Women's Pelvic Health

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Womens Pelvic Health

May 22, 2012
12:00 p.m. – 1:00 p.m. (EST)

  • G. Willy Davila, MD

Cleveland_Clinic_Host: Welcome to our Online Health Chat "Women's Pelvic Health" with G. Willy Davila, MD. We are thrilled to have him here today for this chat. Let’s begin with the questions.

janoctmar: 1. Can Stage 3 Uterine Prolapse with Stage 3 Cystocele and with Stage 2 Rectocele be successfully repaired without mesh? 2. Regarding mesh, there are a lot of concerns expressed in FDA communication about transvaginal placement of mesh. Are there similar concerns and complications with the abdominal placement of mesh? 3. Can a ring with support pessary push up and support the uterus but make a cystocele and rectocele worse?

Dr_Davila: Thanks for your questions.

Dr_Davila: 1. Traditional repairs - without mesh - can be very successful for most types of prolapse. Most especially, in someone without previous prolapse surgery, "native tissues" or traditional repairs work very well.

Dr_Davila: 2. Abdominal mesh can also cause problems - this is being looked at by various groups now.

Dr_Davila: 3. Pessaries can provide better support to some segments than others - depending on the type of prolapse and severity. Many times, multiple pessaries are tried before an ideal one is found.

CatJo: Do you use Botox shots for generalized vulvar pain?

CDr_Davila: Although Botox for vulvar pain is not an FDA approved indication, our vulvar pain specialist, Dr. Trabin may consider its use on an individual basis.

stf897: I am 42 and experiencing urinary leakage with sneezing etc. I thought since I never went through childbirth, this wouldn’t be a problem for me. Are there other reasons for stress incontinence besides multiple births?

Dr_Davila: Sure. Pelvic muscle weakness can develop for many reasons, or even be congenital. If you are very physically active, that can weaken the pelvic muscles. Other reasons include diabetes, chronic coughing, etc. Kegel exercises always work, at least to some degree.

Cleveland_Clinic_Host: For those now joining us, we are currently chatting with G. Willy Davila, MD, who is taking your questions about Women's Pelvic Health. To ask a question, type in the box below and then click 'Ask'.

Pronut4: I am a 53 year old healthy professional. Mesh bladder sling 2009. Now rectocele and cystocele primarily exacerbated by chronic severe constipation. Any new effective treatments for these conditions? Any clinical trials available?

Dr_Davila: For you, dealing with your constipation is key. Otherwise, whatever you do for treatment will not be a long term solution. After that, surgery will be your main treatment option. The sling only lifted the bladder neck, not the vagina. We have a current clinical trial evaluating the repair of prolapse with a human source material (as compared to synthetic mesh).

MaryA15: Are there any medications to treat incontinence?

Dr_Davila: Sure. There are multiple depending on the type of incontinence. Overactive bladder has the most drug options. Stress incontinence less.

mrd65: Is there a surgical solution that can completely resolve the incontinence issue? If so, what are the side effects?

Dr_Davila: AMost stress incontinence can be treated very successfully with a sling surgery. It is not a 100% success rate, but close and urodynamics before surgery can improve the success. Slings are very safe (not the mesh issues you are hearing about for prolapse mesh), but need to be done by someone who does a lot of them in order to minimize any voiding problems afterwards.

sus679: What do collagen injections do for stress incontinence? Where does the injection actually go? How many treatments will need to be done?

Dr_Davila: Bulking agent injections - collagen is not longer made - are injected into the bladder neck to reduce the opening of the urethra. We now use a silicone material. Most people do well with one treatment, but some need 2 or 3. It is an office procedure, so very well accepted by patients.

janoctmar: Does putting off repair of prolapses like in question 1 and using a pessary for as long as some relief increase the chance of unsuccessful traditional repair and thus increase the need for mesh?

Dr_Davila: No. Pessaries are good "band-aids" pro prolapse. There is never a situation where vaginal mesh is the only option.

aNg167: How is sexual dysfunction diagnosed? Can it be cured? Is there anything like Viagra or Cialis for women?

Dr_Davila: It needs to be evaluated by a sexual dysfunction specialist. There are some medical options, but their use needs to be individualized. We do have a specialist - Dr. Veneroni, in our department.

Cleveland_Clinic_Host: We are receiving many great questions so far! Please remember that this chat is for general questions about Women's Pelvic Health. If you have a medical question not related to this condition, or that is diagnostic in nature, please follow-up with your personal health care provider or use our contact link clevelandclinic.org/webcontact to submit your questions.

ltdbr12: I have tried Kegel exercises but I’m not sure if I’m doing them correctly. They don’t seem to be helping me at all! How do I know if I’m doing them correctly?

Dr_Davila: Your GYN can tell you during a pelvic exam. If not doing them correctly, you may need to see a physical therapist who specializes in Pelvic Floor care - there are only a few around.

mswh679: What causes incontinence and are there different types?

Dr_Davila: There are many causes and types - treatment depends on identifying the correct type.

autumn43: My mother has chronic pelvic pain. She had a hysterectomy about a year ago. Could this be directly/indirectly related? What options does she have?

Dr_Davila: That is a very complex issue as there are many organs in the pelvis which can cause pain. She needs to see someone who can help tease out what the likely cause is.

umaT34:Can yoga and Pilates help with my chronic pelvic pain?

