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Below the Belt: You and Your Pelvic Health Christina Lewicky-Gaupp, MD Assistant Professor Associate Residency Program Director Medical Director, PEAPOD.

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Presentation on theme: "Below the Belt: You and Your Pelvic Health Christina Lewicky-Gaupp, MD Assistant Professor Associate Residency Program Director Medical Director, PEAPOD."— Presentation transcript:

1 Below the Belt: You and Your Pelvic Health Christina Lewicky-Gaupp, MD Assistant Professor Associate Residency Program Director Medical Director, PEAPOD clinic Department of Obstetrics and Gynecology Division of Female Pelvic Medicine and Reconstructive Surgery Northwestern University Feinberg School of Medicine

2 What is Female Pelvic Medicine and Reconstructive Surgery? 4 year OB/GYN Residency 3 year Urogynecology Fellowship! Some Urology + some Gynecology “Leaks and Bulges” –Pelvic Floor

3 What is “The Pelvic Floor” Muscles in the walls of the pelvis Keep organs in place Prevent urine and stool from leaking Must relax for child birth

4 What are Pelvic Floor Disorders? Pelvic Organ Prolapse Constipation and Fecal Incontinence Female Sexual Dysfunction Urinary Incontinence

5 How Common are Pelvic Floor Disorders? 1/9 women: surgery –1/4 women more than 1 surgery 25 to 50% of women will have incontinence of urine during their lifetime 5% of women will have bowel incontinence

6 One Soldier Field Unit 350,000

7 DeLancey Which types are common? Surgical Procedures/year Bulges 200,000 (78%) Urine Incontinence 80,000 (21%) Bowel Incontinence 4,000 (1%) Nat’l Center Hlth Stats 2006 Boyles AJOG 2003;188:108 Boyles AJOG 2003;189:70

8 Why is Vaginal Delivery Important in Pelvic Floor Disorders?

9 DeLancey Injury Rates for Athletics and Vaginal Birth *2006 NCAA Data & Kearney, Obstet Gynecol 2006;107:144-9

10 DeLancey

11 Birth Simulation

12 More Babies = More Bulges & Leaks

13 Key Question: What happens during birth that causes these problems later in life? 29 years old 60 years old

14 What Tears?

15 Muscles Tear DeLancey, et al. Obstet Gynecol, Feb, 2007 Looked at women with prolapse vs. women without prolapse All bulges were at least 1 cm outside the vagina None of the women had previous surgery

16 Major Pelvic MuscleTears 7.3 times MORE LIKELY to bulge or leak!!!!

17 Not all Women are the Same

18 What do Women Perceive? “I was moving furniture and felt a sudden bulge.'" "I was riding the tractor one day, bouncing up and down, and the bulge was there that night.“ "My doctor told me that my bladder is dropped and that it needs to be fixed. I didn’t feel anything different."

19 76% discovered their own bulge –The rest were diagnosed by their doctor 94% of women who found their own bulge ALSO HAD OTHER SYMPTOMS –Only 50% of physician diagnosed group had symptoms As the old saying goes, “if it’s not broke, don’t fix it!” What is the Natural History of Bulges? Lewicky-Gaupp et al. Int Urogyn J (2009)

20 Women who discovered their own bulge actually had prolapse beyond the vaginal opening What is the Natural History of Bulges? Lewicky-Gaupp et al. Int Urogyn J (2009)

21 How Long Does it Take for a Bulge to Develop? Lewicky-Gaupp et al. Int Urogyn J (2009) 27% recalled “sudden worsening” of bulge

22 How Long Does it Take for a Bulge to Develop? Lewicky-Gaupp et al. Int Urogyn J (2009)

23 What Symptoms Bother Women? Lewicky-Gaupp et al. Int Urogyn J (2009)

24 Reasons for Seeking Treatment

25 Progression and Treatment Lewicky-Gaupp et al., Int Urogyn J (2009) Fact or Fiction: –Women live in secret with this condition for years and don’t tell anyone including their doctor

26 Treatment Seeking Progression and Treatment Lewicky-Gaupp et al, Int Urogyn J (2009) Fiction!

27 How do You Treat Pelvic Organ Prolapse? Only treat if YOU have symptoms

28 Pessaries

29 Historical Pessaries 27 B.C A.D.: Diocles and Soranus pomegranate treated with vinegar 326 A.D.: Oribasius uses tampons dipped in “medicine” 1050 A.D.: Trotula (first recorded female gynecology practioner) uses ball made of strips of linen 16 th Century: Ambrose Pare uses hammered brass and waxed cork

30 Do Doctors Suggest Pessaries for Therapy? Two studies reported over 87% of gynecologists use pessaries in their practice 77% of urogynecologists offer pessaries as their first therapy for prolapse Cundiff GW. OBG Pott-Grinstein E. J Reprod Med

31 What are Pessaries Good for? 1.Bulges 2.Patients with prolapse who still want to have children 3.Urine incontinence 4.Not quite ready for surgery, but want surgery in the future

32 Do Women Actually Like Pessaries? 100 women were given a pessary –At 2 months 92% of women were satisfied 98% of symptoms resolved (bulges, pressure, discharge, pain) 50% had improvement in urine leakage Clemons JL. AJOG 2004

33 How Many Continue Pessary Use? 2 months: 92% were satisfied 1 year: 73% were satisfied 2 Years: 64% were satisfied Clemons JL. AJOG Best Predictor of Satisfaction: AGE!

