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Medicine has answers for pelvic floor disorder sufferers

Patients no longer need to suffer in silence with increasingly common ailment

By Leslie Mann, Special to the Tribune

November 7, 2012

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The term "pelvic floor" was not part of polite conversation a generation ago, when women with pelvic floor disorders, or PFDs, often suffered in silence.

Fortunately for the millions of women who know this acronym all too well, times have changed.

"It's no longer taboo," said Dr. Sandra Culbertson, urogynecologist with the University of Chicago's Center for Pelvic Health. "Women are talking about it and getting help earlier. Younger women, especially, are not accepting the idea that the symptoms have to be a natural part of aging, and they don't."

Culbertson is a spokeswoman for the Pelvic Floor Disorder Alliance, which formed in 2011 to educate patients and primary-care physicians about treatment of PFDs. An offshoot of the American Urogynecologic Society, the alliance includes physicians, researchers and medical-product manufacturers.

The Tribune asked Culbertson about this enigmatic part of female anatomy.

Q: What is the pelvic floor?

A: A woman's pelvic floor is a muscular shelf that supports the organs that affect reproduction, urination and defecation.

Pelvic floor disorders include urinary or bowel control problems, prolapse of a pelvic organ (bladder, urethra, cervix or rectum) and chronic pain.

Q: How many women suffer from PFDs?

A: None of the major medical organizations keeps track, but we estimate one-third of women will have a PFD at some point in their lives.

You're more likely to suffer from a PFD when you're older, and our population is aging, so the numbers are up. A Duke University study said the number of women with at least one PFD will increase from 28.1 million in 2010 to 43.8 million in 2050.

But it's not just older women. Ten to 15 percent of pre-menopausal women will have some form of urinary incontinence, one of the more common PFDs.

Q: Now women are mad as hell and not going to take it anymore?

A: More women are, but I still hear some say, "I leak when I cough, but doesn't everyone?" A poll conducted by the Alliance said 40 percent of women plan to manage their symptoms with over-the-counter products until they're too uncomfortable.

Through our Break Free from PFDs campaign, we're educating women about solutions and empowering them to speak up. The symptoms are embarrassing, but you have to talk to your doctor about them to get help.

Q: How do you treat the urinary problems, which the Duke study said are the most common?

A: Urinary problems include urge incontinence (you can't make it to the bathroom or feel like you have to go all the time) and stress incontinence (you leak when you cough, sneeze, laugh or exercise).

The first-line treatment for both types is pelvic-floor strengthening exercises. If that doesn't work, urge incontinence can be treated with medications or Botox injections. For stress incontinence, the next step may be surgery.

What used to be a 11/2 surgery, though, is now outpatient and minimally invasive.

Q: What is new with the treatment of the bowel problems?

A: This one is tough. It may be caused by damage to the anal sphincter muscles during childbirth. But you may not have problems until you're older.

Physical therapy may strengthen the muscles. If not, we can implant a sacral nerve stimulator. It works like a cardiac pacemaker, using electrical impulses.

Q: How has treatment of prolapsed organs changed?

A: If pelvic floor strengthening exercises don't work, some patients can use pessaries, which are diaphragm-like devices that help support the organs.

Many women need prolapse surgery, but it has also become much less invasive. It's laparoscopic, so you just have a small incision.

Q: What if the patient's symptom is chronic pelvic pain?

A: Pain is complicated because we have to determine what's causing it. That's the hard part. It can be from many sources like the bladder or bowel or involve other gynecological issues such as endometriosis.

We can use a combination of medications and physical therapy. If the pain originates from the pelvic floor muscles, we can relieve the pain by injecting Botox into the muscle.

Q: What makes a woman predisposed to having a PFD?

A: It can be genetic. In some families, organ prolapse, especially, is more likely to occur. I tell my patients to tell their daughters.

Having vaginal births makes you more likely to have a PFD than women who had C-sections or did not give birth, but you may not have symptoms until you're older. Like all muscles, the pelvic floor muscles weaken with age.

Chronic constipation can contribute to PFDs, too, because you are straining the pelvic floor. Constipation is a side effect for many common medications.

Also, lifestyle risk factors include obesity and smoking. Your occupation makes a difference too. Women who have jobs that require a lot of lifting, like nurses and factory workers, are more likely to have PFDs because they're putting strain on the pelvic floor.

Q: What about men?

A: Men do get PFDs but at a much lesser rate. For treatment, they should see a urologist.

Q: Who treats PFDs for women?

A: Primarily, you see us — the urogynecologists. Also, some urologists just treat women and have done the same fellowships as we have.

For the first time in 2013, urogynecologists will be board-certified. We hope this will attract more doctors to the field. It's not glamorous, but it's challenging. Every pelvis is different, so you have to think on your feet. That's what I like about it.

You may be referred to a physical therapist who specializes in treating women with PFDs.

But your internist or primary-care physician is the one who should get the ball rolling. Part of the alliance's outreach is to educate them, to make sure they recognize PFDs. It's all about creating awareness.