Melanie Cole, MS (Host): If you experience urinary leakage, pelvic pain, or dysfunction, you are not alone. Welcome to LifeCast, the podcast from the specialists at Infirmary Health. I'm Melanie Cole. And we are talking about pelvic floor dysfunction. Joining me is Dr. Jeff Fahy. He's a gynecologist and pelvic surgeon with Infirmary Health.

Dr. Fahy, thank you so much for being with us today. I'd like you to first give us a little physiology lesson. Before we learn about pelvic floor disorders, tell us what the pelvic floor really is. What does it consist of?

Jeff Fahy, MD: Thanks, Melanie. Well, the pelvic floor is a very complex group of muscles and connective tissues and ligaments and nerves. It forms the lower boundary of the pelvis. So, it plays an important role in bladder and bowel control, sexual function, reproductive support, and maintaining the position of the pelvic organs. So, it's kind of a complex hammock, or you might think of it as a sling. If you think about the bony pelvis, the skeleton that we all know of, both men and women have it, you know, the skeleton pelvis. You have this trampoline of muscles and connective tissues that literally has this job of supporting all the pelvic organs and working in a coordinated fashion to help with bowel and bladder function and sexual function, all these things I just mentioned.

Melanie Cole, MS: That was an excellent explanation, Dr. Fahy. And as somebody who's worked with people with pelvic floor disorders for years, I can tell you that many people don't understand, and you just explained it so very clearly. Now, tell us about some of the disorders that people can come up with as far as the pelvic floor and the different types of conditions that you see. And Dr. Fahy, do you think that they are underreported, because so many people are really hesitant to discuss them?

Jeff Fahy, MD: Yeah. There's a lot of stigma associated with what's happening with our bowel and bladder and sexual issues and pelvic pain and that's one of the things we'll talk about is the importance of awareness. But we'll talk a little bit about the abnormal conditions that exist. So, it's not always that the pelvic floor is too weak. Sometimes it's too tight, and sometimes it's poorly coordinated or damaged.

And what I see as a urogynecologist and pelvic surgeon is usually people are referred to me at the point where they have pelvic organ prolapse. And this is the area I specialize in. However, I don't want to fail to mention the importance of pelvic floor PT that doesn't necessarily need surgery, but needs help with pelvic floor problems.

So, as a surgeon, the things that I see, Melanie, are people who come to me with something is out of place down there. You know, they have a bulge. What can happen is as things weaken. And as things tear, so to speak, over time, people can develop a weakness that allows the bladder to push into the vagina, so the vagina begins to distend along the front part of the vaginal wall or the back part, or the uterus begins to migrate south, and people literally can have their cervix at the opening of the vagina because things have begun to prolapse.

And these are the things that I repair, either through supportive repairs or sometimes hysterectomy. We do a lot of incontinence surgery for people with stress urinary incontinence. And you mentioned earlier, you know, is it underreported? I think that what happens is, you know, people have this embarrassment and stigma, and they think, "Ah, I guess I'm going to leak the rest of my life." And we see commercials now that say, "Just go get a protective undergarment. If you leak—you know, you'll go about dancing, but just, you know, wear your protective undergarment." Well, that doesn't have to be the case. We can actually fix these things. Pelvic floor exercises with a PT or on one's own can help stress incontinence, and we certainly have easy outpatient ways to treat stress incontinence and also pelvic organ prolapse. So anyway, it's a new day when it comes to quick and easy repair of pelvic floor problems.

Melanie Cole, MS: Well, you certainly have a lot more tools in your armamentarium than we used to have. Now, one of the questions that I've heard is is this just a normal part of aging? And as you said, you tell people to go, you know, use a pad or to go do something for leakage. But is this normal? Is it just something we have to deal with, especially women that have had babies or put on a little extra weight? You know, people that maybe lift heavy weights or runners. I mean, there's a lot of people who have various problems with their pelvic floor. Is it normal? Is it just a part we have to accept?

