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Adoring Your Pelvic Floor From Drips to Dry - Conquering Female Urinary Leakage and Menopausal Dryness

Join Dr. Croak and Karen Liberi as they discuss how to adore your pelvic floor as women age. They will address many common questions from patients and various treatment options as well.
Adoring Your Pelvic Floor From Drips to Dry - Conquering Female Urinary Leakage and Menopausal Dryness
Featured Speaker:
Karen Liberi, MS, MPT, WCS | Dr. Andrew Croak, D.O., M.S., F.A.C.O.O.G.
Karen Liberi is one of only 300 physical therapists in the United States with the designation of Women’s Health Clinical Specialist. She is committed to educating health care providers and community members alike about the importance of addressing the often neglected area of the body between the belly button and the upper thighs. Pre-natal and post-partum care are also of utmost importance in setting the stage for good pelvic floor health throughout a women’s lifetime. Just as a hip, knee, or back would need rehabilitation after a trauma or injury, the pelvic floor will need rehabilitation after child-birth to restore its normal function and help to prevent any number of pelvic floor dysfunctions later in life including bladder/bowel incontinence, prolapse, and pelvic pain.

Learn more about Karen Liberi 

A new pain here, some urinary leakage there. Part of a woman’s life, right? Wrong. When it comes to pelvic pain or incontinence, Dr. Andrew Croak knows this discomfort is often more troublesome than a woman wants to admit and knows how to effectively help problems like persistent pelvic pain, bladder and bowel control, and prolapse (descent of pelvic organs). Dr. Croak is the director of the Center and is a Urogynecologist. This term describes an Obstetrician/Gynecologist who completes additional training to care for women with complex problems related to pelvic health. There are few of these specialists in the country. To become one, Dr. Croak studied long and hard at the Mayo Clinic, one of the top clinics in the world. At Mayo, he gained world-class, state-of-the-art technical skills. Dr. Croak’s most important medical skill is one he already had – how to listen. When you visit him for your urogynecology service, you can trust that we will listen to your concerns and provide you with answers to every question.

Learn more about Dr. Andrew Croak 


Maggie McKay (Host): If you are in the throes of menopause, you may already know that dryness and urinary leakage just come with the territory, but there is good news. There are ways to treat those annoying side effects and get back to the things you enjoy. Today, we'll learn more about adoring your pelvic floor from drips to dry, and how to conquer leakage and dryness.

Joining us is Dr. Andrew Croak, Urogynecologist and President of Northwest Ohio Center for Urogynecology and Women's Health and Karen Liberi, Physical Therapist at Northwest Ohio Center for Pelvic Rehab. This is Top Docs Podcast. I'm Maggie McKay. Thank you so much for being here. Can you please introduce yourselves, Dr. Croak, we'll start with you.

Andrew Croak, D.O., M.S., F.A.C.O.O.G.: Hello, my name is Dr. Andrew Croak. I'm a Board Certified Fellowship Trained Urogynecologist.

Host: And Karen.

Karen Liberi, MS, MPT, WCS: Hi, my name is Karen Liberi, and I am a Board Certified Pelvic Floor Physical Therapist.

Host: Well, let's dive right in cause there's a lot to cover today. What are some of the things that happen to women's pelvic floor as they age Dr. Croak?

Andrew Croak, D.O., M.S., F.A.C.O.O.G.: Sure. We always kindly kid with our patients that their children should give them flowers on Mother's Day because during childbirth in particular, it can really wreak havoc on the pelvic floor. Menopause also can be a bad culprit in weakening the pelvic floor over time. Two of the biggest things that we take care of or treat are incontinence and menopausal atrophy or dryness of the intimate tissues.

Host: And Karen.

Karen Liberi, MS, MPT, WCS: So I always talk to my patient about the pelvic floor as being a reflection of all the experiences that it has had over time. So as we age, we look back to, whether it be sports injuries or as Dr. Croak has alluded to childbirth, or if they have a job that requires a lot of heavy lifting and on their feet all day. Chronic cough, constipation. So there's many things that are going to contribute to the dysfunction of the pelvic floor over time. So as we age, that may reveal some of that dysfunction, which is where they come in for physical therapy to be helped with that.

Host: I never even thought of all those other things. Like you said, there's such a long list throughout your life. Who knew? That's why we're here to learn. Dr. Croak, besides medication, what are some of the ways you as a urogynecologist can address urinary incontinence?

Andrew Croak, D.O., M.S., F.A.C.O.O.G.: Sure. Well, I think most urogynecologists and pelvic floor specialists will have an array of tools in their toolbox. We like to give our patients lots of choices. Everything from lifestyle modifications to medicines to fantastic pelvic floor therapy that folks like Karen provide, but sometimes we need to move to second or third line therapies.

