Jaime Lewis (Host): According to the National Institutes of Health, nearly one quarter of women in the United States are affected by pelvic floor disorders, including urinary incontinence, pelvic organ prolapse, and bowel control problems. These conditions can significantly impact daily life, but women do not need to suffer through.

With proper diagnosis and treatment, they can find relief and and improve their quality of life significantly. Here to discuss female pelvic health is Dr. Costas Apostolis, a double board-certified physician in Obstetrics and Gynecology, and a subspecialist in Urogynecology and Pelvic Reconstructive Surgery at Southwest General Health Center. He'll talk about common pelvic floor disorders, treatment options, and ways women can maintain their pelvic health.

This is Southwest General Health Talk, the podcast from the specialists at Southwest General Health Center. I'm Jamie Lewis. Dr. Apostolis, thank you so much for being here today.

Costas Apostolis, MD: Thank you very much for having me. It's a pleasure.

Host: Let's start with the basics. What exactly is Urogynecology and what types of conditions do you treat?

Costas Apostolis, MD: Absolutely. A urogynecologist is a subspecialist that has gone through four years of Obstetrics and Gynecology and then has chosen to do an additional three years in a subspecialty known as Urogynecology and Pelvic Reconstructive Surgery. Now, historically, general gynecologists would do a lot of the things that we as urogynecologists do today.

Over the years, it's become a lot more specialized with a lot more advanced procedures and the use of different materials to help enhance surgery and to give patients better recovery. And so, a primary subspecialty was formed. As urogynecologists, we treat women with, number one, pelvic organ prolapse. That means something has dropped from its normal location in the pelvis, such as the bladder, or the uterus, or the rectum. And we can come up with different ways, both non-surgical and possibly surgical, in order to replace those organs and put them back up where they belong. We also treat conditions such as urinary incontinence. We treat women with recurrent urinary tract infections, pelvic pain, and other issues that affect women below the belt.

Host: So, I don't generally do this, but I wanted to see if I could get personal for a minute because I actually suffered from urinary incontinence and prolapse after the birth of my children, but I didn't talk to a doctor for years because I thought it was sort of part of the deal of being a woman in a certain life stage.

Fortunately, a friend who is an athlete told me about how critical it was for her to see a urogynecologist to help her with urinary incontinence so that she could keep running competitively, and it changed her life. And that actually empowered me to do the same. And my quality of life has been improved astronomically by having had a couple of procedures that really, really helped when things like Kegels or pelvic floor exercises just didn't help at all.

So that being said, I know there are so many, many women who experience urinary incontinence, but they're so embarrassed to talk about it with a doctor or anyone, frankly, or they think they're stuck with the issue. Can you speak about how common this condition is and maybe what kinds of treatment options are possible?

Costas Apostolis, MD: Absolutely. So, I'm glad to hear about your personal journey through Urogynecology and how it's improved your quality of life. You know, the stigma that you have to live with this because it's a natural part of aging or urinary leaking. "Ah, my grandmother did it, so therefore I'm going to live with it as well" is absolutely not true. There are things that can be done to help women who suffer with urinary incontinence, even if it's a little bit, to as much as leaking constantly throughout the day. There are a number of treatment options out there that can help women live a more comfortable way of life.

When we talk about urinary incontinence, when a patient first comes into my office, they're always presented with this paper. It's just a little diagram, a care pathway that I've developed to help patients understand that urinary incontinence comes in essentially two different flavors. There's leaking with coughing, sneezing, laughing, running, just as you had. And that's called stress incontinence, but not emotional stress, but rather stress on your bladder, something that increases abdominal pressure leading to a bladder squeeze and a leak such as running, jumping, coughing, sneezing, that sort of thing.

The other type of urinary incontinence is what's known as overactive bladder. And that's characterized by urgency, the sudden feeling that you have to get to a bathroom or having to go to the bathroom all the time. I love asking patients, "How many times a day do you think it's normal to have to go to the bathroom?" Well, let me ask you, how many times a day do you think it's normal to go to the bathroom?

Host: Oh my gosh. Well, it depends on how much water I'm drinking, but let's say maybe six to 10 times.

