 So welcome everybody for the Women's Wellness lunch series. I'm excited to talk to you about urogynecology. This is the first lecture in the series. And so we're excited to have you here and to join us to learn a little bit about urogynecology, which is what I do. So I'm excited to share with you. So just an introduction about myself. I am a urogynecologist. My name is Nina Batia. I'm physician that is board certified in both OBGYN, obstetrics and gynecology, as well as urogynecology. My practice consists of urogynecology only. So I don't do any general gynecology, meaning annual exams, breast exams, pap smears, and that sort of thing. My specialty is strictly urogynecology. So I trained first as an OBGYN for four years of residency. And then I did a three-year fellowship in urogynecology. And we'll talk a little bit more about what that means and what types of patients and conditions that I treat. I do have an office in Old Bridge. We do have a satellite location in Shrewsbury as well. I am affiliated with several hack and sack learning hospitals, including Bayshore Riverview and Old Bridge Medical Center. My specialty includes vaginal surgery and robotic surgery for conditions like prolapse and urinary incontinence. So today, these are objectives for the talk today. We are going to learn about what urogynecology is. We're going to learn about some common urogynecology conditions, which include prolapse, or active bladder, stress, urinary incontinence. We'll talk about signs and symptoms that should prompt you to see a specialist like myself or any urogynecologist. And then we'll also talk about treatment options, which include surgical options, as well as non-surgical options. So we'll start first with what is urogynecology. So we are a subspecialty of OBGYN or urology, and we provide comprehensive care for women with pelvic floor conditions. So urogynecologists may have been a urologist or an OBGYN before subspecializing into urogynecology. The conditions we treat include pelvic organ prolapse and urinary incontinence. When you're looking for a urogynecologist, you might find some other type of wording, such as female pelvic medicine and reconstructive surgery, urogynecology, sometimes even female urology. In general, you want to look for board-certified physicians who are specializing in these conditions. So what is the pelvic floor? So the pelvic floor is what we are helping our patients with. The pelvic floor consists of muscles, ligaments, and connective tissue that are supporting some vital organs in your body. The organs that are being supported by your pelvic floor are your bladder, the uterus, the rectum, and the vagina itself. So this image just shows you where those organs are and how close and proximity they are. So your vagina supports the uterus, the bladder, and the rectum. So we'll learn as we go through these slides, when the vagina starts to fall or loses its support, organs such as the bladder, the rectum, and even the uterus can actually start to fall down as well. So our pelvic floor is very important for women and it really gives us a lot of our supports, but unfortunately over time and with age, the pelvic floor can actually weaken and lead to other significant problems. So we want to know, or what you think, what is the likelihood of or what's your chance of getting a pelvic floor disorder? So for women, the likelihood of getting a pelvic disorder is probably more common than you think. Is it one in three women that get this, one in eight, or one in 15? So normally if I were to present this in a front of a live audience, we would pull to see what the thought would be in the audience, but since this is virtual, you'll just have to kind of come up with an answer yourself and I'll give you the answer. The answer is one in three. So it's more common than you think. One out of three women will develop a pelvic floor disorder. So between yourself, your mother, your daughter, one of you will have one of these conditions. Or amongst your friends, if you're sitting with two friends, one out of the three of you will probably develop a pelvic floor disorder. It's very common and unfortunately we don't really talk about it that much, but hopefully with webinars like this and just kind of getting the awareness out, women should know that these are really common conditions and they're very treatable. So we just want to make you aware that it is quite common that you may experience a pelvic floor disorder in your lifetime. So what are the pelvic floor disorders? Urinary incontinence, pelvic organ prolapse, urinary urgency, frequency, and nocturia. We're going to talk about each of those, what they mean, and how do we address them. So urinary incontinence is just leakage of urine. So it can range from small drips or small drops of urine leaking. It can be your entire bladder that's letting out or anything in between, but any unwanted loss of urine, whether that's if you cough and sneeze and a little bit of urine leaks out. If you have that feeling that you need to go to the bathroom and you just can't make it in time and you just start to lose urine, that's incontinence. So whether it's a little bit or a lot, it's all urinary incontinence, which is just leakage of urine. What are some of the symptoms of this? So again, any leaking with things like coughing, sneezing, running, jumping, exercising, lifting, I've had patients tell me when they are at the gym and they're exercising, that's when they leak. When they're lifting their children, they might leak. When they're bending down to, you know, empty out the dishwasher, they might leak. So those are all forms of something called stress incontinence. Sometimes it's more of a frequency urgency issue where you get a