Dr_Davila: Sure. Pilates in particular helps strengthen pelvic and core muscles.

sweetTreat3:I’ve been using Estrace for 3-4 years and have noticed no difference in my pelvic area, yet my urologist said that he has noticed a difference. What is he seeing? What should I see as the result of using this medication (very expensive may I add).

Dr_Davila: He is seeing healthier vaginal skin. You may feel less dryness and needing to get up less at night.

liLyT: Is the Monarc sling an outpatient procedure? How long is the down time?

Dr_Davila: Yes. No lifting more than 5 lbs. for 6 weeks is recommended after the procedure. Most people can go back to work in a few days.

janoctmar: In regard to rectocele and constipation, do you consider the daily use of a stool softener like Miralax to be a safe helpful treatment along with a high fiber diet?

Dr_Davila: Yes, although Miralax is also a laxative, so something like Cilace may be better on a long term basis.

leslielubich: Surgical indication for second degree rectocele, cystocele, uterine prolapse?

Dr_Davila: Indication - patient symptoms, especially if the prolapse can be felt sticking out.

leslielubich: Name the elements of a nonsurgical approach to second degree pelvic prolapse.

Dr_Davila: Pessary, kegel exercises, avoiding constipation.

leslielubich: What is state of the art diagnostic tool and biopsy technique for thickened endometrium in perimenopausal woman to rule out endometrial cancer?

Dr_Davila: There are numerous ways to perform an endometrial biopsy. Discuss it with your doctor.

rickR79: Can men also suffer from pelvic pain?

Dr_Davila: Sure. Causes are different, but most can be evaluated by an urologist.

AmberW: I have a stage 3 cystocele and waiting for my surgery at the end of the year. This prolapse is causing my pelvic floor to become numb when I’m walking, even short distances. It then becomes so sore that I cannot site comfortably for a day or two. I find that all I can do is stand or sit for short periods of time. Why is this happening and is there anything that I can do to get relief until my surgery?

Dr_Davila: It is stretching your pelvic muscles and nerves. You can get a pessary, or wear a tampon (largish size, wet it before inserting) to provide some support. Do your Kegels as well.

janoctmar: In regard to the Miralax question, did you mean Colace may be better for long term? Also is there a specific protocol you advise in terms of fiber, meds, etc. in the avoidance of constipation with these pelvic organ prolapse problems?

Dr_Davila: Yes, Colace is likely better as it is not a laxative.

Dr_Davila: Daily fiber (or good diet)+ exercise + stool softener = best recipe. Add laxative only when needed.

teaAT2: How are stress incontinence and overactive bladder different?

Dr_Davila: Stress - leak with physical activity.

Dr_Davila: Overactive bladder - get urge and not make it to the restroom in time.

MurtleW: How effective is Premarin cream?

Dr_Davila: Depends for what. Excellent for dryness, urgency at nighttime, recurrent infections, preparation for pelvic surgery, among others.

delilaD:I have been on many meds for incontinence and have been catheterized for retainment problems, are they any medicines that can help me. I heard about a device that is inserted to control urine flow. Can you talk about that?

Dr_Davila: Depends on what type of incontinence/voiding problems you have. There are nerve stimulating devices that are used including Interstim. Urethral plugs have not been shown to work as well.

DCleveland_Clinic_Host: We have approximately 15 minutes left in the chat. We received a large amount of questions and we will continue to answer as many as possible. We apologize if we did not get to your question. If you have additional questions after the chat, please use our contact link clevelandclinic.org/webcontact to submit your questions.

autumn43: I’ve heard some horror stories about women having problems with synthetic mesh used in many sling procedures. How common are mesh problems?

Dr_Davila: Mesh problems occur mainly with mesh used for prolapse repairs via the vaginal route (approximately 10% have mesh exposure through the vaginal skin) - not for incontinence. Currently used incontinence slings are very safe.

trudyA: I have pain in my groin area that has been getting progressively worse since my surgery for an ovarian cyst in 2011 – the pain is so bad that I cannot even carry a purse. Do you have an idea what’s going on?

Dr_Davila: Could be multiple things including scar tissue. Sounds like pain in the abdominal wall from the incision. You need to be seen by a doctor who can do a very careful exam to help you figure it out.

janoctmar: Do you consider the use of estrogen cream in pessary care necessary and safe in postmenopausal women with familial history of breast and uterine cancer?

Dr_Davila: Low dose - for sure. 1/2-1 gram 2 nights per week should not result in any absorption into the bloodstream.

pAdY7: How can I tell the difference between my normal menstrual abdominal pains and something possibly more severe?

Dr_Davila: If it only occurs during menstruation, then likely not anything else. Otherwise, you need a good pelvic exam while having pain, possible an ultrasound, labs, etc. janoct mar: Thank you so much. This has been very helpful. If a person has been on Miralax daily for 6 months then would it be reasonable to start Colace BID and then gradually wean off Miralax at same time until only need to use it prn with the Colace BID?

Cleveland_Clinic_Host: I'm sorry to say that our time with G. Willy Davila, MD is now over. Thank you again, Dr. Davila, for taking the time to answer our questions today about Women's Pelvic Health. To make an appointment with Dr. Davila, or any other specialist at Cleveland Clinic Florida, please call 877.463.2010. You can also visit us online at vanity clevelandclinicflorida.org.

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