Your Pelvic Health Questions: Answered

In this episode, I’m answering some of the most common (and commonly avoided) questions about women’s pelvic health, questions that too often go unasked but deeply affect the quality of life.

We dive into the difference between a rectocele and rectal prolapse, what causes urinary leakage during sex (and what you can do about it), and how to know when it’s time to seek care for incontinence. I also share why early education and intervention matter so much, and why these conversations belong in every doctor’s office, whether your provider is male or female.

Suppose you’ve been putting off asking about your symptoms or don’t know what to expect at an urogynecology visit. In that case, you’ll also get practical tips to help you prepare, feel confident, and advocate for yourself.

This episode reminds you that your pelvic health matters, and your questions deserve answers.

Transcript

 Hi there. Today is my third episode answering questions. The first two episodes I answered questions that came from Janice Mitchell's um, coaching group. And today I'm gonna be answering questions that you have sent into me. I usually figure that if one person has a question, lots of other women do as well.

And so I think this is a great way to answer some of the things that you may be thinking. So let's go ahead and let's get started. The first question that was sent to me is what's the difference between erectus seal and a rectal prolapse? And this is something that a lot of people, even practitioners confuse.

So a erectus seal is when there is a defect between the rectum and the vagina, and the bulge comes outside the vagina. The rectal prolapse is when the bulge actually comes outside the anus, so the rectum prolapse is outside the anus, so the, the bulge is in a different place, but I frequently get referrals from other physicians for a rectal prolapse, when in fact it's a rectus seal.

So it depends on where the bulge is coming from. This can be really important. They're treated very different ways. They're also treated by different subspecialists. So if you have a rectocele, that's something that a urogynecologist would fix, or a colorectal surgeon. If you have a rectal prolapse, that's something that is fixed by a colorectal surgeon alone.

That's not something that I would fix as a urogynecologist. You can absolutely have these defects together. So you could have erectus seal and a rectal prolapse, or you could have a cystocele, which is a bladder prolapse or different prolapse of the vagina or uterus with a rectal prolapse. And so sometimes when correcting these issues, um, and a rectal prolapse frequently gets corrected surgically.

We have to do that together. So you might have a combined surgery with a urogynecologist and a colorectal surgeon. So again, rectal prolapse and erectus seal are different things. They're both bulges that are centered around the peroneal body, so that tissue between the vagina, um, and the anus. But a rectal seal comes outside the vagina.

Rectal prolapse comes outside the rectum. Okay. So switching gears a little bit, the next question that I got asked is, can you treat leaking that happens with intercourse? And the answer to this is yes, absolutely. So leaking with intercourse is a problem that is very, very bothersome to women. I've seen a lot of women who have had incontinence over the years and they're dealing with it.

But once they start leaking with intercourse, that's when they come in to have things fixed. And the most important thing is that you can leak with both stress urinary incontinence and urgency urinary incontinence. So both of those types of leaking can cause leaking during intercourse. And so the most important thing is to figure out what type of leaking you have.

It isn't just one treatment that will make this better. So we start by, you know, talking to you, figuring out if you have stress urinary incontinence or urgency urinary incontinence, or if maybe you have both types of leaking. And then once we figure this out, we talk to you about the different treatment options for each type of leaking and then move forward and, and treating the type of leaking and then treating the leaking.

With intercourse. So for overactive bladder, usually we start with behavioral changes, talking to you about different bladder irritants, doing some muscle strengthening, then medications. Um, I. You can also do tibial nerve stimulation, so stimulating a nerve that runs along your ankle as the second line therapy, or you can move on to sacral nerve stimulation, which is stimulating a nerve in the back or Botox.

And then for stress urinary incontinence, we usually start with muscle strengthening. Then a pessary, then perhaps bulking, where you're strengthening the urethra, that tube that goes from the bladder to the outside, or surgery if you're leaking during intercourse, muscle strengthening. It may not work as well.

It's hard to contract a muscle and relax at the same time. Pessaries definitely don't work very well because you take them out for intercourse, or at least most people do. And even if you're not taking them out, the position can shift. So that wouldn't work very well. So if, um, you're leaking is because of stress incontinence during this situation, then we're looking more at an intervention like bulking or, um.

A surgery and for overactive bladder? I would say the same. I mean, the, the lifestyle changes are obviously very important. Um, but you're probably gonna need to move on to that second line of therapy. I. To correct this problem that is so bothersome to you. And the other thing that I would say is this is a problem that bothers everybody who has it.

