​In general the aspects of the pelvic floor span over multiple therapeutic areas that involves issues with the urinary tract, bladder control, problems with support and pelvic organ prolapse which involves the tissues of your pelvic floor that support break down. There are a variety of pelvic pain symptoms, inlcuding — female sexual dysfunction, bowel dysfunction and defecation disorders.  ​           

​Yes there are many alternatives. Some are behavioral, some are medicine, and some are simply educating.                          

​Vaginal atrophy is a medical term for lack of estrogen. When the body goes through any form of menopause, whether it be from menopause induced by chemotherapy or surgically induced menopause, the body loses estrogen and the body goes through changes due to that loss of estrogen. Some of the symptoms you may feel are vaginal dryness, burning, pain with intercourse, bladder infections. All of these things relate to lack of estrogen.                           

​Bioidentical means it's the same as the substance that is in your body. When you talk about bioidentical versus pellets, they have no difference in safety. All hormones carry a risk. You have to put them into perspective in terms of quality of life and how they are going to help you. Does the small risk (for most people) of being on hormones outweigh the benefits? Keep in mind that pellets do not have a nice even delivery system.                

​We often hear our patients say I don't feel the same as I did 10 years ago. There's a lot of things about libido and they are not straight forward. A man's libido is 90 percent testosterone and 10 percent emotionally driven. This means men, in general, are very easy to get excited. Women are 90 percent emotional. This means that as women grow in life and have more demands and less times for emotional connections, it's not unusual to not feel that strong drive like you used to. That doesn't mean you need to continue with that, but it does mean that you have to prioritize time for intimacy and make sure that you aren't being interrupted and spice things up. Talk to each other and come up with options. There are uses for testosterone and you have different opinions on its safety and helpfulness. Those things are available and can be helpful, provided that the emotional part has been addressed.                          

​This actually pertains to many of the pelvic floor disorders. They are very multifactorial, meaning it is never just one thing. Childbirth and pregnancy are definitely big risk factors but there are other things, including genetics. Whiel not fully understoof, we think that genetics play a big role in pelvic floor disorders. Certain races can have more pelvic floor disorders than others. Caucasian women develop pelvic floor disorders more frequently than African American women. Other things that can contribute can be anything that increases belly pressure. This can be chronic coughing, chronic strain, obesity, and constipation. Patients often ask "If I get a C-section will I not get a pelvic floor disorder?" and not necessarily. A vaginal delivery holds a higher risk than a C-section, but just the act of being pregnant and having that chronic pressure for nine months is a risk factor. The reason that someone who has never had children could develop leakage could be a variety of things, including genetics, chronic lifting and obesity.                       

​Everything ages, including the pelvic floor. As an individual ages, the ability to utilize your pelvic floor muscles appropriately, the ability for the bladder to function as it's supposed to, deteriorates. Various sensory things change — the aspects of your bowels and bladder change, your vagina becomes thinner and drier, so it's an aging process. We know the loss of hormones and estrogen contribute. While it's an aging process, it's not something that you have to deal with. People have these issues for a long time before seeking treatment, not knowing there are treatment options available.            

MonaLisa Touch is a fractional CO2 laser that, put simply, revitalizes the skin of the vagina and the vulva. We take a lot of this from dermatologists and plastic surgeons who had been using fractional CO2 lasers in the skin of the face and neck for a long time. In Italy, the company that implemented a lot of this therapy outside of the vagina started to work with some gynecologists and pelvic floor specialists about four to five years ago and they developed specific probes to deliver this energy. It's nothing more than light energy into the vaginal canal and to the vulva. It restores the tissue to the way it was when you had normal circulation of estrogen. There are a variety of metrics that change that are very objective. We were the first hospital in the country to have this therapy. It's three very simple treatments that take five minutes or less and a variety of changes occur — the lubrication comes back, the ph changes, and all the things that estrogen would normally do occur. Our studies seem to indicate that these effects last about one year. At The Christ Hospital Health Network the cost is $700 per treatment, and at least three treatments are required, bringing the total cost to $2,100. Additional treatments are each $700.                       

