Pelvic Floor Disorders by Peter OHare MD

8/17/2019 Pelvic Floor Disorders by Peter OHare MD

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Pelvic Floor Disorders

Peter G. O'Hare III, M.D.

Co-Director, Division of Female Pelvic Medicine & Reconstructive Surgery


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Quiz

As a wom an, your c hance of

get t ing a pelv ic f loor d isord er is:

A. 1 in 3.

B. 1 in 4.

C. 1 in 5.

WH-175304-AA. Slide 2 of 44. August 2013.

Risks for pelv ic organ prolapse

(POP) include:

A. Age.

B. Giving birth.

C. Smoking & chronic lung disease.D. Lifestyle factors.

E. All of the above.

The num ber of adul ts wi th bow el

incont inence is :

A. 5 million.

B. 12 million.

C. 18 million.

Bladder cont ro l prob lems only

occu r in wom en af ter menop ause:

A. True.

B. False.

“POP”


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Agenda

• What are pelvic floor disorders (PFDs)? – Bladder control.

– Bowel control.

– Pelvic organ prolapse.

• How can I break free?

– Pelvic floor workouts.

– The Voices of PFD.

• What is the PFD Alliance?


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PELVIC FLOOR DISORDER

(PFD)


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One in three women will

experience a PFD in her lifetime


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What is the Pelvic Floor?

• Set of muscles, ligamentsand connective tissue in

the lowest part of the

pelvis.

• Supports internal organs: – Bladder.

– Uterus.

– Rectum.

– Vagina.

Food and Drug Administration. Information for Patients for POP, www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/UroGynSurgicalMesh.

Pelvic floor


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Pelvic Floor Problems

• Problems with bladder and/or bowel caused by weakened

pelvic muscles or tears in the connective tissue.

• One or more symptoms:

– Feeling pelvic pressure or bulge in the vagina.

– Urine leakage (urinary incontinence).

– Overactive bladder (―gotta go‖). – Difficulty emptying the bladder.

– Problems having a bowel movement.

– Gas or stool leakage (fecal

incontinence).


National Institute of Child Health and Human Development. Pelvic Floor Disorders. www.nichd.nih.gov/health/topics/pelvicfloor/conditioninfo/Pages/default.aspx


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PFD Risk Factors

• Age and life stage:

– 1 in 3 women—risk increases with age.

– Pregnancy and childbirth.

– 1 in 4 younger women (20 to 39 years).

• Lifestyle and behaviors:

– Obesity and limited physical activity. – Smoking.

• Health conditions:

– Stroke.

– Problems urinating and having a bowel

movement.

– Pelvic injury, pelvic surgery.

Nygaard I, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA, 300(11), Sept. 2008.

Tahereh E., et al. The Frequency of Pelvic Floor Dysfunctions and their Risk Factors in Women aged 40‐55. Journal of Family and Reproductive Health 6(2), June 2012.

1 in 4 younger women


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Types of PFDs

Bladder control problems

Pelvic organ prolapse

Bowel control problems

1

3

2

Nygaard I, et al. Pelvic Floor Disorders Network. Prevalence of symptomatic pelvic floor disorders in US women. JAMA, 300(11), September 2008.


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BLADDER CONTROL


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You are not alone—18 million women in

the U.S. have urinary incontinence

Wu, Jennifer et al. Forecasting the Prevalence of Pelvic Floor Disorders. Obstet and Gynecol, 114 (6), December 2009.


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• Your body stores water

(urine) in the bladder.

• The bladder connects to a

tube called the urethra.

Muscles and nerves help

control the bladder and

urethra.

• When you go, these muscles

and nerves signal urine to

leave the body through the

urethra.

National Institute of Diabetes and Digestive and Kidney Diseases. Urinary Incontinence in Women, kidney.niddk.nih.gov/KUDiseases/pubs/uiwomen.

WH-175304-AA. Slide 11 of 44. August 2013

Bladder Opening

Vaginal Opening

How the Bladder Works


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Symptoms of Control Problems

• Problems with muscles and nerves that help to

hold or release urine: – Loss of urine (urinary incontinence).

– Difficulty emptying your bladder, for example,

trouble starting the flow of urine.

• Symptoms vary: – Strong, sudden urge just before losing

a large amount of urine.

– Involuntary loss of both small and large

amounts of urine with activities such as

coughing or straining.

– Slow or interrupted urine stream or sense of

incomplete bladder emptying.

– Sexual dysfunction.




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Types of Urinary Incontinence

• Stress incontinence:

– Urine leaks with activities (coughing, sneezing,laughing, lifting, exercising).

