Pelvic floor disorders affect many women. Urinary incontinence, fecal incontinence, pelvic organ prolapse and overactive bladder can be uncomfortable and embarrassing.
Rudolph Tovar, MD shares how providers can start the discussion with their patients to help ease the conversation and discuss treatment options available for pelvic floor disorders.
Selected Podcast
Pelvic Floor Dysfunction
Featured Speaker:
Rudolph Tovar, MD
Rudolph Tovar, MD is the Medical Student Clerkship Director and an Associate Professor of Obstetrics and Gynecology. Transcription:
Pelvic Floor Dysfunction
Melanie Cole (Host): Pelvic floor disorders affect so many women including me. I must admit. So, urinary incontinence, fecal incontinence, pelvic organ prolapse are all things that can happen to women and it can be uncomfortable and embarrassing to discuss. Well, here to tell us about that today is my guest Dr. Rudolph Tovar. He’s an Associate Professor in the Division of GYN Subspecialties at UK Health. Dr. Tovar, the first question that I think so many of us wonder about is are pelvic floor disorders a normal part of aging? Are we just supposed to accept it and move on?
Rudolph Tovar, MD (Guest): They can occur with aging, but they are not a normal part to be accepted.
Host: So, tell us a little bit about the different types that you see and what are some of the common causes for them?
Dr. Tovar: Well pelvic floor disorders is fairly broad. And that can be talking about prolapse of the pelvic organs which would be where the bladder or the bowel or the uterus seems to bulge from the vaginal opening and that commonly comes with urinary incontinence and occasionally fecal incontinence. That can occur with a traumatic birth delivery. It can occur with pelvic trauma related to chronic constipation where you are constantly having to bear down. It could occur from a chronic smoker who has bouts of bronchitis more frequently than somebody who is a nonsmoker, where they are always coughing and bearing down into the pelvic floor.
This can be differentiated from pelvic floor dysfunction which is more of a muscular disorder.
Host: So, yes, there are so many different kinds and you mentioned dramatic birth, but are some of these things like the different types of urinary incontinence, can’t they just be because of pregnancy, normal pregnancy, some women just are going to be more susceptible than others?
Dr. Tovar: There does appear to be a genetic link in some women, however, not every woman has incontinence in pregnancy. About 30% will experience some level of urinary incontinence during pregnancy. But that frequently often resolves within three or four months post-partum.
Host: And then as we get older, and because we were pregnant, then is that another common cause that if you had been pregnant, had a few children that this is something that can happen?
Dr. Tovar: Not necessarily just because of pregnancy and that was illustrated when looking at twins where one twin had babies and the other didn’t. the difference was the woman who had had children developed the symptoms at an earlier age. Whereas the other may have began to experience more symptoms in a postmenopausal age.
Host: Wow, how interesting. So, then let’s talk about when it’s time to see a physician to assess the situation because as I said in my intro, Doctor, not everybody wants to discuss these things. It’s a little embarrassing, you’re not sure who to see. So, when is it time to see a physician?
Dr. Tovar: Well, I would say when the problem is keeping you from doing your regular activities. It’s keeping you from going out in public, going out to meet friends, exercise. More optimally you would have some knowledge of it before the symptoms even began but where we see most patients is when the symptoms have already started.
Host: So, then first talk about some nonsurgical treatments that you might try first for pelvic floor issues, pelvic floor PT, Kegels, bladder training; what do you recommend that people try first?
Dr. Tovar: I recommend pelvic floor therapy and that doesn’t necessarily just include the physical therapist. You can start by doing Kegels and there are apps for it. there are books with instructions. There are devices you can buy to help you. But it’s more than just squeezing and letting go. A therapist or myself we might say contract that muscle you would contract to stop urine flow. And then relax it. But when you see a therapist, they take it to another level where you are holding that contraction for longer periods of time and then learning to relax it as well.
So, I would begin with attention towards the pelvic floor.
Host: And then if you’ve done those and you mentioned pelvic floor physical therapy which is really a newer and burgeoning field; what’s next? We see commercials for medications and women running to the bathroom. What do we think about those? Are there medications to help?
Dr. Tovar: There are medications. I will say real quickly, the issue with the therapy is that it takes months for it to work and it stops working if you quit. So, even if I move on to a medication, I’m going to encourage a patient to continue working on the pelvic floor and weightloss and multiple other modifiable risk factors. Now there are medications that you can use to treat certain types of urinary incontinence, specifically urgency incontinence, which is the leakage you might see when you are trying to get to the bathroom or when you are in a car and you feel the urge to urinate and the minute your keys hit your front door, you urinate all over yourself. Those medications are called anticholinergics. You might see a commercial where they are singing the jingle: gotta go, gotta go. And that treats that urgency type of incontinence.
