Chapters Transcript Pelvic Floor Disorders Sara C. Wood, MD, MHPE, outlines the treatment strategies of pelvic floor disorders. Well, I'm excited to be here and uh share a little bit about the world of UY and, and how it might come into your office and hopefully give you some of the, the tools that you want to be able to both identify, evaluate treat. And then when's that point to refer? Obviously, at any point can be a point to refer. But, but where, where would you get um and find the most value and your patients would find the most value in that. Hopefully, we can be a resource in our division to you. Pelvic floor disorders is a broad topic. I mean, some of you might be seeing this topic and thinking, oh gosh, these are the patients. I'm, I'm not sure what to do about and I feel like I'm opening Pandora's box because pelvic floor disorders are those things that often are marginalizing, isolating, stigmatizing to women and our patients. And so I hope that after uh our time here together, you feel uh more equipped and comfortable to uh manage these patients and certainly uh a good resource for you to uh help take care of them in the future. So I have no uh financial or other conflicts of interest to disclose. I will say that there are some surgical images of vaginal prolapse that are present and so it they can be graphic. So if you are in a public place that you might wanna as we enter into that section, and I'll give you a heads up um just to be aware. So I started by mentioning the the world of pelvic floor disorders. And Nikki brought up many of the conditions that we treat my expertise. Um Well, I practiced the breadth and depth of urogynecology and reconstructive pelvic surgery. I tend to do a lot of work in the space of vaginal surgery. So, caring for women with post childbirth injuries, prolapse, incontinence, fistula vaginal anomalies, vaginal mass, things like that. And it is even, it's probably in a further niche of urogynecology and across our division, we are able to offer the, the great breadth and depth of urogynecology from minimally invasive to open uh approaches to caring for patients. But today, we're gonna focus on a few of the things that I think you might most commonly see in your office. We're gonna talk a little bit about prolapse. We're going to talk about recurrent urinary tract infections, vaginal atrophy and urinary incontinence and we're gonna get all that done in an hour and have time for questions. So let's do it. Our objectives. Today, we're going to talk about the demographic, demographic symptoms and anatomy and, and we'll really kind of hone in on prolapse here because it really ties in the anatomy of the pelvic floor. Good news. No one's gonna be asked a quiz question, a pop Q exam. Um But we do want to give you again some tools to be able to manage the patients uh as you feel comfortable to and know when to refer. We'll also talk about the treatment strategies that uh are really great. First line treatments for most of these patients, pelvic floor disorders have such a huge pre prevalence that only continues to grow. So at the age of 25 the prevalence of at least one pelvic floor disorder is nearly 25%. This doubles as women age with noting that higher BM I greater parity and hysterectomy associated with higher odds. And certainly we know that as the population continues to both age and uh and increase in our challenges related to obesity, that this becomes a significant issue. When we look at a vaginal exam, the prevalence is even higher. So many of these patients may have pelvic floor disorders that they don't even know. For instance, like prolapse, they might not realize that they have prolapse. But when examined on vaginal exam, it is indeed present by the age of 81 in five, women will undergo surgical correction. So clearly on any given day, you are coming across women who are struggling with symptoms of pelvic floor floor disorders or perhaps have undergone treatment for it. And yet it remains highly under reported, as I mentioned earlier, this tends to be a space in health care that does leave women feeling embarrassed to ask for help, uh might be reticent to uh come forth with their symptoms. And that really leaves a lot of opportunity for education. And studies have shown that this is even more of a dire need in developing culturally sensitive education for our patient population. So education is important. We know we need to deliver it and yet most of our patients are getting education from these sources, right? They're, they're hearing an influencer that shared their experience about a surgery or about a condition. And you can find obviously on any of these sites and even just the good old internet, all sorts of options of how you can treat your own pelvic floor disorder. You've got Joan right here, Jones toned in places you can't even see like your pelvic floor. So I think that one of the the great things about pelvic floor disorders is that it does apply to so many different medical professionals, whether you are in the, the niche that I am in or whether you're an obgyn or if you're more broadly in a primary care specialty, without question, you will be running across patients who have these symptoms. So let's talk by starting about prolapse and we'll start with some risk factors for prolapse. Many of these are probably not a surprise to you, but this was a recent uh publication that came out looking at what is the, the up to date data on risk factors for primary and recurrent pelvic prolapse? Shouldn't surprise you. Right. Vaginal birth parody Lavater hiatus. So Lavater Hiatus references the pelvic floor muscles, the lavater anna and the stretch and pressure and strain that they may come from, from childbirth and we'll talk about that a little bit more later. BM I baby's birth weight, we see a couple of protective factors. It it's always interesting when smoking winds up as a protective factor. Although interestingly, um as patients age with smoking and develop more and more bronchitis and COPD symptoms that actually then becomes a problem. Um younger age uh pre-op advanced prolapse, we stage prolapse from a scale of 0 to 40 is nothing. Four is the worst and so younger age and that early advanced stage become significant risk factors for recurrence. And then there is some mixed data around increased intraabdominal pressure. So perhaps patients who have a job that involves a lot of heavy lifting or perhaps they had an operative birth. There is some question if these uh are are true risk factors or not. And the data is a little mixed on that mode of delivery. Let's talk about that a little bit more. So for years, the thought has been mode of delivery, vaginal birth would be associated