 So, thanks everyone for joining us. Sorry for the little hiccups here in technology, but welcome. My name is Nina Batia. I'm a urogynecologist. I'm here in practice at Hack of Secondary Indian. We have two office locations, one in Old Bridge and one in Shrewsbury. I'm a board certified urogynecologist, and I'm actually double board certified both in obstetrics and gynecology as well as in urogynecology. I also am a robotic and vaginal surgeon. Let's go to the next slide. So today we're going to talk about urogynecology. What is urogynecology? We'll review some common conditions that affect patients that we can help with. Those are public core conditions, which include prolapse, erectabladder, and stress incontinence. We're also going to talk about some signs and symptoms that you should, that if you're having that you would want to seek a urogynecologist's help with, and we'll also go over the treatment options, which includes surgical and non-surgical options. Let's go to the next slide. So we're going to talk about urogynecology. What is it? So urogynecology is a subspecialty of obstetrics, gynecology, or urology, and we provide comprehensive care for women with pelvic floor disorders. So pelvic floor disorders are patients such as pelvic organ prolapse as well as urinary incontinence. Our field of urogynecology is also known as female pelvic medicine or reconstructive surgery. Also, could be known as urogynecology and sometimes female urology. It was important to know that we are born certified physicians providing women's health care to help with conditions such as pelvic organ prolapse and incontinence. The majority of my talk today is going to be on incontinence. You'll meet Dr. Tennyson next who's going to talk about prolapse. So we're both urogynecologists and we treat both of these conditions. What is the next slide? So we'll talk about what is the pelvic floor? The pelvic floor is a set of muscles and ligaments and connective tissue that support the pelvic organs. This includes the bladder, the uterus, the rectum, and the vagina. As a woman, what is your chance of getting a pelvic floor disorder? So you'd be surprised. It's quite common. And the answer is one in three. So one in three women will actually get a pelvic floor disorder at some point during their lifetime. Pelvic floor disorders are quite common. These include urinary incontinence, pelvic organ prolapse, urinary urgency frequency, as well as nocturia. And we'll go over some of those different conditions as we go through our talk today. So what is urinary incontinence? Urinary incontinence simply means leaking urine and that can range from a few drops of urine leakage to complete bladder emptying without any control. So oftentimes patients will complain of symptoms of incontinence and what are those? So most common symptoms can be leaking with laughing, coughing, sneezing, lifting, exercise. I've had patients tell me that they leak urine with simple things such as reaching in their kitchen cabinets, raising their voice sometimes, or doing things that they like, going for bike rides, playing tennis, playing pickleball, any kind of activity or exercise. So you can leak with lots of different types of activities. Another common symptom is related to frequency or urgency, meaning when you have to go, you have to go. You get a strong urge to go, can't make it on time, running to the bathroom quite frequently, and then often waking up at night. So the urge to urinate can wake you up at night where sometimes you may not even make it. So you may get up and start making your way to the toilet, but drops of urine are coming out before you get to the toilet. Some women wake up wet already. Other symptoms could be a slow or interrupted urine stream, a sensation that your bladder isn't quite empty and completely. And there can also be sexual problems such as urgency during intercourse or leaking urine with sexual activity. Remember that if you suffer from urinary incontinence, you are not alone. Why? Because it's quite common. So so many women over the age of 18 suffer from urinary incontinence and just how many? It's about one in four. So one in four women over the age of 18 will actually suffer from some sort of urinary incontinence. And unfortunately, this actually increases with age. So we know that if we follow out women over their lifespan, approximately 50% of American women during their lifetime will have some form of urinary incontinence. So we know that it's quite common as far as the condition, but the most important thing to know is that it's very treatable. We're going to help you. There are specialists available that can help you with incontinence. Any leak of urine is not considered normal. So if you go to your doctor or if you're talking about this with friends and, you know, and we might say, oh yeah, after I've had kids, I've noticed that I leak a little bit. You may while you may be able to live with it, because perhaps it's not bothering that much just realize that it's not necessarily normal. While it's common, it is something that is very treatable and it's a condition that you do not have to live with. So what causes urinary incontinence. Most of the time it's from a pelvic floor disorder weakening of your pelvic muscles, which can happen after childbirth, which is related to obesity and other collagen defects or how our bodies age, but we know over time our pelvic floor muscles weaken with time and that often leads to incontinence. There are some other causes of incontinence urinary tract infections, excessive caffeine intake, alcohol intake, there's some medications that can add to incontinence such as diuretic medications, also commonly