WHEN THE PELVIC ORGANS START TO FALL OUT, IT MAY BE A SIGN OF A WEAK PELVIC FLOOR.

STAY WITH US AS WE TALK WITH NEUROGYNECOLOGIST Dr. JOHNNIE WRIGHT JUNIOR ABOUT REPAIRING THE FAILING PELVIC FLOOR.

NEXT ON "KENTUCKY HEALTH."

>> "KENTUCKY HEALTH" IS FUNDED IN PART BY A GRANT BY A FOUNDATION FOR A HEALTHY KENTUCKY.

OUR DISCUSSION CENTERS AROUND AN ALL FEW COMMON PROBLEM THAT PREDOMINANTLY AFFECTS WOMEN, IT IS TOO INTENSE FOR OTHERS AND THAT PREDOMINANTLY AFFECTS WOMEN.

SOME MAY DEEM THIS TO BE TOO INTENSE FOR THEMSELVES AND/OR OTHERS IN THE HOUSEHOLD.

IF I CHOOSE NOT TO WATCH THIS SEGMENT, I HOPE THAT WE WILL SEE YOU AGAIN NEXT WEEK FOR A DISCUSSION ON A DIFFERENT TOPIC.

TO QUOTE SHAKESPEARE, A ROSE BY ANY OTHER NAME WOULD SMELL AS SWEET.

SO IT IS BY NOMENCLATURE NOT BY SMELL, THAT SYSTEM SEALS, RECTAL UTERINE PROLAPSE AND RECTAL PROLAPSE ARE ALL A PIPE OF PELVIC PROLAPSE.

IN THE PREVIOUSLY MENTIONED EXAMPLES, THE PROLAPSE OR MAY CONSIST OF BLADDER, RECTUM OR ANY COMBINATION OF THESE SUBSTANCES THROUGH THE ORGAN.

THE UNDERLYING PROBLEM IS A WEAKNESS OF THE PELVIC FLOOR AND THROUGH THIS ANATOMICAL PRESENTATION CAN BE QUITE DRAMATIC, THERE ARE ALSO FUNCTIONAL PROBLEMS THAT MAY BE OF EVEN GREATER CONSEQUENCES FOR THE PATIENT.

FORTUNATELY THERE IS NOW A GREATER UNDERSTANDING OF THE CAUSES OF PELVIC FLOOR WEAKNESS AND IN HAS LED TO IMPROVEMENTS PREVENTION MANAGEMENT AND TREATMENT OF ITS COMPLICATIONS.

TO EXPLAIN ALL THINGS RELATED TO THE PELVIC FLOOR, WE HAVE AS OUR GUEST TODAY Dr. Dr. JOHNNIE RIGHT, JR., GRADUATE OF SOUTH CAROLINA COLLEGE OF MEDICINE, CONTINUED HIS TRAINING WITH RESIDENCY IN OBSTETRICS AND GYNECOLOGY AT THE SAN ANTONIO UNIFORM HEALTH EDUCATION CONSORTIUM JOINT BASE SAN ANTONIO AT FORT SAM HOUSTON TEXAS.

HE ALSO DID A FELLOWSHIP IN FEMALE PELVIC MEDICINE IN REPRODUCTIVE SURGERY AT THE NATIONAL CAPITOL CONSORTIUM IN FAIRFAX, BETHESDA MARYLAND.

Dr. WRIGHT IS CURRENTLY THE DIVISION DIRECTOR OF THE FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY AND OBSTETRICS AND GYNECOLOGY AT THE UNIVERSITY OF KENTUCKY COLLEGE OF MEDICINE.

Dr. WRIGHT, JOHN ANY, THANK YOU FOR BEING WITH US TODAY.

>> THANK YOU FOR THE INVITATION.

>> HOW DOES A GUY GET INTO NEUROGYNECOLOGY AND FIRST OFF WHAT IS THAT?

>> IT IS ONE OF THE SUBSPECIALTIES ON THE OBSTETRICS AND GYNECOLOGY WHERE ONE CAN GO BACK FOR ADDITIONAL TRAINING TO FOCUS ON IN THE UROGYNECOLOGY CASE FEMALE PUBLIC FLOOR AND RECONSTRUCTIVE SURGERY.

RYE MY ROAD BEGAN IN OBSTETRICS AND GYNECOLOGY.

I THINK VERY RESPECTFULLY, I WANTED TO HAVE THE OPPORTUNITY TO TAKE CARE OF, YOU KNOW, WOMEN LIKE MY MOTHER, MY AUNTS AND MY SISTERS.

AND REALLY WANTED TO GIVE BACK TO MY COMMUNITY AND IN DOING SO, I FOUND A GREATER LOVE FOR GYNECOLOGICAL SURGERY AND SOME OF THE CHALLENGES ASSOCIATED WITH JUST SOME OF THE COMMON PATHOLOGY ASSOCIATED WITH GYNECOLOGY.

