At The Forefront Live: Pelvic Health Disorders

Reproductive and urologic health can be a cause of concern for many women. And some of these conditions can be hard to discuss with your physician. Now, often, the topic of prolapses, incontinence, and public health is not discussed until a patient has already experienced symptoms. We will discuss these topics, take your questions, and much more coming up right now on At The Forefront Live.

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And remember, we're taking your questions for our experts live, so start typing. Also, we want to remind everyone that today's program is not designed to take the place of a visit with your physician. Joining us today is Dr. Dianne Glass and Dr. Shilpa Iyer Welcome to the program.

Thank you for having us.

Thank you.

So let's just get right to the questions. I'm sure we'll get quite a few from viewers, but we have a few that we wrote up in advance, so we'll ask those. And the first one is, what is prolapse and how does it occur?

Absolutely. So prolapse is just a relaxation of the support of the uterus and of the vagina. And so as those structures relax, you can have a descent of the uterus and the vaginal walls into the vagina, and in some cases, out through the opening of the vagina.

And I would imagine there's got to be a lot of pressure and discomfort associated with this, so people know that this is happening.

It depends. Sometimes, people will have a lower amount of prolapse and not really necessarily know. And if that's the case, that's not a problem. But as they start to have more advanced prolapse, people will experience a pressure in the vaginal area, sometimes they will notice a bulge, and sometimes people will describe it as the feeling like there's maybe a tampon stuck low in the vagina.

And then it's time to see your physician, obviously.

Absolutely. So, doctor Iyer, who is at risk to experience, say, pelvic prolapse and how common is this?

It's more common than we think. So 10% to 15% of women have surgery for prolapse every year. And that's just the tip of the iceberg because there are, additionally, a lot of women who don't have surgery for prolapse who have conservative office management. And then there's a lot of people who have prolapse and never see anyone about it or ever talk about it. So it's probably a lot more prevalent than we think.

And people at risk for prolapse. So any woman who's ever walked is at risk for prolapse because we're not designed well to stand upright. And so even women who have never had kids, who have never been pregnant are at risk for prolapse. People who've had pregnancies and had vaginal deliveries are at higher risk for prolapse than others.

People with connective tissue diseases are at higher risk than others. There's also some genetic component. Where there's a family history of prolapse, we think it's how the tissues are that you're more likely to prolapse if that's kind of in your family.

Sure. And we've discussed this on programs before, we kind of talked about it a little bit, that oftentimes, I think, that women if they have a physical issue they just figure they're going to work through it and a lot of times they don't go to see their physician. But this is another example where they should. If you do have an issue, you don't have to suffer through this. There is help and things that can be done.

Yes. So there is a lot that can be done for prolapse. And it's not something that you have to suffer in silence about. It's something that's very, very common. About 50% of women have some degree of prolapse. And so it is absolutely something that your gynecologist or your urogynecologyst has seen before. And there's a lot of different options for things that we can do to help take care of prolapse.

So we can do things ranging from pelvic floor exercises to help strengthen the pelvic floor musculature to reduce the symptoms of prolapse. You can place something inside the vagina like a pessary, which is just a vaginal support that sort of helps tent up the walls and helps tent up the uterus to relieve the symptoms of the prolapse. Or in some cases, we can actually do surgery to help correct the prolapse so that it is a problem that you don't have to deal with.

Yeah. So we're already getting questions from viewers, which is always great to see. We're excited what people want to participate and be involved. And we want encourage people just type in your questions. We'll get to as many as possible as we can in this half hour. Now, the first one is, thoughts on surgical adhesions as a cause for prolapse.

You know? It's kind of funny because surgical-- if you've had abdominal surgery, there's two types. Sometimes, the adhesions actually hold things up so you're less likely to have prolapse when things are less likely to fall down. That being said, if you've had a hysterectomy, you're at greater risk for things falling down again. And I think that's just because when we do hysterectomies, we take away some of those natural supports of the vagina.

Another question from a viewer, can prolapse also cause incontinence?

