Transcription:
Female Pelvic Medicine & Reconstructive Surgery

Melanie Cole (Host): Welcome to Back To Health, your source for the latest in health, wellness, and medical care. Keeping you informed, so you can make informed healthcare choices for yourself and your whole family.

Back To Health features, conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And joining me today is Dr. Larissa Rodriguez. She's the Chair in the Department of Urology at Weill Cornell Medicine and urologist-in-chief at New York Presbyterian Hospital Weill Cornell Medical Center. Dr. Rodriguez, thank you so much. And I'm so glad that you're here to join us to talk about female pelvic medicine and reconstructive surgery today. Can you start by telling us a little bit about the pelvic floor and how common pelvic floor disorders really are?

Dr Larissa Rodriguez: Hi, Melanie. Thank you so much for having me today. Yes, the pelvic floor is a collection of muscles that form the inlet to the pelvis. So if you can think of it, it's like a ball that are a bunch of different muscles that sit like a ball. And through those muscles, the urethra, the rectum and the vagina go through them. So the function of those muscles really regulate the functions of those other organs. It also helps in the support of the bladder as well as the rectum. Pelvic floor disorders just is a collection of different disorders that affect mostly women, but it can affect some men as well where the muscles of the pelvic floor are not functioning as normally. And it can manifest with pelvic organ prolapse, with urinary incontinence, fecal incontinence, defecatory dysfunction and pain with intercourse. And these disorders can affect about 25% of women in their lifetime.

Melanie Cole (Host): Wow. It's pretty common. So is this, and I suppose this is a question that many people have, are these kinds of things we hear about, incontinence and all that, are they a normal part of aging? And do you feel that women don't always want to come see a urologist because they're hesitant to discuss them and it can be embarrassing?

Dr Larissa Rodriguez: Yes. I mean, I think, unfortunately, women don't feel that they can talk about this. This feels shameful for a lot of women. And although we see a higher prevalence of this disorder as women age, so meaning yes, as you get older, you're more likely to suffer from these conditions, they're not a normal part of aging per se. I mean, there are treatments or things you can do so you don't experience this as you age. Urinary incontinence, as an example, affects up to 50% of women through their lifetime, especially as they get older. But 50% of women do not suffer from it at all. And even those that do, their risk factors of why they might be affected by it is very treatable and they should not be accepting this as a normal part of aging.

Melanie Cole (Host): Well, thank you for saying that. So what are some of the conditions and factors that can lead to these pelvic floor disorders? I mean, being a woman or being pregnant, tell us about some of the different things.

Dr Larissa Rodriguez: So we understand from epidemiologic studies what are things that put women at risk of developing these disorders. Unfortunately, we have not really advanced very much into how to prevent them. One of the main risks of developing pelvic floor disorders, actually all of them, is having had a vaginal delivery. As you can imagine, this is a normal aspect of reproductive age in women. So a lot of women have vaginal deliveries and that's one of the main risk factors. We are trying to understand what related to the process of labor and practices of delivering babies put some women at risk while others to not have the risk. But we don't have great ways to prevent it at this point.

It is felt that the head of the baby, when it engages in the pelvis, probably puts pressure not only in the muscles, but also the nerves of the pelvic floor affecting its function. And although women when they're young can compensate for this and do quite well for many decades, at the time of menopause, as women age and tissues become a little bit more relaxed, this is when we start seeing a higher incidence and prevalence of these conditions. So aging is definitely a factor. Obesity is a factor. Diabetes is a known risk factor. Smoking for some of these conditions is also a known risk factor. Some of these are very modifiable, like diabetes, obesity, and smoking. Some, we really have to work as to how we can help women prevent these conditions from happening.

Melanie Cole (Host): So for patients, Dr. Rodriguez, who are looking for care from the urology team at Weill Cornell Medicine, can you tell us about your newly established center for female pelvic health and what services you offer?

Dr Larissa Rodriguez: We offer them a whole gamut of diagnostic and treatment options for all pelvic floor disorders. So we see women with pelvic organ prolapse, fecal and urinary incontinence. And we evaluate women by taking a history, a physical exam, and sometimes we need to do more advanced studies like urodynamics to really understand how the bladder is functioning. Sometimes a cystoscopy to ensure that there's nothing in the bladder that is irritating the urinary tract, leading to the incontinence. And then we sit down with a patient and start with very conservative treatments, minimally invasive treatments and sometimes more advanced treatments.

