Urogynecology

Welcome to Yale Cancer Center Answers with your hosts doctors Anees Chagpar, Susan Higgins and Steven Gore.  Dr. Chagpar is Associate Professor of Surgical Oncology and Director of the Breast Center at Smilow Cancer Hospital.  Dr. Higgins is Professor of Therapeutic Radiology and of Obstetrics, Gynecology and Reproductive Sciences and Dr. Gore is Director of Hematological Malignancies at Smilow and an expert on myelodysplastic syndromes.  Yale Cancer Center Answers features weekly conversations about the research, diagnosis and treatment of cancer and if you would like to join in, you can e-mail your questions and comments to canceranswers@yale.edu or you can leave a voicemail message at 888-234-4YCC.  This week it is a conversation about urogynecology with Dr. Leslie Rickey.  Dr. Rickey is Assistant Professor of Urology and of Obstetrics, Gynecology and Reproductive Sciences at Yale School of Medicine and here is Dr. Steven Gore.

Gore That is a lot of adjectives in your name, in your title, urology, obstetrics, gynecology, reproductive sciences, could you think about a few more that you could have added in there?

Rickey Well, the pelvic floor is a funny place or the pelvis in general in a female, you have the bladder, you have the reproductive organs, you have the rectum and colorectal function and so for a long time care of women’s pelvic floor was sort of fractionated and separated between urology, gynecology, colorectal services, so now this long-term female pelvic medicine and reconstructive surgery is actually an effort to cross-train people from these backgrounds so they can provide more comprehensive global care for the female pelvic floor.

Gore Interesting, when I think of urology, first of all I usually think of guys, it seems a male directed field, I am sorry to say, but I think kidneys, ureters, bladder, urethra, that is kind of traditionally what I have thought of, prostate for sure, and of course that is just my male perspective, but it sounds like you are dealing regionally rather than what organ systems it is. 

Rickey No, that is absolutely correct, and I think women in particular because of their pelvic floor, because of childbearing and the stress and trauma that can result on the pelvic floor that these pelvic floor disorders, especially lower urinary tract disorders which can cause incontinence or frequent urination disproportionately effect women, so men can these symptoms too, but women experience them far more often, and the bladder does not live in isolation; for a long time, it was treated that way and that is one of the things I love about my training is the majority of women that show up with a urinary complaint, up to 80% will have another pelvic floor symptom or disorder that if not appropriately treated or thought about in the treatment plan, you can actually treat one thing and make something else worse, so I think it is critical for women to go to somebody that has this training, so that the full spectrum of all their pelvic floor issues 

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can be dealt with in one place or at least someone that has the training to appreciate some of these disorders and send them out to referrals.  You know, we have a great multidisciplinary team here at Yale between urology, gynecology and colorectal services, we share many patients, we have conferences, so we try to really coordinate their care and make sure it is being dealt with in a thoughtful way.

Gore I remember as a medical student studying anatomy, I found the pelvic floor incredibly difficult to get my head around and my guess is that most of my listeners do not even know what we mean when we say pelvic floor, that is my guess, so could you explain to somebody as simple as me what the pelvic floor is exactly?

Rickey What I tell my patients is that it is a bowl of muscles, nerves, connective tissue that goes from the pubic bone back to tailbone and hip to hip.  It is a little more complex than that, but that it is a bowl of muscles and when you really have to go to the bathroom and you are not near a bathroom that is pelvic floor muscles. 

Gore To hold it in.

Rickey Yes, to hold it in.

Rickey Those are the pelvic floor muscles which are squeezing, and just like you might go to the gym to build up your biceps these might get weak, people have all different sorts of muscle tone, and so that is how I tend to describe the pelvic floor and those muscles are very much related to the function and health of the bladder, the vagina and the rectum, so you can just imagine when there is something wrong with these muscles, the sort of chaos or untoward effects that can result in the bladder, the rectum and the vagina.

Gore And so as I am thinking I remember, the bladder sits on top of the pelvic floor.

Rickey Yes, that is right.

Gore And the vagina passes through, no.

Rickey Right, so the bladder and the vagina and the rectum sit on the pelvic floor but they all have openings, so then the urethra, the vagina and then the bottom of the rectum and anus passes through the pelvic floor, so if those muscles are weak, you can get urine leakage, bowel leakage, vaginal hernias.  If they are too tight, sometimes actually 

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people have trouble emptying their bladder, their bowel, they can even develop pain, so there is just a whole spectrum of symptoms that can result from disorders in the nerves and muscles in this area.