with a higher degree of of pelvic floor disorder findings, it makes sense logistically with the mechanics involved with vaginal birth. So this was a, a study published about 56 years ago looking at women and following them actually for 5 to 10 years and you saw that Cesarean birth was indeed protective. And you also saw this trend of when patients presented. So pelvic organ prolapse surgery peaking in the seventies versus stress incontinence peaking in mid forties and seventies. And and why that might be is if you think about patients who have prolapse, I will see women who have advanced stage prolapse, complete aversion of the vagina bladder uterus rectum and they're walking around and no one knows it except perhaps their partner, but stress incontinence and incontinence in general, people know it. They're worried that they can see perhaps a wet mark on the back of their clothing. They are concerned that someone may smell them. The age of 46 makes sense. Women have completed childbearing many times by that point and they're ready to go ahead and have treatment at that time. And on top of that, then we see this delay in pelvic organ prolapse symptoms that may have something to do with the theory of levator ani trauma. So let's take just a quick dive into anatomy and understand how that genital hiatus and the levator may give you uh make you at a higher risk for developing prolapse. John delancey who is a a nationally known well regarded urogynecologist at Michigan published in the early nineties, the three levels of support to the vagina and designated level one support as sense suspension support. So this is at the top of the vagina or the apex. And in the world of uy, the apex is where it's all at. So this is what we always see to be very important in doing a a prolapse repair. The second level is the attachment level, these are considered like more of the mid vaginal defects. So the terminology that that was may have been popular and now is actually kind of passed out of popularity, which is cystocele and recusal. Now, the uh appropriate nomenclature that, that we're um educating to use is anterior prolapse and post prolapse. That being said, many patients understand the word sole and recusal um more than they do anterior vaginal wall prolapse. So um use whatever you wish. But uh but that refers to that level two attachment support. And finally, the level three support is at the perineum and this is where the genital hiatus comes in. So if you look on the picture here on the left, you can see the pubovaginal musculature, encircling, the urogenital hiatus or just think of it as the vaginal opening and the per uh puborectalis musculature wrapping around both the vaginal opening and the anal opening. And this is what is forming the lavater hiatus. OK. So the lavater hiatus and the urogenital hiatus. And these measurements both are seen to be both predictive of uh continuing pro progression of prolapse and recurrence of prolapse. Looking at it on a little bit of a different depiction. So on the left here, you can see a pro uh a pelvis that has not undergone childbirth. And you see in the dotted line levator hiatus here from pubic sumps back below the anus to the coccyx. And then you see the, the urogenital hiatus, the opening of the vagina and with prolapse, you see that distention and enlargement of both of those uh measurements allowing the prolapse of the uterus here and the vagina to come through the levator plate. So here we're getting into some pictures now just to give everyone a heads up again, urogenital hiatus. Think of this as representing the vaginal opening with an intact perineal body here. And here's an example of what we call hiatal failure. So this patient has what is seen visibly as prolapse. And you can see that based on this measurement of an enlarged genital hiatus. And what, what really, what you need to identify is this is a vaginal bulge. She has vaginal prolapse. That's pretty much all you need to do um to be able to educate the patient on what they might be feeling and, and this, this patient may have even gone to the er because one night in the shower, after a hard day working outside, she was uh h completing her hygiene and felt a bulge at the vaginal opening and this scared her and this happens time and time again where the first time patients have ever realized that they've had prolapse has been with um by, by accident really in, in the shower and they present to the er and then all of a sudden it starts a uh an investigation into what's going on. If you look at this again, on a different depiction of what's happening. I mentioned that levator evulsion. So you can see here again, intact non paris depiction of the pelvic floor muscles, perineal body. Ok. Perineal membrane attaching perineal body up to the, the uh pubic bone and then levator ani below. And in this case, you have this evulsion of the levator ani from the perineal membrane and from the bone and allowing this progressive urogenital hiatus, enlargement and lavater hiatal enlargement. But really, what comes first? Is it the prolapse or is it in large genital hiatus? And uh a few studies have examined this, trying to understand from a preventative standpoint and also helping us predict what patients are ultimately going to need surgery or maybe need more treatment. We see that those with prolapse do indeed have a larger average levator hiatus at rest and with valsalva and that this rate of urogenital heis increases faster in women who are going to develop prolapse. So, both the enlargement of the vaginal opening and a rapid change in symptoms is more likely preceding the development of prolapse. In other words, how does this pertain to you? A patient might first start reporting symptoms of heaviness, uh pressure before they're reporting a bulge. And on exam, you might notice that enlarged genital hiatus, this then becomes associated with the faster loss of apical support. And as I mentioned a few moments ago, that level one apical support is really where it's all at that's going to give you the most likely uh chance of having a well supported uh repair that is going to last. And then finally, specific measurements of the Euro genital hiatus have been studied by the team here at wash U. Actually, Doctor Jerry Lauder and Doctor Kage Getty and other institutions looked at the measurement of genital hiatus and how it impacts uh predicting apical support defects. So here's an example of a patient who has, you know, profound stage four advanced prolapse. This is an operative photo. So she's uh coated in beta dyne. Hence the the coloring there, you can see the ulcerations on the vagina, these open sores. This is an example of of really, really massive