very strong urge to go to the bathroom and it's not an urge that you can defer. So when you have to go, you have to go. You get that urge and you instantly just really, really have to run to get to the bathroom. And if that happens to you quite often, that's called frequency. For some women, they can make it to the bathroom in time. For some women, they cannot you know, so if you're getting that urge to go and you can't make it to the bathroom in time, that would be called urge incontinence. Waking up in the middle of the night to go to the bathroom, some women can make it and some women cannot. So if you cannot make it to the bathroom at night, that would be another form of urge incontinence. And for some women, unfortunately they wake up already wet. So they wake up because they've noticed that they've lost urine. For some women, urinary incontinence occurs with sexual activity. So that could be another form of incontinence. So if you suffer from urinary incontinence, just know that you're not alone. It again is quite common. So for urinary incontinence itself, how many women over the age of 18 will actually suffer with urinary incontinence? And again, this is one in four. So these conditions, whether it's a pelvic floor condition or just urinary incontinence, it's quite common. Unfortunately, as we get older, our incontinence or risk of incontinence actually increases. So incontinence will increase with age. As you get older, you may find more urgency, more frequency, more need to go to the bathroom. Urgency can present itself in so many different forms. It can be you're at the sink washing dishes, that running water is what triggers you to get that urge to go. You're out shopping or out with friends, but as soon as you pull up to your driveway or put your keys in the door, all of a sudden you really have to go to the bathroom. That's an urgency. And eventually that may lead to urge incontinence. We can't get to the bathroom time and all this increases with age. So over your lifetime, approximately 50% of women will experience some form of urinary incontinence. But the good news is it's very treatable and you know, you're going to call just like myself and others in the area are all here to help treat this for you. What can cause urinary incontinence? Pelvic floor conditions like weakness of the muscles, urinary tract infections, drinking lots of caffeine, lots of coffee, alcohol, certain diuretic medications can all make it worse. If you suffer from constipation, this can be problematic. Some women have neuromuscular problems such as if you've had a stroke that can increase your chance of urinary incontinence. MS can increase the risk whether you have anatomical problems such as prolapse or kinestones can be a risk factor as well. How is it diagnosed? So you're a doctor. So whether that's your primary care, your OBGYN, your urologist or your urogoncologist, you definitely want to be evaluated with a simple medical history and physical exam. We can diagnose you with lots of these conditions. So there's no special testing that would need to be done to confirm that you have these problems. It's really based on your medical history and your physical exam. When should you see a urogoncologist? You should see a urogoncologist if you're bothered by these conditions. Some women unfortunately wait a really long time before they see a specialist. If you're wearing pads for urine leakage, if you feel like it's interfering with your lifestyle, your day-to-day activities, if you feel like you have to map or search for bathrooms or if you're planning out like your commute based on where bathrooms are, if you're restricting your fluid. So let's say you don't drink as much water because you're afraid that you're going to have to keep going in the bathroom. If it's affecting your sexual life or your intimacy with your partner, if incontinence is preventing you from doing things you love, exercising, socializing with your friends, going out and doing things. So if you're bothered by this, there's help available to you. Whether you start that conversation with your primary care doctor or OBGYN or if you call us directly and make an appointment just to be seen to talk about your problems that you're suffering with, there's treatments available for you. The types of urinary incontinence we touched on a little bit, but stress incontinence and urgent incontinence. So those are the two most common types. Now there are others, but those are the most common. So again, stress incontinence is when you leak with coughs, knees, laugh, run, jump, lifting, things like that. Urgent incontinence is when you leak when you get the urge to go or that feeling that you have to go and you just can't make it in time. Within the umbrella of something called overactive bladder, there's urgent incontinence, urgency, which is that strong urge to go and you can't defer it. Frequency when you go quite often or nocturia is when you wake up at night. Now someone wouldn't have both. Some women have both stress and urgent incontinence and that would be called mixed incontinence. For some women they can't tell. They can't tell what's causing them to leak. They just know that they're wet, that the urine's just coming out without any sort of warning or any kind of control. So those are all things that we can help you with. What are the treatment options? So there's lots of treatment options, whether it's conservative therapies like exercises, physical therapy, there are medications, there are surgeries, there's office-based procedures. There's plenty of things to help treat these problems and often we'll use a combination of therapies. So there may not be one solution for everybody. There's a combination of different things