AND THE APPROPRIATE MATURATION FOR ME PROBABLY WAS TO STICK WITH THE SURGICAL REALM WHILE I TRULY APPRECIATED AND LOVED OBSTETRICS AS WELL, I WANTED TO FOCUS MORE ON BEING A WELL ROUNDED SURGEON WITHOUT HAVING TO DEAL WITH GYNECOLOGIC CANCERS.

DURING THE TIMING OF IT, THE SUBSPECIALTY BEGAN TO MATURE.

I HAD SOME REALLY GOOD MENTORS WHO WERE REALLY GOOD PELVIC SURGEONS AND THEY INVITED ME TO EXPLORE DOING A FELLOWSHIP BECAUSE THEY KNEW I WANTED TO TEACH AND DO SOMETHING MORE THAN JUST GENERAL OBSTETRICS AND GYNECOLOGY.

>> WE ARE GLAD TO HAVE YOU AT THE UNIVERSITY OF KENTUCKY TO TAKE CARE OF US IN THE COMMONWEALTH.

LET'S START OFF.

WHAT IS THE PELVIC FLOOR.

WE ALL KNOW WHAT THE DIAPHRAM UP TOP IS BUT WHAT IS THE PELVIC FLOOR DOWN BELOW?

>> THE PELVIC FLOOR IS A BOWL OF MUSCLE THAT IS CONNECTED TO THE BONY AMAT MI, THE HIP BONES, TAIL BONE AND THE PELVIC BONES BY LIGAMENTS.

THAT BOWL OF MUSCLE SERVES AS A PLATFORM AND BACKBOARD FOR THE ORGANS THAT PROTRUDE FOR THEM.

YOU HAVE THE RECTUM THAT COMES DOWN THROUGH OUR FEMALE PATIENTS, THE UTERUS AND CERVIX AND THEN THE BLADDER ON THE FRONT END OF THAT BOWL, IF YOU WILL.

>> SO INHERENTLY IT SOUNDS LIKE YOU'VE GOT THREE HOLES IN THIS BIG MUSCLE THING.

SO AUTOMATICALLY YOU'VE GOT AREAS OF WEAKNESS, RIGHT?

>> NOT NECESSARILY.

THAT IS A GREAT ASSUMPTION BUT NOT NECESSARILY A WEAKNESS.

SO THERE ARE THREE NATURAL AVENUES FOR PROJECTION OF EACH OF THOSE ORGANS.

HOWEVER THEY'RE NOT NECESSARILY WEAK.

THERE IS ENOUGH CONNECTIVE TISSUE AND MUSCLE OF THAT TO MAKE IT VIABLE FOR THESE ORGANS TO EXIST AND FUNCTION PROPERLY WITHOUT NECESSARILY PROLAPSE.

>> HOW DOES IT GET INJURED?

WHERE DO YOU SEE PROBLEMS DEVELOPING?

>> IT'S MULTIFACTORIAL.

I WOULD SAY EVERY PATIENT HAS A UNIQUE SET OF POTENTIAL ASSOCIATIONS OR TRIGGERS FOR IT.

BUT I WOULD TELL YOU THE MOST COMMON THAT WE SEE IN THE UNITED STATES IS AGE, RIGHT?

IT'S A PROCESS THAT WE SEE WITH PATIENTS THAT ARE MATURE.

AND THE SCIENCE BEHIND THAT IS THERE IS AN EXCHANGE OF CONNECTIVE TISSUE THAT LEADS ONE FROM A THICK RIGID TO A THIN STRETCHY, MAKING THOSE LIGAMENTS A LITTLE MORE AMENABLE TO RELAXATION, IF YOU WILL.

AND THEN STRAIN OR STRESS.

AND I SAY THAT STRAIN OR STRESS IN THE SENSE THAT YOU CAN HAVE SOME OCCUPATIONAL HAZARDS LIKE HEAVY LIFTING, PUTTING EXCESS STRAIN ON THE PELVIC FLOOR WITHIN ITSELF.

AND PROBABLY THE MOST COMMON ONE THAT WE HAVE SEEN IN WOMEN IS PREGNANCY WITHIN ITSELF.

THERE IS A NATURAL RELAX ANT HORMONE AWLD PROCEED JESSE TROAN THAT IS SUPER HIGH AND GREAT AND ALLOWS WOMEN TO CARRY IMMATURE BABIES TO BIRTH.

THAT RELAX ACTUALLY ALLOWS THE LIGAMENTS TO GIVE A LITTLE BIT AND BIRTH ITSELF.

WITH THE PASSAGE OF THE BABY THERE IS STRETCH ON THE LIGAMENTS, STRETCH ON THE NERVES THAT PROVIDE INNERVATION TO THE MUSCLES AND EVERY NOW AND THEN THERE IS TRAUMA TO THE MUSCLES THEMSELVES.