The pelvic center is really geared towards looking at a multidisciplinary approach to treating women. So we're really aiming at having the input of colorectal surgeons because of the fecal incontinence and some of the bowel issues that women experience, gynecologist, urologist, pelvic floor physical therapist, and rehabilitation doctors.

Melanie Cole (Host): Well, it's a real multidisciplinary approach. And can you speak about some of the symptoms for women that have these things, when you feel it's time that they see a doctor because I mean, Dr. Rodriguez, I've had two kids, I laugh or I sneeze, and sometimes I leak a little. It's a fact. It doesn't bother me because it's so minimal. But I do know that for some women, it's a lot more than that and can really, really affect the quality of their life. So can you speak about the things that are really affecting how they function and how they feel and what would send them to a urologist?

Dr Larissa Rodriguez: So quality of life is really the key. You just mentioned that in your question, this is not cancer. So it's not something that if you have it, you have to have it fix. It really has to be addressed when it bothers you as a patient. And every patient is different and their lifestyles are different. So a small amount of incontinence in a marathon runner can be very bothersome versus a large amount of incontinence or more severe incontinence in somebody who is not very ambulatory might be less of an issue. It's a very personal choice. But if it's affecting what you do, the choices you make in your life; if you're not staying at your grandkid's home because you're afraid you might wet the bed; if you're not going to a movie, because you think you're going to have to go to the bathroom two or three times during the movie; if you're not going out with friends; if you don't feel like you can run and play soccer with your kids, then you are really making major adjustments in your life and that doesn't need to be the case. And that's when you should see a doctor.

Now, there are other reasons why you should see a physician. If you're having a lot of urinary tract infections, as an example, you probably should see a doctor. But if you're not, it's really dependent on how much the symptoms bother you.

Melanie Cole (Host): And that's the key, really, if the symptoms do bother people. So now, let's start with some of the treatments available. First, non-surgical treatments. Tell us a little bit about what you can do to help women with some of these issues that don't involve real interventions.

Dr Larissa Rodriguez: So it depends on the symptom. For urinary and fecal incontinence, behavior modifications, bladder retraining where really the bladder kind of can learn, in a way, we can teach it when it should go to the bathroom instead of responding to the bladder as if the bladder owned us. So we can teach patients techniques to retrain their bladder, space the times they go to the restroom and not leak in between. What you consume, what you eat in your diet can really affect your urinary and fecal symptoms. And then we're looking at treatments such as physical therapy, which really doesn't have any risk to the patient, but can be incredibly effective working with a good pelvic floor physical therapist to strengthen those muscles and to train you how to control those muscles, because it's not just a strong pelvic floor that helps. I mean, it definitely helps, but we need to learn how to relax it when we go to the bathroom. We need to learn how to contract it when we cough and do other things. So really getting a better control of that pelvic floor can be extremely helpful and it can help up to 70% of patients with these conditions.

And then if these options are not really giving you the results that you want or the improvement that you're seeking or you're not responding adequately, that's when we start looking at other therapies that might be more surgical, some are very minimally invasive, and we can even do in the office, like injecting Botox into the bladder can be very helpful for people who suffer from urgency incontinence. It works just like Botox works in wrinkles in the face, paralyzes the muscle a little bit so that if you're having spasms of the bladder, you don't leak. Injecting materials in the urethra for people who have leakage of urine when they have activity like coughing and sneezing or increases in abdominal pressure can be very helpful, but it's also very low risk and minimally invasive.

And then we have surgical therapies, that some are robotics, some are transvaginal. Most of the things that we do, the patients stay in the hospital tops one night. Many of them are outpatient, and they can be quite effective. For pelvic organ prolapse, there are devices that people can put into the vagina, like a pessary to put the organs back where they belong. So they don't have that much bother, but it doesn't really fix it. Pelvic floor physical therapy can also be helpful in very mild prolapse to try to reduce it or revert it. And for advanced prolapse, usually surgical options are needed.