prolapse. And and ideally, we are identifying these people and these patients before that in, you can imagine her ureters, her bladder are out here, her small intestine is in this. So it's creating obstruction from both a defecated function and a urinary function. And this particular patient as well had hydronephrosis noted on her renal ultrasound indicating the impact this was causing to her kidney as well as some uh renal insufficiency on her lab findings. Again, this all in line you can see imagine that picture. I just showed you this photo here on the right now, if you would superimpose all the, all the skin and anatomy on top of it, how similar that would look once we open everything up, this is a different patient but a very similar uh presentation. Um and exam you see on this picture on the left, the large bladder that has completely distended vagina is up here, bladder is here and then small intestines are coming out and this is a very large enterocele. And so again, these patients are suffering often from obstructed urinary and obstructive defecated functions. This is the uh post operative picture of her post after her repair. So now let's dig into a little bit about evaluation, pelvic exam with an ob objective staging system. I said at the start, no one's gonna have a quiz question on Pop Q and we're not going to do that. Um I I have a couple of things that I'd recommend that can help give a lot of understanding both to patients and knowing that referral time as well of what you can be looking for in public exam. Other components of the evaluation could include a post void residual. I'm sure you can imagine that patient, I just showed you is gonna have an elevated postvoid residual, right. She's got bladder that is uh fairly dependent. She may have to reduce the prolapse, meaning push the prolapse back in to be able to empty the bladder. Once the patients come see us, we will often order some urodynamics based on their associated urinary symptoms. We might do a cough stress test and this can be a great test to do when we talk about urinary incontinence as well for patients that you may be seeing in your practice. Finally, radiological over physiological studies if there are G I symptoms. So we tend to lean more into um like defecography rather than uh anal rectal manometry. Now, in terms of examining patients and understanding uh associated defecated dysfunction that may present the history to take vaginal bulge symptoms are highly sensitive for prolapse. This has been studied and looked at if a patient says they do have a vaginal bulge doctor, something is coming out of my vagina that is highly sensitive for prolapse. It makes sense. However, there are a number of patients who have pelvic floor dysfunction that will say I sense something is falling out. So the important question is, is there a bulge there? No, I don't see or feel a bulge? Ok. So they might have more of a pelvic floor dysfunction picture and that becomes important just in trying to triage if you will, where are they gonna best um be be treated next? Pelvic floor dysfunction is not a surgical uh treatment. So those patients are definitely gonna benefit from pelvic floor physical therapy. You also want to ask questions about their bladder function, bowel function, sexual function. These all kind of come in line together. But at the, at the beginning stage, you might just start with, um, asking about associated urinary symptoms with their prolapse with the bulge. Are you able to empty? Do you have to push the bulge in splinting is a common symptom patients will report splinting is the need to support or press on the back of the vagina or the perineum to be able to completely evacuate stool. And then again, we've talked a little bit about some of the risk factors that may be in a patient's history as well. Ultimately, though degree of bother is the name of the game here. And we use a lot of validated questionnaires in neuro gynecology to help us measure that in terms of how bothersome it is. But I'm a big fan of what my mentor taught me years and years ago. Ask the patient listen to the patient. It does it bother her if it does? That's absolutely an appropriate person to refer on in prolapse staging. We're looking to see each segment of the vagina. So in our offices, we will use a half speculum. So we can carefully examine the anterior vaginal wall, the vaginal apex, whether that is a cervix in a uterus or the vaginal cuff and someone who has post hysterectomy as well as the posterior vaginal wall. And we'll do that standing, we'll have them supine at times. We're just trying to see how far can the prolapse come out and, and in general, for uh for a, a primary care provider, the question of does the prolapse nearly reach or extend past the hymen? Because within a centimeter inside of the hymen and anything beyond a stage two prolapse and stage two prolapse often will be bothersome to women because as it starts to distend, the vaginal opening, it'll become difficult to retain Tampines, it will feel like there's something in the way it may begin rubbing on their undergarments. So these are all patients that would certainly be appropriate for referral treatment strategies and certainly observation and pelvic floor pt can be something that, that anyone can start in their own practice. So let's go through a few of those. So what happens if I do nothing? Well, when we look at studies examining the natural history and progression of prolapse, we see that over the course of about nine months, patients who have prolapse that is bothersome. So this study was particularly done in patients who already have troublesome prolapse, nearly 30% are going to progress. And so there is a set of progression. If a patient is mentioning it to you, it's probably gonna keep on getting worse. Not surprisingly, the anterior and posterior vaginal walls come with the apex or the uterus cervix or the cuff coming down. And then as we've hit on so many times that genital hiatus is gonna evolve. As you see the anterior and apical descent, once they get beyond four centimeters beyond the hymen, you're gonna really see uh a, a quicker progression. So if patients say to you, well, do I need to do anything about this? I think a really fair question is to say A, does it bother you? No, then it's reasonable to observe or B does it not bother you? But maybe it's impacting other medical conditions. Um it might be contributing to recurrent UTIs because they're not emptying. It might be contributing to their chronic kidney disease because of that. And in those cases, they do need to um probably move forward with seeking some degree of treatment. Pelvic floor physical therapy is absolutely the right thing to offer