Gore And you are saying that these problems are mostly uniquely female?

Rickey Not uniquely female, men have a pelvic floor too, they just do not have a vagina. And are not delivering bowling balls through the vaginal opening so they can still absolutely. They can have obviously issues with pain in the pelvic floor, bladder and bowel issues.  They do not tend to happen in the numbers that they effect women, but women report these symptoms more when you look at large population studies and more severe symptoms typically.

Gore And what percentage of women actually have problems with, incontinence, that will be one of the things I suppose or things like that.

Rickey Yeah, so urine leakage and urinary tract infections are the most common of the pelvic floor disorders and 1 in 3 women will report a bothersome problem with her bladder whether it is leakage or voiding too much, however, very few or less than half of women with moderate-to-severe symptoms report them, so if you look at a doctor’s office and how many people you know you look at the diagnoses and you say, yeah you know not many people have it when you do a large population study and you ask specific questions, do you have this and does it bother you, then the numbers come out a lot higher, so 1 in 3.  These symptoms also increase in prevalence or frequency and severity of the issue as women age and the nerves and muscles change, so you know as far as we understand, these are not diseases of older age exclusively, even women in theirs 20s up to 10% will report an issue and then it goes up and up and up until you get to over 50% of women that are over 60 might have these issues.

Gore It is mostly limited to people who have born children vaginally?

Rickey That is a risk factor across all pelvic floor disorders whether you look at bowel disorders, vaginal support issues or prolapse and urinary symptoms, however, that does not mean if you have not ever had kids or only had C-sections you are not going to get these, I see these issues in young women, even earlier than 20 and then I see them up through women in their 80s, so while many women have had vaginal childbirth or have been pregnant and have these issues, you are not protective from it necessarily, if you have it.

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Gore It seems like this pelvic floor thing was not well designed somehow if you have all these problems, I do not know.

Rickey Well, if you think about it, I have heard it explained this way that the pelvic floor muscles were originally apparently used for tails.

Gore Makes sense.

Rickey 2-legged animals with all the things that come around pregnancy and childbirth.

Gore Right.

Rickey And some women do not talk about it to their friends, they do not report it to their doctor, they just assume that everybody has it.

Gore It is normal, you could see it on TV, get those adult diaper things, right.

Rickey They think it is absolutely a normal part of aging and it is inevitable part of aging and part of the message I would like to get out whether I am talking to primary care physicians or to women in the community that just because it is common does not make it normal and there are many women that do not have these issues, 25% of women 18 years and older will have some problem, 1 in 3 women have some sort of urine leakage issue, but there are many women that do not, so the women that do have it I really would like to empower them to bring it up to their own doctor, talk to your friends about, it is not a bad thing, it is just a chronic issue just like having high blood pressure or diabetes and if you talk to your primary care physician or you are embarrassed to bring it up, look up a specialist, there are many people specializing in pelvic floor disorders right now.  You can just make that appointment, come in to talk to somebody.  It does not mean that someone is going to stick you with a needle or do some tests on you, but you should absolutely come in, get checked out.  There are a lot of very conservative, nonsurgical lifestyle modifications that can make a huge difference in these symptoms.

Gore I have got to ask you Leslie, I am just guessing that you didn’t sort of wake up one day before you went to medical school and said, gee I really want to be a pelvic floor specialist of a urogynecologic nature. Rickey No, that is true.

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Gore I mean, it never occurred to me right. I guess being a hematologist probably didn’t either, but I am just wondering like what is your path there, how does one end up and what kind of training is it involved?  It seems like it is across several disciplines as you mentioned.

Rickey Yeah, that is right.  I mean, I went into urology.  I never thought I was going to be a surgeon, that was way off my radar, I thought I was going to be a pediatrician at first, but I got into the OR, the surgical field and really fell in love with it and really enjoyed urology, which like you said the perception out there as it is mostly male; however, there are you know up to a third or 40% of urologic patients are women actually, but I really more liked the disorders we were treating, all the different surgical and nonsurgical things you could do for pelvic disorders whether they are men or women.  Truth be told though, I never thought I was going to be a female urologist treating exclusively women and in fact I thought as a female in urology you can imagine only about 8% of practicing urologists are women.

Gore Right.

Rickey So if you go into a practice, community practice, you are going to be really flooded with requests for women. Gore I thought you are going to say that the guys do not want to see you, maybe push back from the guys.