Jeff Fahy, MD: Well, I will say that it is a normal part of aging that people can have these problems. Pregnancy and childbirth is probably the first and foremost issue for young people that leads to the beginning of pelvic floor problems. Multiple pregnancies, large babies, prolonged labor, maybe they had to have an instrumented delivery. They could have a significant tear. All these things can lead to the early part of weakening of pelvic floor tissues. And you really can't get around that necessarily, even with cesarean sections. Because pregnancy itself puts so much pressure on the pelvis, there can be some injuries to the pelvic floor.

But those don't necessarily have to lead to problems. But then, you combine that over time with aging and menopause. And then, some people with chronic increased abdominal pressure. Maybe they have a chronic cough or chronically constipated and straining. Maybe they have a job that leads to heavy lifting. And then, the big issue nowadays is obesity plays a role with this too.

So, there's ways that we can try to minimize this and prevent it. But yes, we have an aging population. And because we have an aging population, we see all kinds of issues such as heart disease and increased risk of cancer and people with joint replacements. These are things we didn't see 100, 150 years ago, because people didn't live long enough. But now, that we have an aging population, it is inevitable that a certain percentage of the population will have these problems. And the good news is there's corrective procedures and surgeries that can be done to help these things. Whereas years ago, we didn't really have those tools. You mentioned we have more tools in our toolbox, and that is so true nowadays.

Melanie Cole, MS: Well, it certainly is. It's a actually a pretty exciting time in your field. And before we get into those treatments, I'd like you to speak about how someone would know. And we are talking mostly about women here, but men do have some pelvic floor disorders. And certainly if they've had prostate issues, they can have all of these things. But we're talking about women mostly, and what would send her to the doctor? These are quality of life issues for sure, but also pain, which could be idiopathic. It's usually hard to diagnose. We're not sure. But what would send someone to the doctor? What do you want women to know about when it's really time to go see someone?

Jeff Fahy, MD: We talked earlier about incontinence, whether it's stress urinary incontinence or urge-related urinary incontinence or fecal incontinence, stool. Those are things that definitely bring people to my office, because they have issues and they're over it. Now, there are some people who still live in silence and they never see the doctor, and it's sad because they just accept this as a way of life. And as we mentioned earlier, that doesn't have to be the case. So, that's one thing.

But another thing too, Melanie, is a number of women who suddenly develop pelvic organ prolapse, and it can come quickly. All of a sudden they go, "Wow, something's going on." They'll notice a bulge. They'll feel like there's something inappropriate bulging from the vagina. And a number of individuals have ended up in the emergency room thinking something, you know, horrendous is happening. And then, they're reassured in the emergency room. And then, an appointment's made with our office, and they come in and we'll stage what's going on and draw them pictures and show them what's happening. But that's what'll bring women to the emergency room sometimes and to our office. But interestingly enough, there's a lot of women who come to see me for something completely unrelated. But when I look at their intake questionnaire, they check the boxes for bulge from the vagina, "I leak when I cough, I have problems holding my stool," and then we can address it.

So, a questionnaire is a very helpful tool for us to kind of find out who has this problem but didn't really want to mention it, and really didn't even come to see us for that. But once they find out there's something that can help that problem, it's a game-changer for them.

Melanie Cole, MS: Well, so tell us, after someone comes to you and explains their history, which again, as you said, is so important, what are some of the—let's start with non-surgical treatments for pelvic floor disorders, some of the treatment techniques. You did mention pelvic floor physical therapy, which is a relatively new field, but really making a big difference. Tell us about some of the treatments out there.

Jeff Fahy, MD: I think, first and foremost, we think about just general health, okay? Weight loss pretty much helps just every part of our being, right? So, that's key. Get to an optimal weight. That is helpful. If you're in an occupation that requires heavy lifting, maybe we need to talk about changing to a different occupation. People with chronic constipation, let's get that under control. Maybe they need to see a gastroenterologist because they have some type of inflammatory bowel issue, or they just need to be on some care that will really help with bowel situations that go beyond what we'll do as a gynecologist. And then, chronic coughing. So, if we get those things under control, those are super helpful. So, lifestyle, behavior changes. And then, we'll oftentimes refer people to pelvic floor PT as needed.