known as water pills. If you suffer from constipation that can a add to your urinary incontinence. There are some women who have things like MS Parkinson's these neuromuscular disorders that can also lead to urinary incontinence, and there's always anatomical problems. If you suffer from pelvic floor and prolapse where you feel a bulge or sensation or something coming down with shock or what Tennyson is going to speak on during her talk, that can actually be a source of urinary incontinence bladder stones kidney stones etc. How do we diagnose urinary incontinence. As a patient you most likely already know whether you have incontinence not because if you're having any unwanted leakage of urine, that's urinary incontinence. However, it's important to be one of your physicians, your primary care doctor, your gynecologist, urologist or even one of us or your gynecologist. We can help you as far as figuring out what type of incontinence you have and then help you figure out the best treatment options for you. So when you come to see your physician they will of course take a detailed medical history and do a physical exam to get a better idea of how your incontinence is affecting you and what the cause of it is. We'll go to the next slide. You might want to know well when should I see a urinary oncologist. So while you can see a primary care doctor or urinary oncologist to start the discussion of urinary incontinence and even start some preliminary questions there are times where you're going to want to see a specialist and when would those be. It's really up to you and how bothered you are by the incontinence but some of the questions you might want to ask yourself. Are you wearing a pad for your leakage every day. If you are you really should see a urinary oncologist because we can help you and we can help improve that so that you don't have to wear a pad every day for leakage. What is the courage to urinate interfering with your daily lifestyle with your work. Are you stopping what you're doing to go to the bathroom frequently is it interrupting you from being able to do your work. Is it preventing you from doing the things in your life that you want to do because you're worried about leaking. Are you know you know not going out with friends are you not going to the movie theater are you sitting in the aisle, the movie theater because you don't want to sit in the room you're afraid you may have an accident because you can't make it in time. Are you not exercising not going to the gym is it affecting your lifestyle because if it is we're here to help you. Another thing you may want to ask yourself is, are you mapping out bathrooms it's called bathroom planning, where you kind of plan your day around bathrooms, or when you're going out, you know where the best vaccines are in the grocery store at the mall other places. If you're going on a plane or your fluid. So are you decreasing or restricting your fluids intentionally to avoid your leakage is incontinence interfering with your intimacy or sex life with your partner. Are you, you know, just limiting your lifestyle. Are you not exercising are you not socializing. These are all things to ask yourself because if the answer is yes to any of these questions. We would recommend that you see one of us as a specialist to help you. These are all signs of a problem and and these are things that we can help you if you don't have to live with the incontinence. There are different types of incontinence and coming to a specialist will help us help you figure out which type you have. The most common are stressing confidence, urging confidence and mixed incontinence. So again stressing confidence is when you leak with things like coughing sneezing exercise any kind of physical activity. Urgent confidence is more when you leak with the urge so you have the urge to go to the bathroom, we can make it in time you're going frequently. You're getting up at night multiple times. That's all under the umbrella of a condition called overactive ladder which includes urgency frequency. Nocturia getting up at night and urging confidence. Another common type of incontinence is mixed incontinence, which is actually when you have both when you suffer from both stressing confidence and urgent confidence. And those are the most common types while there are other while there are other are other forms of incontinence most common are the stress and the urge were mixed. There are many options available to you that we can help with. So there are non physical treatments. There are medications. There are two procedures and surgical treatments, and often we'll use many of these treatments together to help get you the best outcome or the best result. The non surgical treatments include lifestyle changes, dietary changes, flatter training, physical therapy by feedback and support devices. So from a lifestyle changing that we talked to you about tobacco use if you're smoking decreasing or limiting smoking can help. When we talk about diet we're really more interested in fluid intake, how much fluid how many fluids you drank throughout the day and what you're drinking so if you're drinking lots of caffeinated beverages, things that are acidic and you may ask what are the acidic beverages, cranberry juice, orange juice, lemonade. These are things are not great for your bladder. So just making some simple changes with your diet and lifestyle can make a big difference in your incontinence physical therapy is available. We have great physical therapists in the area that are specialized in pelvic floor physical therapy to help improve your pelvic floor muscle strength and to help decrease your incontinence, and also to