Melanie Cole (Host): Thank you for that comprehensive list of available treatments, how comfortable are women? Like, suppose they're getting pelvic floor physical therapy, is this uncomfortable? Tell us a little bit about privacy and compassionate care, because as we said at the very beginning, some women find it shameful or embarrassing, which it absolutely is not.

Dr Larissa Rodriguez: So pelvic floor physical therapy can be quite effective, as I said. And usually, it's conducted with people who are specialized in the pelvic floor. It's not just any physical therapist for your arm or shoulder that we'll be doing pelvic floor physical therapies. These are people who are highly trained to treat these conditions. Many of them are women. I will say the big majority in my experience are women and they really work with the patient in a private office that is usually a very peaceful setting, because you need to concentrate to really be able to locate that muscle and work with somebody and they take their time. You know, some of this visits are an hour long and they talk about what you should be drinking and eating and how you should be managing when you have urgency as an example. And then they teach you how to localize those muscles, how to exercise them and then they usually send you home with kind of an exercise routine.

I try to tell my patients, you know, patients talk about Kegel exercises, which are great if you know how to do them. They're actually hard to teach. We all think we know how to do Kegel exercises, but it's hard to locate the pelvic floor without squeezing your rectum or squeezing your abdomen or many other things that you really should not be doing. And what I tell patients is a difference between me telling you, go to the gym and come back in three months and let's see if you lose weight versus giving you a personal trainer. So I want to think of physical therapy as having your own personal trainer. The outcomes are so much better when you have your own personal trainer than just telling you to go to the gym and come back in three months.

Melanie Cole (Host): As someone who's been a personal trainer for 30 years, I completely concur with that, except that this is for the pelvic floor of this group of muscles. So it's so important. Tell us a little bit, as we wrap up, about any exercises and you've mentioned Kegel exercises that women can do at home or lifestyle and behaviors. I'd like you to summarize it all for us with your best advice about female pelvic medicine and reconstructive surgery and pelvic floor disorders.

Dr Larissa Rodriguez: So in terms of things that you can do at home, Kegel exercises can be very helpful, as I said, for keeping that muscle healthy and strong and help prevent urinary and fecal incontinence. And we really should be teaching young women at the time of pregnancy and after delivery to use that muscle and keep it healthy throughout their lifetimes.

There are other therapies that have been shown to be helpful, like Pilates, as an example, because you have so much core engagement and engagement of the pelvic floor. That has been shown to be, useful as well as yoga, believe it or not. We don't have a lot of studies looking at these therapies, but there's definitely studies that show that the pelvic floor can be strengthened using those techniques.

In terms of dietary things, there are some things that are irritants to the bladder, especially if you have a lot of urgency or urge incontinence. Unfortunately, there are things that we really like, coffee, alcohol, but things that make you produce a lot of urine that are diuretics in a very quick manner can trigger contractions and spasms of the bladder that can lead to the sensation that you have to run to make it to the bathroom.

You know, I like telling my patients, "Who has not had a diet Coke and not feel they have to run to the bathroom at some point?" They are these irritants, especially NutraSweet and some of these sugar substitutes that can be quite irritating to the bladder and lead to urgency and leakage of urine. In terms of fecal incontinence, again, dietary maneuvers are one of the first things that we try on patients. So what we want is patients to be able to empty what we call the vault, basically empty their bowels completely with one bowel movement so that they don't have stool left in the rectum for 24 hours until they have to go to the bathroom again. And usually, those are high fiber supplements that we give patients so they can have one big bulky bowel movement. And usually with that alone, patients will stop having leakage of the stool.

For prolapse, it's a little bit different because it's almost like a hernia in the vaginal region. And when it happens and it's very significant, there's not a lot patients can do. But to prevent it, clearly obesity or chronic cough, anything where you're putting a lot of strain in that pelvic floor would lead somebody to be more likely to develop it. So there are things that you can do behaviourally to try to prevent them from developing.

Melanie Cole (Host): What great advice, what an excellent guest you are. Thank you so much, Dr. Rodriguez, for joining us today. And Weill Cornell Medicine continues to see our patients in person, as well as through video visits and you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today's episode of Back To Health.

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