that we'll use. It might be a combination of physical therapy and medications or a procedure. It really depends on you specifically and what your symptoms are and what your goals for treatment are. But the good news is that a lot of this is curable. You don't have to live with incontinence. You don't have to wear pads while it's common and it's something that you may hear is something that women have to deal with or that they do deal with. So the truth is you don't have to live with it. You can treat it and there's pretty simple ways to address it. So some of the non-surgical treatments, what can you do? Just simple lifestyle changes, whether that's decreasing the number of cups of coffee a day that you drink or if you're someone who let's say drinks wine in the evening but you get up a lot at night, you might want to cut that down because that may make a difference for you. There is some simple bladder retraining exercises that we can do where we have you keep a log of how often you go to the bathroom and we look and let's say you're going to the bathroom every hour. We're going to try to push you by about 15 minutes to see can you get yourself to let's say an hour and 15 minutes. Little by little by making those changes we can get you into more normal range. You're not going as frequently. Physical therapy is very helpful. You can work with the therapist to strengthen your pelvic muscles and these are specialized therapists that work on the pelvic floor only. So it may not be the same therapist that does shoulders and elbows and knees. It's a specific pelvic floor therapist to help you train those pelvic floor muscles. There's other types of therapies that a physical therapist may do for you including something called biofeedback where we work on the nerves and the muscles of the bladder and there's also support devices. So if you suffer from something called prolapse which we'll talk about soon prolapse is something that can be supported without surgery by using something called a pessary. There are medications that help with urinary control so if you're having trouble where when you have to go you have to go and you have that strong urge to go or you're going frequently going to the bathroom all the time not making it a time waking up at night that condition is called overactive bladder and there's some really good medications out there to help treat that. Now there are older medications and newer medications and they all have different side effects which we'll talk to you specifically about. We'll look at the list of medications you're on to see if there's any interaction but there are some really good medication options out there for this for this condition. The medications work by blocking some of the extra bladder spasms so when you have overactivity of the bladder the muscles are overactive they contract and then spasm too much and by taking the medications you can decrease those muscles spasm. By doing that it allows you more time to get to the bathroom less of that strong urge you'll still get the urge and you'll still know that you have to go but you won't have to go you won't have to drop everything and run to the bathroom it's a more controllable situation hopefully you'll get up less at night and just not have to go as often. The office-based procedures work really well for urgency frequency nocturine overactive bladder. There are several options there's Botox. Botox is something that we use to inject into the bladder it's a very short procedure takes less than a few minutes to do it's right here in the office we do numb patients a little bit to help them with any discomfort. Most patients tell it very well and it works very well for most patients it lasts about six to nine months so it is something that needs to be repeated it's not something that is just done once and it works rather it does eventually wear off but it is a it is a very good treatment option for patients. We also do a procedure called urethral bulking so if you leak with stress and continence where you leak when you cough and sneeze your urethral bulking is something that can be done either in the office or in the hospital with sedation where we use a gel type of material in the urethra which is where the urine comes out of to help block it off a little bit to help prevent that type of leakage and the success rates are pretty high for that as well. PTNS is another treatment it's also called tibial nerve stimulation it's similar to acupuncture there's a small little needle similar to an acupuncture needle that's placed at the level of the ankle and it helps control the signals that your bladder is getting to help decrease the urge and the frequency so PTNS is a treatment that we do in our office it's it's for most patients completely painless it's a short procedure and that does help with the control as well. We also have surgical options which you may have heard of you know from from other physicians if you if you bring up your incontinence they may talk about some surgical options available to you so slings are a common procedure that we use for stress incontinence for leakage with coughing and sneezing for most women who get a sling their success rates are quite high and they it's it's considered you know something that that will cure the stress incontinence so the likelihood of still having any kind of stress incontinence after having something like a sling is very low it's a it's a about a 30 minute simple outpatient procedure with minimal recovery time and patients do very well there are other ways to suspend urethra with sutures or stitches there's also a procedure called sacral neuromodulation now sacral neuromodulation is a wonderful procedure that does help with the overactive