work with these for something called bladder training. So we can literally retrain your bladder to help you hold it better so you don't have to go to the bathroom as frequently so that when you cough or sneeze you will have some improvement because you've improved some of your muscle tone as well. So our bladder support device is called pessories, which can support if there is any sort of collapse along with the incontinence. And those are all options for you that are not suitable treatments. In terms of medications. There are medications that can help your bladder control. So if you're suffering from the overactive blood or urgent continents medications can help. If you're suffering from stress incontinence to leaking with the coughing and sneezing that these medications will not help but we do have other treatments for that. For the urgent continents the medications can help their daily medications that are taken just once per day that can decrease your urgency frequency and urgent continents to give you more of a gentle urge to the bathroom as opposed to that strong sudden urge where you have to stop or you're going to the bathroom. So we want to help your bladder hold more for a longer period of time so that you can get to the bathroom more comfortably. Some of the medications work by decreasing muscle spasms, or bladder contractions, and that's how they help to prevent leakage. There are some newer medications that work by relaxing the bladder muscles, allowing you to store more urine and to prevent you from having leakage in that way. There are some office based procedures that we can offer as well. So if you're suffering from urgent continents, we actually offer in office Botox Botox is very safe it's been used for many years in the bladder and it really helps patients and most patients are having a 75% improvement, or their incontinence. The Botox is something that's going right in the office without any anesthesia needed and it's repeated generally every six to nine months to help maintain the results. If you're suffering from stress incontinence and office based procedure that can be done is called urethral bulking where we actually place the material into urethra to help decrease your stress incontinence. The technology has improved dramatically in this field to the point that we actually have a material that can last for on average about seven years. So we're getting significant improvement in stress incontinence in this office based procedure. The third office based procedure is called tibial nerve stimulation or PTNS, similar to acupuncture where we put a very small acupuncture type needle at your ankle to help gently stimulate the nerves that control the bladder to help decrease urgency frequency so that would help with urgent incontinence as well. Surgical treatments are very helpful when it comes to stress incontinence. We do a procedure called a sling and this is to support the urethra to permanently cure you so you no longer with coughs knees, laugh or exercise. It's a small outpatient procedure it takes about 20 minutes under very light situations similar to colonoscopy you can go back to work usually the next day, and it's very helpful for women stress incontinence because we can cure that. There are other procedures that we do there's suspension suit procedures where we use sutures or stitches, as opposed to a sling to help with incontinence. There's a procedure called sick or neuromodulation, which works on the nerves and the muscle, more than the muscles of the bladder to help decrease urgency frequency and urgent continence. And of course if you are suffering from prolapse, there are prolapse surgeries to help because if we address the prolapse we can often address the incontinence at the same time. So just to reiterate, you're not alone. If you're suffering from incontinence, please remember, remember that there is health available, and you don't have to live with it. It's something that we don't talk about often, but we should only ask our patients or when we study our patients to see you will how, how, how often or how long the patients live with this before they talk to their doctors. While about 40% of women are seeing their doctor within about a year of having incontinence. Unfortunately, 60% of our patients or women in general are waiting more than anywhere from one to five years if not longer before they talk to their doctors about it. And, and I think it's helpful to do these types of talks, because we want to get the point across that you don't have to live with it and we can help you. If you're interested, there's lots of resources available to you. We'll show you the websites on the next slide, but there's a life impact tracker. If you're not sure if you want to seek help yet, but you know that you have some incontinence and you're not quite sure how much it really is bothering or affecting you. This is a simple tool that's available to you online of voices for pfd.org. And it's something that you can fill out to kind of get a better sense of what your, how the incontinence is affecting you, is it preventing you from exercising or going out and doing things. And on our next slide. There are great resources available for patients. The American Urgana Clogic Society website is AUGS.org. They have patient fact sheets that talk about many conditions, including incontinence and prolapse, UTIs, and other types of conditions that you may be dealing with. The voices for pfd is a website that was created by the American Urgana Clogic Society. And this is an online community developed for women to connect with each other to learn more about these public floor disorders, and with information and