as a first line therapy in any patient with prolapse. We don't see a significant improvement when you look at large scale studies and women postoperatively. Um But I personally, in my practice, if I have patients that have certain uh voiding dysfunctions, deary dysfunctions, or they have baseline pelvic pain 100%. Absolutely. They are going to benefit from it postoperatively. Pelvic floor physical therapy is is not invasive, although you should prepare patients that there could be a pelvic exam involved. We have exceptional teams here as part of our uh our uh wash U and Barnes system. So the, the teams that I work with the most just from the geographic location I'm in are here at Barnes Jewish Hospital, as well as at Missouri Baptist and Barnes West. These pelvic floor physical therapists have done more than like a, a weekend course. If you will, they have done a more rigorous clinical experience to be able to evaluate treat and manage these patients. So I can't emphasize enough how important that piece of it is as well. Patients that aren't ready for surgery, but they need something to help more than pelvic floor physical therapy. A pessary use is gonna be great for them and, and if they don't have an obgyn, getting them set up with an obgyn is perfect. This is not someone that needs to see your gynecology for a pessary placement. Um We see that when patients are able to maintain pessary use for about a month, many times, they'll be able to continue using it. Some women are gonna use it almost as a band ad. I don't have time right now to have surgery. This is my busy season of work. I'm gonna use a pessary and then when winter comes, I'm gonna get surgery. So that's another option for a pessary. When combined with pelvic floor physical therapy, you see an even greater increase in quality of life outcomes. So, helping patients understand the benefit of marrying the two treatments is also important. However, we still see about 54% that are gonna cross over to surgery at some point. So once patients are inquiring about treatment, like with a pessary or with surgery, again, this is a great time to get them in with a provider. A and it can absolutely be a general OBGYN or nurse practitioner, midwife, et cetera who does pessary care. And then there are always some factors that are associated more with an unsuccessful pest refuting. But that doesn't mean that you can't offer it and can't try it. So prolapse, referral certainly, if patient request it, they say look, I my my sister just had surgery for prolapse. I have this bulge too. I wanna have surgery. Perfect person to refer on someone who's looking for more definitive treatment. A pessary nor pelvic floor physical therapy are going to cure prolapse. They are essential, essentially gonna work to control symptoms. So for a patient who says, I don't want to start with those, I want to go directly to surgery that is appropriate. I think there used to be more of a, a feeling of patients have to try these, these conservative measures as, as like a step therapy and that is no longer the case. Patients absolutely can proceed right, right to surgery if they have the the clinical findings that would support that decision making. So you can feel free to refer those as well, unsuccessful non surgical therapy. So patients who've tried the pessary. It didn't work. They tried pelvic floor physical therapy. Now, we may still talk to them about that again because perhaps they did two sessions of pelvic floor or they tried one pessary and there is a whole plethora of pessaries. So it doesn't mean that we won't offer them that opportunity and treatment again. But that would again be a good reason to send on. And finally, simply for patients who say, I just want to learn more about this. I want to know if, if this is something I need to do something about. We're happy to give that education and counseling. So let's shift directions a little bit into uh recurrent UTIs. So recurrent UTIs are something again that essentially almost anyone I know any of my peers and colleagues and friends that are in primary care, say this comes up all the time in the daily office on the exchange calls. Um All sorts of times that you will encounter patients with recurrent UT I and a fair amount of women will have a recurrent ut I after they have an initial first bladder infection, 50% will go on to have a third if they've had two UTIs in six months. And we'll talk about what that definition of recurrent ut I is here in just a moment. Overall, we see the highest rates in women 18 to 34 and then a second increase 55 to 66. So let's talk about some non antibiotic options that are helpful to prevent recurrent UTIs. First of all, I should uh take a moment and say it's important to fully treat the ut I. If the ut I wasn't adequately treated or the antibiotic uh was not sensitive to the particular uh micro organism, the patient has that isn't recurrent ut I, that's, that has not been a treated ut I to begin with. So, what is a recurrent ut I? We see right here, two or more symptomatic UTIs within six months or three or more infections within a year. And these really need to be a culture proven uh ut I. So it's, it is challenging and, and any woman that calls in to our practice as well at 10 p.m. on a Saturday, we're not going to say you have to wait with your ut I until you can get a culture. But we do really emphasize if it is during the work week um to get them in to uh to get a culture and, and leave a specimen. So we can know what we're tracking. There is a tremendous overlap in patients who have uh voiding dysfunction, overactive bladder, urgency issues and recurrent ut I si would say easily 50% of the patients I see who come for a diagnosis of recurrent UTIs actually haven't had recurrent UTIs and instead have overactive bladder. So you're talking about a burden of antibiotics that they've been receiving. Uh that weren't treating their symptoms, that they didn't have a UT I and sometimes that takes some time to help counsel the patients as well because they may say, yeah, but I got better on the antibiotics even though I didn't have a culture confirmed infection. And, and I can, I often see the notes and the dialogue that has happened between the primary care provider and the patient in that education. So you all are doing a great job with trying to help understand and explain that to them. But here, the clear winner is one. And if there's anything you remember and take home today, I hope it is a use of vaginal estrogen cream, vaginal estrogen cream or the ring um or tablets, all three of them, whatever is administered vaginally that the patient tolerates the most. This is the clear winner. It is absolutely the gold standard in