bladder or the getting to the bathroom in time waking up at night going frequently sacral neuromodulation is a simple outpatient procedure as well it it's basically sort of like a bladder pacemaker that's controlling the nerves of the bladder it lasts for about 15 to 20 years so it's not something that needs to be redone yearly or often and it makes a huge difference for most patients there's a test that we do for at first to make sure you're a good candidate for it to make sure it actually helps you but the key takeaway i think is that there's many options so if you're suffering with incontinence it's not something you have to live with it it really is something that's treatable and in most cases curable where you can come in we would get your medical history we'll do an exam we'll figure out the best options for you and together we'll come up with the plan that's best for you so that we can help you in achieve your goals whatever those goals may be we haven't talked yet about prolapse but when we do we'll talk about some of the options for that too which are sometimes surgical and sometimes non-surgical so that again if you're suffering from incontinence you are definitely not alone one in four women over the age of 18 do suffer from incontinence so it's a common procedure i'm sorry a common condition it gets worse with age so if you do have it it's not going away it most likely will just get worse with time if you get older and there's typically not much benefit to waiting till it gets really bad to come in and fix it so while we may not talk about it that much amongst our friends or if you go to the doctor it may not come up it might not be a question that they ask you about but if you're suffering from any type of urinary incontinence just know that it's common and you don't have to deal with it and just because you don't really hear anybody else talking about it it doesn't mean that you're the only one that has that problem it's so common and i think you know as the years go on if we talk about it more i think patients will be more willing or open to to some of the treatment options that are out there but feel free to talk to your primary care about it your obgyn if you wanted to come in directly to see us you can always do that too but just know that there's treatment options out there it's not something you have to live with and you're not the only one that has it it's so common um and it's also quite treatable most women are suffering for years before they seek help help so about 33 percent of women wait somewhere between one years to five years to to ask their doctors about it or to look for some sort of help um 26 percent of women wait more than five years so the majority of women are waiting you know a long period of time before they're actually even bringing it up so um i hope that a seminar like this will help bring some education out to the population so that we know that we don't have to suffer with this we don't have to just live with this there treatments out there and it's okay to ask for help it's okay to bring it up with your primary care or your objuan or even come to a urologist or your gynecologist directly to bring up the problem so that you can be helped this is um from voices for pfd.org and i have that website on it on one of the upcoming slides um this website is very helpful i think for patients because it comes from the american gynecologic society or augs which is um our medical society and and they have this website that's dedicated for patients with just information for you so um this is a life impact tracker for overactive bladder so if you're suffering from the urge to go going frequently waking up at night and um you know kind of want to gauge how much it really is bothering you it's a nice little tracker where you can keep track of you know is it making you feel anxious depressed embarrassed angry um how often is this happening is it affecting your intimacy and um it's just a and i think a nice little tool to just kind of help figure out well how much is it really bothering me and it might be bothering you more than you think um the other condition i wanted to talk about today is pelvic organ prolapse so the majority of what i do as a urologist is helping women who are suffering from urinary incontinence but also women who are suffering from pelvic organ prolapse so prolapse is quite common it happens to many women and it tends to get worse as you get older um some of the risk factors for prolapse are pregnancy and childbirth just aging going through menopause certain health conditions such as obesity chronic cough constipation women who do heavy lifting there are tons of risk factors for pelvic organ prolapse so genetics isn't the only reason um if your mom didn't have this but you have it you know there's so many reasons why that could have happened or just because you have it doesn't mean necessarily your daughter will have it because it's not just genetics so what is prolapse prolapse is when those pelvic floor muscles which we had talked about earlier um start to weaken and as they weaken the floor of the the vagina actually starts to fall so when the vagina loses its support the nearby organs can come down as well so if the top or front wall of the vagina starts to fall the bladder can come down with it if the bottom wall of the vagina um loses its support the rectum can actually start bulging into the vagina and that creates um a prolapse the uterus itself can lose its support and the ligaments are just not as strong as they used to be and over time the uterus can fall down and for some women who have had a hysterectomy where they've had the uterus removed they still have their vagina intact and the vagina itself can lose its support