Prolapse absolutely can contribute to incontinence. The prolapse itself doesn't necessarily cause incontinence, but you sort of have a similar relaxation of the supports of the vagina. The bladder sits-- if you think of the vagina like a house with four walls and a roof, your uterus sits in the roof of the vagina and the bladder actually sits just in front of the wall of the vagina. So as you get relaxation of that bladder wall and it descends into the vagina and kind of towards the opening, the bladder is going with it.

And so you get less support of the urethra, which is all those mechanisms that help hold the bladder shut and keep you continent. But you also can sometimes have a kinking of that area, which makes it all the more difficult to empty your bladder.

And there are a lot of things that can be done for incontinence. So we're going to discuss. There was one on the list of questions, but since we're talking about it, if we can jump to that now.

Yeah, absolutely.

I think it's certainly appropriate. So, again, there is hope. So if you're suffering from this, there are things that can be done. Can you talk to us a little bit about that?

Yeah. I think the thing that people get confused with the most are the different types of incontinence. So there's the type of incontinence where everyone talks about it, and when you laugh you have to squeeze your leg shut and you pee on yourself, and I have this since I've delivered. So does Dr. Glass and a lot of our colleagues. And that's the one everybody talks about. And that stress incontinence. And that's due to a weak urethra.

So if you have your bladder and the urethra, which is the tube from the bladder to the outside, as you lose the support that doctor Glass was talking about, you catch it anymore, your urethra, so you go.

[COUGHS]

You used to be able to catch it.

So it actually moves?

But now you can't, so it's like.

[COUGHS]

You can't catch it, and that's why you leak.

Interesting.

And so that, we have the same kind of similar treatments, like pelvic floor physical therapy to strengthen those muscles, a pessary, which is the device that you can control yourself that goes in the vagina to keep more support underneath the urethra. And then we have procedures, very simple procedures that we could do to help with stress incontinence. Then there's urgent continence, which is different and a totally different beast.

So if you think about the bladder like a balloon, where stress incontinence is a problem with holding the balloon shut, urge incontinence is a problem with the balloon squeezing when it's not supposed to. And so with urge incontinence, you will often get that sense of, oh, I've really got to go and I can't make it to the bathroom. That's when people will rush off and a leak drops on the way, or in some patient's case can lose their entire bladder volume.

And so that is a completely different kind of incontinence and so we treat it in different ways. Often we will treat that with focusing on things that maybe make your bladder a little bit more irritable, so things like coffee, tea, alcohol, citrus, carbonation and spicy food, so a lot of the fun things in life will irritate your bladder and make it a little bit more sensitive. So kind of when you get a sunburn on your arm, how it's just a much more sensitive thing, it will make your bladder contract more than it should. So avoiding some of those things, that is a good first step. But we have medications. In some cases, we can do things like inject Botox into the bladder. We can also do electrical stimulation of the bladder so we have a lot of options.

So it is fascinating to me the diet is that big of a contributor to it.

Yeah.

That's interesting. So, again, I think, like you said, some of those are the fun things, but that's a fairly easy step that people can take to make a difference.

And also, knowledge is power, right? So it doesn't mean that just because your bladder is sensitive to coffee, that you can never have coffee. You just may say, I'm going to be out-- I'm going to go out shopping today and I would really like to make sure that I don't have to rush off to the bathroom, or I'm going to be out having dinner with friends, I want to be there for most of the dinner, not consciously running back and forth to the bathroom. And so you opt not to have it that day. But a day that you're going to be at home, then, yeah, for sure, no problem. Have as much coffee as you'd like.

Right. So we're still getting questions from our viewers, which is good. And we're kind of sensing a theme here now. The next one is, why do you leak when you're older? So does age have an impact? I'm guessing it does. And can you talk to us a little bit about that?

I probably there's different humps as to when people get incontinence. There's the right after delivery when I'm a young person, and then after menopause, about 10 years after menopause. And we think this really happens because as you get older, you lose the blood vessel supply, as you lose the estrogen to your bladder, your vagina, and your urethra, which is the tube from the bladder to the outside.