helping to prevent recurrent bladder infections and it it doesn't unfortunately start working instantly. So women really need to give a good 8 to 12 weeks on, on this uh treatment before they are really gonna see a change. We know that adding back estrogen to the vaginal epithelium will change lubrication elasticity. You have this shift in the lacto bacila and it creates an environment that's going to be more suppressive of bacterial growth. The administration is typically 0.5 nightly for two weeks and then it decreasing to 2 to 3 times a week at bedtime. Um I always encourage patients, you can have intercourse if you just put the estrogen cream in, it's not gonna hurt him. I get that question a lot from husbands that are in the room. What happens if estrogen cream gets on my penis? It'll be OK. Um But generally the cream isn't gonna do a lot cause it'll probably come right back out. So I encourage patients once they complete that two week course when possible using the cream on nights that they don't intend to be sexually active or that they haven't been sexually active. And you see the significant difference coming from, you know, less than one episode a year compared to about six episodes a year. So there is really strong data, time and time again. That really says vaginal estrogen cream is the is the key cream may be more effective than the ring. Patients don't always love the cream. It's messy. The next morning there's discharge associated with it. So that is a bit of a burden to, to keep in mind. Now, it is not uh going to reach uh blood circulating levels like oral estrogen treatment will and oral estrogen treatment does not work to prevent recurrent UTIs. So if you have a patient that's on hormone replacement therapy and she says, no, I've got my estrogen already. It is not going to be helpful in this particular treatment. She still would need vaginal estrogen treatment. Um The administration of which is a little bit uh challenging to see. I personally find that the cream uh tends to actually work a little bit better in patients unless they really are bothered by the administration and the messiness of it. And the reason is is that the cream comes with an applicator that they insert and then deploy the cream into the vagina. But they can also put like a, I tell them, put a pea sized amount on your fingertip. And if you feel comfortable to do so, you can rub this cream in right around the vaginal opening and around the urethra meatus to really coat that tissue right there, which is what we're really trying to work on. But what about patients with a history of breast cancer? I mean, as soon as I say the word estra, I get stopped, but I'm worried about breast cancer. So we're gonna come to that in just one minute. Let's go through some other non antibiotic treatments to prevent recurrent UTIs cranberry for years. The the jury was out on cranberry. It was a real mixed uh a mixed uh opinion on on does this really benefit? And in the most recent Cochran review, it now has come out that there is a benefit um in patients, although they weren't able to determine that uh in elderly women, which is clearly a population that tends to have recurrent urinary tract infections. However, I think it's certainly reasonable to extrapolate out the findings to that population as well as the risk of taking cranberry is low. However, this is not drinking ocean spray, cranberry juice. There is more uh concentrated forms of cranberry that patients should have. I also always give a little caution to women who suffer from recurrent urinary tract infections are very, very bothered by these symptoms. And if someone tries to sell them on Q BC A supplement, that's $600 that is going to treat their UTIs, they'll probably try it. So I I really encourage them. You don't need anything fancy. The exact dosage is actually still up in the air as well, but definitely in a tablet form versus um a juice form. De Manos. De Manos has really been think of it as like a uh uh disinfectant if you will, makes the, makes the urothelium slippery and that really prevents the adhesion. So it has been a real game changer as well in preventing urinary tract infections. You can see that when you look at de Manos versus a Macrobid suppression versus placebo, it's nearly equivalent to uh to nitrofurantoin and it doesn't have obviously the antibiotic uh issue with it. Um It can be very well tolerated dosing ranges from 200 mg to 2 to 3 g. Um And this is a great thing as well to be able to start patients on. Finally methan amine salts, methan amine salts work a little bit in, in the same way in terms of not allowing uh the bacteria to really bind and adhere by affecting the bacterial proteins on the cell wall. Adding in ascorbic acid might be beneficial because this process works best in these acidic environments. And so you can see some dosing here, the what you can prescribe or what patients could get over the counter. Again, being thoughtful in patients who have uh renal insufficiency as well. So, vaginal estrogen is absolutely a must please feel free to start patients on vaginal estrogen before you're sending them to the OBGYN or, or to a urologist or gynecologist. This makes such a difference. Now, I mentioned in particular here, genital in patients with genitourinary syndrome of menopause. This is again a nomenclature update where no longer saying Volvo vaginal atrophy. We're saying genitourinary syndrome of menopause. Uh I will even use this in patients who are premenopausal, but they're in that perimenopause phase. And again, you're not going to have um harm in hurting them. Let's go back to the what about that risk of vaginal estrogen therapy in women with a history of breast cancer? Well, we finally had three large studies that came out in the past couple of years that help us answer this question and establish safety for patients. This was a large study that was done with the primary outcome of looking for need for treatment or occurrence of a secondary malignancy within three months to five years after starting vaginal estrogen therapy. So the patients that um were excluded. It are those that had um uh no, that, that had active breast cancer three within the past three months. So we got outside of that three month window and then they were followed for five years and then the year after their diagnosis were on vaginal estrogen therapy. The study design entailed almost 13 years of data, a little over 13 years rather of data. And again, excluding some of these patients with active breast cancer or a other primary malignancy. And then they also looked at patients based on their estrogen receptor status because that's something else that I'll hear from patients. Yes. But my