SO WITH A REGULAR DELIVERY, PASSAGE OF THE BABY THROUGH THE BIRTH CANAL CAN RESULT IN RUPTURE OF THOSE MUSCLES AND I WILLING AMOUNTS.

INSTRUMENTATION AS WELL: SO OPTIONAL VAGINAL DELIVERIES WITH FORCEPS AND VACUUMS CAN FURTHER STRAIN AND STRETCH AND TRAUMATIZE A PELVIC FLOOR.

>> IS THE LENGTH OF A DELIVERY AN INDICATOR THAT THERE MAY BE DAMAGE TO THE PELVIC FLOOR OR EVEN THE NUMBER OF TIMES A WOMAN MAY HAVE DELIVERED?

>> THAT'S A GREAT QUESTION.

SO LENGTH OF DELIVERY ITSELF HAS NOT BEEN SHOWN TO BE A TRUE INDEPENDENT RISK FACTOR OR STRONG ASSOCIATION; HOWEVER, PARITY HAS BEEN, RIGHT, IN THAT WE DO SEE THAT THE MORE BABIES OR MORE VAGINAL DELIVERIES A WOMAN HAS HAD, THE GREATER RISK FOR RELAXATION.

HOWEVER, MAKE NO MISTAKES ABOUT IT.

WHEN PREGNANCY AND/OR ONE DELIVERY CAN RESULT IN SIGNIFICANT TRAUMA AND DAMAGE.

>> DOES IT MATTER THE IJ OF THE INDIVIDUAL WHEN THEY'RE HAVING THEIR PREGNANCY.

I LOVE YOUR TERM, MATURE.

: WHEN GET OLDER.

BUT AS THE WOMANNINGS GETTING OLDER-- AS THE WOMAN IS GETTING OLDER THERE MAY BE DAMAGE TAKING PLACE AND THEN THAT PERSON HAS PREGNANCY.

DOES THAT COMPOUND THE PROBLEM?

>> I'M NOT SURE THAT WE HAVE THE DATA RIGHT NOW TO SUGGEST THAT A MATURE IS HIGHER RISK FOR PELVIC FLOOR DYSFUNCTION FOLLOWING VAGINAL DELIVERY THAN, I WOULD SAY SOMEONE THAT'S LESS THAN AGE 20.

WE HAVE SOME DATA, THE PATIENTS WITHIN THEMSELVES, HAVE LITTLE MORE COMPLICATED PREGNANCIES BUT THAT HAS DO WITH WITH MEDICAL COMORBIDITIES THAT COME WITH AGE LIKE HYPERTENSION AND DIABETES AND THE LIKE.

>> ARE THERE OTHER MEDICAL CONDITIONS NOT NECESSARILY RELATED TO PREGNANCY AND AGE; FOR INSTANCE, THE DIABETIC PATIENTS, PATIENTS THAT MAY HAVE OTHER CONNECTIVE TISSUE DISORDERS.

COULD THEY BE A FACTOR?

>> PATIENTS WITH CONNECTIVE DISH U DISORDERS, IN FOR OUR LISTENERS, PATIENTS WHO HAVE A LITTLE HIGHER RISK FOR HAVING STRETCHY TISSUE, STRETCHY CONNECTIVE SKIN AND THEY'RE AT DEFINITELY HIGHER RISK FOR ADVANCED PROLAPSE, ADVANCED RELAXATION RESULTING IN MORE PELL PELVIC ORGAN PROLAPSE.

HOWEVER DIABETES AND HYPERTENSION ARE CONCERNED, WE SEE A LITTLE MORE PATIENTS WHO HAVE HAD DIABETES, PARTICULARLY UNCONTROLLED DIABETES, WITH VAGINAL DELIVERIES BECAUSE THE BABIES TEND TO BE LARGER.

AND SO REALLY, IT GOES REALLY BACK TO THE TRAUMA ASSOCIATED WITH THE DELIVERY, NOT NECESSARILY THE DIABETES OR DISEASE PROCESS ITSELF.

>> DO YOU SEE SOME OF THE SIMILAR PROBLEMS DEVELOPING IN THE PELVIC FLOOR IN WOMEN WHO HAVE HAD CESAREAN SECTIONS OPPOSED TO GOING THROUGH A TRIAL AND LABOR?

>> THAT'S A GREAT QUESTION.

AND THE HONEST ANSWER IS YES.

CESAREAN DELIVERY DOES NOT REMOVE THE RISK ASSOCIATED WITH PELVIC FLOOR DYSFUNCTION.

