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Pelvic Floor Disorders

Peter G. O'Hare III, M.D.
Co-Director, Division of Female Pelvic Medicine & Reconstructive Surgery

“POP”
As a woman, your chance of
getting a pelvic floor disorder is:
A. 1 in 3.
B. 1 in 4.
C. 1 in 5.
The number of adults with bowel
incontinence is:
A. 5 million.
B. 12 million.
C. 18 million.
WH-175304-AA. Slide 2 of 44. August 2013.

Quiz
Bladder control problems only
occur in women after menopause:
A. True.
B. False.
Risks for pelvic organ prolapse
(POP) include:
A. Age.
B. Giving birth.
C. Smoking & chronic lung disease.
D. Lifestyle factors.
E. All of the above.

Agenda
• What are pelvic floor disorders (PFDs)?
– Bladder control.
– Bowel control.
– Pelvic organ prolapse.
• How can I break free?
– Pelvic floor workouts.
– The Voices of PFD.
• What is the PFD Alliance?

PELVIC FLOOR DISORDER
(PFD)

One in three women will experience a PFD in her lifetime .

www. • Supports internal organs: – Bladder. ligaments and connective tissue in the lowest part of the pelvis. – Vagina.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/UroGynSurgicalMesh. – Rectum. Pelvic floor  Food and Drug Administration.What is the Pelvic Floor? • Set of muscles. – Uterus. . Information for Patients for POP.

– Urine leakage (urinary incontinence).fda. • One or more symptoms: – Feeling pelvic pressure or bulge in the vagina. www. Pelvic Floor Disorders.nih. – Gas or stool leakage (fecal incontinence).gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/UroGynSurgicalMesh.  Food and Drug Administration. – Difficulty emptying the bladder. – Overactive bladder (―go tta go‖). www.nichd.gov/health/topics/pelvicfloor/conditioninfo/Pages/default.aspx . Information for Patients for POP.Pelvic Floor Problems • Problems with bladder and/or bowel caused by weakened pelvic muscles or tears in the connective tissue.  National Institute of Child Health and Human Development. – Problems having a bowel movement.

The Frequency of Pelvic Floor Dysfunctions and their Risk Factors in Women aged 40‐55. JAMA. – Pregnancy and childbirth. 2008. . 300(11). – Problems urinating and having a bowel movement.PFD Risk Factors • Age and life stage: – 1 in 3 women—risk increases with age. Journal of Family and Reproductive Health 6(2). – 1 in 4 younger women (20 to 39 years). Sept. et al.  Nygaard I.. • Lifestyle and behaviors: – Obesity and limited physical activity. • Health conditions: – Stroke.  Tahereh E. Prevalence of symptomatic pelvic floor disorders in US women. June 2012. et al. 1 in 4 younger women – Smoking. – Pelvic injury. pelvic surgery.

Prevalence of symptomatic pelvic floor disorders in US women. . 300(11). Pelvic Floor Disorders Network. et al. September 2008. JAMA.Types of PFDs  1 Bladder control problems 2 Bowel control problems 3 Pelvic organ prolapse Nygaard I.

BLADDER CONTROL .

S. December 2009. Forecasting the Prevalence of Pelvic Floor Disorders. . have urinary incontinence  Wu.You are not alone—18 million women in the U. Obstet and Gynecol. Jennifer et al. 114 (6).

Slide 10 of 44. 297(5). WH-175304-AA. Distress and Delay Associated With Urinary Incontinence. August 2013 33% wait 1 to 5 years . P A et al.Don’t Wait to Talk with Your Doctor 26% of women wait over 5 years to seek help 41% seek help within 1 year  Norton. BMJ. November 1988.

kidney. Slide 11 of 44. Urinary Incontinence in Women. • When you go.  Bladder Opening National Institute of Diabetes and Digestive and Kidney Diseases.How the Bladder Works • Your body stores water (urine) in the bladder.gov/KUDiseases/pubs/uiwomen. Muscles and nerves help control the bladder and urethra. • The bladder connects to a tube called the urethra. August 2013 Vaginal Opening . these muscles and nerves signal urine to leave the body through the urethra.nih. WH-175304-AA.niddk.