breast cancer was estrogen receptor positive. So I have a lot of hesitancy to use estrogen cream and this population in particular really does suffer from the um some of the challenges that come with survivorship. Our, our treatments in the space of breast cancer have been emerging and and the technology has been advancing in immunotherapies that are now allowing patients to survive, which is phenomenal. These are some of the side effects though that wind up coming with it. And then they looked at those on concurrent aromatase inhibitor use. So this study involved 42,000 women and interestingly, only 2000 or 5% were actually in the vaginal estrogen cohort. So right off the bat, we see that there's definitely a disparity in those women that are even prescribed or maybe they are prescribed it but actually take it and they saw no difference in recurrence. So the recurrence rate was similar. They saw no difference in repeat treatment whether that was surgery or chemo radiation. They actually saw a lower risk of secondary malignancy and no difference in recurrence free survival or all cause mortality. They saw that estrogen receptor status had an even greater impact on those receiving vaginal estrogen. As I mentioned, understandably, patients who have estrogen receptor positive breast cancer may feel very hesitant to take estrogen cream and still no difference in recurrence risk or recurrence free survival. But now we saw a big difference. So we saw a difference here in patients in the sub analysis who are on an aromatase inhibitor and this is where you do want to to be weary and I personally would not advise using um vaginal estrogen cream. Although it might be fine, there is some mixed data and this data very clearly indicates the concern in using vaginal estrogen cream where you see that overall recurrence and the difference in those patients. So if I see a patient that's on an aromatase inhibitor would, would not recommend vaginal estrogen cream. But if they are not on that, I will take the time to counsel them about the benefits of vaginal estrogen cream. I also think it's a great partnership and a conversation to have with your oncologist. Having that conversation with the oncologist can help. Um Also the patient come to a a more educated decision and and how they wish to proceed. So, in conclusion of vaginal estrogen, no increased risk of breast cancer, be aware of that concurrent aromatase inhibitor use. This is where I'd I'd probably pull back and yet the ideal dosing is still under investigation. Like most things with hormone therapy, the verbiage of the the lowest dose for the least amount of time possible tends to roll out. But unfortunately, once you stop vaginal estrogen cream, the symptoms of thinning of the vagina dysuria, recurrent urinary tract infections, irritation, itching, et cetera will all return. So generally, this is not something that is a short term plan for many patients times to send on for a referral. Those culture proven recurrent urinary tract infections. What getting those cultures is important if it's possible those that are refractory to treatments really great for patients just to get started on vaginal estrogen before they've even come. It gives them a chance to experience and trial that treatment. Perhaps they've had ac T urogram and there's abnormal findings in the urinary tract. This would be a great reason to send on and need for advanced evaluation. Also could include obgyn. So this is by far not uro gyne. Um This is OBGYN, this is urology and oftentimes it can perhaps even be a bit easier to get into an established care within those specialties. Um and that way the patient can begin to start receiving uh more evaluation as needed. Let's skip right into urinary incontinence. So we can have some time for questions here at the end. Again, another highly prevalent uh symptomatology that women face and yet only about 45% are going to seek out care. This is something that really leads to isolation, both physical activity, social activity, work activities and sexual activity. It's really begun to have an impact. I uh did a uh article for USA today back in April or May talking about Botox and Botox had gotten popular in the press for use in overactive bladder because patients were getting it um to drive from New York City to the Hamptons and, and they didn't want to have to empty their bladder on the way. And, and while that is not the exact use of Botox, I do think that we saw such an increase in patients seeking care for overactive bladder as patients started returning back to work from the pandemic as all the social activities and avenues started opening up again. They weren't just at home, they were out and about more and it really dawned on them how troublesome these symptoms were. The differential diagnosis can be broad uh from genitourinary to non genitourinary etiologies. And the main types that you might see in your practice could include stress incontinence. So this is leaking with laugh, cough, sneeze, lifting, bending, exercise, this tends to be more of a small volume. So if a patient says, you know, I'm trying to run on the treadmill and it's like every step I take there's this little spurt of urine or every time I sneeze, I get this spurt of urine. That's very much in line with a stress incontinence diagnosis as opposed to urgency, which is loss of urine. Uh with that sudden desire to go to the bathroom or maybe with no warning at all. All of a sudden it's like, oh you gotta go. It's not like they were holding it, but all of a sudden they had to go and they just can't make it to the bathroom in time. This tends to be a larger volume. This is more likely due to a a bladder spasm. It's a bladder of storage issue as opposed to a urethral failure issue with stress incontinence and the unexpected nature of these symptoms tends to impact quality of life to a larger degree. So often I'll see women who have mixed incontinence. Few women have just one or the other. And if you ask them which of these is most bothersome to you, almost always. It's gonna be the urge because that comes when they don't know that it's gonna come. So many women wind up being a mixed with a predominant OAB feature, basic office evaluation, the kinds of questions that you might be asking pad use again, degree of bother comes into play here. Um Are they able to empty? Do they have incomplete emptying. See a lot of coincident constipation. How many times have I seen patients once they get that constipation, treated their urinary symptoms improve. Kind of coming back to the picture of the pelvic floor dysfunction patient that doesn't necessarily have prolapse, but has a lot of pelvic floor symptoms that often get associated with