Uncovering Women’s Pelvic Health Issues

Below the Belt

Uncovering women’s pelvic health issues

BY SHANA LIEBMAN

More than 50 million women suffer from pelvic floor dysfunction in the United States, a number that is projected to nearly double by 2050. These “below the belt” issues, such as incontinence and prolapse, are commonly the result of a weakened pelvic floor—and they usually begin during or after pregnancy. Unfortunately these problems can dominate a woman’s physical and emotional life, and often lead to anxiety, inactivity, and diminished intimacy. We spoke to Sovrin Shah, M.D., a Mount Sinai Health System urologist specializing in female pelvic medicine and surgery who is now seeing patients at Richmond University Medical Center, to understand these afflictions and what women can do about them.

PElviC Floor iSSuES in WomEn

A woman’s pelvis includes her bladder, uterus and cervix, vagina, and rectum. The pelvic floor is a group of muscles that support these organs. “The two main complications associated with problems with the pelvic floor are urinary incontinence and pelvic organ prolapse,” Dr. Shah explains, noting that pelvic organ prolapse is when the bladder, uterus, or rectum protrudes into the vaginal opening and is sometimes visible outside of the vagina.

Pelvic floor issues usually begin in pregnancy because of hormonal fluctuations, as well as the weight of the uterus and the baby. “During pregnancy, all those forces are working to loosen the pelvic floor, to get ready for delivery because that tissue has to be able to stretch to allow the head of the baby through,” Dr. Shah says. “But the problem is that after that’s all done, all that stuff has to kind of regain its form.”

One of the ways women can regain those muscles is through Kegel’s exercises, named after a gynecologist who developed it. It is an exercise where you intentionally contract and then release the muscles of the pelvic floor to strengthen them. “The whole idea of Kegel’s exercises is to gain awareness of where these muscles are and how to contract them. Also knowing how to relax them is very important,” Dr. Shah says.

But while Kegels can help, many women do not fully regain strength in their pelvic floor, which can lead to incontinence. “Stress incontinence is leakage caused by pressure on the belly— as opposed to urge incontinence, which is a sudden desire to pee that you just cannot hold off on,” Dr. Shah explains. (Urge incontinence can also be caused by a dropped bladder, certain medications—especially those for diabetes, as well as consuming diuretics like caffeine or alcohol.)

The majority of Dr. Shah’s patients suffer from an overactive bladder—which afflicts about 15 percent of Americans, and means they frequently have to pee, feel the urgency to pee, and wake in the night to pee. (Though, women who wake up in the middle of the night to urinate do not necessarily have an overactive bladder.) “About a third of the women who have overactive bladder symptoms have urge incontinence, because they didn’t get to the

bathroom fast enough. Two-thirds are able to hold it until they get to the bathroom,” Dr. Shah says.

Prolapse, another common pelvic floor issue among women, is often caused by vaginal delivery, prolonged or difficult labor, and hormonal changes that women experience with menopause— mainly lack of estrogen which weakens the vaginal tissue. (This vaginal weakening can also lead to overactive bladder symptoms, as well as stress incontinence, Dr. Shah says.) Another possible contributing factor to prolapse is a woman’s weight, as well as things that cause a chronic cough like asthma or smoking. Dr. Shah also notes that genetics can play a role.

hoW CAn WomEn BE ProACTivE ABouT ThEir PElviC hEAlTh?

Pregnant women should have regular OBGYN appointments, stay healthy, and do their Kegel’s exercises to prevent problems during or after birth. But as women age, they are also susceptible to incontinence, overactive bladder, and prolapse.

Medication can often help symptoms of an overactive bladder and for some, procedures like bladder Botox or a nerve stimulator (such as the Axonics or Medtronic nerve stimulator) are novel treatments that may help. Women who have leakage of urine with a cough or activity (such as laughing, exercise, bending, or lifting) often have excellent long-term results with urethral sling surgery—a simple outpatient procedure that has a high success rate with low risk for complications. Prolapse of the pelvic organs can also be successfully treated with the use of a pessary or with outpatient trans-vaginal surgery where no scars are seen.

“The vast majority of the women that I operate on for prolapse are probably around 60 or 70 (years of age) and a few that are 80,” Dr. Shah says. He’s also noticed that as octogenarians become more active and informed by social media, they are increasingly taking control of these issues. “More and more older folks are seeking care, which is really refreshing. But I don’t think that we’re anywhere near what we can really do,” he says.

In fact, he laments that many women are unaware of how much they can do to treat pelvic issues. “It’s unfortunate that a lot of women see incontinence and prolapse as a normal part of aging. They see print ads for incontinence products rather than a cure,” he says. “And I’ve had patients come to me and they’re like, ‘I don’t know why I waited so long to get help.’”

Dr. Shah says he encourages doctors to ask about pelvic issues as a regular part of an exam. “There are not that many physicians like myself who specialize in women’s urologic health,” he explains, which means many doctors do not have a steady referral for their female patients with pelvic issues, and therefore do not ask about these issues. And if the patient does not ask, then these issues are never addressed. “But there are folks that you can go see,” Dr. Shah says. “The treatment works.”

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