resources about help that's available to you. Another website is yourpublicfloor.org. This is from our International Urgana Clogic Association. And this is a very beneficial website with a lot of information for patients. And most importantly, the leaflets or information that they have are available in many, many different languages. So I think that's that can also be quite helpful. There's a lot of information online. If you're to go online and Google about incontinence, certainly you can find things, but we also want to make sure you're getting your information from trusted resources. I've done a couple of webinars that are available online. If you are interested in the chat, we'd be happy to send you those links as well. So I'll introduce myself now. Hello, everybody. I'm Lauren Tennyson. I am also a urogynecologist here. I did a urologic surgery residency training followed by a fellowship in female, female pelvic floor reconstruction. So you can arrive at our field as a urogynecologist from two different backgrounds from a urologic surgery or OB-GYN, which is kind of cool. So I'm going to talk to you today about pelvic organ prolapse. So it is the dropping of the pelvic floor organs, such as the bladder, the uterus or the rectum down into the vagina due to a lack of vaginal and pelvic support. Next slide. And this is a tough concept for people to understand. What is something falling down into the vagina? So we use a lot of pictures and diagrams to explain it, especially to patients. So on the left is one analogy of imagine a hammock and on that hammock is sitting the bladder, the uterus and the rectum. And so if that hammock is droopy and one or all three of those organs are kind of falling down into it, that's kind of how to think about pelvic organ prolapse. And the image on the right, you see a fist, which is what you would see if you were looking at the vagina and the vulva. The fisted hand is the vagina and you see a circular bulge actually coming out of it depending on the degree of severity. And so this is an exciting time in women's pelvic health and women's wellness and for your gynecology that pelvic floor has been in the mainstream media. And Washington Post, The Guardian, even Goop and Gwyneth Paltrow's health and wellness brand are talking about the pelvic floor so that means that people are going to be thinking about it more and hopefully patients are going to be feel less embarrassed about the topic and more willing to seek treatment because you don't have to, these are quality of life things, but you don't have to live with them. So pelvic organ prolapse is common up to 50% of women will have it on exam. It's but more mild to moderate, many of those women won't have symptoms and so you know if you're in a room, half of the women clearly aren't going to have had treatment for pelvic organ prolapse and that's because not everyone has symptoms. So next slide. What we, you know, it's a quality of life issue. But you don't have to live with it. And so treatment is available for those women who do have symptoms. So what we care about really is, is who's who's symptomatic and who's going to be seeking treatment and it's not 50% of all women and so the more realistic number is about two to 3% of women age 40 to 50 are going to be symptomatic enough to be seeking treatment for prolapse, and about 10% of women age 70 to 80. And, you know, in us there was a study out of Australia which showed a 19% lifetime risk of undergoing prolapse by the age of undergoing prolapse surgery by the age of 85. So 19%, that's a high number, that's like double those numbers that I just showed you of two to 3% or about 10% of women in their 70s and 80s. And so I included this to kind of show you how, you know, it's this is a tough thing to measure and they can, there can be variability in these numbers and so maybe it's under reported patients are under reporting this problem in the United States. Maybe there's cultural differences between the US and Australia, but it's always important to kind of look at these numbers critically and ask questions. So the risk factors for prolapse are pregnancy and childbirth vaginal delivery specifically, aging and menopause. As women get older, you know, tissues get thinner because of decreased estrogen in the body. There are certain health problems that predispose to prolapse like a chronic cough, obesity, constipation really just increased straining activities, heavy lifting, and then genetics as well it does run in the family. The most common symptom of prolapse will be a sensation of a vaginal bulge or pressure in the vagina. Other things that might be signs are not being able to wear a tampon or keep a tampon in. Vaginal dryness and irritation can happen to the tissue if it's protruding out of the vagina similar to the picture that I showed earlier on in the talk and the tissue can rub on clothing. And then urinary and bowel symptoms as well and I'll get into that in a minute. So a urogyne ecologist will take a detailed history and perform a brief pelvic exam in the office to further diagnose prolapse. And back to a diagram in a picture. So this is this is a picture of a female pelvis and a profiler side view. And so the white structure is the is the pubic bone and then behind that sits the bladder and the urethra tube. And then there's the uterus sitting on top of the vagina behind that and then the rectum. And so this is this is normal looking anatomy, you can see that all of these structures are kind of well supported in the pelvis. And so this is uterine prolapse or something called vaginal vault prolapse in someone who's had a hysterectomy. And now you see comparatively the uterus