We are investigating a variety of other treatments with the MonaLisa Touch. There is a condition of the skin of the vulva called Lichen sclerosus which impacts up to 20 percent of women. The tissue becomes very thin and we have an open study looking at that which is very encouraging. We are starting to look at the reason a woman develops a urinary tract infection when she goes through menopause, just because the estrogen goes away, things dry up and the defense mechanisms to prevent the normal bacteria in the vagina from going up in the bladder break down. And so we are getting ready to start a study on that. There's a painful vulva disorder and I think there's some potential there as well. It seems to have a lot of potential success. 

​The answer is maybe. With some of the cases we see, we start to see some muscle weaknesses and things like that. Kegels can be helpful, but by the time people start possessing some of the disorders we are discussing here, we can actually do a bit better than Kegels. We have a great team here. Kegels are a tough muscle to isolate. They are very deep. That is why we use a lot of physical therapy to understand that you actually aren't isolating those muscles when you think you are. There are many more precise techniques like physical therapy and biofeedback that can actually show you how to isolate the right muscles to make it a much better result. ​                      

With pelvic floor exercises or Kegels, same thing, for people with extremely advanced prolapse for example where everything is out, pelvic floor muscle rehab is not going to make that go back up. But where we find pelvic floor rehab really useful is for people with more mild symptoms. We can sometimes eliminate symptoms with physical therapy. Also for people with pelvic floor disorders, and even those who have had pelvic floor surgery, you can only benefit in terms of preventing reoccurrence by doing pelvic floor rehab. The best evidence for pelvic floor rehab in the urogynecology world is for stress urinary incontinence, and also can help with overactive bladders. We see as much as 70 percent symptom improvement in motivated people who do them correctly and regularly. The trick with pelvic floor exercises is really getting into a therapist and learning to do them correctly. By large, the majority of women who try to demonstrate Kegel exercises aren't really isolating the right muscles. 

There is some thought that people should be doing pelvic floor exercises even before they have babies, and even in some European countries women are automatically sent to pelvic floor rehab after they have babies. So I would say in terms of prevention number one is getting back into a pelvic floor physical therapist after giving birth. Some of the risk factors for pelvic floor disorders are modifiable and some are not. So again, you can't fight your genes. You can't fight your connective tissues or things like that but the things that are modifiable are obesity, smoking as it contributes to cough, controlling allergies. Some risk factors are modifiable and some are not. Physical therapy is covered by insurance. If you know you have a weak pelvic floor there is no reason to wait. Ask your obstetrician for a referral today.​                    

​There is a whole range of procedures that are done for urinary incontinence. Luckily in this day in age the best procedure for cough/sneeze leakage, which is typically what the sling would have been used for, is a 20-to-30 minute outpatient procedure and probably has the best success rates of any procedures that we do with the lowest complication rate. Why do they not always work? Our slings have about a 90 percent success rate, so if we do 100 slings, there will be 10 for whom they don't work, or don't work the first time. Thankfully we do have other options and it can sometimes be repeated or we have more advanced slings that can also be preformed. Sometimes slings don't "work" because there is a lack of knowledge on what these slings are actually designed to do. These slings are designed to help stress incontinence. What they are not helpful for is urinary urgency and not making it to the bathroom in time leakage. One of the things we can see with slings even when done correctly, are people can get a bit of exacerbation of their urinary urgency and frequency. Thankfully we see that much less with our modern day slings. To some degree some of that is unavoidable. Today we rarely see post-op urgency or leakage, and we rarely see failure.                         

The most important thing that everyone needs to understand is the diagnosis has to be accurate. There are different reasons why a woman leaks. In general it's one of two reasons or a combo of both, which are stress incontinence and urgency. They are completely different problems and they co-exist 30-50 percent of the time. The bladder is a very poor witness. If your bladder tells your brain and you tell the doctor what you think is happening, it doesn't always jive with what is true. We go to great lengths to do a couple of things. First we understand how bad it's bothering someone — regarding some of the new technologies, we have many things that are remarkable, including neuromodulators that can control the bladder and the bowel that work phenomenally. We inject Botox into the bladder; we do slings that are minimally invasive. Unfortunately lawyers have gone to great lengths to confuse everybody but they are very safe. In general we are able to treat things in a less invasive fashion and are a lot better off than we were 10-15 years ago.