And then, losing the blood vessels, you also lose the nerves that control your bladder. So we know that as you get older, everybody who eats anything good at all has heart disease, diabetes contributes.

It's so said when you say it.

[LAUGHTER]

Sorry. But we all know that. We love our chocolates, OK? But that all contributes to losing blood vessel supply and nerve supply to your bladder. So that contributes to the urge incontinence or the leaking on the way to the bathroom or overactive bladder, where you're in the bathroom all the time, because that's really a nerve problem between your bladder and your brain. And as you get older and you lose your estrogen and you lose your good nerve connection, that becomes more of a problem. So that is associated with age.

Stress incontinence is similarly associated with age just because you've had more time to put pressure on those structures. So the older you get, the more times in your life you've been constipated, the more heavy things that you've picked up. And those tissues are wearing, out just like anywhere else in your body. You have your cartilage in your knees that's wearing out. And so you, again, kind of have trouble catching that urethra. And so when you cough and sneeze, you will tend to leak more as you get older.

That makes sense. More questions. Actually, this one's a comment. And I want to pass this along. He says, I love these ladies-- many exclamation marks-- amazing physicians-- many more exclamations marks and a big heart. So you have fans out there, so that's nice.

Maybe a nurse.

[LAUGHTER]

Question, does incontinence cause UTIs?

It's interesting because, unfortunately, I think that some people, there's some overlap. So about 10 years after menopause, as you lose the estrogen and the blood flow to your bladder, women tend to have more urinary tract infections. And I like to think about it like when you lose the estrogen to your bladder and you lose the blood supply, your own fighter cells can't get there to fight off those little small infections that you could have done when you were 20.

And also your bladder and your vagina is just more delicate, so you're more likely to let bacteria into the walls that cause those little infections. So those just happen kind of after you go through menopause. And that's a common thing. And we can treat those and prevent those very easily. So don't suffer with those.

When you have overactive bladder, there is some kind of research that's shown that when you have those little kind of contractions, like little spasms, like the Charlie horse in your bladder that Dr. Glass was talking about that you don't want, a little bit of urine in your urethra goes back into your bladder kind of every time that happens. And so with that, you're a little bit more likely to get bladder infections than if you didn't have that. But you could also just have bladder infections from losing estrogen over time.

Patients can also get bladder infections because patients with incontinence are wearing more pads, and so kind of having that dampness there all the time can contribute, as well.

Another question from a viewer. We're getting a lot, so this is excellent. Kind of a follow up question to the one we just had. So when you're a diabetic, can you get UTIs more often?

You absolutely can get UTIs more often as a diabetic. The main reason is actually that you have more sugar in your urine. And so diabetics, their body is trying to get rid of sugar in any way it can, and so it will put a lot of sugar into the urine. And so it contributes to urinary tract infections, also that sugar is going to contribute to yeast infections. But additionally, diabetics, as their disease progresses, are going to have more damage to the blood vessels, and so they have similarly a little bit less ability to fight off that bacteria when it does get there.

Yet another viewer question. Can pelvic disorders affect bowel movements?

Yes. It's different. There's different types of bowel movement problems. You have just constipation, old fashioned constipation, which is really common and can just wreak havoc on your poor pelvic floor. So the good solution to that is adding fiber to your diet, which could be in the form of fruits and vegetables, water, or a fiber supplement like Metafiber, Metamucil, any of those ones. Buy the cheapest one and go with it.

And then, if you're having a lot of constipation, those same nerves that are making it hard for your bowels to empty are the same nerves that are connected to your bladder. And they cross talk a lot. So if you have a lot of constipation, your overactive bladder is probably worse. So addressing the constipation will likely help your bladder, too because those nerves kind of go back and forth.

You can with constipation and prolapse actually have some issues with constipation from the prolapse. So going back to what I was saying about the vagina, kind of like a house with four walls and a roof, if that back wall is sagging into the vagina, the mechanics are not aligned anymore. So where your body was pushing and pushing the stool towards the opening of the anus, it's now kind of pushing it into this pocket.

