Melanie Cole, MS (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 to discuss bladder and pelvic floor health as women age is Dr. Larissa Rodriguez. She's the Urologist-in-Chief at New York-Presbyterian Hospital/Weill Cornell Medical Center and the Chair of Urology at Weill Cornell Medical College Cornell University. Dr. Rodriguez, thank you so much for joining us today. I'd like you to speak a little bit about pelvic floor disorders, the different types that you see, how common they are. And do you think that women specifically underreport them, because they're hesitant to discuss them because they're not always pleasant to discuss?

Dr. Larissa Rodriguez: Hi, Melanie. Thank you very much for having me today. This is a subject that I love talking about because, yes, the answer to your questions is yes, yes, and yes. Pelvic floor disorders affect about one in five women, one in four to five women, really, so it's really quite common. About 25-35% of women will have a pelvic floor disorder that will need treatment. The prevalence is probably a little bit higher, but not all of the individuals that suffer from them will need treatment.

There are different types, you know, the pelvic floor is a collection of muscles that they form almost like a ball and it sustains all the pelvic organs in place. Those organs are the bladder and the urethra, which is the tube people urinate through; the vagina and the uterus as well as the rectum. So, the rectum, the vagina, and the urethra all go through this collection of muscles to the outside world. So, the function of this muscles are essential to the sexual function, to defecation as well as to urination. So, pelvic floor disorder is kind of our collection of syndromes that can affect urinary continence, really incontinence, some sexual dysfunction or prolapse or things that fall into the vagina that we can discuss a little bit more in a second, as well as fecal incontinence.

Prolapse are like hernias. As people get hernias in the abdomen that are covered by skin, but there's like an outpouching of an organ that is protruding through, the same thing can happen at the level of the vagina. So, these organs that I just mentioned can herniate into the vaginal canal, creating kind of a bulge or discomfort, and that's why we call it prolapse. So, the bladder can fall down, the uterus can fall down, or the rectum can fall in into the vagina. These are called cystocele if it's the bladder, uterine prolapse or rectocele if it's the rectum.

A lot of women don't report these. There are many reasons for this. You know, it is shameful or some people feel that it is shameful to have urinary or fecal incontinence. They're not aware of how common they are and how many of their peers or relatives might have the same condition, because nobody has really spoken about it. So, it's not one of those things that mothers talk to children and that is accepted in a family setting. Some people think that it's part of aging and this is something they have to deal with in silence. And often, doctors don't have the time in a routine visit to really inquire about these conditions. So, a woman are left with suffering from this, thinking that it's part of aging or one of those things that happen to women as we get older, and that there's nothing to be done about it, so why bring it up?

Melanie Cole, MS: Well, I'm glad and thank you for mentioning that it's not necessarily a normal part of aging and that it's not embarrassing to speak to your doctor about that. I'd like you to speak a little bit about symptoms that we might notice as a woman ages, whether it's something that's happened right after a pregnancy and maybe we pee a little when we cough or laugh or something that's happening to an older woman along those same lines and what you've been discussing. Tell us some of the symptoms that we might notice that would signal it's time to visit a physician and talk about this.

Dr. Larissa Rodriguez: So, pregnancy and vaginal delivery is an important risk factor for developing these conditions. But when women are younger, with estrogen in our bodies, with tissues being a little bit stronger, women can compensate and they might have symptoms around the time of delivery, they might have very mild symptoms, and they learn to deal with them. As women get older and estrogen leaves our body, there's a lot of estrogen receptors in the pelvic floor and the bladder and the urethra, as well as tissues getting more lax, these symptoms become more and more severe. And they are related to these organs that we discussed. So if it's the urinary tract, it's usually incontinence of urine, and this can happen because people don't make it to the bathroom on time. We call that urge incontinence, so with a feeling of urgency to go, but you can't quite make it on time, or stress urinary incontinence when you leak urine, when you cough, sneeze, lift something heavy, jump up and down, or any increases in abdominal pressure, severe constipation or defecatory dysfunction or fecal incontinence, where it's similarly related to urge or with stress maneuvers, people might lose small amount or larger amount of stool. And prolapse is feeling of having a bulge or pressure or kind of a mass in the vaginal canal that sometimes can protrude outside the vaginal canal, making it really uncomfortable for a woman to walk, to sit, to have normal activities of their daily life, because of the discomfort of these conditions.

