Maggie McKay (Host): Meaningful Medicine is a Novant Health podcast, bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. Today, I'm sitting down with Dr. Cary Fishburne, and we're going to talk about pelvic pain. Before we get started, I would love to know how women's health became a passion of yours. What made you become an OB-GYN?

Dr. Cary Fishburne: Well, thank you for asking, and thank you for having me on. I, many years ago, enjoyed the balance between taking care of patients medically and surgically, and I enjoyed very much thinking deeply through sometimes complex problems and finding answers to problems that have been bothering patients sometimes for many, many years. It was a natural fit for me. I have been practicing in the subspecialty of Urogynecology and Reconstructive Pelvic Surgery now since I became board-certified back in 2015. So, I practice exclusively in that subspecialty for nearly 10 years now and that is the subspecialty that is primarily focused on advanced minimally invasive surgical techniques involving urinary and bowel incontinence issues, pelvic organ prolapse issues for women, but does also very much focus on complex pain disorders and also complex surgical needs all the way from simple surgical techniques through robotics. I just basically like fixing problems that sometimes are complicated.

Host: Well, speaking of pain, a lot of different conditions can cause pelvic pain in women. Can you talk about some of the most common causes you see in your patients?

Dr. Cary Fishburne: Yeah, absolutely. And I think when I answer that question, I think it is important to know that pelvic pain in women can be complicated and most often involves more than one underlying source. So, 86% of women actually will have more than one underlying source of pain contributing to their overall symptom complex. I think it's very helpful to realize that pelvic pain can involve a number of different systems, which all are intimately involved in the pelvis. These systems can include certainly GYN organs, such as the uterus, tubes, and ovaries. But it also can involve the bladder, can involve the rectum and colorectal concerns, musculoskeletal disorders of the pelvic floor, and also dermatologic conditions.

One common condition that is frequently considered is endometriosis, which is when the lining of the uterus is implanted out in the wrong area, so not inside the uterus, but actually out in the pelvis. And associated inflammation from that can certainly contribute to pain, but there are a lot of other conditions in the pelvis that can contribute to pain as well. And as I said at the outset, it's really helpful to realize that most patients who come in with chronic pelvic pain have more than one underlying condition involving. And so, sometimes we need to treat pelvic pain almost like layers of an onion and peel away various aspect of these pain conditions to get a patient back to her full healthy self.

Host: And Dr. Fishburne, what surgical treatments are available for pelvic organ problems?

Dr. Cary Fishburne: Certainly, it depends on what, the issues are. Thinking about issues primarily involving the uterus where there may be something like adenomyosis or fibroids, those treatments can be medical, but also involve sometimes removal of the fibroids and surgical management of the adenomyosis. If those issues are involving abnormal ovarian cysts, surgical options may include removal of that cyst or even sometimes removal of an ovary. Endometriosis lends itself to surgery with resection of those implants. Some of the other things we talked about, bladder conditions, we offer cystoscopy in the office to evaluate that further. That's simply placing a camera in the bladder to further investigate those conditions, and we have treatments that we can offer in the office. And I'll touch a little bit more on that in a minute. Pelvic floor dysfunction, so myofascial muscular disorders can be managed with a number of treatments to include trigger point injections up to and including Botox. All of these issues are to be considered once we figure out the underlying diagnosis. There are even nerve pacemaker implants that we use for bowel and bladder function that actually can have an off label role in some of these pain conditions as well.

Host: When it comes to urinary incontinence, which a lot of people seem to suffer from, how successful are surgical treatments specifically for that?

Dr. Cary Fishburne: Highly successful. I think with urinary incontinence, the key again, just like with pain, is really understanding what is causing urinary incontinence. And to be pretty simple about it, we have the bladder, and we also have the urethra, which is the outlet tube from the bladder. And patients can have problems with either the bladder or the urethra or with both.

And so, sometimes surgical management or medical management may involve treating both aspects. And the key is to really understand for my individual patient what her issues are, and then to offer her solutions based on what her underlying issues are that contribute to her incontinence. When a patient comes in to me, all she knows is that she's leaking, and that's the problem. It's up to me to help her understand what her underlying issues are. But we have phenomenally successful surgical treatments. A lot of people have heard of slings and we have a variety of slings and different slings work better for different indications. We even have urethral bulking where I can inject a filler in the bladder neck and essentially tighten the sphincter and make it a more competent sphincter. We offer that even in the office or in the operating room, depending on what variety of bulking that patient might prefer. And then, we also utilize things such as bladder Botox to inject Botox in the bladder for difficult-to-manage overactive bladder. And again, that implant I mentioned for pain is primarily indicated for overactive bladder conditions, urgency, and frequency and urgency incontinence, and also bowel incontinence and can be phenomenally successful. All of those treatments are in the north of 80-90% effective. And we have long-term durability data on many of those with long-term success.

