My Bladder is Running My Life

My Bladder is Running My Life


I had the pleasure of introducing our
gynecology team tonight our topic is my bladder is running my life which never
applies to me but of course all of us have this Bible and I and I’ve struggled
with it myself for years so I’m really happy
everybody such a great team here to help us learn some good information tonight
maybe some new things that we didn’t know before so I’m gonna introduce dr.
good who I’m standing in front of and I’m taller than you are so I have to
move doctor good is a your gynecologist a surgeon specializing in the Caribbean
with pelvic floor disorders she came with a bachelor’s degree from the
University of Florida doctorate in osteopathic medicine to Midwestern
university completed her residency in ob/gyn and female pelvic medicine a
reconstructive surgery at UT Southwestern Medical Center as she
received the American uragan ecologic Society resident scholar award excelled
in leadership and she’s assembled a wonderful team of specialists who are
going to give us a lot of good information tonight I’m gonna hand it
over to dr. good and let her introduce her team I’m not talking closely enough thank you so much and thanks everybody
for coming this is a really special night and we’re very excited to be able
to talk to you guys about this important topic and just like Kathy said and thank
you so much for putting this together for us
we have a wonderful team here at UF health Jacksonville and so it’s my
pleasure to introduce everybody who helped us thank you so um we have a
fantastic team here our title here is female pelvic medicine and
reconstructive surgery however you will commonly hear us refer to as Bureau
gynecology or urogynecology team and is my pleasure to introduce myself medow
good doctor good and this is dr. Singh Ricci Racine she’s my partner surgically
and we collaborate on our health on the care healthcare for our patients along
with the rest of our teams we have a Doctor of Physical Therapy doctoral
Elijah Rivera and an advanced nurse practitioner Monica major Harris and all
of us see your see our patients and see you regularly and collaborate as a team
as well we have two nurse care coordinators in the back if you guys
don’t mind wave and that’s Ashley night and Lynn Talley and we are very very
blessed to have a fantastic team to take care of you here okay
both dr. Singh and I our fellowship trained
female public medicine and reconstructive surgery specialists so
what does that mean that means we went through four years of ob/gyn and in
three years of additional uro gynecologic training we have seven
years and we are one of the first in the country to sit for our boards so this is
a now of nationally recognized forward subspecialty so it’s important that you
know that you are actually coming to the people who are trained to take care of
this and that’s important especially to tell
your friends if they were interested in getting help
like that so how much for coming to see yesterday so just to give you a quick
overview tonight when we’re going to talk about is pelvic floor disorders if
you’re interested in the fact that your bladder is running your life and you’re
interested in this topic then you probably or you may have or you may know
somebody who has a pelvic floor disorder that includes three main topics urinary
incontinence urinary issues pelvic organ prolapse and bowel issues and we will
talk a little bit about all those three topics we’ll go over some Anatomy
diagnosis and treatment options we’re gonna go over what again what PFDs are
and a fantastic resource for you it’s actually called voices for PFD or
go we’ll go over that and it will have time for questions and answers and we’re
actually a pretty relaxed group and we like to have fun so if you have a
question please feel free to interrupt us raise your hand ask questions because
you know that question may be gone by the end of the talk and you forgot it so
just raise your hand and let us know okay so we’ll get started I have a
question for you how many women have a pelvic floor disorder what is your
chance of having a public floor disorder does anybody know the answer to this yes
one in three so chances are you’re sitting at the dinner table with a group
of girlfriends a couple of you probably are silently suffering with this and
don’t know that the other person has this this is why we have this tonight to
talk about it to open the communication one in three women will have a pelvic
floor disorder in their lifetime what is the pelvic floor a lot of people
ask me what are you talking about what is going on down there most people know
the vagina is down there and I love that orange is the new black episode I don’t
know if you everybody watch that and one of the characters took a mirror into the
bathroom and they started taking turns going in and looking at the anatomy and
talking about what their Anatomy is because a lot of people do not
understand what their Anatomy is and so hopefully tonight you’ll have a better
understanding of so the pelvic floor actually is the
public floor is a hammock of muscles and I like to make your hand a hand like
different hammock of muscles yes from your pubic bone to your tailbone and
what it does is it wraps around all your organs down here so your your refre
which is connected to your bladder your vagina and your rectum so you have a
pallet for loop of muscles actually they’re called the levator in I’d wrap
around those muscles so when you do a cable or okay these muscles are what
helps control your bowel movements voiding and actually helps you with