People should seek medical care when they're bothered by these conditions, when they're affecting their quality of life. And quality of life is kind of a subjective measure. So, it really depends on the patient. But if they're keeping you from going to a movie theater, because you're afraid that you cannot sit through a movie and therefore you're withdrawing socially from things you want to do; if you are afraid to be sitting or staying, spending the night at your adult kids homes because you're afraid you're going to wet the bed or that you're going to need to go to the bathroom and the bathroom might not be available to you; if you are restraining yourself from exercise, from doing things that are good for your health, but that you don't want to do because you're afraid you might lose stool or urine; or if you're really in pain, discomfort, pressure, uncomfortable, you definitely should seek care. That's probably a time. These things definitely need to be treated. But it is not unreasonable to seek care earlier when there might be things that you can do to prevent them from getting to the point when you might need a surgical correction.

Melanie Cole, MS: Well then, let's talk about some of the non surgical treatments first for pelvic floor issues. We're hearing more and more about pelvic floor physical therapy, which is something we didn't know about decades ago. And we've heard about Kegels and what those can help do to strengthen because it is a muscle. Speak about some of the non-surgical treatments that you might try and recommend for women that are starting with some of these symptoms.

Dr. Larissa Rodriguez: So, I think pelvic floor physical therapy is extremely useful. It depends on having a good a physical therapist and it depends on having a good patient, meaning a compliant patient that is motivated to do these exercises. Kegels are a form of exercise in the pelvic floor. The pelvic floor is what we call a voluntary muscle, just like your arm or legs, meaning you can activate it, you can deactivate it. Having said that, not everybody knows how to activate it or deactivate it because we're not consciously, throughout our lives, using that muscle. So, some people don't even know where it is and don't know how to use it. So, part of working with a therapist is first to identify and learn how to control it. Once you know how to control it and activate it, then it's to do a certain amount of exercises, just like any other muscle in your body, to make it stronger. By making that muscle stronger, you can help or improve symptoms of fecal and urinary incontinence. And for some individuals, learning how to relax that muscle is necessary to have more complete bowel movements, to void more to completion, and to avoid pain with intercourse. So, both relaxation of the muscle and strengthening of the muscle is important for different functions related to the organs that we have discussed.

Kegel exercises is a form of doing some of those exercises at home. The trick with Kegel exercises is that they're great if you know how to isolate that muscle and use it. And even though a lot of women think they know how to use that muscle, it's amazing how many women really do not. You know, you're not supposed to contract your bottom. You're not supposed to contract your abdomen. It's really an isolated muscle in the pelvis. It's like a contraction of the vagina, what you do when you stop your stream when you're urinating. That movement that you do when all of a sudden somebody opens the door and you have to stop the stream, that is a Kegel exercise. And for some people, they are able to do that, but for a lot, a lot of people, they cannot do that unless they're taught how to do that. So that's where I think having a good physical therapy comes to mind.

You know, what I tell my patients is there's a difference between me saying, "Hey, go exercise and come back in three months," or "Let me give you a personal trainer and a gym, and you come back in three months." You know, the outcomes are going to be a lot better if you work with a physical therapist. But what's important is that you exercise. So, it's the same with the pelvic floor.

 There's some behavioral things that people can learn as well in terms of how much people drink as an example, for the urinary tract. You want to drink enough to stay healthy, but not so much that you're producing urine at such a fast rate that your incontinence is going to be difficult to manage. There are things that are very irritating to the urinary tract, like coffee, caffeinated fluids, tea, some of the caffeinated teas as well as alcohol that are kind of like having a water pill or a diuretic so it makes you produce urine at a very fast rate and worsen symptoms of incontinence.

People who have leakage of stool, we want to keep the bowel movements regular. If you're very constipated, although it's counterintuitive, people can leak stool because theyre never emptying their rectum. They always have stool behind so they can smear continuously. You don't want to have diarrhea either. So, it's important to be in a regimen where you have normal bowel movements and completely empty your rectum to help you with those symptoms. So, there's some behavioral things you can do and some kind of exercise things you can do that are all conservative treatments.

Melanie Cole, MS: Thank you for that. You've given us such great advice. Now, can you tell us a little bit about some of the interventional treatments for pelvic issues? Where do surgical interventions fit in and what are some of those options that are available today?

Dr. Larissa Rodriguez: If a patient has tried behavioral modification and they have tried pelvic floor physical therapy, and they're still bothered by their symptoms, or they're improved, but not to a level where they feel their quality of life is where they want it to be, then we start thinking about, you know, other interventions. And these interventions are different depending on the condition.