SO PREGNANCY WITHIN ITSELF IS AN INDEPENDENT RISK FACTOR, RIGHT, ASSUMING THAT A PATIENT CARRIES A BABY TO TERM, THAT PRESSURE ASSOCIATED WITH CARRYING A HUMAN, ALSO HAS SOME IMPACT ON THE PELVIC FLOOR; HOWEVER, WE DO HAVE THE DATA THAT WOULD SUGGEST THE VAGINAL DELIVERY ITSELF CARRIES AN ADDITIONAL RISK.

AND SO WE'VE DONE A FAIR AMOUNT OF STUDIES TO MAKE IT VERY REASONABLE FOR A WOMAN TO REQUEST A CESAREAN SECTIONS ON DEMAND AND THE ATTEMPTS OF TRYING TO AVOID FUTURE PELVIC FLOOR DYSFUNCTION?

>> SO WE ARE TALKING ABOUT PELVIC FLOOR PROBLEMS, DYSFUNCTION.

SO TELL ME, WHAT DOES IT LOOK LIKE?

WHAT ARE THE THINGS THAT'S PEOPLE COME IN COMPLAINING OF HAVING?

>> WELL, IN THAT TERM, DYSFUNCTION, YOU CAN HAVE RELAXATION, WHICH IS THE MOST COMMON.

SO PROLAPSE.

A PROCEED-- A PROTRUSION OF SOMETHING BEYOND THE VAGINAL OPENING AND THAT COULD BE THE UTERUS OR CERVIX.

THAT WOULD BE THE BLADDER.

THAT COULD BE THE BOWEL.

IT COULD ALSO BE THE INTENSE TINS IN-- INTESTINES IN A PATIENT WHO HAS HAD A PREVIOUS HYSTERECTOMY.

YOU CAN ALSO HAVE URINARY INCONTINENCE AS WELL AS PAIN WITH INTERCOURSE AND SEXUAL DYSFUNCTION ASSOCIATED WITH YOU KNOW, THE EPIDEMIOLOGY WOULD SUGGEST THAT IT VARIES FROM POPULATION TO POPULATION; HOWEVER, PROLAPSE IS PROBABLY THE MOST COMMON DISORDER OR DYSFUNCTION THAT WE SEE IN PATIENTS WHO ARE PREMENOPAUSAL AND IN POST MENOPAUSAL WE SEE A DISPROPORTIONATE AMOUNT OF URINARY INCONTINENT INCONTINENCE OF PROLAPSE.

THERE ARE DIFFERENT SUBSETS.

YOU CAN HAVE LEAKAGE OF URINE WITH AN INCREASE IN BELLY PRESSURE WHICH WE CALL STRESS INCONTINENCE.

YOU CAN HAVE URGE RELATED INCONTINENCE.

YOU GET THE URGE TO GO TO THE BATHROOM, YOU DON'T HAVE TIME TO MAKE IT THERE.

AND THEN SOME OF THE OTHER TYPES OF INCONTINENCE ASSOCIATED WITH ABNORMAL CONNECTIONS WITH THE BLADDER TO THE VAGINAL AREA OR THE RECTUM TO THE VAGINAL AREA.

AND THOSE TEND TO BE A LITTLE MORE RELATED TO TRAUMA AND/OR CARCINOMA, UNFORTUNATELY.

>> YOU SAID THE BULGING COMING THROUGH THE VAGINA.

THIS ISN'T SOMETHING WHERE IT'S PUSHING DOWN JUST ON THE, I GUESS THE SKIN DOWN THERE AT THE BACK END, BUT IT'S TISSUE IS ACTUALLY COMING THROUGH THE VAGINA?

IS IT COMING OUT THROUGH THE VAGINA OR JUST PUSHING?

>> IT'S JUST PUSHING THE VAGINA.

WHAT I INVITE MY PATIENTS TO DO IS TO THINK OF THE VAGINAL TUBE AS AN INVERTED SOCK.

AND THERE IS POTENTIAL SPACE AND CONNECTED TISSUE BETWEEN THE SOCK AND ALL OF THOSE ORGANS, THE BLADDER, THE BOWEL, AND THE RECTUM.

AND ANY TIME THERE IS A BREAK IN THAT CONNECTIVE TISSUE, THEN YOU CAN GET A HERNIATION OR AN AVENUE FOR THOSE ORGANS TO PUSH DIRECTLY ON TO THE SOCK.

AND THEN THAT FRONT WALL, IF IT'S THE BLADDER, OR THE TOP IF IT'S THE UTERUS AND CERVIX, OR THE BACK WALL, THE RECTUM, PROTRUDES OUT THROUGH THE OPENING OF THE VAGINA.

PATIENTS ARE INVITED TO EXPLAIN HOW, WHAT THEY FEEL AND WHAT THEY SEE AND THEN WE DO A COMPREHENSIVE EXAM TO TRY TO CONFIRM AND/OR, YOU KNOW, EDUCATE THEM ON WHAT REALLY IS PROTRUDING THERE.