pleasure with sex for him and for her so those muscles aren’t very important so
pelvic floor problems and probably people who do have health at for
problems look like this that is because they have an embarrassing topic they
don’t want to talk about so they could be urine when they don’t want to whether
it’s coughing sneezing laughing or trying to run to the bathroom or they
have accidental bowel leakage and they can’t get to the bathroom in time to
have a bowel movement or what’s worse than all that is they don’t have a
healthy sexual relationship and that’s something that everybody wants to have
so these problems can be very embarrassing and time-consuming so
here’s a list of all the things we just talked about like we said there are
three main types of pelvic floor disorders one is bladder control issues
getting to the bathroom and time is one of them and also leaking when you cough
sneeze jump exercise neither neither one of those are fun problem pelvic organ
prolapse that is the weak mean of those muscles I just showed you and your
pelvic organs are now starting to turn inside out so I like to describe the
vagina as a sock a tube sock so if the tube sock where the toes are are
starting to come down and turn inside out that’s a pelvic organ prolapse and
we’ll go more into that in a minute and then the third issue is bowel leakage
problems like we talked about so what are the
risk factors we have some options here pregnancy age overweight smoking does
anybody have any idea what risk factors what what our risk factors are all of
them yes all of the above and here’s a list lifestyles of course smoking is
actually an independent risk factor but if you go down this line obesity having
trouble with weight especially the abdominal weight drinking and eating the
things that you eat and drink may affect your pelvic floor so we want to maintain
good health blood sugar and in less controllable is actually as you get
older especially after you hit menopause menopause can affect the tissues and how
strong they are and how healthy they are so that can be an independent risk
factor for a pelvic floor disorder pregnancy and childbirth and health
conditions that have been putting pressure on those muscles your whole
life so pregnancy in and of itself because you’re walking around with I
always say a bowling ball in your pelvis for 10 months is a risk factor in and of
itself but people who have who are just pregnant or have c-sections or vaginal
births can also have pelvic floor disorders so unfortunately just having a
c-section doesn’t save your pelvic floor the other thing that’s really important
is genetics okay so you can always think your mom or blame your mom for this
because Jeanette she probably gave you a lot of the genetic traits of why you
have public floor disorders and then your children of course you can thank
them as well because you had children and they’d be willing to say oh they
ruined my pelvic floor well that’s not necessarily true but they probably
didn’t help so Anatomy basics like we talked about earlier we have their
urethra the bladder the vagina which the anterior wall of the vagina is attached
to the bladder the posterior wall of the vagina is attached to your rectum and
the very top of the vagina is the uterus and a lot of people tell me my uterus is
tilted backwards or my uterus is tilted forwards and that’s a good thing your
uterus should tilt one way or the other and it really doesn’t matter that’s
pretty normal so why how does the bladder work and why
are you having issues with your bladder well the second question is
complex and we’ll get a little bit more into that later but the bladder actually
is a complex system and what happens is usually there are sensory these sensory
receptors in your bladder that are notifying your brain when your bladder
gets really full so as you can see here there is a network so the bladder gets
full and it goes a signal goes to your spinal cord and then goes up to your
brain to tell your brain it’s time to pee tell the person to go look for a
black a bathroom and then your brain says two years let me tell you squeezes
your bladder it’s time to go to the bathroom and so you try to look for
somewhere appropriate to go to the bathroom so this is a natural connection
here bladder brain brain bladder what happens sometimes though is the bladder
starts taking over and squeezing when you’re not in a normal place to go so
then the broad bladder brain communication is being it’s broke down
and the signal is not working appropriately so a lot of times you have
to retrain your bladder we have to retrain the brain and the bladder to
work together as friends so your body stores urine in the bladder
did you pee through the urethra and your bladder can yeah we went on that and
muscles and nerves help control your bladder and your urethra so it’s
voluntary you being able to squeeze those muscles when you don’t want to go
that’s a voluntary muscle but your bladder also squeezes all on its own so
there’s two different mechanisms they’re working but they have to work in
coordination so the pelvic floor like we talked about is a network of muscles and
they help to control those organs by squeezing so that’s why kegels are so
important to do and everybody in here may or may not know how to do a cake
with a cat not know how to do a Kegel hopefully by the end of this talk today
you’ll actually know what a Kegel is and hopefully we’ll be able to teach you or
or you can reach out to us to find out if you do know how to do a Kegel
properly so we have a question for you is this true or false
just bladder control problems only occur in women after menopause all so