Costas Apostolis, MD: Okay. Eight to 10 times is considered normal.

Host: Oh, great.

Costas Apostolis, MD: And it does, it depends on the amount of fluid that you drink. But no amount of leaking is normal. Our anatomy, our bladders, are made in such a way that, yes, we're supposed to realize or get the urge to go, but if that results in a sudden leak, well, that's something that we need to seek care about, because there are easy solutions to help women get the treatment they need for that.

One final question for you. I know you're supposed to be asking the questions here, but how many times at night, if any, is it normal to get up out of sleep to go to the bathroom?

Host: Gosh. Well, pre-children, I would say zero. Post children, in my 40s, I would say one or two. Two on a horrible night.

Costas Apostolis, MD: That's the right answer. It's normal to be able to get to have to get up once or twice at night to go to the bathroom. When it's three or more, then we start to think about, okay, are there medications that are maybe having you to get up? Blood pressure medications are notorious for causing women to have urinary frequency and urgency and that sort of thing. But getting up once or twice at night to go to the bathroom is completely, potentially normal.

Host: That's good. That's very good to know and to clarify. Well, in the recent past, we've heard a lot about the material mesh for different procedures that you do in your field. Can you explain a little bit more about that?

Costas Apostolis, MD: Absolutely. So probably, eight to 10 times a day when I see patients, I get the question about the mesh. Every time I bring up a treatment option that involves mesh, the first thing patients do is they go, "Oh no, mesh!" Because of what we've seen on TV and what we've heard about the negative connotation that comes with the use of mesh.

Mesh historically has been an excellent treatment option for women suffering with prolapse and urinary incontinence. In 2008 and then again in 2011, the use of big pieces of mesh, and I'm going to show you some examples of mesh, but the use of big pieces of mesh To fix vaginal prolapse, not abdominally corrected prolapse, but vaginal prolapse came under scrutiny.

And there's a number of different reasons why that happened, but Those procedures are gone. The use of mesh for vaginal prolapse is gone. So, in this day and age, when your urogynecologist talks to you about using a mesh to correct your incontinence, or an abdominally through your belly button incision to correct prolapse, that is a very good thing.

Some examples, if we look at this pelvic model, this is the bladder, this is the urethra, and we use what's called a sling. A sling is a piece of mesh, as you can see, looks like a shoelace. And we fasten it right underneath the urethra. And as soon as it goes underneath, which you can see right here, it corrects stress urinary incontinence. It's a very thin strip of mesh. Mesh is made of polypropylene or a synthetic, a plastic. We've been doing slings since 1996 in the United States. It's been supported by every major society, Urogynecology Society, Society of Gynecologic Surgeons, the American Medical Association supports the use of slings because it's the most minimally invasive procedure to help women treat their stress urinary incontinence. It's a very safe procedure. It takes about 15 minutes or so to do, minimal downtime. And you can typically get back to your routine exercising and intimacy and all that within two weeks of having the procedure with almost near immediate results.

The other type of mesh that we continue to use in urogynecology is something called a Y-mesh. And a Y-mesh is used over the vagina in order to correct prolapse. And there's certain indications for the use of this mesh. Many of which are put in through a robotic or a laparoscopic approach to help suspend the vaginal canal to the tailbone. And so for women who suffer with advanced prolapse, the use of this type of mesh gives them a near 100% success rate long term. There are other materials that we use, such as cadaveric skin that is treated and cleaned and radiated so that we can get a good piece of graft material to help assist patients in their prolapse repair.

So, Urogynecology has really evolved over the last 30 years with the use of meshes and implantable material to help increase success rates so that women can live a more comfortable way of life.

Host: And if I could just add, it's easy to think that this is only for people maybe who are so active that they're trail running or they're, you know, doing major things, but really you brought up the fact that it can be for the smallest things. It can be for when you have a cold, and you're sneezing a lot or coughing a lot and you don't want to be out in public. If it's affecting your ability to live and carry out normal day-to-day activities, it's something worth considering.