And in particular for incontinence, we have two types of incontinence, stress incontinence or that laugh, sneeze, cough, leakage, and we have a wonderful treatment that bulks or plumps up the cushions of the inner urethral tube to help cut down on leakage. So think of plumping up a celebrity's lips on Oscar night, except we are doing it for the urethra to help cut down on leakage.

The other type of leakage is urge, incontinence, and that's that gotta go, can't make it to the bathroom, or I have a cup of coffee and I have to excuse myself 10 times in an hour. And for that procedure, medicines are not always helpful and especially older patients they aren't necessarily the safest to take.

So we have a wonderful therapy. Think of it as like a pacemaker for the bladder. It's a small, little implantable neurostimulator that helps to calm and settle down the bladder so that women can take better control of their lives. These pacemakers, particularly from companies like Axonics or Medtronic, they have about a 10 to 12 year lifespan, so they're quite durable and long lasting, and they can be controlled remotely with a little key fob remote. So if you're traveling and you know you can't visit every restroom on the turnpike, you can dial up the remote and if you're at home in the comfort of your bed, you can dial it down. So it's fantastic therapy.

Now for vaginal atrophy or that dryness, we have a remarkable technology called the Mona Lisa Touch, and that is a CO2 based laser. No different than many folks use on their face for wrinkles and crow's feet, but it helps to rejuvenate or revive very dry, frail tissue by bringing in better moisture, glycolic acid through reconstruction of the skin tissues and on the cellular level, and it's an outpatient treatment. There's really no downtime as with the bulk, the mid- urethral bulking, and quite frankly, the neuro stimulator is very well tolerated and minimally invasive. So all three of these therapies are quite life changing and for the long term with minimal downtime and minimal risk to the patient.

Host: That is amazing. I'm still back at the remote control. That's so Jetsons. When it comes to your health. Oh my goodness. That's so great for people who need it. That's amazing. Doctor, you also mentioned that women can experience vaginal dryness and you talked a little bit about Mona Lisa Touch laser. How does it help with that?

Andrew Croak, D.O., M.S., F.A.C.O.O.G.: Sure. Well, we have been doing this procedure for almost 10 years now and we have a population of well over 700 to 800 women that have been treated with the three treatment course. They often achieve 80 to 90% improvement that lasts a year and longer, sometimes they will come back for an occasional treatment, but the laser itself is an aconical probe and we rotate that probe inside of the vaginal canal and it emits a very gentle laser that superficially heat treats the lining of the skin.

And by doing that, you're causing microthermal regrowth of the cells. We're bringing in better blood supply, glycolic acid, collagen, and that helps to decrease that painful sensitivity or that dry burning feeling that many women will experience. So it's not uncommon that we've had women that are very drastically miserable; then after treatment, they're able to be intimate for the first time in several years with their partners. And we see depression scores fall dramatically and they stop having to use their estrogen creams and because it stabilizes the bladder floor, we often see improvement in urgency and frequency.

So one patient said she was able to save over $4,000 off of her overactive bladder medicine by using the laser, so it's quite effective.

Host: That is amazing. How often do you have to do it? Or is it just a one time thing for life?

Andrew Croak, D.O., M.S., F.A.C.O.O.G.: The three treatment course often is just a one-time treatment, but many women will come back in, once or twice a year for a one-time touchup. Now the important thing to remember is that although it's not in an insurance approved or an insurance reimbursable procedure, the money that is saved and the value that is created for the patient often greatly exceeds the cost of the laser treatment, which in our locale is very, very affordable.

We have dozens of women that fly in from New York City, Chicago, Miami, Florida, Detroit because the price of the plane ticket and the hotel stay and the laser treatment is cheaper and more affordable than what they can get in their own city. So right now, we have held our price steady at a very affordable $2,100 for the treatments, and that's obviously a subject based on the market, but we offer discounts and specials such as a Mom and Mother's Day, or spring into April, where we really give discounted prices.

And we work with patients that have tight budgets because it is the hardworking woman that does have a budget to consider, that is signing up for this procedure. It isn't considered a fluff procedure or a vanity type procedure necessarily. We're really changing lives and improving people's health here.

Host: It sounds like it, and I love that you don't gouge them. You may be the only one in the nation that hasn't raised your prices since the pandemic . Oh my goodness.

Andrew Croak, D.O., M.S., F.A.C.O.O.G.: Yeah, we've tried to be sensitive to that. Yes.

Host: Good for you. Well, Karen, talk to me about pelvic floor physical therapy. How can that help with incontinence and pelvic floor dysfunction?

