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?
Urinary Incontinence
Pelvic Organ Prolapse
Constipation and Fecal Incontinence
Female Sexual Dysfunction

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

8. Why is Vaginal Delivery Important in Pelvic Floor Disorders?

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

10. DeLancey

11. Birth Simulation
We will now use the model to simulate vaginal birth, starting at the beginning of the second stage of labor. For clarity, we show every other muscle band, and use a sphere, equal in size to the 50th percentile fetal head, to represent the molded fetal head.
Watch the stretch in the orange PC “2” band, and compare it to the posterior IC band.
(show simulation twice)
(finish simulation)
Now let’s find out which muscle is stretched most….

12. More Babies = More Bulges & Leaks

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

14. What Tears?
Let’s contrast our “dog hammock” with the “bear hammock.” The hammock on the right is not only sagging in its attachments, but the fabric of the hammock is less strong, more porous and even has a defect in it. PLAY VIDEO HERE

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
What we see everyday in clinic is that not all bulges are the same.
Here is a woman with a cystocele 6 days after delivery.
Here she is at 6 months after delivery
And here is 6 years after delivery.
This is in stark contrast to the woman who says … 17

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."
“I was moving furniture and felt a sudden bulge.'" OR
"I was riding the tractor one day, bouncing up and down, and the bulge was there that night.“  words that start with TR are just bad in urogyn (tractor, trampoline)
"My doctor told me that my bladder is dropped and that it needs to be fixed. I didn’t feel anything different.“
It was these kinds of observations and comments that led us into our next research endeavor – the natural history of pelvic organ prolapse.

19. What is the Natural History of Bulges. Lewicky-Gaupp et al
What is the Natural History of Bulges? Lewicky-Gaupp et al. Int Urogyn J (2009)
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!”
We performed a cross-sectional study of new patients presenting to the urogyn clinic who had no history of prior surgery for POP.
We included anyone who had complaints related to POP or who was refereed for consultation for POP
Everyone completed a health history questionnaire and had a POP-Q
What we found was that
76% of patients had discovered their own POP
Over a quarter were diagnosed by her PCP and more interestingly,
94% of those who self-discovered their POP were symptomatic from a bulge in contrast to
Only 50% of those who were TOLD they had a bulge actually had symptoms …

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

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
And, when we looked at treatment-seeking, we were surprised to find that
(1)Half of all women (48%) sought medical attention “immediately” after discovering a bulge
(2) Median time to seek care was only 4 months and
(3) 80% sought care within one year of bulge discovery
All of this challenged our notion that the majority of women with POP are living with this condition in secret for years and years.
So …

26. Progression and Treatment Lewicky-Gaupp et al, Int Urogyn J (2009)
Fiction!
Treatment Seeking
And, when we looked at treatment-seeking, we were surprised to find that
(1)Half of all women (48%) sought medical attention “immediately” after discovering a bulge
(2) Median time to seek care was only 4 months and
(3) 80% sought care within one year of bulge discovery
All of this challenged our notion that the majority of women with POP are living with this condition in secret for years and years.
So … 26

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
16th Century: Ambrose Pare uses hammered brass and waxed cork
Pessaries have a very long and interesting history.
Diocles: Greek philosopher and pioneer in medicine  second only to Hippocrates
Soranus: also Greek philosopher and MD
Oribasius: Greek medical writer and personal physician to Roman emperor Julius the Apostate
Trotula: She claimed that both men and women could have physiological defects that affected conception. To admit that a man could be responsible for infertility was a daring notion at that time. She also described the use of opiates to dull the pain of childbirth. This practice was strictly against the teachings of the church, which maintained that women should suffer childbirth without any relief.
Ambrose Pare: 16th century France  father of modern medical surgical practice

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?
Bulges
Patients with prolapse who still want to have children
Urine incontinence
Not quite ready for surgery, but want surgery in the future 31

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
So, overall, symptom improvement in prolapse is better than that of incontinence with pessaries
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
Kaplan-Meier curve
Age greater than or equal to 65 years is most predicative of prolonged pessary compliance
Best Predictor of Satisfaction: AGE!
Clemons JL. AJOG

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?35

36. Who Tries a Pessary and Probably Won’t Like It?
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.
Users were women who continued pessary use
Non-users stopped pessary use during study period

38. What about Having Sex? Fiction!
Long-term use acceptable to sexually active women
Can remove or not remove pessary  up to you!
Users were women who continued pessary use
Non-users stopped pessary use during study period
Brincat. AJOG 2004 38

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’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
Well, the EPI study which stands for “Establishing the Prevalence of Incontinence Study” came out of our division in 2008 looking at racial differences in UI and what we found was that not all women are the same
This study looked at Community-dwelling black and white women (we had 1,922 black and 892 white women ) and we looked at their UI frequency, type of incontinence and amount of UI and found that
Prevalence of UI was significantly lower in black women and
More black women complained of UUI while white women complained of pure SUI
So, we decided to take this study in a different direction and ask “Are black and white women equally bothered by their UI?”
All of the women that we queried had completed the IIQ-7 which is a short questionnaire about the global impact of UI on their life and then we calculated a Sandvick score (which basically is a SEVERITY score that takes into consideration the amount and frequency of incontinence)  this is important to try to equalize the drama queens (like myself, for example) who may be EXTREMELY bothered by the one drop of leakage they have once a day with the women who soak the floor and just don’t have the time to care about it.

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. Women with moderate UI may/may not seek treatment
Modified Sandvik Score
IIQ-7 Score
Black Women White Women
Mild
Moderate
Severe
19.9 ± 4.3
22.6 ± 2.4
31.4 ± 3.5
23.7 ± 1.9
36.7 ± 3.0
34.9 ± 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
We found that black and white women were equally bothered when they had mild and severe incontinence, but at a moderate severity, black women were more bothered than white women.
Now, why is this important? Well, you could deduce that many women with mild incontinence may not seek treatment and conversely, most women with severe UI WILL seek treatment  it’s the group in the middle that may/or may not seek treatment and that’s the group where black women reported a higher degree of bother …
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
So, from this study we concluded that
True racial differences in bother exist
that the disease burder is equal or more bothersome in black women
And from here we can extrapolate that screening for UI should be routine for all women regardless of race because bother is inexorably tied to health-care seeking especially in determining barriers to care, lack of understanding about the condition and possible treatments, and whether health-care providers are not inquiring about UI symptoms in black women
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 Urinary Incontinence
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)