I've only seen one person in my entire career who was not bothered by this particular problem. She had it, and it just, it just didn't bother her. And so it is very bothersome and it's not something that you should be ashamed of bringing up. Um, it, it's something that bothers most people and so I, I wouldn't let that stop you from seeking care for this problem.

And if you're not comfortable bringing up when you're leaking, you can bring up other times that you're leaking, right? If you don't wanna bring up that you're leaking during intercourse during the first. Um, session, but I would tell you that if you are speaking to a urogynecologist, we have definitely heard this before, um, and we know how bothersome of a problem this can be.

Okay, so the next questions and these questions are all really different, so there isn't really a theme for today. Um, but I, I really like all of these questions. So the next question is, when should I see a physician about my leaking or a provider about my leaking? This is a very personal issue, right?

When you would actually go and, and seek care. Lots of women have smaller amounts of incontinence that they're managing on their own. Um, I, I personally think that we need to start educating people much younger. So I think as part of. Sex ed in high school. We should be talking to girls about pelvic floor issues and the different things that they can do and things that might happen over time, just so this isn't such a surprise to some women.

I think we should educate women more during pregnancy and after delivery. And again, around the time of menopause. We should probably be doing more screening questions so that. Women don't have to seek care and it's just part of routine care, but we're, we're not quite there yet. I think it's a good idea to seek care before it's a huge problem.

I have lots of women who come in to see me and they're not quite ready to do anything yet, but they need education. They need to learn more about what is going on with their body. Perhaps why it happened. Perhaps things that they can do to mitigate their symptoms, to make their symptoms better, or to even stop the symptoms from progressing.

So getting that education is very important, even if you're not at a point where you would want to intervene. And I think, you know, when you have that information, you're also more likely to share it with your friends and kind of spread the information that you have gained and that is beneficial to everybody.

So my answer would be, if you're thinking about it, if it has crossed your brain, then absolutely you should be going out and and seeking care for. Your incontinence, even if you're not at a point where you would necessarily intervene or there may be something small and easy that you could do to help your symptoms that, um, you hadn't considered or you didn't know about.

And so all of that is, is good for you. Just because you're looking for care does not mean that you are looking for a surgery. And that is a super important point. There have been some studies that indicate that women wait five to seven years. So they have five to seven years of leaking before they actually seek help.

And that's not something that we would do with another medical condition. Um, and that can just be a ridiculously long time to wait and suffer or maybe just not enjoy life as much as you could have if you had addressed the problem a little bit earlier. So I think once it crosses your mind, you should seek care.

So the next question is, can I bring up my bladder leaking to a male physician? And the answer to this is yes, of course. You know, physicians are trained to te treat all body parts. Primary care physicians take care of the whole body for both female and male physician or patients. And so you should absolutely feel comfortable.

Bringing these issues up to a male physician. But I, I think from a personal perspective, that's something that, you know, we're frequently not comfortable with. Um, patients don't wanna bring this up to anyone, much less someone of the opposite sex. But it really is our job to, to handle these things. And if you're not comfortable bringing things up to your physician, then I would suggest you probably need to find another physician.

Um, because there will be other things that you wanna talk about and you need to be comfortable bringing up other things. Sometimes male physicians. Um, aren't as comfortable handling these issues. And then I would say in that situation, most of those physicians will refer you onto someone else who is more comfortable or who has more expertise.

And that is a totally reasonable thing to do. And we don't handle everything, but sometimes we use other people to address, um, physical issues. Uh, people with more expertise. Um, but you should absolutely be comfortable having that first conversation and if you don't get the response that you need, I also think it's important.

Or reasonable for you to ask for a referral to someone else? Um, our first line of treatment for a lot of most urinary incontinence is physical therapy. And so you could. Ask for a referral to a physical therapist who specializes in incontinence or a pelvic floor physical therapist, and that person will surely know everyone in the community who handles urinary incontinence.

It's usually a pretty small knit community, even if you're a physician, doesn't know. So yes, I think it's totally reasonable to. Um, ask a male physician about urinary incontinence and you should feel comfortable with that. Um, if you're interested in talking to a urogynecologist, there are physician finders.

Um, so you can go online. If you go to the website voices for PFD. So voices for pelvic floor disorders, voices for pfd.org. Um, that is a website with lots of information about pelvic floor disorders for patients or for women in general. And, um. There is a link for Find a Healthcare Professional and you can use that link to find someone who is near to you.