Karen Liberi, MS, MPT, WCS: Sure. So whenever our patients come in for pelvic floor physical therapy, they kind of come in with a questioning look of how can physical therapy help with my bladder? Which is a very fair question. So, more than half of our time is spent on education, on the roles and the jobs of the pelvic floor because they do have jobs to help to support our bladder, support our bowel, and support with sexual function.

And as we start t o tease all of that out with all of their symptoms that they're coming in with, they start to see the relationships between their bladder, bowel, and sexual dysfunction. And they start to say things like, Karen, I've done kegels for my whole life, but I still have leakage when I cough. And I'll say, okay, but do you kegel as you cough?

And they say, no. So once I kind of educate them about their pressure system and how the pressure from above, if that's greater than what your little pelvic floor can do from below, then you're gonna leak. So if we can really try to time that and improve your coordination, then that will help to keep you dry.

And then in terms of the urge incontinence that Dr. Croak has alluded to as well, there's a lot of like easy tips and tricks that should help them to be able to stay dry and be able to make it to the bathroom on time once we educate them on some training techniques to help to calm that pelvic floor and then kind of take them away from that as Dr. Croak alluded to like the getting home like the key and lock syndrome, as soon as you get home, oh my gosh, it feels like I have to pee. That is a learned response and if we can unlearn that response through some physical therapy techniques, it's amazing how quickly women can turn that around and are thrilled and disappointed at the same time that, that it happened so quickly that there was improvement.

And they're so sad that they hadn't gotten treatment years earlier. So a lot of what pelvic floor therapy does is educate so patients have a really good understanding of what's happening and why, so that they can start to put the pieces together. And then the exercises that we are giving them and strategies that we're giving them really catapult them forward to be able to achieve what they want, which is to be more dry.

Host: And Karen, what do you feel differentiates your private practice from the hospital owned practices in the Northwest Ohio area?

Karen Liberi, MS, MPT, WCS: Yes, I am very blessed to be working with Dr. Croak because I am able to treat the patients as I see fit. So I am able to have one-on-one time for an hour and a half with my patients to go through their entire history and really put the pieces together for them. And then we see them for one hour follow up visit.

So it's always one-on-one with a physical therapist or a physical therapist assistant. And we're all specialty trained and I also have the time to reach out to the community. So I, I feel that because we're independent, I have that really great relationship with my patients, but then can also reach beyond our walls and look to the community and be able to connect them with others in the community that might be able to help out with their care.

Host: And what do you feel differentiates your private practice Dr. Croak?

Andrew Croak, D.O., M.S., F.A.C.O.O.G.: Sure. You know, I am blessed as well. We really have tailored our practice and have such a excellent staff that really believes in that independent spirit of medicine and really looking out for the patient and the patient's best interests. Time is not a factor. We don't have the pressures of seeing so many patients a day or being told you have to keep up with the quota, so to speak.

And I have a staff that really, they take initiative and they take pride in what they do, and it really shows because of that independent spirit. And you can't pin it on one thing, but you know, my father recently passed away and he was a gynecologic surgeon for 33 years and he exuded that energy and that spirit and you know, so many neat stories of him delivering a baby in his office and running it across the field to the hospital. Remarkable stories like that I think hold true to our practice. We have had similar types of crazy situations, that we tend to with our patients. And, I think the care that we show, really gives our patients hope and it makes our patients feel safe, and well taken care of. And we hope to continue that for a long time.

Host: I'm sorry about your father. He sounds like a wonderful doctor. Yeah. Very personable.

Andrew Croak, D.O., M.S., F.A.C.O.O.G.: He was.

Host: I bet. Thank you both for sharing all this invaluable information and giving women hope. I think that is a key word here. Like you just said, Dr. Croak, that they don't have to just live with certain consequences of menopause, you can do something about it.

So if someone would like to find out more about this or make an appointment with you, where would they go Dr. Croak?

Andrew Croak, D.O., M.S., F.A.C.O.O.G.: Sure. So you may call 419-893-7134. That is the Center for Urogynecology's office number, and please look us up on the web at www. or you can just Google Andrew Croak or Karen Liberi, and we will pop up in a respectful forum.

Host: Perfect. Karen, do you have any other added information?

Karen Liberi, MS, MPT, WCS: Yes. So in order to make an appointment with physical therapy, the phone number is actually the same 419-893-7134, and we are option five. And then our website is

Host: Thank you both so much for your time. I know you're both extremely busy and we appreciate you being here. Again, that's Dr. Andrew Croak and Karen Liberi. If you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Top Docs podcast. I'm Maggie McKay. Thanks for listening.