AND SO WHILE WE, YOU KNOW, GO BACK AND FORTH.

IF SOMEBODY TELLS ME THEIR BLODY BLADDER DROP, I UNDERSTAND IT'S THE FRONT WALL OF THE SOCK PROTRUDING BY THE BLADDER PROTRUSION OUT THERE.

>> HOW FAR OUT DOES THIS STUFF COME?

>> THAT'S A GREAT QUESTION.

SO I EXPLAIN TO PATIENTS THAT WE USE NUMBERS TO TALK ABOUT SUPPORT.

WHERE ONE IS PROBABLY WHERE THEY WERE BEFORE THEY STARTED MATURING, RIGHT?

EVERYTHING IS HIGH AND INSIDE THE VAGINAL VAULT AND NOTHING MOVES.

STAGE 4, WHICH IS COMPLETE LOSS OF SUPPORT, THAT PROTRUSION CAN COME AS FAR AS THEIR MID THIGH.

>> WOW.

SO YOU ARE SITTING THERE AT HOME WATCHING BOLD AND THE BEAUTIFUL...

COUGH AND... >> YEP.

>> THAT'S IMPRESSIVE.

>> IT IS.

IT CAN COME OUT.

>> YOU HAVE TO PUSH IT BACK UP.

>> YOU CAN PUSH IT BACK UP, RIGHT?

WHICH IS A GREAT SEGUE TO EXPLAIN TO PATIENTS THAT THE BEAUTY WITH PROLAPSE AND INCONTINENCE IS THAT IT'S NOT GOING TO KILL YOU.

IT'S NOT LIKE CANCER WHERE HAVE YOU TO BE, YOU KNOW, UPSET AND WORRIED THAT YOU'VE GOT TO INTERVENE QUICKLY.

WHATEVER YOU NEED TO DO TO ALLEVIATE THAT INITIAL PELVIC PRESSURE AND HEFNESS, GO FOR IT.

YOU ARE NOT GOING TO MAKE IT WORSE BY MANUALLY REDUCING THAT BULGE.

>> SO YOU GAVE US A GOOD OPENING HERE.

I SHOULDN'T SAY OPENING.

YOU BROUGHT US AROUND TO THIS.

SO YOU HAVE A PERSON PUSHING IT BACK IN BUT CLEARLY THIS IS NO LONGER ALONE.

START WITH THE MINOR PROLAPSING OUT AND DOES IT MATTER IF IT'S RECTUM, BLADDER, SMALL INTESTINES OR UTERUS FALLING OUT?

YOU TREAT THEM ALL THE SAME WAY OR DIFFERENT APPROACHES THAT WOULD YOU TAKE?

>> DIFFERENT APPROACHES.

HOWEVER, I BEGIN BY EXPLAINING TO THEM THAT YES, THEY PAY ME TO OPERATE.

HOWEVER, IF YOU CAN PEE WHEN YOU WANT, POOP WHEN YOU WANT AND HAVE A MEANINGFUL SEXUAL RELATIONSHIP IF YOU WANT, OBSERVATIONS TOTALLY REASONABLE AS FAR AS TREATMENT OPTION.

SO IF YOU CAN DO THOSE THINGS AND YOUR OVERALL QUALITY OF LIFE IS STILL GOOD, OR IF YOU ARE HAVING MORE GOOD DAYS THAN BAD DAYS, THEN HEY, YOU TAKE MY NUMBER, YOU GIVE ME A CALL WHEN THINGS CHANGE, OKAY?

AFTER THAT, THEN WE TALK ABOUT NON-SURGICAL OPTIONS FOR INTERVENTION.

AND IN 2024, PROBABLY THE BIGGEST OPTION FOR MANAGEMENT OF PROLAPSE IS A PESSARY.

A SPACE OCCUPYING DEVICE.

>> WHERE DO YOU PUT IT?

>> WE PUT IT IN THE VAGINAL TUBE ITSELF TO REDUCE THOSE AREAS OF BULGE IN THE SOCK, IF YOU WILL.

THEY COME IN DIFFERENT SHAPES AND SIZES.

SOME SQUARES, SOME CUBES, DISK, AND IF THE PATIENT IS ABLE TO MANAGE THE PESSARY HIRS HERSELF, WE EDUCATE HER ON HOW TO REPLACE IT, CLEAN IT AND TAKE IT OUT.

THAT'S A GOOD OPTION.

AND FOR MY MATURE PATIENTS WHO HAVE HORRIBLE OSTEOARTHRITIS OR JUST DON'T HAVE THE MOBILITY, WE INVITE THEM TO COME INTO THE CLINIC.

AFTER IT HAS BEEN APPROPRIATELY FITTED, EVERY COUPLE OF MONTHS WE TAKE IT OUT, INSPECT THE VAGINAL TUBE AND REPLACE IT.

