break free - okpa.org · •pelvic organ prolapse •anatomy basics •urinary incontinence...

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BREAK FREEfrom Pelvic Floor Disorders

WELCO M E & IN T RO D UC T ION

MEET THE PRESENTERJameca Price, MD MPH MCR

Assistant ProfessorOU-Tulsa Patient Safety Medical Director

Associate Director of Clinical ResearchUrogynecology, Department of

Obstetrics and Gynecology

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• CHECK OUT OUR PRACTICEOU-Physicians-Tulsa

Schusterman Clinic

4502 E. 41st Street Tulsa, Oklahoma 74135

(W) 918.660.8365 (F) 918.660.8355

http://www.ou.edu/tulsa/ou_physicians

• INTRODUCTION TO PELVIC FLOOR DISORDERS

• RISK FACTORS FOR PFDS—SOME PATIENTS CAN CONTROL• ANATOMY BASICS

• PELVIC ORGAN PROLAPSE

• URINARY INCONTINENCE

• ABOUT VOICES OF PFD

• QUESTIONS AND ANSWERS

P RO G R A M OV ERV IEW

• SYMPTOMS• TYPES• DIAGNOSIS

• TREATMENT


AS A WOMAN, YOURCHANCE OF GETTING APELVIC FLOOR DISORDER IS:

A. 1 in 3

B. 1 in 6

C. 1 in 9

Quiz“POP”


IN T RO TO P ELV IC F LO O R D IS O R DERS

About one in three women will experience a PFD in her lifetime


Source: van Breda HMK, Ruud Bosch JLH, de KortLMO. Hidden prevalence of lower urinary tract symptoms in healthy nulligravid young women. In Urogynecol J.18 Jun 2015. [epub ahead of print]

What is the Pelvic Floor?

• Set of muscles, ligaments andconnective tissue in the lowest part of the pelvis

• Supports internal organs:– Bladder

– Uterus

– Rectum

– Vagina

• Helps control pelvic organfunctioning

P E LV I C F L O O R D I S O R D E R S

Pelvic floor


Pelvic Floor Problems

• Problems with bladder and/or bowel caused by weakened pelvic muscles or connective tissue that support thepelvic floor

• 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 (accidental bowel

incontinence)



Three Types of PFDs

BLADDER CONTROL PROBLEMS• Urinary incontinence (UI) or accidental urine leak is most common

• 16 % of women

PELVIC ORGAN PROLAPSE• Least common

• 3% of women

BOWEL CONTROL PROBLEMS• Accidental bowel leakage, fecal incontinence, anal incontinence

• 9% of women


1

2

3


Source: Nygaard I, Barber MD, Burgio, KL, et al. Prevalence of SymptomaticPelvic Floor Disorders in US Women. JAMA 2008;300(11):1311-1316

WHICH OF THE FOLLOWING ARE RISKS FACTOR FOR PFDS:

A. Pregnancy

B. Age

C. Being overweight

D. Smoking

E. All of the above

Quiz“POP”


PFD RISK FACTORS

IN YOUR CONTROL

• Life style:– Don’t smoke

– Maintain normal weight

– Be physically active

– Be cautious with extreme sports

– Limit caffeine and excessive

intake of fluids

– Avoid constipation

• Maintaining good health:– Keep pelvic floor healthy

– Control blood sugar

LESS CONTROLLABLE

• Life stage:– Risk increases with age

– Pregnancy and childbirth

• Health conditions:– Pelvic injury, pelvic surgery

– Chronic lung disease

– Neurological problems


U R IN A RY IN CO N T IN EN CE ( U I )

In the US,

18 million women have UI


Source: Whitcomb EL, Subak LL. Effect of weight loss on urinary incontinence in women. Open Access J Urol. Aug 1 2011; 3: 12 3–132

41% seek helpwithin 1 year

Patients Wait to Talk with Your

Doctor

26% of women wait over 5 years to seek help

33% wait 1 to 5 years

U R I N A R Y I N C O N T I N E N C E


Source: Norton, P A et al. Distress and Delay Associated With Urinary Incontinence. BMJ, 297(5), November 1988

Bladder Opening

VaginalOpening

DID YOU KNOW?The urethra and vagina are separate openings


Urinary Incontinence—Anatomy Basics


UI—Anatomy Basics

• Your body stores urine in thebladder

• The bladder connects to a tubecalled the urethra

• Muscles and nerves help controlthe bladder and urethra

• When you go, these muscles and nerves signal urine to leavethe body through the urethra