has dropped down so you don't see really any length to the vagina because the uterus is sitting down in it. And similarly, when there's a history of a hysterectomy, you see, you see the same thing externally, there's just no uterus on top. This is comparing the normal anatomy with what is what we call a sister seal or a dropped bladder. So on the left, you see the normal well supported bladder and urethra tube and on the right, you see that the bladder has dropped down into the vagina. And there's there's you can appreciate a dependent portion to that bladder that's dropped down. So it's possible that the urine won't completely empty from the bladder the bladder has to work harder to get the urine out, because it's not well supported. So if the uterus and I say and or bladder because oftentimes the uterus and bladder will drop down together symptoms that a patient may experience from that is a bulge sensation urinary frequency or urgency because the bladder is kind of having to work harder to get the urine out leakage of urine, an incomplete bladder and a weak stream. So now this is this is the image of erecticeal or erectile prolapse into the vagina. So again on the left, you see the kind of normal well supported rectum and on the right, you see this bulge down into the vagina. And so sensation that a patient may have from a recticeal or rectal prolapse is is the again the sensation of a bulge because no matter if it's the bladder the uterus or the rectum prolapsing down into the vagina patient is going to have certain symptoms but they're not going to know exactly what's dropping down you just feel this bulge but something that may kind of make you think it would be the rectum would be if there is something called stool trapping where you have this sensation that stool this is so lovely to talk about isn't it but some stool is getting stuck or trapped and and you need to perform what's called the splinting maneuver where patients will describe that they kind of have to put a finger almost into the vagina to help push out that trapped stool and Kailin if you wouldn't mind going back to the last slide for a second you can see looking back at this how it's easy to understand that stool could get stuck into that into that area of the rectum that's collapsing down into the vagina. Okay, we can go on to the next slide so the treatment for these for these different forms of prolapse range from doing nothing and just kind of observing to all the way to surgical intervention. So watch and see just means let's just not do anything about it right now because you may have some prolapse but the symptoms are mild and you don't you don't want to do anything and that's okay because this is at the end of the day a quality of life issue for most patients. And that's fine behavior and lifestyle changes involve. You know, if you're doing a lot of heavy lifting or chronically constipated treating the constipation being more careful in terms of how much you lift. There's something called a pessary which Dr. Bhatia mentioned, and that is a device that goes up into the vagina to offer better support I will go into all of these things in a little bit more detail. And then there's pelvic floor physical therapy and finally surgery. So pessary is a silicone object that goes into the vagina and props up the dropped pelvic organs. It's a non surgical treatment options so that's nice so if someone is older has more mild prolapse but is still bothered by it wants to avoid surgery. This is a good option. There's all different types of pessaries that can be tailored to the patient's anatomy. Some of the kind of downsides of past fear that it is a foreign object that sits up in the vagina and so you know there's, there can be some symptoms of that some patients find it uncomfortable sometimes a pessary won't stay in on because it falls out and so there's different, there's different things to consider there. So this is looking down into a woman's pelvis. Imagine a bowl that's lined with muscles and all of those muscles are the pelvic floor muscles and a laxity of those muscles that can happen after injury with childbirth or just aging in general is what leads to pelvic organ prolapse many times and so we can strengthen these pelvic floor muscles to help improve prolapse it's not going to be the best option for someone with very severe prolapse, but in the more mild to moderate cases this is a good option. And so there's pelvic floor physical therapists, similar to if a patient got surgery on their knee, and they had to learn to move the need to walk again, they would work with a physical therapist pelvic floor muscles there are therapists that specialize in strengthening these muscles may work with the patient to, to, to better strengthen the muscles and they do things called biofeedback where you can actually see how you are contracting and relaxing these muscles it's very very helpful and effective. And then there's surgery and then there's surgery and this is going to be the most definitive long term treatment for someone with prolapse in a younger patient. 5060 70s even a healthy 80 year old that has severe prolapse that is interested in having kind of having it treated and not really have to ever think about it again. So surgery is the best option in that scenario, we are able to tailor the surgeries to the patient, because we do them both through the vagina and through the belly using laparoscopic and robotic surgeries. And so that decision really kind of comes down to is very individualized to the patient and their anatomy and their preferences and things like that. And so that's, that's really kind of the run of the mill on pelvic organ prolapse.