PELVIC FLOOR PHYSICAL THERAPY, I WILL MENTION, IS A REASONABLE ALTERNATIVE.

HOWEVER, IT'S NOT A TREATMENT PER SE, RIGHT?

I'M A HUGE FAN OF PELVIC FLOOR PHYSICAL THERAPY AND PELVIC FLOOR EMPOWERMENT BECAUSE IT PROVIDES EDUCATION IF NOTHING ELSE FOR THE PATIENT.

PATIENTS UNDERSTAND THEIR ANATOMY.

THEY UNDERSTAND WHAT IS SUPPOSED TO HAPPEN UNCONSCIOUSLY WITH RESPECT TO CONTRACTION OF THE PELVIC FLOOR AND HOW THAT WORKS IN CONJUNCTION WITH THOSE ORGANS PROTRUDING DOWN THROUGH THE PELVIC FLOOR.

HOWEVER, I WILL EXPLAIN TO THEM AS WELL, IT WILL NOT AUTOMATICALLY REDUCE OR GET RID OF THE PROLAPSE.

ON THE FLIP SIDE OF THAT CONCERN THOUGH, IT HAS BEEN SHOWN TO BE A BENEFIT IN PARTICULAR FOR PATIENTS WITH URGE-RELATED INCONTINENCE.

PATIENTS WITH STRESS INCONTINENCE AS WELL.

IF IT'S FROM, YOU KNOW, A NEED TO BOLSTER OR STRENGTHEN THE PELVIC FLOOR, YOU CAN FIND SOME IMPROVEMENT THERE AS WELL.

>> DISTINGUISH FOR ME BETWEEN URGE AND STRESS INCONTINENCE TO MAKE SURE WE ARE UNDERSTANDING THIS?

>> SO URGE INCONTINENCE IS I GET THE URGE TO GO TO THE BATHROOM; HOWEVER, I DON'T HAVE TIME TO GET THERE.

THINGS START SQUEEZING AND COMING DOWN BEFORE I'M ABLE TO RELAX AND GET TO THE BATHROOM.

ON THE FLIP SIDE OF THAT, STRESS INCONTINENCE IS ANY INCREASE IN MY BELLY PRESSURE MAKES ME LEAK COUGH, LAUGH, SNEEZE, MOVEMENT, CHANGING POSITIONS.

SURGICAL INTERVENTION IS TYPICALLY APPROPRIATE FOR PATIENTS WITH STRESS INCONTINENCE, NOT SO MUCH FOR URGE RELATED INCONTINENCE UNLESS THEY HAVE ADVANCED INCONTINENCE AND WE THINK IT'S ASSOCIATED WITH SOME TYPE OF NEUROLOGIC CONDITION OR HORRIBLE URGE INCONTINENCE, SINKING MODULATION.

HOW DO WE GET THE CONNECTION BETWEEN THE BLADDER, THE SPINAL CHORD AND THE CENTER IN OUR BRAIN THAT CONTROLS OUR ABILITY TO HOLD WHEN WE GET THE URGE TO GO TO THE BATHROOM.

>> OKAY, SO YOU'VE TALKED ABOUT PHYSICAL THERAPY, THE PESSARY AND NOW WE HAVE A PERSON WHO HAS RECTUM PUSHING FROM THE BACK WALL, BLADDER FROM THE FRONT WALL, UTERUS SOMETHING PUSHING STRAIGHT DOWN AND YOU'VE GOT THIS BIG BULGE.

>> WE TALK SURGERY.

>> NOW WE'VE SEEN THESE COMMERCIALS.

VERY STERN LOOKING LAWYER LOOKS US IN THE EYE AND SAYS ON THE COMMERCIAL, DO YOU HAVE MESH?

WHAT ARE THE WAYS YOU FIX THIS THING?

>> I WILL SAY THAT MESH IS AN OPTION; HOWEVER, NATIVE TISSUE REPAIRS MEANING USING THE PATIENT'S OWN TISSUE IS A VERY REASONABLE OPTION TO APPROACH MANAGEMENT OF ADVANCED PELVIC ORGAN PROLAPSE.

WE HERE AT THE UNIVERSITY OF KENTUCKY ARE HUGE FANS OF NATIVE TISSUE REPAIR.

MY PARTER-- MY PARTNER DOES A GREAT JOB IN PARTICULAR WITH THE BEST QUOTE UNQUOTE PROCEDURE, LEVERAGING THE PATIENT'S FACIA IS THE TERM, THEIR OWN CONNECTIVE TISSUE TO REESTABLISH THE SUPPORT.

>> SO YOU SAID SACRAL-- WHAT YOU ARE RECREATING THE FLOOR?

>> I'LL GO BACK TO THAT THINKING OF THE VAGINAL TUBE AS A SOCK.