And so, sometimes, patients will have that sense that they've had a bowel movement, but they feel like there's still something left, they can't quite get it completely out. And that is something that's very related to prolapse.

And can that cause issues down the road, then?

It is more uncomfortable than something that causes a health issue, but it makes it more difficult to have bowel movements and so patients are unhappy with that.

I have to do a plug for-- we have this Center for Pelvic Health and we work very closely with our couple of colorectal surgeons, who are specifically interested in pelvic floor. So if you have problems with both your bladder and your bowels, we all work in a team with our physical therapist, with our colorectal surgeons, and we address things together. So there's a lot of help out there.

Great. Couple more questions for our viewers. They are really coming in faster-- they're not allowing me to ask my questions. But that's good because your questions are better than mine, quite frankly. So this is good. Keep them coming. I like this one. Does lupus caused problems with pelvic health? Interesting.

Lupus is one of these autoimmune disorders. So I think when it causes problems with public health, what I've seen is there tends to be-- sometimes your body can fight itself, which is part of what lupus is. So sometimes patients with lupus have this thing called bladder pain which is really your body reacting to your bladder, that can cause pain, make you feel like you have to go to the bathroom all the time, also make you feel like you have a pressure, a bladder pressure. And then we can treat that too. That's kind of what I've seen with patients with lupus.

Another viewer question. How often should you do pelvic floor exercises? And I guess the follow up would be, what would that entail?

Well, I'll start with explaining what a pelvic floor exercise is. Most people know them as kegels. What you do is-- I tell people the easiest way to try and figure out how to do them is to sit down and urinate and while you're urinating, see if you can slow down the stream of urine. If you can slow it down, you've got the right muscles. Most women can't stop their stream of urine. I think that's a myth that a lot of people come in and they say, oh, I can't stop it anymore. Well, most women can't, so don't worry, you're in good company.

But if you can slow down the stream of urine, you have the right muscles. And then you do kegel exercises actually away from the toilet, so do not do them while you're urinating. So away from the toilet, you're going to squeeze those muscles and hold them for 10 seconds. Relax for 10 seconds, hold for 10 seconds, relax for 10 seconds. And I have patients do that in sets of 10.

Is just something you should do when you're sitting, standing?

You can do them in any position you like.

You can do them right now.

You can do them while walking. I could be kegeling and you never know.

Yeah. I'm kegeling right now.

[LAUGHTER]

But I have patients do 50 or 60 of them a day. And I tell patients the easiest way to remember doing them is every time you're done urinating, do 10 kegels. While you're washing your hands, getting your clothes back in order, you just do 10 kegels, and then it's just part of your day. It's not something you have to say, OK, tonight I'm going to do my kegels, because you never will.

It's just like any other muscle. You exercise it and you will build it up and you're in better shape.

Yeah. And the good thing about pelvic floor exercises is that they are helpful with most all pelvic floor disorders, they're helpful with prolapse, they're helping with stress incontinence, they're even helpful with overactive bladder because when you do those good strong kegels, it helps to cue the bladder itself to relax so that you're not having that same sort of kind of bladder contraction.

Another question from a viewer, and I probably will mispronounce this but I'll do my best, diastasis recti. Is that correct? Close? Can it be corrected?

I think that's more of a-- when you have this rectus diastasis, so sometimes what happens is when you're pregnant, your rectus muscles, which are your big abdominal muscles that kind of go up and down that are trying to hold things in, at some point they give way because they can't keep it in any longer, which is just normal. And sometimes that doesn't always go back together.

So that can be corrected. You can do exercises with a physical therapist, that can be corrected surgically. We don't usually do that but, it definitely can be done.

But I think patients have a lot of success with physical therapy, with exercise. And so if that is something that is bothersome for you, then I highly recommend mentioning it to either your gynecologist or primary care doctor and see if they can refer you.

We also work with pelvic floor physical therapists, so this is a new topic for a lot of people. And I have to say that these are physical therapists who work on the pelvic floor. So they work on the abdomen too, but these are ladies-- they're almost all women, although some men are pelvic floor physical therapists, they're specially trained to work on the pelvic floor muscles. They do put their fingers in people's vaginas, they help you locate all of your muscles, and they really work on it. I have never had one person go and say, OK, that didn't work for me. It is great.