Host: Well, that's very encouraging. How have you seen pelvic pain reduce somebody's quality of life? At what point should you seek help?

Dr. Cary Fishburne: Because I'm a subspecialist in Urogynecology, a lot of my patients have been living with chronic pelvic pain for a very long time and have been suffering in silence, and it may get to the point where they start limiting their normal activities. They may stop exercising, going to the gym. They may avoid intimacy with their partners. And they often suffer in silence, and some of those private things that they are avoiding, such as intimacy with their partners, they may even be reluctant to talk to their partner about, and it can spill off into relationship issues, where they don't talk to each other about this very important issue going on that she's embarrassed to talk about.

Host: I mean, why suffer in silence? Why don't people go to their doctor and tell them? Are they just embarrassed?

Dr. Cary Fishburne: That's a great question. I think that as a man in a woman's world, I realized that women carry burden on their shoulders while they're caring for other people oftentimes. And they tend to absorb this and sometimes not seek help. many times people have sought help and doctors are just not sure what to do with these concerns or maybe not sure what's going on. I think, again, it comes down to realizing there are multiple underlying causes of potential pelvic pain. Not all pelvic pain is endometriosis. And when people get stuck, I would encourage them to seek a subspecialist who can think across all aspects of sources of pain to thoroughly investigate other sources that maybe her doctor just may not be aware of and not know how to treat. And so, rather than get stuck in the dead end, continue to explore those treatment options out there that can be very helpful.

Host: Dr. Fishburne, what about pelvic pain associated with a menstrual cycle? Is that normal? And what about in between cycles?

Dr. Cary Fishburne: When I see somebody who comes in for pelvic pain, and I'm thinking through all of these different things that it could be, and again, pelvic pain is probably best thought of as layers of an onion. There are oftentimes more than one underlying issue going on. I do investigate the cyclicity of that pain. And if there's a very common association with the menstrual cycle, we explore whether that may just be her baseline, we call it dysmenorrhea, pain wit cycle, that shouldn't be overly limiting, but if it is overly limiting, we explore other underlying reasons. Endometriosis is something that's certainly hormonally active and can flare with cycles. And as endometriosis gets worse for a patient, it may start to more and more take over the rest of her month as well and not just be about around the time of her cycle.

Other issues such as fibroids and adenomyosis can contribute to that GYN cyclic pain as well. But some of the other things we've talked about, we've talked about bladder sources of pain a little bit and musculoskeletal sources of pain. They can flare related to the cycle as well. And I tell patients that during the cycle, everything's flared up, everything's inflamed. And so, things that are not directly hormonally active may actually be more uncomfortable around the time of the cycle just because the overall balance from that inflammation. And so, I do very much consider the cyclicity of pain in terms of guiding me towards what may be going on. But it doesn't rule out the other aspects of things that can also be contributing to a woman's pain.

Host: And what misconceptions do you encounter on this topic the most?

Dr. Cary Fishburne: I think the misconceptions that I hear most often are "It's all in my head. I'm imagining this, I've been told there's nothing to do about this pain, and I just have to live with it. I can't find any other source. So therefore, there must be no other treatment options available. Those are kind of common misconceptions that patients carry and lead to real frustration with the condition and indeed with medical care if they're not seeing relief and improvement in their symptoms.

Host: So in closing, doctor, is there anything else you'd like to add that maybe we didn't cover?

Dr. Cary Fishburne: I just think the overall theme here is for women to continue to search for answers for their problems and to not just give up, to not let their problems be dismissed, as perhaps not being real, and to seek care where people are trained to understand the pelvic floor in a comprehensive way and not just in a siloed approach of it's got to either be GYN or Urology or Colorectal or Musculoskeletal, but to seek care from providers who may understand that there is a comprehensive approach to be considered to realize that these conditions may be like layers of an onion. And just because we address one issue doesn't mean we don't get closer to well by addressing the other layers. So, I'd encourage patients to keep asking the questions and to not be frustrated and to not give up.

Host: Well, thank you so much for sharing your expertise on this. It was really fascinating.

Dr. Cary Fishburne: Well, thank you very, very much. It's been a pleasure being with you today.

Maggie McKay (Host): Again, that's Dr. Carrie Fishburne. To find a physician, visit novanthealth.org. For more health and wellness information from our experts, visit healthyheadlines.org. 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 Meaningful Medicine from Novant Health.