• Urge incontinence/overactive bladder (OAB):

– ―Gotta go now ‖ sensation (urgency). – ―Gotta go now ‖ with leakage (urge incontinence).

– ―Gotta go often ” (frequency).

– Going often during the night (nocturia).

• Other types: – Mixed incontinence (stress and urge).

– Continuous (unpredictable) incontinence.




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Treatments: Urinary Incontinence

• Find out what treatment is best for YOU:

– Ask your doctor about risks, potential complications, andfollow-up care.

• Diet and exercise:

– Lose weight (if overweight).

– Limit alcohol and caffeine.

– Keep pelvic muscles healthy and working well.

– Do pelvic floor exercises (kegels).

• Bladder diary—app or paper: – Track how often you go.

– Try to ―schedule‖ bathroom trips.



PFD Alliance. www.voicesforpfd.org.


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• Pessary:

─ Silastic rubber vaginal insert.

─ Different shapes and sizes.

─ Sized to fit each patient.

─ Inserted into the vagina.

─ Supports the bladder.

• Physical therapy:

─ Biofeedback.

─ Bladder retraining.

─ Pelvic floor muscle nerve

stimulation. ─ Exercises to help strengthen and

control the pelvic floor muscles.

Treatments: Stress Incontinence



American Urological Foundation. A monograph from the AUA Foundation: Stress Urinary Incontinence.

http://www.urologyhealth.org/resourcecenter/bladder/bladderBrochures/SUI_Monograph.pdf, 2011.


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• Bulking therapy:

– Outpatient or office based procedure.

– Inject gel like material around the urethra

just outside of the bladder.

– Bulk up the area to close the lumen of the

urethra and help block leaking.

– Lower success rate than surgery.

• Goal to improve quality of life.

• Surgery:

– Helps to support urethra and bladder.

– Aims to stop or reduce urine leakage.

– Goal to improve quality of life.



American Urological Foundation. A monograph from the AUA Foundation: Stress Urinary Incontinence. www.urologyhealth.org/resourcecenter/bladder/bladderBrochures/SUI_Monograph.pdf, 2011.

Treatments: Stress Incontinence


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• Lifestyle changes:

– Retrain your bladder and learn ways to control when you go. – Exercise your pelvic floor muscles and make diet changes.

• Physical Therapy: – Biofeedback (pelvic muscle training).

• Medicines: – Bladder relaxant medicines.

• Surgeries: – Botox™ Preparation bladder injections.

– Bladder nerve stimulator (electrical stimulator

or neuromodulator).

– Tibial Nerve Stimulation.

• Combination of treatments.



Gormley EA, et al. American Urological Association (AUA) Guideline: Diagnosis and Treatment of Overactive Bladder (non-Neurogenic) in Adults: AUA/SUFU Guideline. May 2012.

Reprinted with the permission of Medtronic, Inc. © 2006

Treatments: Urge Incontinence/OAB


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You Are Not Alone


• Patient story—hear from others with bladder control

problems.

• Join the conversation at Voices for PFD:

− Women share stories.

− Get support from other women.

− Ask experts about pelvic floor disorders.


…and visit voicesforpfd.org


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BOWEL CONTROL


22/40WH-175304-AA. Slide 19 of 44. August 2013

Nearly 18 million U.S. adults—about 1

in 12—

have fecal incontinence, alsoknown as accidental bowel leakage.

National Institute of Diabetes and Digestive and Kidney Diseases. Fecal Incontinence, http://digestive.niddk.nih.gov/ddiseases/pubs/fecalincontinence/index.aspx


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Don’t Be Embarrassed

• Bowel control problems can beupsetting and embarrassing.

• Don’t be ashamed to discuss

with your doctor.

• It is often due to a medical

problem.

• There are treatment options.




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How the Bowel Works


• Muscles and nerves in therectum and anus:

− Hold stool.

− Let you know when the rectum

is full.− Signal when to release stool.

• Pelvic floor and sphincter

muscles work together to help

with bowel and gas control.



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Symptoms of Control Problems


• Accidental loss of gas and/or bowel contents.

• Chronic constipation (4+ million people in U.S.):

− Bowel movement fewer than 3 times per week.

− Stool is hard, dry, small, and difficult to get out.

− Straining and bloating.

− Pain with bowel movement.

• Diarrhea:

− Loose, watery stools.

− Passing loose stools three or more times perday.

− More than two days may signal a problem. National Institute of Diabetes and Digestive and Kidney Diseases. Constipation. ttp://digestive.niddk.nih.gov/ddiseases/pubs/constipation/index.aspx



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Treatments: Diet Changes


FECAL INCONTINENCE CONSTIPATION• Avoid spicy foods and caffeine. • Avoid starchy foods such as white rice, pasta,

or white bread.