THE TOP OF THE SOCK IS FALLING DOWN, WE GO INSIDE THE BELLY AND ATTACH A SLEEVE OF THAT FACIA TO THE FRONT WALL OF THE SOCK AND THE BACK WALL OF THE SOCK AND WE ATTACH IT TO A LEG AMOUNT THAT RUNS ON THE FRONT OF THE PATIENT'S TAIL BONE TO CREATE A SUSPENSION BRIDGE.

THERE IS GREAT DATA THAT'S BEEN LOOKED AT IN THE LAST FIVE TO SEVEN YEARS THAT REESTABLISHING SUPPORT TO THE VAGINAL TUBE PROBABLY DOES MORE FOR OVERALL VAGINAL WALL PROLAPSE THAN ANYTHING WE CAN DO.

SO WE FOCUS ON REESTABLISHING THAT SUPPORT AT THE TOP AND THERE ARE DIFFERENT APPROACHES TO THAT.

YOU CAN LEVERAGE LIGAMENTS THAT ARE DEEP IN THE PELL VISION FROM A-- FROM THE PELVIS FROM A VAGINAL APPROACH OR ARTHROSCOPIC ROBOTIC APPROACH FROM ABOVE.

>> I WAS THINKING ABOUT THIS.

YOU TALKED EARLIER ABOUT SOME OF THE THINGS AT THAT TIME CAN LEAD TO PELVIC FLOOR WEAKNESS.

WHAT ABOUT IN WOMEN BECAUSE IT'S A VERY COMMON OPERATION: HYSTERECTOMIES.

>> YES, SIR.

>> YOU SAID THERE WERE HOLES ALREADY.

WE ARE NOW MAKING A BIGGER HOLE?

>> THAT'S A GREAT QUESTION.

HYSTERECTOMY ITSELF IS AN INDEPENDENT RISK FACTOR/ASSOCIATION, RIGHT?

WE WENT THROUGH AN ERA WHERE WE FELT LIKE PROPHYLACTIC RESUSPENSION OF THE VAGINAL TUBE TO THE SACRAL LIGAMENTS WOULD PREVENT PROLAPSE.

I'M NOT SURE THAT WE FOUND THAT TO BE THE TRUTH LONG-TERM.

SO, YES, WHILE HYSTERECTOMY IS AN INDEPENDENT RISK FACTOR, A LOT OF PATIENTS END UP NEEDING A HIFT HYSTERECTOMY FOR OTHER REASONS.

AND OVER ALL STILL HAVE A GOOD QUALITY OF LIFE.

IF I THINK ABOUT A WOMAN WITH A SYMPTOMATIC FIBROID UTERUS, SHE IS SUPER HAPPY TO HAVE HER UTERUS REMOVED EVEN THOUGH DOWN THE ROAD SHE MAY DEVELOP PROLAPSE, RIGHT?

AND WE DON'T HAVE GREAT EPIDEMIOLOGIC STUDIES TO SUGGEST HEY, I CAN GIVE YOU 20, 30, 50, 80% CHANCE OF DEVELOPING PROLAPSE IF YOU HAVE A HYSTERECTOMY.

WE ARE JUST CLEAR TO PATIENTS THAT, HEY, IT'S AN INDEPENDENT RISK FACTOR AND SO ANY DECISION TO MOVE FORWARD WITH HYSTERECTOMY SHOULD BE MADE WITH ALL THE DATA ON THE TABLE.

>> SO YOU MADE AN INTERESTING POINT ABOUT TRYING TO DO NON-OPEN RATTIVE THERAPY WHEN YOU CAN.

LET'S STEP BACK FURTHER.

HOW CAN WE PREVENT PEOPLE FROM HAVING PELVIC FLOOR WEAKNESS?

>> YOU KNOW, PROBABLY THE BIGGEST ONE IS KEEPING AN EYE ON WEIGHT, WHICH IS A VERY SENSITIVE THING BUT WE DO SEE MORE PELVIC FLOOR DYSFUNCTION, PROLAPSE, INCONTINENCE IN PATIENTS WITH OBESITY.

TRYING TO PREVENT LUNG DISORDERS LIKE C.O.P.D.

PATIENTS WITH CHRONIC COUGH ARE AT HIGHER RISK FOR THAT.

AND THEN A FOCUS ON JUST REGULAR OCCUPATIONAL HAZARDS, RIGHT?

SO IF LIFTING IS A REQUIREMENT OF EMPLOYMENT FOR YOU, USE GOOD LIFTING MECHANICS TO AVOID VECTORS OR FORCES THAT GO RIGHT DOWN THROUGH THE PELVIC FLOOR AND THEN, YOU KNOW, PROBABLY THE OTHER IS JUST MAKING SURE THAT PATIENT UNDERSTANDS AND THAT TRAUMA WITHIN ITSELF CAN DEFINITELY RELATE TO THAT.