prolapse when they're really not. And this is more due to the uh communication if you will of the pelvic floor muscles, the bladder muscles and the nerves that uh go to these organs. Clearly use of diuretics, caffeine alcohol. These are all going to impact. Um I mentioned some things to think about in screening, screening for UT I, for example, a bladder diary, bladder diary is a great thing to do. Um to get an idea of what's going on. I had a patient who um I realized she was drinking about 620 ounces of Mountain Dew a day. Well, good news, your kidneys are working. So you're gonna have frequency, you're going to have urgency because of that. Therefore, we need to pull back on some of that liquid intake that can be really revealing for patients as well because often if I ask them, what do you drink? How much do you drink it? It, I it would be hard for me to remember everything I drank in a day. So that diary can help give some good data treatment strategies. So these third line treatments I'm not gonna touch on today, but those are all third line treatments we offer here. Those are great options for patients. And I think it's imp important for patients to know if they've tried pelvic floor physical therapy and it didn't work. Please don't stop there. You know, please know that there are other options that you don't have to live life. Um A as I've heard from several patients, my kids aren't in diapers anymore, but now I am, I carry a diaper bag. My purse has become a diaper bag with spare clothes, spare underwear, all these big pads, et cetera. So first line treatments including behavioral therapy should be recommended for all patients. Bladder training data is a little bit mixed. Is it helpful? Is it not timed voiding might be helpful for patients timed voiding is where you say if you normally would go every uh hour, then you back it up and you go at 50 minutes for three or four days and you set a clock and every 50 minutes you go and the next week you take it to every hour and then you take it to 70 minutes. Bladder training. I find works best when they're in a pelvic floor physical therapy um plan because they're also getting support to do this from the pelvic floor physical therapist. It's hard just to tell someone to do bladder training and um for them to maintain that in a long term. Uh plan beverage modifications. Of course, make a difference, weight loss makes a huge difference. I mean, there have been several good studies that show um how in for instance, in this case, is RCT looking at losing 8% of body weight resulted in a decrease of weekly incontinence episodes by nearly half. So that is really good data. And um and I talk to patients a lot about this, I generally will say, you know, is today a good day to talk about weight um because it is a noise and, and I know that at times, patients can feel like every doctor is talking to them about their weight. And now the vaginal surgeon is too, but it is important to note because it really can make a difference. Here. Here are some of uh a graphic depiction of, of those results and it really is quite astounding the difference and change of incontinence episodes. Additionally, what is interesting is I am anecdotally seeing a tremendous amount of patients who have lost weight on their G LP ones and their urinary incontinence symptoms are better. So I think it'll be interesting long term to follow some of these cohorts, not as though G LP ones are indicated for decreasing urinary incontinence, but the impact of weight loss and what that ultimately has on their bladder symptoms as well. Pelvic floor pt, there's great evidence to support it improves quality of life, but there are some factors that make it more successful. A pelvic floor, physical therapy is not Kegels. I hear that frequently from patients. Oh, well, I always did my Kegels or I didn't do my Kegels. And I say, well, let me unburden you. It's not that you didn't do something that led you to get here. Pelvic floor physical therapy is much more robust in how patients can coordinate the pelvic floor along with their core, their low back, their gait comes into play. There's so many different factors that come into play of avoiding function and dysfunction, electrical stimulation can be very beneficial in patients as well. With urge U I. Again, these are some of the features that our pelvic floor physical therapy teams here have. But I do find it interesting that that the concluding comment of the most recent Cochrane review talks about we need to consult women to further identify outcomes of importance because a lot of the data in this world still remains um mixed and it and it isn't the most robust data. Um So I I'm eager to see where we continue to take this to, to keep improving our patient's quality of life medications. So there really are no medications for stress, incontinence, your patients that are complaining of and and have concerns of less leakage with laughing, coughing, sneezing. Unfortunately, the medications are not going to cover that. These are solely for patients who have overactive bladder or urge U I, antimuscarinic improved quality of life compared to placebo. But boy do patients really struggle with the side effects. So it does lead ultimately to a high withdrawal of use. One of the most quoted studies is that after one month, less than 25% of patients refill a prescription indicating the fact that it did not provide relief of symptoms or the side effects were so bothersome, they couldn't continue. So the dry mouth, the dry eyes tend to be very difficult. Now, if you have a patient who has fecal incontinence, that actually can be a little bit of help because it can uh constipate them a little bit and can improve some of the fecal incontinence. So if you have both of those, these are not a bad option. However, I also want to highlight these should not be used in patients over the age of 65. There's very clear data that looks at uh cognitive decline and memory and dementia issues in patients over the age of 65. And so if I have a patient, even who's 63 I generally will steer them away from this just because I think why get them on a treatment that a year from now, we're gonna need to talk about changing. In addition, it's additive. So it's all the, all the medications, the, the Benadryls, the antihistamines, it's a, it's a combined effect throughout their lifetime that can impact uh memory. Now, in opposition, the beta three agonists do not do that. Mira Beron and its new sister Vera Beron. Um, they work in a slightly different way and they don't have that same uh effect of and uh side effects of the anti muscarinic beta. Uh Mira Beron can have an effect of hypertension. So in someone who has uncontrolled