Host: If we’ve tried pelvic floor physical therapy, and we continue with that therapy, you’ve discussed medications with us; what are some other interventions you might try whether they are injections or in some cases, surgical intervention?
Dr. Tovar: So, you can use a pessary. A pessary is an often silicone device inserted vaginally. It serves the purpose of placing the pelvic organs in their proper location. It doesn’t fix it, but it does keep it from getting worse. And it in some ways will mimic what surgery would do. These pessaries designed specifically for urinary incontinence come with a knob that fits right below where urine exits the body, the urethra. Similarly, you would look at a bulking agent. You can do periurethral bulking which is where we would insert a camera through the urethra after you’ve been numbed of course, and then you are injecting a bulking agent just below the urethra so that when you got pressure on the bladder, it also closes the urethra by applying pressure there.
So, then you can look at treatment like Botox. And Botox would also treat urgency incontinence and that’s aimed at reducing the involuntary bladder spasms that lead to urinary incontinence. And then one other common treatment is neuromodulation which it would be easier just to go by the trade name which is InterStim which is basically like putting a pacemaker in for your bladder. Two procedures. There is a testing procedure that we allow you to loosely test drive the treatment for a week to ten days. If there is success in that, then we move on to placing a permanent pacemaker like device in the lower back.
Host: How interesting. Thank you for describing many of those types of procedures. So, are women comfortable discussing this? If you were speaking to other providers, Dr. Tovar, or to women listening, how would you advise them to start that discussion? Should it be something we discuss in our well-visits? How does that discussion begin?
Dr. Tovar: I think if you are doing a typical general health examination and you are working a review of systems or a head to toe questionnaire, one of the symptoms that you would be looking for is bladder control and it could start simply by that question do you leak urine when you don’t want to, do you leak stool when you don’t want to. But I would encourage, and I have encouraged general practitioners to incorporate it into their annual visit. There’s occasionally modifications to medicines that can be made like a diuretic. And that would come up obviously more in a general practice than it would in mine.
So, I do encourage other physicians to ask about it. Because it can certainly lead to other affects such as you need to exercise. Well I don’t exercise because I pee all over the treadmill. So, it’s certainly important.
Host: It certainly is and thank you so much for such great information Doctor and thank you for joining us today.
That wraps up this episode of UK HealthCast with the University of Kentucky Healthcare. To learn more about pelvic medicine and reconstructive surgery at UK Healthcare head on over to our website at www.ukhealthcare.uky.edu for more information and to get connected with one of our providers. If you found this podcast as informative as I did, please share with your friends and family and share on your social media. Be sure to check out all the other interesting podcasts in our library. I’m Melanie Cole.
Pelvic Floor Dysfunction
Melanie Cole (Host): Pelvic floor disorders affect so many women including me. I must admit. So, urinary incontinence, fecal incontinence, pelvic organ prolapse are all things that can happen to women and it can be uncomfortable and embarrassing to discuss. Well, here to tell us about that today is my guest Dr. Rudolph Tovar. He’s an Associate Professor in the Division of GYN Subspecialties at UK Health. Dr. Tovar, the first question that I think so many of us wonder about is are pelvic floor disorders a normal part of aging? Are we just supposed to accept it and move on?
Rudolph Tovar, MD (Guest): They can occur with aging, but they are not a normal part to be accepted.
Host: So, tell us a little bit about the different types that you see and what are some of the common causes for them?
Dr. Tovar: Well pelvic floor disorders is fairly broad. And that can be talking about prolapse of the pelvic organs which would be where the bladder or the bowel or the uterus seems to bulge from the vaginal opening and that commonly comes with urinary incontinence and occasionally fecal incontinence. That can occur with a traumatic birth delivery. It can occur with pelvic trauma related to chronic constipation where you are constantly having to bear down. It could occur from a chronic smoker who has bouts of bronchitis more frequently than somebody who is a nonsmoker, where they are always coughing and bearing down into the pelvic floor.
This can be differentiated from pelvic floor dysfunction which is more of a muscular disorder.
Host: So, yes, there are so many different kinds and you mentioned dramatic birth, but are some of these things like the different types of urinary incontinence, can’t they just be because of pregnancy, normal pregnancy, some women just are going to be more susceptible than others?
Dr. Tovar: There does appear to be a genetic link in some women, however, not every woman has incontinence in pregnancy. About 30% will experience some level of urinary incontinence during pregnancy. But that frequently often resolves within three or four months post-partum.
Host: And then as we get older, and because we were pregnant, then is that another common cause that if you had been pregnant, had a few children that this is something that can happen?
Dr. Tovar: Not necessarily just because of pregnancy and that was illustrated when looking at twins where one twin had babies and the other didn’t. the difference was the woman who had had children developed the symptoms at an earlier age. Whereas the other may have began to experience more symptoms in a postmenopausal age.