34 What Kind of a Woman Chooses a Pessary? She doesn’t want surgery She has conditions that make surgery more risky Her symptoms gets worse when she’s on her feet for a long time or when she’s exercising Cundiff GW. OBG Pott-Grinstein E. J Reprod Med

35 Who Tries a Pessary and Probably Won’t Like It?

36 Women know what they want: –She wants surgery at her initial visit and was talked into a pessary Women with bigger bulges Clemons JL. AJOG. 2004

37 What about Having Sex? Fact or Fiction: If you’re having sex, you won’t want to use a pessary.

38 What about Having Sex? Fiction! –Long-term use acceptable to sexually active women –Can remove or not remove pessary  up to you! Brincat. AJOG 2004

39 Surgical Management of POP Hysterectomy +/- removal of ovaries Resuspension of vagina –Through the vagina Anterior repair or “Bladder lift” Posterior repair or “Tucking down the rectum” –Through the abdomen Laparoscopy Robot

40 “I’m wetting myself every time I cough or try to run after my children. I’ve stopped exercising and am always afraid I’m going to embarrass myself”

41 Types of Urinary Incontinence Stress Urinary Incontinence –Laughing, coughing, sneezing, lifting Urge –“Gotta go, gotta go …” Mixed –Laughing, coughing, sneezing AND “Gotta go, gotta go”

42 How do you Diagnose Urinary Incontinence? History Pelvic Exam Voiding diary


44 Urinary Incontinence 10 – 35% of adults 10 million Americans > 50% of 1.5 million nursing home residents #2 leading cause for nursing home placement Impact on quality of life –Depression, insomnia, isolation, reduced mobility and socialization

45 The EPI Study Fenner et al., J Urol (2009) Racial Differences in Women’s Patterns of Urinary Incontinence – Prevalence of UI lower in black women (14.6% vs. 33.1%) –Black women: “Gotta go …gotta go” –White women: Laughing, coughing, sneezing Are black and white women equally bothered by their UI? –Questionnaires

46 Racial Differences in Symptoms Lewicky-Gaupp et al., AJOG (2009) As UI frequency and amount of leakage increased, bother increased –No difference between black and white women

47 Modified Sandvik Score IIQ-7 Score Black Women White Women Mild Moderate Severe 19.9 ± ± ± ± ± ± 1.8 Black and white women with mild and severe leakage are equally bothered by their incontinence Women with moderate UI may/may not seek treatment This is the group that black women reported being more bothered compared to white women Lewicky-Gaupp et al. AJOG 2009

48 Incontinence: In Summary… True racial differences in symptoms exist Symptoms are equal or more bothersome in black women Screening for incontinence should be routine for all women regardless of race Unpleasant symptoms  health-care seeking Lewicky-Gaupp et al AJOG 2009

49 What can I do to Prevent Incontinence and Bulges? Keep you pelvic floor muscles strong Maintain a “normal” body weight Avoid constipation

50 Non-Surgical Therapy of Urinary Incontinence Pads Behavioral modification Biofeedback Medicines Pelvic Floor Exercises

51 Behavioral Modification Fluid management –40 to 60 oz. per day Healthy bladder diet –Avoid too much caffeine, carbonation, fruit juices Scheduled toileting –Don’t wait too long! Bladder retraining

52 Behavioral Treatments ADVANTAGE Simple Few side effects Inexpensive Efficacy Involves YOU and YOUR needs DISADVANTAGE Motivation Expense increases with intensity Efficacy varies

53 Biofeedback Implies use of visual cue to help isolate muscle contraction Variety of balloon, pressure, or EMG sensors –Used to monitor contraction/record muscle strength

54 Medicines Primarily for Urge Incontinence –Detrol –Ditropan –Enablex –VESIcare Some medicines are available for stress urinary incontinence and getting up at night many times

55 Which Treatment Should You Use? Bladder training and pelvic floor strengthening can be used for stress, urge, and mixed incontinence Voiding diary and physical examination guide therapy

56 Kegel Pelvic Floor Exercises Arnold Kegel 1951 “Physiologic therapy for urinary stress incontinence” 10 contractions 3 times a day DO NOT stop urine flow

57 Vaginal Cones Peattie et al., BJOG (1998) 39 premenopausal women with incontinence 30 completed study 70% improved or cured Urine loss significantly reduced

58 Kegel Exercises with Vaginal Cones

59 Surgical Management of Stress Urinary Incontinence Tension Free Vaginal Tape

60 Tension Free Vaginal Tape: TVT Outpatient <5% chance of going home with catheter or self- cathing 2 small incisions No heavy lifting for 1 month

61 Surgical Management of Urge Incontinence If all else fails …. Interstim Botox

62 Take Home Points Prolapse –Only treated if you are symptomatic –Treated with Pelvic floor exercises Physical therapy Pessaries Surgery Urinary Incontinence –Treatment depends on type of incontinence Stress –Pelvic floor exercises –Physical therapy –Pessaries –Surgery Urge –Same (minus surgery) –Medicines

63 Thank You Christina Lewicky-Gaupp, MD Female Pelvic Medicine and Reconstructive Surgery The Integrated Pelvic Health Program 676 North St. Claire, Suite 950 (312)

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