your hand or getting your bowel movements really, really soft. And so, other symptoms are usually sort of insidious, you know, heaviness and pressure and a vague sense of discomfort and something there that doesn't belong there. "I sit on something," et cetera.

Host: You mentioned sometimes childbirth could, you know, bring this on. What if you have a cesarean? Are you less likely to have pelvic floor issues or that's just one of the ways you can get it?

Jim Raders, MD: No. Actually, vaginal childbirth more and more as new dynamic MRI imaging and we progress in understanding this disorder and how to be more effectively at treating it, vaginal delivery is probably the primary insult that uses all of those other causes to make itself known. And there is evidence that cesarean section or avoiding vaginal delivery, particularly forcep vaginal delivery and those kinds of things can help prevent pelvic floor disorders. But what people have to realize is that having cesarean delivery is a surgery in of itself has risks that vaginal delivery does not have.

Host: True. So, is pelvic floor dysfunction just a normal part of aging? Do we all have that to look forward to or are there factors that can increase the risk of developing a week pelvic floor, like you've mentioned?

Jim Raders, MD: There are many, many factors. To answer the first part of your question, I can't stand it when I hear people say, patients particularly, say, "Oh, well, I'm just getting older and that's normal." It's never normal ever to leak, urine or bowel contents. And it's always treatable. So, it's common as people age, because that's the way it is. Gravity is the way it is. And so, these disorders are more common in what I call mature women, post-reproductive healthcare primarily. And in terms of risk factors, managing all of those risk factors, maintaining your body weight, having a healthy lifestyle, avoiding constipation, exercising your core, and I know we're going to talk a little bit about that in a minute. All of those things can help reduce your risk.

Host: What if you have a hysterectomy? Does that solve all pelvic floor problems?

Jim Raders, MD: It doesn't solve any pelvic floor problem. In terms of prolapse, the uterus is just a passenger on the bus. It's the support systems of the vagina that are actually defective. So if there's a uterus there, it comes with it. I always say it's like when the bookshelf falls, the book comes along. Actually, hysterectomy is an independent risk factor for pelvic organ prolapse. So, the uterus doesn't cause any of the problems we're talking about. It's just an organ system in the pelvis.

Host: You mentioned genetics earlier. Does that mean if your mom had a weak pelvic floor, you will?

Jim Raders, MD: Yeah. Not exactly a weak pelvic floor, but pelvic floor disorders, yes. Prolapse, incontinence, you are more likely to. It does not necessarily mean you will.

Host: Now, let's get to a question that a lot of people are wondering about sexual health and function. How does a weak pelvic floor affect that?

Jim Raders, MD: Well, in many ways, primarily, it affects it psychologically. If you're leaking or you have prolapse, you're going to have psychological overlay on how you feel about yourself and how you relax and enjoy your sex life. So, it's much less common these days than in my mother's generation because they never talked about that kind of thing. It there are some loose evidence, so to speak, no pun intended, that weakened pelvic floors can cause diminishment in sexual enjoyment independently of psychological factors.

Host: So, how do you advise your patients who are experiencing these issues?

Jim Raders, MD: It depends on what the issue is. We talk about all of the different disorders and my role is to educate patients in what's actually going on and what their options are, because everything we do in the world has some good and some trade-off, and they need to make choices for themselves about how this affects their quality of life. Everyone is different.

Host: When it comes to-- I've heard it pronounced both ways, so tell me if there's a right way Kegel exercises for maintaining pelvic floor strength, I've heard, you know, pros and cons, like they do help and they don't help. So, are there other things we can do to prevent pelvic floor weakness and do those help?

Jim Raders, MD: So, first of all, pelvic floor muscle exercises, even if they don't help, they can never hurt you. A friend of mine, when I was in Academics, did a study looking at focused, and this goes to physical therapy and the role of physical therapists in this disorder, randomized patients to going to a physical therapist and being trained to use their pelvic floor muscles and then following a prescribed exercise program to those women doing Pilates and yoga, and then objectively measured strengths in the pelvic floor. And lo and behold, they were the same. So, anything that you do to exercise your core will exercise your pelvic floor.

Pelvic floor muscle exercises are most effective in treating stress incontinence and, occasionally, urge incontinence, which we talked about earlier. The role of pelvic floor muscle exercise therapy in pelvic organ prolapse is less clear. However, the evidence says that it doesn't slow it down or stop it or put it back, but some patients are subjectively improved when they exercise their pelvic floor when they have prolapse.