interestingly the majority of our patients will actually find us after
menopause because that’s when the problem can get significantly worse from
a lack of estrogen but the problem our whole life a whole lifetime so we
see patients all the way from 18 19 years old all the way to 100 and beyond
so women of all ages can be affected and it’s not just from pregnancy it can be
for unhealthy lifestyles it can be from lots of coat other conditions affecting
your medical care that causes bladder problems so but more than 40 40 percent
or more happens to women 80 years old or older but we do know that menopause has
a big effect on women one in four women are younger so that is the minority of
people who have problems talk about urinary incontinence that’s a good good
evening everyone thank you for coming I would like to welcome you to youth north
and it’s a great opportunity for us to talk to everyone about pelvic floor
disorders and as dr. Goodhead mentioned that they are very common one in three
women have it urinary incontinence is one of the most common pelvic floor
disorders that we see in the United States 18 million women suffer with
urinary incontinence it’s a big number and as you can see with the big number
how much it impacts our economy and of course it impacts the quality of life
for patients we see people who wait at least on an average one to five years to
seek help or more than five years and it’s sad to see such women and they come
to the clinic and there they have been suffering for five to ten years when the
health is available when there are so many treatment options and that’s why I
tell my patients go talk to your family talk to your friends tell them that help
is available even though it’s not that bothersome to you it’s important to know
what’s what’s out there what’s available so that you know the
options and you can you know you can offer treatment when you want to so as
we had discussed that sorry mr. smoking alrighty okay so as dr. Goodhead
mentioned that – that there many kinds of your own incontinence the most common
types that we see are stress incontinence and or incontinence we
divide these because we treat them separately and then there are other
different kinds of incontinence which is mixed so let’s start with stress so
stress incontinence is basically when the albumin leaks when she coughs
sneezes laughs anything that increases pressure in the abdomen is transmitted
to the bladder and because of the various risk factors that we had
mentioned like age smoking obesity and chronic constipation
they’ll floor the pelvic floor becomes weak so urethra is the tube right here
from the from the year from where the urine comes out of the bladder so that
there is lack of support beneath a urethra and what happens that every time
you cough sneeze a lot the urethra keeps tipping down and because of the lack of
support so that is called stress incontinence
and urge incontinence is basically little bit different from stress because
it’s also called overactive bladder an easy way to explain it to my patients is
that your bladder has its own mind you know it’s not listening it’s not it’s
not listening to you it just keeps on spasming it just wants
to go it has its own routine and you it’s out of control and what happens is
that it still slowly starts with increased urgency frequency that means
you feel like you have to go all the time
you’re not leaking but you’re kind of adjusting you know all the bathrooms in
the mall you know how the bathrooms in the hospital where you go you know every
second where are you going there how far is the bathroom because you anytime you
the her urge hits you’re gonna leave there are some triggers that women
complain that as soon as I hit the dry pane as soon as I see a bathroom that’s
it I cannot make it so it starts with increased urinary urgency frequency
where you pee you have to go all the time and then increase frequency at
night so not tyria that means you’re getting up more than getting up more
than one time is abnormal so getting up a lot at night and then slowly and
steadily it worsens to increase leakage so early
you could make it to the bathroom now you cannot so that’s called overactive
bladder the other types as I had said mixed incontinence is basically a
mixture of stress and urge incontinence and it’s very common a lot of women have
bought then they have a continuous in content which we see in the men belt
they they just can’t figure out when they are leaking
they leak every time and we have a lot of various reasons that can cause it and
other kinds of main contents can be leaking due to sexual activity which can
be predisposed fish can be caused by a lot of factors so they as I said that
the stress incontinence and the urge incontinence we divide them because we
treat them separately like I’m sorry okay so basically we are gonna I’m gonna
switch to the treatment mode before that evaluation is important as dr. Goodhead
mentioned that it’s important for you to go to a specialist and get evaluated
because these a lot of pelvic floor disorders they are they they occur
together so a woman may have felt a common prolapse incontinence sexual
dysfunction together so it’s important to get evaluated for all pelvic floor
disorders at once and to go to a place where you have all kinds of specialists
to help you with those so oh I’ll just give you an overview of the treatment of
incontinence as I said the stress incontinence the first for any kind of
incontinence the first thing we can divide the chief minute to invaded so
the conservative options are improving which improving your lifestyle and