– Sexual dysfunction.nih.niddk. sudden urge just before losing a large amount of urine. Urinary Incontinence in Women. National Institute of Diabetes and Digestive and Kidney Diseases. – Slow or interrupted urine stream or sense of incomplete bladder emptying. – Difficulty emptying your bladder. Slide 12 of 44. • Symptoms vary: – Strong. for example. kidney. – Involuntary loss of both small and large amounts of urine with activities such as coughing or straining. August 2013 .Symptoms of Control Problems  • Problems with muscles and nerves that help to hold or release urine: – Loss of urine (urinary incontinence).gov/KUDiseases/pubs/uiwomen. WH-175304-AA. trouble starting the flow of urine.

– Continuous (unpredictable) incontinence. ― Gotta go now‖ with leakage (urge incontinence). August 2013 . lifting. laughing.nih. WH-175304-AA. • Urge incontinence/overactive bladder (OAB): – – – – ― Gotta go now‖ sensation (urgency). kidney.niddk. Going often during the night (nocturia). sneezing. ― Gotta go often” (frequency).  National Institute of Diabetes and Digestive and Kidney Diseases.gov/KUDiseases/pubs/uiwomen. Slide 13 of 44. • Other types: – Mixed incontinence (stress and urge). exercising). Urinary Incontinence in Women.Types of Urinary Incontinence • Stress incontinence: – Urine leaks with activities (coughing.

• Diet and exercise: – – – – Lose weight (if overweight). Limit alcohol and caffeine. and follow-up care.Treatments: Urinary Incontinence • Find out what treatment is best for YOU: – Ask your doctor about risks. – Try to ―sc hedule‖ bathroom trips.nih.org. Slide 14 of 44. Keep pelvic muscles healthy and working well. kidney. WH-175304-AA. Urinary Incontinence in Women. Do pelvic floor exercises (kegels). www.voicesforpfd. • Bladder diary—app or paper: – Track how often you go.  National Institute of Diabetes and Digestive and Kidney Diseases.  PFD Alliance.gov/KUDiseases/pubs/uiwomen.niddk. August 2013 . potential complications.

pdf.org/resourcecenter/bladder/bladderBrochures/SUI_Monograph. http://www.  American Urological Foundation. Slide 15 of 44. www.  Food and Drug Administration. 2011. WH-175304-AA.urologyhealth. ─ Bladder retraining. ─ Pelvic floor muscle nerve stimulation.fda. Information for Patients for POP. A monograph from the AUA Foundation: Stress Urinary Incontinence. ─ Exercises to help strengthen and control the pelvic floor muscles. ─ Supports the bladder. ─ Inserted into the vagina.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/UroGynSurgicalMesh. ─ Sized to fit each patient. ─ Different shapes and sizes.Treatments: Stress Incontinence • Pessary: ─ Silastic rubber vaginal insert. • Physical therapy: ─ Biofeedback. August 2013 .

– Lower success rate than surgery.org/resourcecenter/bladder/bladderBrochures/SUI_Monograph. www.Treatments: Stress Incontinence • Bulking therapy: – Outpatient or office based procedure. – Bulk up the area to close the lumen of the urethra and help block leaking. August 2013 .  Food and Drug Administration. Information for Patients for POP. Slide 16 of 44.urologyhealth. 2011. – Aims to stop or reduce urine leakage. – Inject gel like material around the urethra just outside of the bladder.fda. • Surgery: – Helps to support urethra and bladder. WH-175304-AA.  American Urological Foundation. • Goal to improve quality of life. www. – Goal to improve quality of life. A monograph from the AUA Foundation: Stress Urinary Incontinence.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/UroGynSurgicalMesh.pdf.

American Urological Association (AUA) Guideline: Diagnosis and Treatment of Overactive Bladder (non-Neurogenic) in Adults: AUA/SUFU Guideline. • Surgeries: – Botox™ Preparation bladder injections.  National Institute of Diabetes and Digestive and Kidney Diseases. May 2012. . Urinary Incontinence in Women.gov/KUDiseases/pubs/uiwomen. – Exercise your pelvic floor muscles and make diet changes. Inc. © 2006 • Combination of treatments. kidney.niddk. • Physical Therapy: – Biofeedback (pelvic muscle training).  Gormley EA. – Bladder nerve stimulator (electrical stimulator or neuromodulator). Reprinted with the permission of Medtronic.nih. WH-175304-AA. August 2013. et al. • Medicines: – Bladder relaxant medicines. Slide 17 of 44.Treatments: Urge Incontinence/OAB • Lifestyle changes: – Retrain your bladder and learn ways to control when you go. – Tibial Nerve Stimulation.