Host: So, we've talked a little bit about pelvic floor therapy. What else does it involve and who can benefit from it?

Jim Raders, MD: My philosophy about pelvic floor physiotherapists is that they're invaluable adjuncts to what we do. The people I think it's most valuable for are patients who cannot identify and isolate and exercise their pelvic floor independently, because it's not a set of muscles you can see. If you want to strengthen your biceps, you put a weight in your arm and you look at that arm and you lift that weight up. You can't see your pelvic floor and there are certain women who just cannot isolate those muscles.

And what a pelvic floor physiotherapist does is literally intravaginally teach you where those muscles are and how to isolate them. In other words, how not to contract your buttocks or your legs or your abdomen, but to isolate your pelvic floor muscles to strengthen them. And that's one of their primary roles. The other thing that does make some sense with pelvic floor physiotherapy, it's a little bit like Weight Watchers, when you have somebody that's watching your progress and actually measuring, you're more incentivized to actually do the intervention than you are if someone's not.

Host: Isn't that the truth? what are some other treatment options, Dr. Raders, for a weak pelvic floor? And when do you recommend surgery?

Jim Raders, MD: So again, surgery doesn't cure a weak pelvic floor. Surgery usually is compensatory things that we do for conditions that are contributed to by a weak pelvic floor. And surgery is always a last option for everything, because surgery has risks. But surgery can be very, very effective in curing stress incontinence, not urgent incontinence is not a surgical condition and can be very effective in curing pelvic organ prolapse.

Host: What are you most excited about when it comes to advancements in Urogynecology?

Jim Raders, MD: Oh my. First of all, the fastest growing segment of the American society is women over the age of 65. And I think it's fascinating by the year 2050, one in four people in America is going to be a woman over the age of 65. So, we're going to need to help these people. I think that the biggest thing that's happening, at least in the academic world right now, is that we're really beginning to understand from dynamic MRI what the contributing factors are to pelvic organ prolapse in terms of pelvic floor injury to the pelvic floor muscles and their connections. And that's going to help us better with surgical planning and surgical outcomes and be able to predict which patients are most likely to do best. It's very interesting that the lifetime risk of having a surgical procedure for pelvic organ prolapse in this country now, and it's going to be higher when that population changes, is 19%. So, one in five women is going to end up having some surgical procedure, statistically. And the better we are at it, the better off our society will be.

Host: How do you see the treatment and understanding of pelvic floor disorders evolving in the next decade?

Jim Raders, MD: I think the biggest change is going to be that people aren't going to sit in the closet like their mothers did and not talk about it. I think that the new generation of young people, note one, are living longer and they're living a higher quality of life into their older age. They're sexually active longer. And so, they're going to pay attention to these things and that's going to drive them to providers like urogynecologists who can take care of them. And as our armamentarian enlarges, we can serve more people and improve quality of life across the board.

Host: Are there more urogynecologists now than say 10 years ago?

Jim Raders, MD: Absolutely. Over 2,000 members of the American Urogynecologic Society. That includes physicians, nurse practitioners, physical therapists, researchers, other healthcare professionals. And the need is growing, as I've told you.

Host: Is it a growing field that more people are looking into?

Jim Raders, MD: Oh, absolutely. Yes, the number of international journals and peer-reviewed articles that are published every month now is breathtaking. And that's why this specialty has evolved into its own board certification with its own requirements.

Host: What's the most important takeaway you'd like listeners to have about pelvic floor health?

Jim Raders, MD: I think the biggest takeaway is, one just be healthy. Manage your weight, exercise, have a right diet, manage your stress, do mindfulness and all those things we do now. Avoid constipation, don't smoke. However, I think the biggest takeaway is if you have a pelvic floor disorder, don't be ashamed. You're not alone. Tell somebody about it. There is help.

Host: If you leave it unattended because you say, let's say someone's embarrassed and they don't go to the doctor and they put it off, put it off, can it get worse?

Jim Raders, MD: Absolutely. But it's never too late to treat.

Host: Okay, great. Well, thank you so much for sharing your expertise. This has been so informative.

Jim Raders, MD: Thank you very much. I appreciate it. It's all about helping women.

Host: Absolutely. We like that. Again, that's Dr. James Raders. And to learn more, please visit hf.org/womenshealth. And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. I'm Maggie McKay. Thanks for listening to Putting Your Health First.