Rickey No, I never had that issue.

Gore Really.

Rickey I really did not, no.  I mean these are pretty sensitive disorders and so I have a lot of, women, even women talking to a female very embarrassed to bring it up.  You know, they apologize, it is really sort of stunning, and crosses generations.

Gore Humiliating right, I mean, unfortunately.

Rickey Unfortunately there is stigma attached to it.

Gore It has got the stigma.13:01 into mp3 file https://ysm-websites-live-prod.azureedge.net/cancer/2016%200508%20YCC%20Answers%20-%20Dr%20Rickey_253245_5_v1.mp3

Rickey So, whether I am talking to someone that is 80 or someone that is 18, I see that across the spectrum, I try to just approach it in a very sort of standardized fashion, we talk about it in plain talk.  I have had women in the community say, oh my gosh, I have never heard someone talk about vaginas and bladders and rectums the way you talk about it, so nice to hear somebody just say these words, and I think it is just something we need to focus on in our society, so you know same thing with men.  You know, when I was a trainee, I did not have really any pushback from the men, they just went to somebody that is going to listen to them, take good care of their problems.

Gore Help them.

Rickey Yeah, but you know the reason that I really ended up in this field is as a third year resident, I was out at Loyola in Chicago and the urology and gynecology shares who had this foresight, you know, it was really insightful to bring a urogynecologist on and train the urology and the gynecology residents in this field, so that is when I got interested, I started seeing the breath and depth of what we could for female pelvic floor disorders, all the different surgeries and nonsurgical treatments and I really fell in love with it.

Gore This is fascinating Leslie.  Right now, we are going to have to take a short break for a medical minute.  Please stay tuned to learn more about urogynecology and the pelvic floor.

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Gore Welcome back to Yale Cancer Answers.  This is Dr. Steven Gore and I have been talking tonight with my guest, Dr. Leslie Rickey about urogynecology and the pelvic floor.  

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Leslie, you have gotten me certainly more interested in the pelvic floor than probably, well probably than I ever even really thought about it which was not very much right. I understand the leaky urine issue seems like a pretty obvious issue the people know about, like what other symptoms would people have to think may be my pelvic floor needs investigation.

Rickey So, you are absolutely right, I think the urine leakage is obvious.  There is something called stress incontinence, it is when you cough or sneeze you leak or exercise and there is an urgency incontinence, focusing to be a little more familiar with because there is medicine that can treat this, so you see at magazines and those of the people that do the got to go, got to go, they might not be able to hold it, they might leak on the way to the bathroom.  There are also a lot of women though that have this complex called overactive bladder where they just have urgency and frequency, so they might not leak, but they know where every bathroom is, everywhere they go.

Gore I know someone like this.

Rickey Yes, all of us do and the thing is women lived like this for decades and there are so many easy treatments for this, so you do not need to toilet nap, you do not need to know where every bathroom, you do not need to get up four times at night.  There are very effective lifestyle modifications, sometimes medications.  There is actually a whole area, they are pelvic floor physical therapists who are physical therapists who have taken women health courses, so they do treatment centered around the pelvic floor, they can be very effective in treating a lot of these disorders.  There is also something called pelvic organ prolapse.  This is when the vagina starts to herniate, you know down there, as many women will say and its main symptom is a vaginal bulge.  The will feel something coming out and it really is like a hernia and other women have some pain issues, you know, either pain with intercourse or painful voiding, recurrent urinary tract infections is something we see a lot and finally around the bowel and rectum, some women develop stool leakage, so if you think urinary leakage has a stigma around it, the women with bowel leakage are really reluctant to come in and seek treatment and we have really effective treatments for them as well, so I would encourage them to come in and a lot of women, you know on the other hand of the spectrum, constipation and difficult bowel movements or painful bowel movements, so we really have all the tools here to evaluate and treat these disorders.

Gore And what about sexual dysfunction?  You mentioned painful intercourse or other sexual problems that relate to the pelvic floor are not really vaginismus, vaginal spasm, it that related or not really?

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Rickey Yes, there are a couple different ways that sexual function can be effected, so one is just after childbirth, a lot of women just feel like things are different.

Gore Everything is different.

