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

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

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

What are Pelvic Floor Disorders?

Pelvic Organ Prolapse

Constipation and Fecal Incontinence

Female Sexual Dysfunction

Urinary Incontinence

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

One Soldier Field Unit

350,000

DeLancey

Which types are common?Surgical Procedures/year

Bulges200,000(78%)

Urine Incontinence

80,000(21%)

Bowel Incontinence

4,000 (1%)

Nat’l Center Hlth Stats 2006Boyles AJOG 2003;188:108Boyles AJOG 2003;189:70

Why is Vaginal Delivery Important in

Pelvic Floor Disorders?

DeLancey

Injury Rates for Athletics and Vaginal Birth

0 10 20 30 40 50

Basketball

Field Hockey

Gymnastics

Soccer

Vaginal Birth

*2006 NCAA Data & Kearney, Obstet Gynecol 2006;107:144-9

DeLancey

Birth Simulation

More Babies = More Bulges & Leaks

Key Question: What happens during birth that causes these problems later in life?

29 years old

60 years old

What Tears?

Muscles TearDeLancey, 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

Major Pelvic MuscleTears

7.3 times MORE LIKELY to bulge or

leak!!!!

Not all Women are the Same

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."

• 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)

• 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)

How Long Does it Take for a Bulge to Develop?

Lewicky-Gaupp et al. Int Urogyn J (2009)

• 27% recalled “sudden worsening” of bulge

How Long Does it Take for a Bulge to Develop?

Lewicky-Gaupp et al. Int Urogyn J (2009)

Distribution of Reported Symptoms

0%

10%

20%

30%

40%

50%

60%

70%

Percent

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

Reasons for Seeking TreatmentReasons for Seeking Treatment

0%5%

10%15%20%

25%30%35%

40%45%

Wor

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To K

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ith In

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ours

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Urinar

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Vagin

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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

0

10

20

30

40

50

60

70

80

90

100

0 6 12 18 24 30 36 42 48 54 60 66

Months from first noticing bulge

Pe

rce

nt

of

co

ho

rt

Treatment Seeking

Progression and TreatmentLewicky-Gaupp et al, Int Urogyn J (2009)

• Fiction!

How do You Treat Pelvic Organ Prolapse?

• Only treat if YOU have symptoms

Pessaries

Historical Pessaries• 27 B.C. - 50 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

Do Doctors Suggest Pessariesfor 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. 2000. Pott-Grinstein E. J Reprod Med. 2001.

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

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

How Many Continue Pessary Use?

• 2 months: 92% were satisfied

• 1 year: 73% were satisfied

• 2 Years: 64% were satisfied

Clemons JL. AJOG. 2004.

Best Predictor of Satisfaction: AGE!

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. 2000. Pott-Grinstein E. J Reprod Med. 2001.

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

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

What about Having Sex?

Fact or Fiction:

If you’re having sex, you won’t

want to use a pessary.

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

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

“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”

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”

How do you Diagnose Urinary Incontinence?

• History

• Pelvic Exam

• Voiding diary

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

The EPI StudyFenner 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

Racial Differences in SymptomsLewicky-Gaupp et al., AJOG (2009)

• As UI frequency and amount of leakage increased, bother increased– No difference

between black and white women

Modified Sandvik Score

IIQ-7 ScoreBlack 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

Lewicky-Gaupp et al. AJOG 2009

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

What can I do to Prevent Incontinence and Bulges?

• Keep you pelvic floor muscles strong

• Maintain a “normal” body weight

• Avoid constipation

Non-Surgical Therapy of Urinary Incontinence

• Pads

• Behavioral modification

• Biofeedback

• Medicines

• Pelvic Floor Exercises

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

Behavioral Treatments ADVANTAGE

• Simple

• Few side effects

• Inexpensive

• Efficacy

• Involves YOU and YOUR needs

DISADVANTAGE

• Motivation

• Expense increases with intensity

• Efficacy varies

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

Medicines

• Primarily for Urge Incontinence– Detrol– Ditropan– Enablex– VESIcare

• Some medicines are available for stress urinary incontinence and getting up at night many times

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

Kegel Pelvic Floor Exercises

• Arnold Kegel 1951 “Physiologic therapy for urinary stress incontinence”

• 10 contractions 3 times a day

• DO NOT stop urine flow

Vaginal ConesPeattie et al., BJOG (1998)

• 39 premenopausal women with incontinence

• 30 completed study• 70% improved or cured• Urine loss significantly reduced

Kegel Exercises with Vaginal Cones

Surgical Management of Stress Urinary Incontinence

• Tension Free Vaginal Tape

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

Surgical Management of Urge Incontinence

• If all else fails ….

• Interstim

• Botox

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

Thank You

Christina Lewicky-Gaupp, MDFemale Pelvic Medicine and

Reconstructive Surgery

The Integrated Pelvic Health Program

676 North St. Claire, Suite 950

(312) 926-4747