Costas Apostolis, MD: Absolutely. My oldest patient is 104 and, you know, she was very active. She walks, continues to walk one mile a day, came in with severe, severe urinary incontinence, stress incontinence, which we spoke about treatment options, and she opted for a midurethral sling procedure, and she was back on the treadmill the next day, walking her mile, you know. And I'll never forget when we saw her at her two-week postoperative visit and she came in, she gave me a big hug and said, "You know what, I used to leak and have to wear pads on my treadmill, and now those pads are gone." So even at 104, doesn't matter how young you are or how old you are, it's all about quality of life. And if there's something you can do to improve that, it all starts with a discussion, evaluate what your options are, and then make the best decision for you.

Host: Yeah. I love that story. That's wonderful. Well, can you explain a little bit more about pelvic organ prolapse? What is it? What causes it? And you did touch a bit on how it's treated, but anything else you want to add there?

Costas Apostolis, MD: So, pelvic organ prolapse, prolapse and urinary incontinence go hand in hand. One in three women will suffer with incontinence. One in three women will suffer with pelvic organ prolapse. A female that has pelvic organ prolapse, 30-40% of those women will also have incontinence. And it's inversely proportional. Women who suffer with incontinence, 30-40% of those women may also suffer with some form of prolapse. Not all prolapse needs to be treated. I believe all prolapse needs to be diagnosed so that patients can be aware of what they have, they can know what the potential symptoms are, and what their options may be.

Pelvic floor physical therapy is an excellent modality to help with symptoms. I can't tell you the number of patients that I see, and I see hundreds of patients a week that come in and are terrified to talk about their symptoms because they think it's going to mean scalpel. Absolutely not. It all starts with a conversation and to learn about what the treatment options are. And the majority of them are not surgical. There are a lot of behavioral techniques. Physical therapy has absolutely revolutionized the way we treat women that suffer with prolapse and urinary incontinence. So, please don't be afraid to talk about your symptoms for the fear that it might end up in surgery because that probably is not the case most of the time.

Host: What are some of the latest minimally invasive surgical options that are available for treating any kind of pelvic floor disorder?

Costas Apostolis, MD: So, there's a number of different treatment options. As I mentioned earlier, prolapse can affect the bladder, where the bladder moves from its normal position and starts to drop into the vagina. That can be corrected vaginally through a minimally invasive vaginal procedure. Or if there's more of a procedure involving the top of the vagina, then we can take an abdominal route.

And typically, abdominal surgery is performed minimally invasive through small little five millimeter incisions. And I use an approach called a straight-stick laparoscopy, where with just four little incisions, typically one in the belly button, one on either side, and one right above the pubic bone, about the size of your pinky fingernail, we can reconstruct the prolapse, meaning push everything back up where it belongs and attach it in a way to help prevent it from coming down in the future. Procedures and techniques are constantly changing. We're always looking for more minimally invasive ways to help get women back on their feet quicker with less downtime, less pain and less blood loss. And that's what we're doing at Southwest General.

Host: Well, how do pregnancy, childbirth, menopause, all these big changes, how do they affect women's pelvic floor health and what can women do to protect themselves during these life changes for the future?

Costas Apostolis, MD: Absolutely. Great question. I have women who come in and say, "You know, Doc, I've got this bulge coming down. I've done my Kegels for years. Why did this happen to me?" Well, Kegel exercises, I tell patients, is an urban legend. You can Kegel all you want. If you don't start when you're two, it's unlikely that the Kegel exercise is going to prevent any prolapse or incontinence.

Kegel exercises are great to know how to do in times of urgency. meaning, when you get that sudden urge like you have to go to the bathroom, you can Kegel in order to get to a bathroom on time. Kegel exercises, unfortunately, are not going to magically put your prolapse back up or really have a profound impact on urinary incontinence. So, pelvic floor exercises and those sorts of things are great treatment options to help women with symptoms: pain, pressure, helping relax the pelvic floor muscles so they can be more comfortable.

Host: What are some warning signs that women should heed that they should not ignore and should prompt them to seek medical attention?