And then, we will also use what's called a pessary, which is a small device that goes into the vagina to help lift these defects and correct them through support within the vagina. This is usually reserved for an older person who's not a good surgical candidate, someone who we would consider elderly perhaps, but has symptomatic problems and just really isn't a good candidate for surgery. And then, the surgical treatments we talked about earlier are really outpatient quick procedures. Whereas years ago, even when I trained back in the '90s, these procedures required a couple of days of hospitalization and prolonged urinary catheterization, all these things that nowadays it's outpatient. You go home without a catheter, and your urinary incontinence is taken care of.

Now, if it's an urge-related problem and they have an overactive bladder, then we're going to want to treat them behaviorally as well with pelvic floor exercises and helping them decide when they're going to empty their bladder preemptively and things like that. But there are great medications now that have fewer side effects that will act on the bladder receptors and decrease the overactive bladder part of the problem. And that can be related to this pelvic floor dysfunction as well.

So, the surgeries, they've come a long way, but we don't really start with surgery. We always give the patient a complete understanding of what's available to them in terms of non-surgical and surgical options, and then we try to fit it to the person where they are in their life, whether they're young and need to get back to work, or they're somebody who says, "Hey, I'd like to do something more conservative, because I really don't want to have surgery," or maybe they're not a good surgical candidate.

Melanie Cole, MS: Well, tell us a little bit—you mentioned a pessary, and I'd like you to speak about Botox for just a minute because it is something that has come onto the scene and has been shown to help. Tell us about what you do with that.

Jeff Fahy, MD: So, when people have refractory overactive bladder, they either have overactive bladder and they're up in the night. It's frequent, they have this urge, their bladder owns them. And they've failed medications, they've tried meds. Usually, we have a couple of different types of medications, and they have failed the different types of medications. We get to a place where we have to either decide to use Botox into the bladder itself or to do something like a bladder stimulator or a pacemaker for the bladder. Those are kind of our two higher level options.

So, I actually do these therapies where we can implant a pacemaker that actually stimulates a nerve in the sacrum, the lower part of the vertebrae down at the lower base of the spine. And basically, it's called sacral neuromodulation. That and Botox both have their pros and cons, but they help to relax that overactive bladder or intractable urge incontinence. They don't help with the defects. If somebody has prolapse or if somebody has stress incontinence, that's a different story. But this is for people with the overactive bladder or urge incontinence that has failed other treatments.

Melanie Cole, MS: Dr. Fahy, why is it so important to raise awareness for pelvic floor disorders? What would you like listeners to know, and where can they find you with questions?

Jeff Fahy, MD: Well, I think it's really important that we increase awareness so that people will seek treatment earlier. This helps their quality of life. Awareness will reduce embarrassment and the stigma of these conditions. And also, just awareness encourages prevention. And I think the central message, the goal here for people who have pelvic floor dysfunction, it's not just having a strong pelvis, not just go and do pelvic floor exercises, because the pelvic floor muscles need to do a lot, and they need to be strong, they need to be flexible, they need to be coordinated and they have need to be capable of relaxing.

So, it takes kind of a team approach sometimes, because it's not just the people with defects. I can fix those. It's not just the people with incontinence. I can help them. It's people who really don't have those things but have problems and need to have a pelvic floor exercise taught to them by a PT. And the awareness is really important. It's a new day when it comes to pelvic floor therapy, and it's a team approach

Oh, and Melanie, I was going to tell you that I can also be found at our website, drfahy.com. And also, through the infirmary as well as we have offices in Bay Minette, Alabama, as well as Daphne, Alabama, Saraland, and Atmore. And our number is easily found. You can find me on the internet, Jeff Fahy. They just Google me, and it'll take them right there.

Melanie Cole, MS: Thank you so much, Dr. Fahy, for such incredible information. You're such a good educator, and you gave us so much to think about. It was so informative. Thank you for sharing your incredible expertise with us today. And for more information, you can go to infirmaryhealth.org.

If you enjoyed this podcast, please share on your social media and subscribe, rate, and review on your favorite podcast apps. This is LifeCast, the podcast from the specialists at Infirmary Health. I'm Melanie Cole. Thanks so much for joining us today.