• Join the conversation at Voices for PFD: − Women share stories. − Get support from other women. August 2013 . WH-175304-AA. − Ask experts about pelvic floor disorders.org  PFD Alliance.You Are Not Alone • Patient story—hear from others with bladder control problems.voicesforpfd. www. Slide 18 of 44.org. …and visit voicesforpfd.

BOWEL CONTROL .

niddk.gov/ddiseases/pubs/fecalincontinence/index.Nearly 18 million U. http://digestive.S.aspx WH-175304-AA. adults—about 1 in 12—have fecal incontinence. Fecal Incontinence. August 2013 .  National Institute of Diabetes and Digestive and Kidney Diseases.nih. also known as accidental bowel leakage. Slide 19 of 44.

nih.  National Institute of Diabetes and Digestive and Kidney Diseases. • Don’t be ashamed to discuss with your doctor. Slide 20 of 44. • It is often due to a medical problem.aspx WH-175304-AA.niddk. Fecal Incontinence. • There are treatment options. http://digestive. August 2013 .gov/ddiseases/pubs/fecalincontinence/index.Don’t Be Embarrassed • Bowel control problems can be upsetting and embarrassing.

− Signal when to release stool.nih.gov/ddiseases/pubs/fecalincontinence/index.  National Institute of Diabetes and Digestive and Kidney Diseases. Slide 21 of 44. − Let you know when the rectum is full.How the Bowel Works • Muscles and nerves in the rectum and anus: − Hold stool.niddk. August 2013 .aspx WH-175304-AA. Fecal Incontinence. http://digestive. • Pelvic floor and sphincter muscles work together to help with bowel and gas control.

gov/ddiseases/pubs/fecalincontinence/index. ttp://digestive. Fecal Incontinence.nih. − Pain with bowel movement. Diarrhea: − Loose. small.): − Bowel movement fewer than 3 times per week. − Passing loose stools three or more times per day.  National Institute of Diabetes and Digestive and Kidney Diseases.nih. − Straining and bloating.aspx WH-175304-AA.gov/ddiseases/pubs/constipation/index. − Stool is hard. http://digestive. Slide 22 of 44. Chronic constipation (4+ million people in U. and difficult to get out.niddk. watery stools. − More than two days may signal a problem. August 2013 .niddk.S. dry.Symptoms of Control Problems • • • Accidental loss of gas and/or bowel contents. Constipation.aspx  National Institute of Diabetes and Digestive and Kidney Diseases.

aspx WH-175304-AA.  CONSTIPATION • Avoid starchy foods such as white rice. − Eat more whole grains. pasta. − Ask your doctor about fiber supplements. FECAL INCONTINENCE • Avoid spicy foods and caffeine. August 2013. Slide 23 of 44. or high fiber cereals. National Institute of Diabetes and Digestive and Kidney Diseases. or white bread.niddk. .Treatments: Diet Changes • Include more fiber in your diet: − Makes stools firmer.nih. − Helps promote more complete passage of bowel movements. • Talk with your health care provider about dietary changes which may help control bowel problems. Fecal Incontinence.gov/ddiseases/pubs/fecalincontinence/index. http://digestive. vegetables. fruits.

endurance. Fecal Incontinence. 2004. PT • Medicines: – Soften stool (laxatives).  National Institute of Diabetes and Digestive and Kidney Diseases. – May include biofeedback. tone. http://digestive. American Journal of Gastroenterology.nih. Practice Guidelines: Diagnosis and Management of Fecal Incontinence. and coordination. – Ask your doctor for a referral to a specialized physical therapist. August 2013 . Slide 24 of 44.Treatments: Medicines.niddk. – Help form stool (antidiarrheal medicines). WH-175304-AA.gov/ddiseases/pubs/fecalincontinence/index.aspx  Satish SCR. • Physical therapy (PT): – Improves the pelvic muscle strength.

− Pace maker for the pelvic floor or bowels (neuromodulator) to help pelvic and anal sphincter muscles contract. − Anal sling.gov/ddiseases/pubs/fecalincontinence/index.Treatments: Surgery • The goal of surgery is to improve bowel function: − Improve bowel emptying.niddk. WH-175304-AA. 2004. Fecal Incontinence.aspx  Satish SCR. American Journal of Gastroenterology. Slide 25 of 44. Practice Guidelines: Diagnosis and Management of Fecal Incontinence. − Help with bowel emptying at appropriate times. − Improve bowel control.  National Institute of Diabetes and Digestive and Kidney Diseases. August 2013 . − Sphincter repair (anal sphincteroplasty). http://digestive. • Types of surgery include: − Bulking agents.nih.