Costas Apostolis, MD: So in the event where you're feeling any type of vaginal pressure, if you can feel or see a vaginal bulge, whether it's from the vagina or from the anus, I would urge you to follow up with your general gynecologist or your primary care or seek out a urogynecologist in your area who can do a exam and kind of counsel you on exactly what's going on. Any type of urinary leakage is not normal. It's normal potentially to have to go to the bathroom quite often, depending on how much fluid you drink, but no amount of leakage should be considered normal.

Host: Good distinctions. And what kinds of tests or evaluations are typically involved in diagnosing a pelvic floor disorder?

Costas Apostolis, MD: So, the first step, typically, you know, we always tell our female patients to always do a self-breast exam, because not that you're going to detect anything abnormal, but you can notice something has changed, at which point you should seek out medical attention. Well, the same for women when they're in the shower. Don't be afraid to just kind of check down there, you know, to make sure that there isn't something that's coming down or there isn't a change from normal. If you do suspect anything, or if your partner mentions, "Hey, something else that I feel down there, it's always important to check in with a medical specialist, you know, in order to get the correct diagnosis.

Host: I'm thankful that you shared that, because I think a lot of people are afraid to discover something.

Costas Apostolis, MD: No, absolutely.

Host: Sooner is better. I know it always is.

Costas Apostolis, MD: Don't be afraid of your own body. It's yours and your duty to make sure that we can keep it as healthy as possible so that we can live a comfortable way of life moving forward. I think you had asked me about tests and things. The initial evaluation, when you come into the office, obviously starts with a discussion. And that discussion is to get to know your symptoms, your medical history, at which point a gentle physical exam is performed where every compartment of the vagina is evaluated. And that will be able to tell you if there is a prolapse and exactly what it is that's prolapsing.

After that initial visit, if there is your incontinence and prolapse, or prolapse, then a couple of tests may be recommended. One of which is called urodynamics. Urodynamics is essentially a fancy way of saying bladder testing, where a small little catheter is placed into the bladder, the bladder is filled with water, and we can tell how much water you can hold, how much you can empty, do you leak, what type of leaking do you have, so that we can make a better diagnosis.

There can be x-rays or CAT scans that can be performed, physical therapy that can be recommended after that initial visit. Typically, once the testing is complete, then patients come back. We sit down in the office and we come up with a treatment plan that would fit, what's right for you?

Host: Great. Well, is there anything else that you want to say? Just share any last thoughts with our audience about pelvic health?

Costas Apostolis, MD: Well, I appreciate this opportunity and I always love, you know, some of my best days are those in the office. A lot of physician surgeons, you know, "I'm in the office today, but I'm in surgery tomorrow." And for me, it's kind of the opposite. I love being in the office. I love interacting with patients and I love giving people hope because it is quality of life issues that we deal with as urogynecologists and a lot of the patients that we see that come to our office are out of hope. They've suffered with urinary tract infections. They're always wet. They've got this bulge going on. They don't know what to do or where to turn. And to be able to give them the hope that there are better days ahead is truly what keeps me coming to the office every day.

I would urge patients, don't be afraid of your body. Evaluate it. If you feel something is off, please see your gynecologist or urogynecologist or primary care. We live in a day and age where technology is over the top, right? So don't be afraid to put those tools at use for you. We are literally a phone call away. We're in the office five days a week at Southwest General and would welcome everybody who suffers with these issues to come check us out.

I just want to throw a little thing out there for my nurse practitioner, Amy Skabar. we always laugh because it's like Amy is The best thing since sliced bread, and I'm kind of chopped liver at the end of the day, because everybody loves Amy. I do the surgery, she gets the credit, which I love, because we are a team. And that's what we have at Southwest General. We have a wonderful team, ready and willing to help women get through any hurdle that they suffer with below the belt.

Host: Awesome. And as a woman who has benefited from your field greatly, I really appreciate everything that you do too.

Costas Apostolis, MD: Well, thank you very much. I appreciate that.

Host: Well, that was Dr. Costas Apostolis, urogynecologist at Southwest General Health Center. And to schedule an appointment or learn more about women's health services, visit swgeneral.com. And thank you for listening to Southwest General Health Talk, the podcast from the specialists at Southwest General Health Center.