It sounds like it would be an incredibly awkward experience.

I'm sure it is the first time.

But I will say that almost universally, my patients after they have seen the physical therapists say that they are incredible at making sure that you were comfortable with them and that they are comfortable with you, and everybody really feels like it was a good experience where they learned a lot and it has improved their health.

That's a common theme. Anytime I talk to people about other types of physical therapy, but we have some very, very fine professional physical therapists and accross the spectrum they do-- it's almost like miracles, it seems like.

Yeah. I am always impressed with the work they do.

It is really impressive. They're impressive people.

Another question from a viewer. Been doing kegels forever, any other options?

There are other options. So it depends on specifically what the problem is. So kegels are usually the first step in our treatment algorithm. So if you have a little bit of prolapse that's bothering you, people will do kegels to try and reduce the symptoms. And sometimes it doesn't work. So sometimes you do need to step to the next level on that algorithm, and you might need to use a pessary if that's appropriate for you, which is that vaginal support for prolapse. Or in many cases, women don't feel like that's something they want to do. And so perhaps that's somebody who might need to progress to surgery.

Somebody with stress incontinence that's been doing kegels may need to do that next step and choose to either do a use a pessary to help support the urethra or move to a small procedure to help correct that stress incontinence. And with overactive bladder, it's helpful and can be good in the beginning and is great for many people, but other patients need to do things like progress to a medication, or potentially progress to using a Botox injection in the bladder. So if your kegels aren't getting the job done, definitely see somebody because there are excellent steps that can be taken.

Along the same lines, another viewer wrote in, yoga has a sequence for pelvic health, have you practiced it? Do you think it works?

I have not practiced it, but I've heard about it from some patients. And I think what yoga really improves is your core body strength, which is generally your abdominal muscles, and it helps you hold your body correctly or in a more upright fashion.

Which is not a bad thing.

Which is always a great thing. And by improving your core muscles, you also improve your pelvic floor muscles. And this is what our pelvic floor therapists also work on, they work on both the core abdominal muscles as well as the pelvic floor.

And so I certainly think that that's beneficial. It's not something that you should shy away from. Exercise in general is beneficial, but I think bringing your attention to your pelvic floor is very helpful and is not something that a lot of women have ever really thought much about.

Well, I like this one. Do you only see patients in Hyde Park?

No. We see oceans all over the place.

No. Everywhere.

Exactly.

I see patients downtown in Streeterville at 680 Lake Shore. I see patients also in Indiana and Chareville, So we have quite a wide range.

I see patients in here at the main Hyde Park location, as well as in Orlean Park and in Hinsdale. And we have partners that go to these locations, as well as Silver Cross, one of our partners goes there.

And if you look at the bottom of the screen right now, you can go to UChicagoMedicine.org or call the number 888-824-0200, and that's how we can work to get you an appointment with either of you or somebody like you that can be very helpful. So it's great. Another question from a viewer. What age should I expect menopause? We're getting a little bit of a different--

Little bit of a difference. The average age for menopause is about 55, give or take a little, maybe a little bit younger than that. A good indicator for when you might go through menopause is when your mother, your aunt kind of family members went through menopause. Usually in mid to late 50s.

If prolapse is untreated, what can occur? What are the dangers of that?

I think there's a bunch of people who come to us and they have prolapse. And we don't have crystal balls yet, so we don't know if it's going to get a lot worse, if it's going to get better. So on average, when we look at our national data, about 40% gets worse, 40% stays the same, and very, very rarely it gets better.

And I think the people who get better as they get older and older and things tend to suck in a little bit. And those are the people who prolapse gets a little bit better. But most people stay the same or get worse, and we don't really know who those people are or we can't really predict it. You're going to be one of those people that gets worse or better.

If you don't want to do anything about prolapse, we generally can watch prolapse and the only time we do something about it is if we think that-- let's evaluate your kidneys and make sure that you're able to empty your bladder well and that the urine isn't going back up to your kidneys and damaging that. And sometimes we do kidney ultrasounds just to make sure that things are normal.