and fall and when it does things like your small intestines or bowels can come down too so there's lots of different organs that can be affected by prolapse for a patient what you may notice is that you feel something some sort of bulge when you go to the bathroom to wipe you might feel something that that wasn't really there before or when you go to shower or clean you might feel that there's something in the vaginal area that feels different or feels like it wasn't really there previously some women describe it as sitting on a ball so they feel like they're sitting on something um it can feel like a pressure and heaviness in the vagina it can feel like a tampon that's sort of either stuck or starting to fall out so it feels like there's something different and something coming down generally prolapse is not painful so most women who have prolapse don't feel pain they feel more of like a bulge sensation or something coming down um and again there's so many different reasons why it can happen um the important thing is to come into have it evaluated whether that's with starting with your gynecologist your primary care doctor or coming in to see a specialist like a your gynecologist or a urologist who deals with prolapse um we will let you know which organ is prolapsed and usually it's a combination where it might be both the bladder and the rectum so the terms that you may hear are cysticeal which is where there's vaginal prolapse that's bringing down the bladder or recticeal is where there's vaginal prolapse that brings down the rectum and then uterine prolapse where the uterus comes down or vaginal vault prolapse which is where you've had a hysterectomy and the vagina itself is is falling down so this um this sheet that we're looking at on the slide is again from that same website voices4pfd.org and again it's a really good website for patients to just do their own research to um learn a little bit more about these conditions but you can see there's pictures showing you what each of those conditions are and it just talks about what the condition is and and how to treat it so from a treatment standpoint what can you do about it generally we tell patients there's about there's approximately three different choices one would be conservative treatments or or sort of living with the prolapse and not necessarily intervening in any way but doing things observation watch and see if it's not that bad it's not really bothering you do you really need to treat it not necessarily it really depends on how much it's bothering you some women opt to do pelvic floor physical therapy to try to strengthen their pelvic muscles um the other choice that some women make is an intervention called a pessary so in these images you can see what a pessary looks like a pessary is a silicone device it's either shaped like a ring and we have tons of different sizes and shapes um and that's something that you get fitted for when you come into the office so if you're looking for a pessary a pessary is a supportive device um and it's placed in the vagina to help push the vaginal walls up and lift those organs that are falling so a pessary can be left in place um depending on which type for sometimes three to four months without needing to be removed um there are pessaries that patients themselves can remove clean and replace as needed and um so that's an option and then the third option would be surgery so there are surgical options as well and if you can see the list of options on this page there are vaginal surgeries there's abdominal surgeries there's robotic surgeries there's lots of different options and the key is to come in to get evaluated so we can figure out what the best option is for you most of the surgeries that we do are typically either outpatient or overnight stays with a you know minimal recovery in general uh I would say it's sort of similar to childbirth in that there's no heavy lifting no intercourse no swimming and things like that for usually about four to six weeks um but patients are up and walking right away so when they have surgery they're walking around immediately that night there's no reason to be in bed rest from a pain standpoint most most patients do quite well um and usually take just over the counter pain medications occasionally they might need something stronger um but from a surgical standpoint most patients do quite well and um it's a it's a pretty simple recovery for most patients so whether you choose to do exercises to do physical therapy to wear a pester or even have surgery there are options for you if you're having a prolapse it's a good idea to get it checked so that way you know what exactly is prolapse which organ what stage how bad is it and and what are your options these are some resources that I think are really helpful for for patients so AUGS.org is the american urologic society with a lot of information fact sheets for patients most of the um information that I've given you today is from this specific website voices for pfd.org um there's an online community that's been developed by the urologic society to help educate patients and caregivers about the pelvic floor disorders um and there's opportunity for um involvement with an online community there's videos there's apps there's printable resources I think it's a very good uh site if you're looking for more information um there's also another site called yourpublicfloor.org and that's from the from iUGA or the international urologic association and um this site is nice because they also have fact sheets for patients in different languages um so I think these are some really good resources if you're looking to do a little bit more online research to understand a little bit more about these conditions