Rickey Everything is different.  Sometimes, it is a pelvic floor muscle weakness, so they just feel like everything is coming out and they feel like everything has gone wrong.  Their bladder is not right, their bowel is not right, their vagina is not right, sex is different and so actually those women that are young and right after childbirth, they are the perfect demographic or age group to come in and start doing pelvic floor muscle therapy.  We are not going to do probably any surgery at this point unless they are done with childbearing but just some generalized pelvic floor muscle rehabilitation can be really effective.  But some people also develop spasms like you said and that is something else that can be treated with pelvic floor physical therapy, the muscles are in spasm, just like you might get a muscle spasm in your back.

Gore Like a charley horse.

Rickey Like a charley horse, the same thing can happen in these pelvic floor muscles.

Gore Sounds horrible.

Rickey People just think that it is the bladder and the vagina down there but is actually surrounded by muscles, it is horrible and then as women age and estrogen levels decrease, they can actually get a little bit of thinning and irritation of the vaginal lining and so that can sometimes lead to uncomfortable intercourse too and there are many women I see who are really interested in maintaining their sex life and intimacy and may be they have stopped you know because of this disorders or it is too dry or it is really a shame because we can really effectively help with those issues as well.

Gore So, how do you evaluate these problems, I mean, obviously it is not an easy area to examine I suppose?

Rickey No part of it is just taking a really careful history. History of present illness, but when you are dealing with quality of life disorders and how it is affecting, what activities someone is avoiding or not doing anymore, you have to be really careful that you are thinking of what their goals are and that can vary based on somebody’s age, what kind of work they do, if they are at home, what their goals are, if they are just going to exercise more, so you have to be really careful because like I said some of the treatments for example, stress incontinence, if someone needs surgery, there is a sling 

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we can do, it is outpatient.  The surgery is simple enough.  However, you have to also make sure that they do not have to be overactive bladder symptoms.  You have to balance and triage your care because doing the sling could make those other symptoms worse, so you just have to be careful that way, take a really careful inventory of symptoms, what they want to fix and then when you do your pelvic floor exam, it is not just you know like when you go to your gynecologist, you get the path, you get the bimanual, we actually really carefully palpate all the muscles, we assess the strength.  Many women think they are at home.  They say I am doing Kegels, I do Kegels, I have been doing it for 20 years and they are not working and I examine them and they are actually not doing it, they think they are doing it, but they are not.

Gore So you can examine the pelvic floor muscles through the vagina?

Rickey Yeah.  We can also assess for any tender spasm in the areas for strength.  We can assess the quality of the tissues, whether there is any atrophy or thinning and then really importantly what their support is like.  If they have any of that vagina starting to come again, which may affect where we go with our treatment.

Gore You do not need to scan people or anything like that?

Rickey Very uncommonly.  We do not have to use a lot of x-rays or anything like that, sometimes for bowel disorders, we do, sometimes depending on the urinary tract symptoms, we need to take a look into the bladder with a small camera called a cystoscopy.  We do that right in our office.  We use that very judiciously, sort of when people get scared of, thinking if they step a foot in the office, they are going to get their bladder scoped, but we do have to do it sometimes and then finally we have some bladder testing called uro-dynamics that we do that can help us really know what the bladder and the urethra is doing, it helps guide our treatment sometimes.

Gore What kind of surgeries are involved if people need surgery, you mentioned the sling to deal with stress incontinence?

Rickey Yeah, so if somebody has tried the pelvic floor muscle therapy and they cannot do it or it has not helped, there is also called an office treatment called periurethral bulking where if you go in with a little camera just like I compare it sometimes to women they have collagen or pillars, we can fill up the opening to the bladder so it is a little bit tighter and it is harder for the urine to leak out, that could be done right in the office.  There is actually something called a pessary or incontinence ring.

Gore They still use that?

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Rickey Oh, we use them a lot.  We use them for prolapse and for incontinence and it is nice especially for say someone leaks only when they play tennis or only when they have a cold, they may not want to put themselves through surgery because it is very episodic, so these incontinence rings are silicone rings that could be taught to put them in and out of the vagina not similar to a tampon and they do not feel it when it is in and it can really affectively control the urine leakage during these episodes but if someone is really having it all the time, they say this is something I hear a lot, I go to the bathroom, I floor exercise, and my pad is just soaked at the end or I get up for my run and half way into it and I need to go back and go to the bathroom or I am out of the golf course and it is riding in, you know, all these things, so sometimes a surgery is indicated if they want to, right.  I never tell somebody they must have this but if they do want these slings, there are 2 ways to do this, there is some where we can use some of your own tissue, it is more involved and involves lower abdominal incision and then there is an outpatient surgery that uses a little strip of material and it goes underneath the urinary tube, the whole thing, when we do the outpatient procedure, it takes about 30 or 45 minutes.