• Include more fiber in your diet:

− Makes stools firmer.− Helps promote more complete passage of bowel

movements.

− Eat more whole grains, fruits, vegetables, or high

fiber cereals.− Ask your doctor about fiber supplements.

• Talk with your health care provider about dietary

changes which may help control bowel problems.



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Treatments: Medicines, PT


• Medicines:

– Soften stool (laxatives). – Help form stool (antidiarrheal

medicines).

• Physical therapy (PT):

– Improves the pelvic musclestrength, tone, endurance, and

coordination.

– May include biofeedback.

– Ask your doctor for a referral toa specialized physical therapist.


Satish SCR. Practice Guidelines: Diagnosis and Management of Fecal Incontinence. American Journal of Gastroenterology, 2004.


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Treatments: Surgery


• The goal of surgery is to improve bowel

function:− Improve bowel emptying.

− Improve bowel control.

− Help with bowel emptying at appropriate

times.

• Types of surgery include:

− Bulking agents.

− Pace maker for the pelvic floor or

bowels (neuromodulator) to help pelvic

and anal sphincter muscles contract.− Sphincter repair (anal sphincteroplasty).

− Anal sling.


Satish SCR. Practice Guidelines: Diagnosis and Management of Fecal Incontinence. American Journal of Gastroenterology, 2004.


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PELVIC ORGAN PROLAPSE


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About half of women between the agesof 50 and 79 have some form of prolapse



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Are you at risk?


• Risk factors increase with age:

– Postmenopausal women. – 11% lifetime risk of prolapse

surgery by age 80.

• Giving birth one or more times.

• Lifestyle:

– Overweight.

– Tobacco use.

• Other health conditions: – Chronic lung disease.

Olsen AL, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 89(4), 1997.


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Least common—

dropping of the uterus

(Uterine Prolapse)

Dropping of the rectum

(Rectocele)

Most common—

dropping of the bladder

(Cystocele)

What is POP?


• Pelvic floor muscles and ligaments are stretched or

become too weak to hold organs in the correct positionin the pelvis.

• As it progresses, women can feel bulging tissue

protruding through the opening of the vagina.

Hendrix SL, et al. Pelvic organ prolapse in the Women’s Health Initiative. Am J Obstet Gynecol 186(6), 2006.


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Symptoms of POP


• Pressure and heaviness in pelvic area.

• Bulging: feeling a lump in the vagina, or lump comingout through vaginal opening.

• Urinary problems

− Difficulty starting to urinate.

− Weak or spraying stream of urine.• Bowel problems

− Chronic straining or pushing to have bowel

movements.

• Pelvic pain, painful sex (dyspareunia).• Low back pain associated with bulge.

Food and Drug Administration. Information for Patients for POP, www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/UroGynSurgicalMesh/ucm262299.htm.

Ellerkmann RM, et al. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol, 185(6), December 2001.


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Treatments

WH-175304-AA. Slide 31 of 44. Au ust 2013

• Best treatment depends on how much symptoms bother you:

− POP is not life-threatening.− Treatments can help improve quality of life and sexual

health.

• Conservative approach:

− Watch and see how things go.− Dietary changes.

− Pelvic floor muscle exercises.

− Pelvic floor physical therapy.

• Pessary:

− Support bladder, uterus and vagina.




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Treatments: Surgery


Food and Drug Administration. Information for Patients for POP, www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/UroGynSurgicalMesh


• Every woman's situation is different.

• No single operation is right for every

patient.

• Specific type of surgery depends on:

− Your body (anatomy).

− Overall health, other healthproblems.

− Prior surgeries.

− Desire to retain sexual function.

− Experience and training of surgeon.


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Treatments: More on Surgery


• Goals of surgery:− Restore normal anatomy.

− Reduce bulge.

− Improve quality of life.

• Success or failure of someoneelse's operation should never

be the deciding factor for you.

• You and your doctor must

decide what’s best for you.

National Institute of Child Health and Human Development. Pelvic Floor Disorders. www.nichd.nih.gov/health/topics/pelvicfloor/conditioninfo/Pages/default.aspx



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BREAK FREE FROM PFDs!


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PFDs are not considered a normal part of

aging—they can be treated successfully

with the help of a specialist


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Empowering Women

• Created in September 2011:

− Raises awareness about PFDs.

− Educates about treatment options.

− Enables women to develop individualized treatment plans.

• Join the conversation:

− www.voicesforpfd.org

− www.facebook.com/TaketheFloorPFD

− www.twitter.com/TaketheFloorPFD


The PFD Alliance



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THANK YOU

Questions & Answers

Pelvic Floor Disorders by Peter OHare MD

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