HOW THE BLADDER WORKS


Quiz“POP”

BLADDER CONTROLPROBLEMS ONLYOCCUR IN WOMENAFTER MENOPAUSE

A. True.

B. False.


UI IS MORE COMMONIN OLDER WOMEN

• Up to 38% of those aged 80 or over

1 IN 4 YOUNGER WOMEN (20 - 39 YEARS)

• Weight pressing on the pelvic floor

(pregnancy, overweight)

• Bodybuilding and intensive weight

training is a risk for both urinary and

bowel incontinence

Sources:

Wu JM, Vaughan CP, Goode PS, et al. Prevalence and trends of symptomaticpelvic floor disorders in U.S. Women. Obstet Gynecol 2014;123:141

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

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


Women of All Ages Can Be Affected

Pressure on the bladder


UI—Symptoms of Control Problems

• Problems with muscles andnerves that help to hold orrelease urine

• UI = urinary incontinence =loss of urine

• Some have difficulty emptying bladder (troublestarting the flow of urine)



of UI Continued

• Strong, sudden urge just before losing urine

• Involuntary loss of both small and large amounts of urinewith activities such as coughing, laughing, or straining

• Slow or interrupted urine stream or sense of incompletebladder emptying

• Sexual problems, e.g., leaking urine with sexual activity



UI—Types


STRESSINCONTINENCE

• Urine leaks withactivities

• Coughing, sneezing, laughing, lifting, exercising

URGE INCOTINENCEOveractive Bladder

• Gotta go now”(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


MAKING CHANGES TOYOUR DIET MAY HELPCONTROL UI:

A. True

B. False

Quiz“POP”


UI—Treatments


• Depends on out what treatment is best for PATIENT:– Discuss risks, potential complications, and follow-up care

• For most, health care providers may recommend:– Lifestyle changes

– Bladder diary

– Kegels (pelvic muscle exercises)

• Additional options for different types of urinary incontinence:– Stress UI—pessary, pelvic floor physical therapy, bulking therapy, surgery

– Urge UI (OAB)—physical therapy, medicines, surgery

• A combination of treatments may be needed


• Lifestyle changes:– Lose weight (if overweight)

– Limit alcohol and caffeine

– Avoid excess water/fluid intake

and ask patients if they are

drinking too much

• Bladder diary– Track of how often they go

– Try to “schedule”

bathroom trips


UI—Treatments Continued


• Lifestyle changes:– Retrain their bladder

– Learn ways to control when they go

– Exercise their pelvic floor muscles

and make diet changes

• Physical therapy:– Pelvic floor physical therapy

– May include biofeedback techniques

• Medicines:– Bladder relaxant medicines

– May need to modify dosage and/or

try different medicines


I’m

Kegeling!

#kegelface

TreatmentsOVERACTIVE BLADDER


OVERACTIVE BLADDER

• Surgery—different types:– Botox® bladder injections

– Peripheral tibial nerve stimulation (PTNS)

– Interstim ® bladder nerve stimulator (electrical stimulator or

neuromodulator)

– Vaginal electrical stimulation

• Combination of treatments


Image Source: Medtronic, Inc.© 2006


Treatments

STRESS URINARY INCONTINENCE

• For many women with stress urinary incontinence (SUI),a pessary helps control leakage:— Silicone vaginal insert

— Different shapes and sizes

— Sized to fit each patient

— Inserted into the vagina

— Supports the bladder and urethra


Treatments

Image Source: www.MediPlus.com.uk


http://www.MediPlus.com.uk/

TreatmentsSTRESS URINARY INCONTINENCE

• Physical therapy:— Biofeedback

— Bladder retraining

— Pelvic floor muscle nerve stimulation

— Exercises to help strengthen and

control the pelvic floor muscles



STRESS URINARY INCONTINENCE

• Bulking therapy:

– Inject gel like material around the urethra

just outside of the bladder

– Tightens the neck of the bladder to prevent

urine leakage

– Typically repeated every 1 to 2 years

• Outpatient or office procedure

• Lower success rate than surgery, but may help improve quality of life



Treatments

• Bladder Sling:– Sling (hammock) placed

under the urethra– Often made of native

tissue or mesh

• Aims to stop or reduceleakage

• Goal to improve quality of life



TreatmentsSTRESS URINARY INCONTINENCE

P ELV IC O RG A N P RO L A P SE ( P O P)