You can pick how far away, 10 miles, 25 miles, 50 miles, um, and you can pick all healthcare professionals. You can look for physicians, nurse practitioners, physician assistants, and also physical therapists. And this would show you the people that have expertise in pelvic floor disorders in your.

Neighborhood. And so this is an excellent tool for you to use if you're looking for a urogynecologist and you know, the, the normal resources that you would use have not proven to be effective for you. This is also a good tool to use if you want a second opinion from someone. This would help you find someone who can give you an educated second opinion.

Um, this is another question that I got asked. So I met with a urogynecologist, but I, I didn't really like this person. I didn't feel like I clicked with them. Um, is it reasonable for me to change and get a second opinion? And I would tell you yes, it's always reasonable. Picking a physician is. You know, like any other relationship, sometimes there's a match, sometimes there isn't a match.

Um, when patients want a second opinion after they see me, I'm always happy to help them find somebody. I think it's important that you feel like there's a connection. Some people also wanna get multiple. Bull opinions before they make a decision. And that is okay too. But I, I never view that as an insult.

And when someone comes to me and says, look, I, I saw this other person and I didn't really like them. I never interpret that as that person is a bad physician or a bad physical therapist. I usually just think, wow, that just wasn't a match for the two of you. So that's a totally reasonable thing to do. So the next question that I got asked is, if I have a cesarean section, will that eliminate the chance of urinary incontinence?

And the answer to that is no. Just being pregnant is a risk factor for urinary incontinence, even if you do not deliver vaginally. So it is true that you are more likely to leak the, the risk goes up with vaginal delivery, but it is not zero. If you have a C-section and a C-section is a major surgery, it is an important thing to weigh and discuss.

There are lots of reasons why you might wanna have one, and you might not want to have one. It's important that you understand everything. This is a big conversation that you should have with your physician, but a C-section is not. Entirely protective. It does protect you against a sphincter laceration or a sphincter injury because when women deliver vaginally and they tear, the most common tears are between the vagina and the anus.

Tearing into the rectum or tearing into the sphincter muscle is not very common. It happens about 3% of the time in a first delivery, but a C-section is entirely productive against that, but not protective. Against, um, urinary incontinence or does not remove all of the risk. Okay, so next question. I, I'm not interested in surgery.

Am I wasting your time if I come talk to you about my incontinence? And the answer to that is, no, you're not wasting my time. A lot of my job as a urogynecologist is educating women and talking to them about their issues, giving them their options. It does not mean that you are coming in to schedule a surgery, and I think that educational piece is probably the most important thing that we do, and sometimes I'll see patients.

Once a year for many years before they actually decide to do anything that involves me, right? They're trying other things on their own, they're doing muscle strengthening. Um, maybe they're trying a pessary but they're not at a point where they want surgery. And all of that is completely reasonable and, and just part of the job.

And it is absolutely not a waste of my time. Um, I, I do work with a lot of nurse practitioners and physicians associates, um, and sometimes they will do some of the education for me, um, just so that, you know, we can see more women together. Um, but I consider that to be kind of an extension of me and it, it is not wasting any of our time.

Okay, so the last couple of questions that I'm gonna address are really about grooming and preparing for an appointment. 'cause I think a lot of people have concerns about this or just wanna present their body in the best light. So yes, it is totally fine to leave on your socks when you go see the urogynecologist.

There's no reason to take off your socks. I mean, if I'm thinking about. Neurostimulation and stimulating, um, the nerve that runs along your ankle. I'll look at your ankles, but you can absolutely keep your socks on. People worry about shaving and grooming and none of that really matters clinically. So, you know, if you haven't shaved your legs for a couple of days and you come in, nobody cares.

That's perfectly fine. And then the other thing people always worry about is leaking during the appointment. And I would tell you that that is frequently the reason that you are in my office. And if you do leak, that actually just confirms what you are telling me, right? It is objective evidence of the problem that you have, and that happens all the time.

And that is not something that anyone should worry about, um, because that is the whole reason that you're there. Um, it's something that happens every day in clinic. We're used to handling it. I'm very. Quick at getting out of the way if I need to. Um, and I frequently wear scrubs in the office so if anything happens, I can change clothes.

So none of it is a big deal at all. So those are all of the questions that I'm going to address today. If you are interested in sending me a question, I'll probably do a similar podcast like this, um, in a couple of months. Um, just email them to me at Sarah at the women's bladder doctor.com and I would be happy to answer any of your questions.