HIGH IMPACT SPORTS AND THOSE TYPES OF THINGS THAT MAY OR MAY NOT BE OF GOOD FOR YOU, LONG-TERM, BUT AGAIN, KEEPING AN EYE ON THAT AND MAKING SURE THAT YOU FULLY UNDERSTAND WHAT YOU ARE ENGAGING IN AND TRYING TO MINIMIZE THOSE DIRECT VECTORS DOWN THROUGH THE PELVIC FLOOR COULD PAY DIVIDENDS LONG-TERM.

>> ARE THERE EXERCISES A WOMAN CAN DO WHILE PREGNANT TO MINIMIZE THIS SINCE PREG PREGNANCY IS A RISK FACTOR?

>> WE ARE CLOSE.

WHEN I COME BACK THE NEXT TIME, HOPEFULLY WE'LL HAVE DATA THAT WOULD SUGGEST THAT WE COULD QUOTE UNQUOTE REHAB THE PELVIC FLOOR BY GETTING PATIENTS PLUGGED INTO PELVIC FLOOR PHYSICAL THERAPY AND REHAB AROUND THEIR PREGNANCY AND DELIVERY.

WE ARE NOT QUITE THERE YET.

>> IF SOMEONE LOOKS DOWN AND SEES SOMETHING HANGING OUT DO, THEY CAL YOUR OFFICE DIRECTLY OR DO THEY GO TO THEIR PRIMARY CARE PROVIDER?

>> BOTH ARE TOTALLY REASONABLE, RIGHT?

WE WELCOME THE OPPORTUNITY TO SEE THEM.

YOU CAN GET TO US WITHOUT A REFERRAL IN SENIOR PRIMARY CARE PROVIDER.

OR YOU CAN GO TO YOUR PRIMARY CARE PROVIDER.

WE JUST WANT FOLKS TO UNDERSTAND THAT WE ARE HERE AT THE UNIVERSITY OF KENTUCKY AND WE WELCOME THE OPPORTUNITY TO TAKE CARE OF THEM.

>> DOES THE PATIENT USUALLY COME IN ON THEIR OWN OR PARTNER OR HEALTHCARE PROVIDER THAT REFERS THEM, TELLS YOU HEY, YOU NEED TO SEE SOMEBODY?

>> I THINK MORE OFTEN THAN NOT, OUR PATIENTS ARE SUPER SAVVY AND THEY MAKE THAT DECISION ON THEIR OWN.

THE PRIMARY CARE PROVIDERS, I WOULD LOVE TO TELL YOU, ARE ALWAYS ON THE CUTTING EDGE AND WOULD TELL THEM HEY, YOU SHOULD PROBABLY GET THIS EXPLORED BUT YOU KNOW, THERE IS AN EDUCATION GAP THERE TOO SOMETIMES.

>> IF I SAW SOMETHING HANGING DOWN, I'M GOING TO GIVE YOU A CALL RIGHT AWAY.

Dr. WRIGHT, I CAN'T TELL YOU HOW MUCH I APPRECIATE YOU BEING WITH US AND DISCUSSING THIS MOST INTERESTING TOPIC.

AND THANK YOU FOR BEING WITH US TODAY.

I HOPE THAT YOU HAVE A BETTER UNDERSTANDING OF HOW DISORDERS OF THE PELVIC FLOOR MAY PRESENT AND THE TREATMENT OPTIONS THAT ARE AVAILABLE.

IF YOU WISH TO WATCH THIS SHOW AGAIN, WATCH AN ARCHIVED VERSION OF PAST SHOWS, PLEASE GO TO WWW.ket.org/HEALTH.

IF YOU HAVE A QUESTION OR COMMENT ABOUT THIS OR OTHER SHOWS, YOU CAN REACH US AT ket.org.

I LOOK FORWARD TO SEEING YOU AGAIN ON THE NEXT "KENTUCKY HEALTH."

AND IF YOU HAVE ANY QUESTION OR CONCERN, IF YOU HAVE ANY BULGING COMING OUT THROUGH THE VIRGINIA VAGINA OR INCONTINENCE, DO TALK TO YOUR HEALTHCARE PROVIDERS BECAUSE THE DAYS IN WHICH WE PAT PEOPLE ON THE HEAD AND SAID MA'AM, YOU HAVE TO LIVE WITH THIS ARE GONE.

THERE ARE A LOT OF VERY EFFECTIVE TREATMENT SOAZ SEEK THEM OUT.

THANK YOU VERY MUCH AND SEE YOU NEXT TIME.

>> "KENTUCKY HEALTH" IS FUNDED IN PART BY A GRANT FROM THE FOUNDATION FOR A HEALTHY KENTUCKY.