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, we're going to learn about pelvic floor health with urogynecologist, Dr. Joseph Malek. Thank you so much for being here.

Joseph Malek, MD: Thanks for having me. Pleasure to be here today.

Host: So, let's start with the basics. What exactly is the pelvic floor and why is it so important for overall health?

Joseph Malek, MD: Pelvic floor is involved with a lot of things in female and women's health. And so, it can affect quality of life-- it might be a term you hear me say a few times today. And so, it functions very importantly for childbirth. A lot of the issues we see after childbirth are a lot of the issues we'll talk about. It has a big role in bladder function and control of the bladder. When there's issues, it can be leakage. And then, also, it involves something called prolapse where we can see some weaknesses in the pelvic floor. And so, the short answer is it affects female's quality of life, and quality of life's important. And so, it's become an important topic.

Host: So, what are some common pelvic floor disorders that you see in your practice? What signs should patients watch for?

Joseph Malek, MD: There's symptoms that a lot of patients will end up having. And sometimes, patients don't always know where to come for these issues. Now, that the field has grown quite a bit in the last 10 or 15 years, I think, it has a lot more notoriety. And so, people have found out about it. The bladder is one of the main ones. That can be control of the bladder. Often, two main issues we see with females would be an urgency issue where it's just a sudden uncomfortable feeling hits them and it's hard for them to make it to the bathroom without leakage.

And the second can be leakages with increases in abdominal pressure: coughing, sneezing, laughing, exercise would be common things that do that. And so, when people have lost control of that, again, it can affect their quality of life. Also, I'd mentioned prolapse. Prolapse essentially works as a herniation through the vagina or the pelvic floor muscles. The bladder, cervix and uterus, if patients still have them, and rectum, all line those vaginal walls. And so, when those walls get weak and those areas start to come down, that can present with issues. And then, also, sometimes control not on the bladder side, but on the bowel side. And so, that can deal with bowel issues such as urgency and trouble making it to the bathroom.

Host: And how does pelvic floor therapy work? Who might benefit from it?

Joseph Malek, MD: Most of them are going to be the people that I've mentioned as far as those symptoms with the bladder prolapse or rectal issues. Sometimes we can also see issues where we have damage to the nerves or to the muscles, especially after deliveries, vaginal deliveries, say for instance, like a forceps delivery or vacuum delivery that causes further damage. And so, people that are having those issues can certainly benefit. And so, with pelvic floor therapy, you know, we have a wide array as far as more conservatively, things like working with a pelvic floor physical therapist to either help strengthen or relax those muscles to a little bit more either aggressive or advanced, whether medications. And then, surgery is commonly performed as well.

Host: So Dr. Malek, understandably, a lot of people feel embarrassed or hesitant to talk about these issues. How do you approach those conversations with your patients so you can de-stigmatize what can feel like a very awkward topic?

Joseph Malek, MD: It's been one of those things for a lot of reasons that people haven't talked about this. Some of that's probably been tried to be normalized, if you will. And people said, "Well, I just thought it was 'normal' that I'd leak urine or that I have these other issues." And so, I think the fact that, one, this field has grown; two, some with just communication, whether internet means like this as far as people becoming aware that there are options there. But we always try to reassure patients. And again, as I said towards the start, that these are quality of life issues and quality of life matters.

And so, when people know that something is having a negative effect on their quality of life, one, it's very reasonable and, two, it's going to be likely that they're going to want to do something about it. And so, just trying to reassure these people that this is not normal, that this is things that you don't necessarily have to live with and that trying to improve quality of life is a very reasonable thing that probably most people would want to do.

Host: Absolutely. What role does childbirth, menopause, or aging play in pelvic floor health? Because I hear a lot of my friends who have had more than one baby say they have some of these issues.

Joseph Malek, MD: And so, all of those certainly play a part. Like many things in medicine, pelvic floor issues are multifactorial. Childbirth, one, carrying the child; just two, delivery. And then, especially delivery, if it's via the vaginal route is going to disrupt those muscles, disrupt the nerves that control those muscles. And so, that can result in a lot of these weaknesses that we see as far as prolapse and bladder or bowel control. It also can cause some damage in a negative way. That's where we get a little bit more into kind of pain, discomfort, a lot of times issues with sexual health. And again, a lot of that's with the nerve and the muscle damage. And that's where childbirth can play a big part.

Menopause has gotten a lot of interest recently and for good reason. Again, a big quality of life issue. One thing I sometimes interestingly say with menopause, is average life expectancy didn't really surpass menopause until the last a hundred years. And so, we have a long way to go as far as figuring out those things for as long as humans have been on this earth, to think that we've really only for a hundred years been to where people are routinely living into menopause a unique situation.