hypertension, you would not want to use it. But if someone's on a medication and their hypertension is controlled, I will still try them. I tell them, check your blood pressure. If you have a cuff at home or if you're having symptoms, that concern you by all means, call us, you stop the med, the blood pressure comes down. Um Unfortunately, these are not well covered from a insurance cost standpoint. So many times, patients will find that they are asked to try an antimuscarinic first and that's really disappointing because they really do need to be on a mirror bed run or a vibe, be run and again, any of these would be reasons to go ahead and, and, and move right to a referral. It's very similar to the prolapse patients. So in conclusion, you know, it's the three, the three A's ask awareness action. So ask be aware and take action regarding pelvic floor disorder symptoms. Patients don't want to bring this up. You know, patients will talk about their heavy periods. Now, Katie Couric and the loss of her husband allowed colon cancer screening need to become a much more visible and and discussed topic. But you know, urinary incontinence, my vagina is falling out. I leak urine during intercourse. Those are symptoms that women are still very reluctant to volunteer. So asking lets them know this is ok for you to share this with me. There's a plethora of non-surgical and surgical options and OBGYN and subspecialty referrals to our team can help in caring and management of these patients. So with that, I will stop and I think we have a few minutes left here. If anyone has any questions, I have also put my email down here at the bottom of the, at the bottom of the slide, please feel free to reach out. And in addition, if you're ever wondering like is this a patient for you guys or is this OBGYN or maybe it's urology or maybe it's G I, please don't hesitate, you know, send me a staff message. I always hate when patients feel like they're, they're running around to all the subspecialists and they, they might need the, the colorectal they might need G I. So if you're not sure we're happy to help, please don't hesitate to send me a secure chat of staff message, send me an email. Um I'd love to connect. Thank you so much. Hopefully, our next speaker is actually a colorectal surgeon. So maybe he can, you know, help out with some of those questions too, but you have a good. Um So there was a question in the chat. Um Many of my patients complain of the high cost of vaginal estrogen. Am I prescribing the wrong version so many times a plan might cover rays versus Premarin differently. So, if you prescribe Premarin and I always tell patients if you get there and it's very expensive, just call us and we'll send the other one and usually it's less. Um I don't try even, even though I prescribe a lot of it, I'm not gonna know everybody's plan d and what's covered and what isn't covered and what's formulary, although sometimes it will pop up as a screen um with an epic about it, but that I just give the patients a heads up if it's too expensive, call us back and we'll send the other one and try that. Secondly, compounded estrogen um by Jennifer's. Uh there's a compounding pharmacy here. We use that um a fair amount as well. Obviously, anytime you compound something, it's not gonna have quite the same rigor and, and controls on it. But I've had a number of patients that have used um uh the compounded vaginal estrogen cream from Jennifer's and I found it to be extremely helpful and much, much cheaper, right. Um Can you please comment on antibiotics to suppress UT? I si know it's not a, it's not first line, but when should I think about this? Absolutely. So, if a patient's on vaginal estrogen cream and they've tried de manos and they still are having recurrent UTIs number one, that's where I would say an evaluation get ac T urogram with and without contrast, if they can't have contrast, you can always uh do a renal ultrasound, you could do potentially do an MRI. But as you all know, those are, those are hard to get covered at times, but that is time for a urinary tract evaluation. Um In addition, uh cystoscopy can sometimes be a part of that evaluation as well. Patients who've had a prior pelvic surgery, prior mesh, um, suffer from kidney stones. All of those would be reasons to say maybe she needs further evaluation. But that would also be the point where you could say I'm gonna start doing a daily suppression of Macrobid or like a cephalexin. Bactrim tends to have a lot more resistance currently in our area and that's really changed over about the past 2 to 3 years. Bactrim used to be pretty good and Bactrim is unfortunately not near as susceptible to many of the urinary tract infections. Ok. And then we got two more. Um, real quick. What about I mega chairs or I'm not sure and I see the chat. So, um, it's spelled Ma Gents chairs, maybe da if you can clarify that. Um The next question is bad pen. Also good question mark. Yes, absolutely, definitely. So that's another great option, Oshea. Um Is another option that, that some patients will, will do better with. I always tend to, again, I always tend to prefer that that cream administration, but that is better than nothing for sure. Um ok. And then Don said Mat is Magenta Ma Gents. I am let me see if I can get the chat open. I am, I am not sure of that. I see. What about macro bed for prevention in the chat? And yes, that would be magnetic chairs. There's magnetic chairs. I am not familiar with the magnetic chairs. That's interesting. That sounds like a good talk for next time, Nikki. Let's get the magnetic chairs going, right. I'm gonna look into magnetic chairs. Ok. Well, thank you all so much. I appreciate the opportunity to share a little bit about women's health with you and in particular pelvic floor disorders. Um I, I hope that uh if you have any questions, like I said about where, where does that patient go next? Um, would love to help, help take care of your patient and uh, I'm turning it over now. I've saved all the hard questions for you, Doctor Chapman. So, so good luck. Fabulous. Thanks. Thanks. If you have any other questions, we can always um, I'll send them to Doctor Wood or you can also email her yourself at Sarah w at wo.edu. Um and she will get those answered for you. Great. Thanks so much, Doctor Wood. Have a great rest of your day. Thank you. Thanks. Welcome, Doctor Chapman. How are you today? I'm doing great. Thank you. Great. All right. Well, if you wanna go ahead and share your screen. I will go ahead and introduce you if that's ok. Sounds good. Let's see here. Perfect. Created by Presenters Sara C. Wood, MD, MHPE Chief, Division of Urogynecology & Reconstructive Pelvic Surgery View full profile