Host: Wow, how interesting. So, then let’s talk about when it’s time to see a physician to assess the situation because as I said in my intro, Doctor, not everybody wants to discuss these things. It’s a little embarrassing, you’re not sure who to see. So, when is it time to see a physician?
Dr. Tovar: Well, I would say when the problem is keeping you from doing your regular activities. It’s keeping you from going out in public, going out to meet friends, exercise. More optimally you would have some knowledge of it before the symptoms even began but where we see most patients is when the symptoms have already started.
Host: So, then first talk about some nonsurgical treatments that you might try first for pelvic floor issues, pelvic floor PT, Kegels, bladder training; what do you recommend that people try first?
Dr. Tovar: I recommend pelvic floor therapy and that doesn’t necessarily just include the physical therapist. You can start by doing Kegels and there are apps for it. there are books with instructions. There are devices you can buy to help you. But it’s more than just squeezing and letting go. A therapist or myself we might say contract that muscle you would contract to stop urine flow. And then relax it. But when you see a therapist, they take it to another level where you are holding that contraction for longer periods of time and then learning to relax it as well.
So, I would begin with attention towards the pelvic floor.
Host: And then if you’ve done those and you mentioned pelvic floor physical therapy which is really a newer and burgeoning field; what’s next? We see commercials for medications and women running to the bathroom. What do we think about those? Are there medications to help?
Dr. Tovar: There are medications. I will say real quickly, the issue with the therapy is that it takes months for it to work and it stops working if you quit. So, even if I move on to a medication, I’m going to encourage a patient to continue working on the pelvic floor and weightloss and multiple other modifiable risk factors. Now there are medications that you can use to treat certain types of urinary incontinence, specifically urgency incontinence, which is the leakage you might see when you are trying to get to the bathroom or when you are in a car and you feel the urge to urinate and the minute your keys hit your front door, you urinate all over yourself. Those medications are called anticholinergics. You might see a commercial where they are singing the jingle: gotta go, gotta go. And that treats that urgency type of incontinence.
Host: If we’ve tried pelvic floor physical therapy, and we continue with that therapy, you’ve discussed medications with us; what are some other interventions you might try whether they are injections or in some cases, surgical intervention?
Dr. Tovar: So, you can use a pessary. A pessary is an often silicone device inserted vaginally. It serves the purpose of placing the pelvic organs in their proper location. It doesn’t fix it, but it does keep it from getting worse. And it in some ways will mimic what surgery would do. These pessaries designed specifically for urinary incontinence come with a knob that fits right below where urine exits the body, the urethra. Similarly, you would look at a bulking agent. You can do periurethral bulking which is where we would insert a camera through the urethra after you’ve been numbed of course, and then you are injecting a bulking agent just below the urethra so that when you got pressure on the bladder, it also closes the urethra by applying pressure there.
So, then you can look at treatment like Botox. And Botox would also treat urgency incontinence and that’s aimed at reducing the involuntary bladder spasms that lead to urinary incontinence. And then one other common treatment is neuromodulation which it would be easier just to go by the trade name which is InterStim which is basically like putting a pacemaker in for your bladder. Two procedures. There is a testing procedure that we allow you to loosely test drive the treatment for a week to ten days. If there is success in that, then we move on to placing a permanent pacemaker like device in the lower back.
Host: How interesting. Thank you for describing many of those types of procedures. So, are women comfortable discussing this? If you were speaking to other providers, Dr. Tovar, or to women listening, how would you advise them to start that discussion? Should it be something we discuss in our well-visits? How does that discussion begin?
Dr. Tovar: I think if you are doing a typical general health examination and you are working a review of systems or a head to toe questionnaire, one of the symptoms that you would be looking for is bladder control and it could start simply by that question do you leak urine when you don’t want to, do you leak stool when you don’t want to. But I would encourage, and I have encouraged general practitioners to incorporate it into their annual visit. There’s occasionally modifications to medicines that can be made like a diuretic. And that would come up obviously more in a general practice than it would in mine.
So, I do encourage other physicians to ask about it. Because it can certainly lead to other affects such as you need to exercise. Well I don’t exercise because I pee all over the treadmill. So, it’s certainly important.
Host: It certainly is and thank you so much for such great information Doctor and thank you for joining us today.
That wraps up this episode of UK HealthCast with the University of Kentucky Healthcare. To learn more about pelvic medicine and reconstructive surgery at UK Healthcare head on over to our website at www.ukhealthcare.uky.edu for more information and to get connected with one of our providers. If you found this podcast as informative as I did, please share with your friends and family and share on your social media. Be sure to check out all the other interesting podcasts in our library. I’m Melanie Cole.