About half of women over 40have some form of POP

Source: Monga A, Dobbs S. ”Pelvic Organ Prolapse” in Gynaecology by Ten Teachers, Nineteenth. CRC Press: Great Britain, 2011


Uterine Prolapse

Dropping of

the uterus

Rectocele Dropping

of the posterior vaginal wall

with the rectum

Cystocele

Dropping of the anteriorvaginal wall with the bladder

POP—Anatomy Basics


• Pelvic floor muscles and ligaments are stretched or becometoo weak to hold organs in the correct position in the pelvis

• As it progresses, women can feel bulging tissue protrudingthrough the opening of the vagina

P E LV I C O R G A N P R O L A P S E

POP—Symptoms


• Pelvic discomfort:– Pressure and heaviness in pelvic area

– Some women also experience discomfort in lower abdomen

• Bulging:– Feeling a lump in the vagina, or lump coming out of vaginal opening

• Urinary problems:– Difficulty starting to urinate

– Weak or spraying stream of urine

• Bowel problems:– Chronic straining or pushing to have bowel movements


• 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


POP—Treatments


POP—Treatments, Surgery

• 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 health problems

– Prior surgeries

– Desire to retain sexual function

– Experience and training of surgeon



POP—Treatments

MORE ON SURGERY • Goals of surgery:– Restore normal anatomy and support

– Repair vaginal wall and support layers

of tissue

– Reduce bulge

– Improve quality of life

• Success or failure of someoneelse's operation should never bethe deciding factor for you

• You and your doctor mustdecide what’s best for you



IS LIVING WITH PFDS ANORMAL PART OF AGING?

A. Yes

B. No

Quiz“POP”


PFDs are not a normal part of aging

B R EA K F R E E—W W W.VO I C ES F O R P F D.O R G


Your Patient Is Not Alone

• Share stories

• Get support

• Ask experts about PFDs

• Join the dialogue @www.VoicesforPFD.org

B R E A K F R E E — W W W.V O I C E S F O R P F D. O R G


http://www.VoicesforPFD.org/

Talk to Your Urogynecologist Today

• Be open with your patients aboutsymptoms and discuss treatments

• May need to refer to specialist—andrequest a referral, if needed

WWW.VOICESFORPFD.ORG



http://WWW.VOICESFORPFD.ORG/

Tools for Patients



Q U ES T IO NS & CO N V ERSAT ION


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

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

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

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

5. Lawrence, JM, et al. Prevalence and Co-Occurrence of Pelvic Floor Disorders in Community-Dwelling Women. Obstetrics & Gynecology. 111(3), March 2008

6. Monga A, Dobbs S. ”Pelvic Organ Prolapse” in Gynaecology by Ten Teachers, Nineteenth. CRC Press: Great Britain, 2011

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

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

9. Norton, P A et al. Distress and Delay Associated With Urinary Incontinence. BMJ, 297(5), November 1988

10. Nygaard I, Barber MD, Burgio, KL, et al. Prevalence of Symptomatic Pelvic Floor Disorders in US Women. JAMA. 2008;300(11):1311-1316

11. Olsen AL, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 89(4), 1997.Pelvic Floor Institute. Pelvic Floor Muscle Training, www.bostonscientific.com/templatedata/imports/HTML/PFI_Patient/pelvic-floor-patient.htm

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

13. van Breda HMK, Ruud Bosch JLH, de Kort LMO. Hidden prevalence of lower urinary tract symptoms in healthy nulligravid young women. In Urogynecol J. 18 Jun 2015. [epub ahead of print]

14. Whitcomb EL, Subak LL. Effect of weight loss on urinary incontinence in women. Open Access J Urol. Aug 1 2011; 3: 123–132

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

16. Wu JM, Vaughan CP, Goode PS, et al. Prevalence and trends of symptomatic pelvic floor disorders in U.S. Women. Obstet Gynecol2014;123:141

R EF ER EN CES


http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/UroGynSurgicalMesh

http://www.nichd.nih.gov/health/topics/pelvicfloor/conditioninfo/Pages/default.aspx

http://www.bostonscientific.com/templatedata/imports/HTML/PFI_Patient/pelvic-floor-patient.htm

break free - okpa.org · •pelvic organ prolapse •anatomy basics •urinary incontinence...

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