So for urinary incontinence of urgency, the medications can be quite effective. They're really newer and safe medications that you can take once a day that they relax the bladder so people don't have urgency and they don't leak on the way to the bathroom because they have urgency. If people fail medications, there are what we call third-line treatments, which usually involve some way of modulating the nerves that go to the bladder. Believe it or not, injecting Botox in the bladder can be quite effective for some patients. It kind of relaxes the bladder so people don't have spasms of the bladder muscle. It wears off, and people usually need a treatment once a year, and it's very simple to do.

There are other forms of neuromodulation, almost like acupuncture, in a nerve that goes by the ankle, that is a branch of a nerve in the bladder, it's called the tibial nerve. There are ways of modulating the nerves more directly that leave the spinal cord in the sacrum and modulate the nerves to the bladder.

For leakage with coughing and sneezing, what we call stress incontinence, we don't have medications. So if somebody has failed conservative management and pelvic floor physical therapy, usually it is either a filler just like people use fillers for wrinkles in the face. Those bulking agents can be placed in the urethra. It takes about 15 minutes. And what you do is pretty much bulk the urethra so that there's increased resistance so that people are less likely to leak with exercise or any increases in abdominal pressure, or simple, minimally invasive surgeries that usually involve putting a sling or a material underneath the urethra. These surgeries can be quite effective and durable and allows patients to run, to do all kinds of activity without leaking urine.

For fecal incontinence, as I said, a lot of treatment has to do with managing the consistency of the bowel and the bowel movements, and a lot of that can be done with dietary modifications, sometimes with bulking agents of fiber. But patients feel that this form of neuromodulation that we use for the bladder can also be quite effective for fecal incontinence as well.

Prolapse is different. So if somebody has failed physical therapy when they have mild prolapse, so the prolapse is so advanced that it's really affecting their quality of life, there are really two options. You either put a pessary. A pessary is like a plastic material. It looks like a diaphragm. The old diaphragm people use for contraception. And what that does is that it pushes the organ in the vagina back to where it belongs so you don't have the symptom. It doesn't you cure it, but it gives people relief and helps them avoid surgery. Or you can have a surgical procedure to fix whatever it is that's falling down, if it's the bladder, the uterus, or the rectum. We can do that robotically or laparoscopically when patients have minimal discomfort and recuperate quite fast. We can do the transvaginally without having to cut into the abdomen at all. We seldom, or almost never, will do an abdominal procedure for this. So, the surgeries tend to be either vaginally or laparoscopic so that woman have less discomfort after surgery and can recuperate faster.

Melanie Cole, MS: Dr. Rodriguez, this has been such an interesting episode. You've given us so much to think about and so many options for treatments for women that are suffering from pelvic floor disorders. I'd like you to summarize by offering your best advice about being our own best health advocate and seeking help when we need it.

Dr. Larissa Rodriguez: I think my best advice to a woman is to feel empowered. Empowered about your body and about your health, to know that this is not a normal part of aging and there's no reason to suffer in silence, that you're entitled to treatment and you're entitled to your quality of life, that just because other people might not talk about it doesn't mean that they're not suffering from this and to know that you're really not alone suffering from these conditions, that they're incredibly common and prevalent.

So that if you feel you're suffering from any of these things that we talked about, you should seek care. Care exists, and it can be very effective and you deserve it. I know as women, women take care a lot of others, but there comes a time that women can take care of themselves. Yes, these conditions are not going to kill you, but you deserve to have the quality of life that you want and you deserve.

The other advice that I would have is that starting doing pelvic floor exercises at home maybe before having a baby or vaginal delivery or immediately after our delivery might be ways for us to try to prevent some of these conditions to affect you in the future. And if you have children or if you're yourself a young woman, it's something to consider telling your daughters about or doing yourself doing pelvic floor exercises earlier rather than after these conditions have developed.

Melanie Cole, MS: Thank you so much for joining us today, Dr. Rodriguez, and sharing your incredible expertise for women. 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. We'd like to invite our audience to download, subscribe, rate, and review Back to Health on Apple Podcasts, Spotify, iHeart, and Pandora. And for more health tips, please visit weillcornell.Org and search podcasts. So many great ones there. And parents don't forget to check out our kids healthcast. I'm Melanie Cole. Thanks so much for joining us today.

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