Gore Fascinating.

Rickey It has effectiveness rates of about 85% in patient satisfaction of 90%.  I really cannot tell you how many times I hear not just with the surgery but even with some of the other simple treatments we have like the exercise, I wish I had done this 10 years ago.  I cannot believe I waited so long and why women wait, you know, I do not know.  I think sometimes women tend to prioritize their health at the bottom and this has been shown in studies.  Actually, the top layer is kids and then pets and then partners underneath the pets.  And then elder care and then their own care, so it is a combination of societal myths around no effective treatments, I think a fear that there is only surgery, other myths floating around that it is common.

Gore Yeah I think what you said about just people assuming that this is just what happens as you age, I think there just seems a lot of that I would think.

Rickey Yes, there is quite a bit and I do applaud the pad industry, the Poise pads because they really made it a national dialogue and they demonstrated it effects women across their life span, it is not just older women, so I do like that.  The one thing that is a little bit distressing is that the pads do not help progression and I think they do not take away the fact that you are still thinking about it and you are having to manage it instead of getting a treatment that takes it away.26:20 into mp3 file https://ysm-websites-live-prod.azureedge.net/cancer/2016%200508%20YCC%20Answers%20-%20Dr%20Rickey_253245_5_v1.mp3Gore Sure.

Rickey You are able to resume your activities, I mean so it does help, you have a little bit of leakage but I think one in three women that have monthly leakage will progress to weekly leakage within a few years, so it does not just stay there, so if you are just wearing pads and you are thinking I am handling it just fine, I can go to the gym now, it is much more treatable at those early stages and so if you wait and wait and wait and all of a sudden it is weekly and this is what I hear, oh! over the last year, I have upsized my pads and now I am getting the bigger pads and now the pads are not holding it, so really the time, I think they should really be coming in and asking questions about how to best treat this.  Pads are good to start with and there are good I guess of kind of Band-Aid but they do not treat the leakage.

Gore And do you treat men with these problems too?

Rickey That is a whole different area.  There are people that treat men with these issues and the pelvic floor, so men tend to as they get older, they will develop overactive bladder symptoms, urgency and frequency and urgency and incontinence, that happens in both sexes, but like the stress incontinence, the leakage with coughing, that really only happens in men that have had a prostate surgery so the numbers are much small.

Gore Right.

Rickey I am not saying it is not an issue and not distressing, much smaller but there are people in our urology department specialized in that.

Gore Leslie, you had mentioned before when we were chatting that you have researched that is involved with folks down in the Baltimore area, can you tell me a little bit about what that is about?

Rickey Yeah, that is really exciting, so the National Institutes of Health and their urinary division, they are locked together, but they have been kind enough, and actually there have been a couple of co-sponsors not just the NIDDK but some other funding agencies who are able to pull together this prevention study which is really innovative because these prevention studies do not get funded at the national level very often and treatment studies do and basic science but it is called the Plus Consortium and its prevention of lower urinary tract symptoms in women across their lifespan, so just like there has been decades and decades of research about heart health and we know that

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we should follow a low-cholesterol diet and low sodium and exercise, there is virtually no information about what bladder health is, what the risk factors are.

Gore Cranberry juice.

Rickey Maybe, but that has a lot of sugar, that is just for the urinary tract infections and in fact, I tried to get my patients on cranberry supplements because they are chugging all this cranberry juice.

Gore I got it.

Rickey You know just sugar or the sugar substitute in it, so this is a multi-center consortium.  We were picked to be one of seven clinical centers across the United States, so it is a great multidisciplinary team of clinicians, nurses, epidemiologists, designed to look at these lower urinary tract symptoms from a public health perspective because there is such a huge financial, societal and individual burden of lower urinary tract symptoms in women.

Dr. Leslie Rickey is Associate Professor of Urology and of Obstetrics, Gynecology and Reproductive Sciences at Yale School of Medicine.  We invite you to share your questions and comments, you can send them to canceranswers@yale.edu or you can leave a voicemail message at 888-234-4YCC and as an additional resource, archived programs are available in both audio and written form at YaleCancerCenter.org. I am Bruce Barber hoping you will join us again next Sunday evening at 6:00 for another edition of Yale Cancer Answers here on WNPR, Connecticut's Public Media Source for news and ideas.