PELVIC ORGAN PROLAPSE .

About half of women between the ages of 50 and 79 have some form of prolapse  PFD Alliance. WH-175304-AA. www.voicesforpfd. Slide 27 of 44.org. August 2013 .

 Olsen AL.Are you at risk? • Risk factors increase with age: – Postmenopausal women. • Other health conditions: – Chronic lung disease. et al. • Lifestyle: – Overweight. – Tobacco use. – 11% lifetime risk of prolapse surgery by age 80. • Giving birth one or more times. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Slide 28 of 44. Obstet Gynecol 89(4). August 2013 . WH-175304-AA. 1997.

Slide 29 of 44. Most common— dropping of the bladder (Cystocele)  Dropping of the rectum (Rectocele) Hendrix SL. women can feel bulging tissue protruding through the opening of the vagina. WH-175304-AA. August 2013 Least common— dropping of the uterus (Uterine Prolapse) . 2006. Pelvic organ prolapse in the Women’s Health Initiative. • As it progresses.What is POP? • Pelvic floor muscles and ligaments are stretched or become too weak to hold organs in the correct position in the pelvis. et al. Am J Obstet Gynecol 186(6).

Information for Patients for POP. or lump coming out through vaginal opening.Symptoms of POP • • • • • • Pressure and heaviness in pelvic area.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/UroGynSurgicalMesh/ucm262299. Bulging: feeling a lump in the vagina. December 2001.fda. Urinary problems − Difficulty starting to urinate. Bowel problems − Chronic straining or pushing to have bowel movements. 185(6). Slide 30 of 44. WH-175304-AA.htm. Correlation of symptoms with location and severity of pelvic organ prolapse.  Food and Drug Administration. www. painful sex (dyspareunia). August 2013 . Pelvic pain. Low back pain associated with bulge. Am J Obstet Gynecol. et al. − Weak or spraying stream of urine.  Ellerkmann RM.

• Conservative approach: − Watch and see how things go. − Dietary changes. • Pessary: − Support bladder. www. − Treatments can help improve quality of life and sexual health. www. Slide 31 of 44.fda. − Pelvic floor muscle exercises.org.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/UroGynSurgicalMesh. uterus and vagina.Treatments • Best treatment depends on how much symptoms bother you: − POP is not life-threatening.  PFD Alliance. − Pelvic floor physical therapy. Information for Patients for POP.voicesforpfd. WH-175304-AA. August 2013 .  Food and Drug Administration.

voicesforpfd. WH-175304-AA. www.Treatments: Surgery • Every woman's situation is different. − Desire to retain sexual function.org.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/UroGynSurgicalMesh  PFD Alliance. Slide 32 of 44. − Experience and training of surgeon. August 2013 . Information for Patients for POP.fda. www. other health problems. − Prior surgeries.  Food and Drug Administration. • No single operation is right for every patient. • Specific type of surgery depends on: − Your body (anatomy). − Overall health.

 National Institute of Child Health and Human Development. − Reduce bulge. • Success or failure of someone else's operation should never be the deciding factor for you. August 2013 . Slide 33 of 44. www.voicesforpfd. Pelvic Floor Disorders.Treatments: More on Surgery • Goals of surgery: − Restore normal anatomy.gov/health/topics/pelvicfloor/conditioninfo/Pages/default.org.nih. • You and your doctor must decide what’s best for you.nichd. WH-175304-AA.aspx  PFD Alliance. − Improve quality of life. www.

BREAK FREE FROM PFDs! .

August 2013 .PFDs are not considered a normal part of aging—they can be treated successfully with the help of a specialist WH-175304-AA. Slide 35 of 44.

August 2013 .org − www.facebook. WH-175304-AA.The PFD Alliance Empowering Women • Created in September 2011: − Raises awareness about PFDs. − Enables women to develop individualized treatment plans. − Educates about treatment options. www.org. • Join the conversation: − www.voicesforpfd. Slide 39 of 44.twitter.com/TaketheFloorPFD  PFD Alliance.com/TaketheFloorPFD − www.voicesforpfd.

THANK YOU Questions & Answers .