And so, a lot of changes can happen. One of the brief ones I'll say is just, for instance, the vaginal epithelium or skin inside the vagina before menopause. Very healthy, good blood flow, good moisture level. And it can become very accommodating. Childbirth, sexual health and, again, help with control as far as strength of the urethra. And when you get into menopause, all those things change as estrogen levels go down. And so, that tissue can become very weak, atrophic and can, again, lead to some of these issues. Age, again, a lot of changes in nerves, muscles, and then the menopause changes play a big part there.

Host: It seems like it used to be nobody ever talked about menopause. Now, you can't get people to stop talking about it, ever since Oprah did that special. Did you see it?

Joseph Malek, MD: Yes. Another one you talked about and then now, with social media and as we know, sometimes good resources and sometimes bad resources. But again, important topic for quality of life, and it's been a good thing. I think that it's come a little bit more to the forefront and that people are talking about it, seeking care for it and hopefully improving on some of the symptoms.

Host: In the end, get the information from your doctor, not the web.

Joseph Malek, MD: There's still a lot of good resources out there. I'm not saying everything that you would read on the internet, for instance, is bad. But yes, for a lot of stuff, it can be confusing to patients in the end.

Host: Can lifestyle changes or exercises help prevent pelvic floor problems?

Joseph Malek, MD: A lot of times, those starters are kind of the more conservative things. But in a good way, they're very low risk things to try and to start with. And a lot of people end up getting pretty good mileage out of them. Sometimes they can be a little bit limited as far as how far, you know, patients go. I think as a subspecialist, sometimes we're a little bit skewed, because we see all the people that are referred to us that have maybe failed conservative management or others, but there's certainly a role for them. As far as exercises go, a lot of them would be things we go over in clinic and/or there are some resources on the internet that have been beneficial for that.

 A little bit of a newer field as well, pelvic floor physical therapists have been a big benefit in this space. Just like I tell patients, if you had a knee surgery or a shoulder issue, you would see a physical therapist. There's physical therapists that now concentrate on and are focused on these groups of these pelvic muscles in the pelvic floor. And so, they can be a great aid in trying to optimize these things.

Same thing with lifestyle and behavioral changes. We all have some habits that we maybe would want to change from time to time and sometimes we don't want to face it. Sometimes maybe a doctor saying something about it might help, it might not help. But yeah, certainly sometimes simple things like eliminating irritants, coffee, tea, soda, or trying to minimize those can help a little bit with bladder function. Certainly, just the overall muscle tone and health. Weight's been a big risk factor for a lot of these issues. And so certainly, a strong place, a big place for lifestyle changes and behavioral modifications.

Host: When should someone consider seeing a specialist like yourself? And what can they expect during that first visit?

Joseph Malek, MD: I think sometimes people say, "Do I need to go see someone?" A lot of these, not to beat up the topic, quality of life. If it's bothering you to a point where you maybe want to learn more about it or do something about it, I think that's a very obvious time you would want to come.

 We see people across the spectrum. Some people, early in this process, this maybe doesn't bother them as much, but they want some more information. They want to know what the future might hold, if things change. I think that's important. And then, we certainly see people that have been dealing with issues, unfortunately, for a long time, sometimes years and years. And so for them, they're more ready to act, if you will, and do something. So, we see it across the spectrum. But I think, one, a better understanding of the diagnosis and, hopefully, certainly a good understanding of what your options are and what has been shown to help you.

Host: So before we close, I'd love to know how you became passionate about Urogynecology. How'd you find yourself in this field?

Joseph Malek, MD: You know, starting med school, if you asked me where I'd be sitting in 20 years, I don't think I maybe would've answered this directly. A lot of people in medicine go towards the Surgery or Medical route. I certainly was interested in surgery. I was very drawn to urogynecology because it does help patients' quality of life. Selfishly with surgery and stuff, we see this instant change in the anatomy and stuff. That's a good satisfaction. But really just seeing patients improve their quality of life. A lot of them come back and tell us, "Wow, why did I wait this long to seek care? You've changed my life." And I think that's just been a very rewarding part of it.

Host: Wow. That's got to feel good. Thank you so much for sharing your expertise on this very important topic to so many women. We really appreciate your time.

Joseph Malek, MD: Maggie, thanks so much for your time today. And yes, important topic in health. And hopefully, it'll continue to get more traction and more attention for female health.

Host: Absolutely. Again, that's Dr. Joseph Malek. To find a physician, visit novanthealth.org. I'm your host, Maggie McKay. Thank you for listening and for more health and wellness information from our experts, visit healthyheadlines.org.