The other time that we would want to do something about it is if you keep getting bladder infections and we think that emptying your bladder is a problem and that's why you're getting infections. And so then we would probably recommend something like a pessary or something like that to help you empty your bladder more so you don't get infections. But otherwise we could just watch it.

Yeah. What I usually tell my patients is, as soon as it bothers you is when it's time to do something about it. Because I'll have patients who are kind of on the reverse of the spectrum coming in, they're like, well, it's not that bad, but it really bothers me, I feel it all the time and I really dislike it. And so it's reasonable to do something both early and late on the spectrum, depending on kind of what your personal preference is.

And we have different options for the whole spectrum. A lot of people think like, oh, I've got to take care of this now because I'm going to be too old later to take care of it, and that's just not true. We have a variety of treatment options. Even now, when we talked about surgery, we have many different ways of doing surgery and we can find one that's right for you.

I've had many patients well into their 90s that I've done surgical things for.

And again, the key here is to always encourage people, you don't have to suffer in silence, there are things that can be done and people who can help you. So that's the best way to go. Another question from a viewer. Are there alternative procedures for us to stop cystoscopy? Cannot pronounce that, but you know what I'm trying to say.

So what cystoscopy is, for those of you who aren't familiar if it, is you take a very small camera and it goes through the urethra and looks into the bladder. So the people who have cystoscopies, seemingly most often, I think, are probably men and they will tell you it was a horrific experience. I don't think it's quite horrific, but for women it's a much easier thing to have done. So a woman's urethra is about 4 centimeters long.

So it's similar to having a catheter put in. So if you've ever experienced that, it's not something that is particularly uncomfortable. We do it for patients when they're awake. When we look inside the bladder, we actually get a really good sense of what the surface of the bladder looks like and that tissue is really thin, and so it's not something that is imaged particularly well. So doing ultrasounds or doing CAT scans doesn't really tell us the same information as looking inside with a cystoscope. And so I would highly recommend a cystoscopy when your physician is telling you that that's what they need because there's really not a good replacement for it.

We've only got a couple minutes left, but I wanted to see if you could share something about your research on pelvic organ prolapse.

We have a lot of research going on. That's exciting. We have two trials we're enrolling in for overactive bladder. So one of our studies is, there's a lot of people who have overactive bladder, meaning going to the bathroom too frequently and when they don't want to and leaking on the way to the bathroom. And we try the dietary stuff that doctor Glass talked about, as well as medications that worked on those nerves to the bladder.

And then we have a bunch of other therapies, like the one doctor Glass talked about, like Botox in the bladder, electrical stimulation and acupuncture, the electrical one, pacemaker stimulation. And very few people go on to that next level, even those that are suffering that medications are working on. So we're now doing kind of interviews and surveys as to why people aren't progressing.

We also have a new therapy and we're going to be involved in this FDA trial that's coming up, we'll start for a new bladder therapy for people who fail medications and diet for overactive bladder as well, and we'll probably start that by the end of the Summer, we'll get everything going. And then we have interesting work. We're collaborating with some of our minimally invasive surgeons on fibroids and type of prolapse and race, as we see it a clinical difference. And there's not that much data out there on that. So that's kind of a new study we'll be starting this Summer too. And then, doctor Glass is involved in very exciting research, too.

I am involved with a multi-center regenerative engineering consortium. And we're trying to look at ways to regenerate bladder tissue, as well as muscle tissue to help with stress incontinence. And so it's very exciting research as well.

A lot going on. But it's good stuff. So you guys were great. Thank you very much.

Thank you.

Appreciate you being on the program.

I had a good time.

And thank for watching. That's all the time we have for the program. I want to thank all of you for your excellent questions, which were very good. To learn more, please visit our website site at UChicagoMed.org or you can call 888-824-0200 to schedule an appointment. Also be sure to keep checking up on our Facebook page for updates on future At The Forefront Live programs. Thanks for watching. I hope you have a great week.