changing your lifestyle and this way you’re gonna focus about and talk about
it in a minute here then they are non-surgical treatments and we gonna
talk about that in a second that would be pathways and will show you those two
which are devices that go up in the vagina and then comes to the surgical
treatment the surgery for stress incontinence and urge incontinence both
are different and that’s why we have to kind of differentiate what kind of
leakage are you having and go from there and then conservative management and
it’s a surprise approach and that’s right and the most and one thing which
we evaluate when somebody comes to our sorry one thing which we evaluate when
you come to our clinic is how much it’s bothering your quality of life that’s
really important because there are a lot of women who are significantly bothered
by the leakage to the point that they slowly start adjusting their quality of
life like they stopped going out they stopped meeting friends and that leads
to a lot of other problems like depression waking up at night falls at
night and a lot of other medical problems so it’s important for us to
assess how much significantly you’re bothered by the linkage a combination of
treatment is important so it it doesn’t mean that when we offer you treatment
that you can only get treated by one thing we can start with conservative
it’s not surgical or conservative with surgical treatment already I’ll hand
over to Eliza all right I’m gonna see if I can get this clicker down here so my
name is Eliza I’m a pelvic floor therapist so I’m actually a physical
therapist by training and then I had took a board certification so I’ve been
doing women’s health therapy for the past eleven years so this is all I do is
treat women like yourself if you’re having these issues we talked about some
different lifestyle factors that may contribute to you having public four
disorders specifically incontinence so weight loss and we keep hearing obesity
is an independent risk factor and things like that so the good thing to know is
it doesn’t necessarily have to be your goal weight so there’s a lot of studies
that show that women that can lose 5% of their body weight and have a 50 to 60
percent improvement in their incontinence symptoms so if you’re 200
pounds and you lose 10 pounds over a few months you can have a 50% reduction in
your incontinence just with that okay fluid management obviously if it goes in
it’s got to come out right so if you’re drinking lots of fluid in the
time it’s probably gonna contribute to you waking up frequently at night the
types of fluids that you’re drinking are you drinking lots of caffeine coffee
colas tea you in the South everybody loves their soda their cokes and their
sweet tea right but those are really irritating to the bladder so that is
gonna cause you to have that I gotta go gotta go feeling things like alcohol
citrus fruits and juices spicy foods tomato these products so does that mean
you can’t have any of those things it’s just we want to start to kind of look
down that list and say are we consuming way too much of one certain type of
thing are we having too many of those things in our day all together and it’s
just culminating in our bladder getting irritated things like that constipation
management I think we’ve kind of talked about that a little bit but obviously
the more you put stress and strain you’re sitting on the toilet you’re
bearing down bearing down bearing down that causes stress to those pelvic floor
muscles so you know having a constipated day one time in a few months isn’t going
to make it it’s the chronic constipation day in and day out also just having hard
stool so if you looked at those pictures everything is right next to each other
right the rectum the vagina and the bladder so when you have hard stools
sitting in your rectum it pushes on the bladder and those sensory receptors that
are there and it can contribute to having worse and continence or having
those overactive bladder symptoms so we want to educate you on those sorts of
things and then obviously coming to see somebody like myself this is the first
line of treatment so if you have stress incontinence urge incontinence bowel
issues really anything painless sex any of those sorts of issues I’m kind of
your first line of defense so we do a full detailed pelvic floor exam and we
look at what are the things that we can change there as well as some of those
behavior own lifestyle factors and we work together as a team so I do that’s
part of stuff on a skilled you know you may see me once a week for a few
sessions and then we say okay we’ve gotten her this much better than what or
hey I’ve gotten a lot better I’m happy with the way things are right now and I
want to continue or you know what it’s 50% better but I want to see what’s next
can I get even okay so we talked about those behavioral
modifications so obviously getting those lifestyle factors in order we know that
as little as 40% of people don’t know how to do public floor muscle exercises
or those Kegel exercises with verbal instruction alone so oftentimes somebody
explains it to you or you might even go to a doctor and they say go ahead and
tighten around my finger and sometimes we don’t really know what they’re asking
us to do we try and we’re squeezing our bottom or our tummy or were you know
using other muscles so that’s where you can come and see me I’ve got the time to
spend with you we make sure that you know how to do them we want to make sure
that you’re getting those muscles functioning as optimal as possible one
of the other behavioral treatment strategies learn as we’ve talked about
you have urge incontinence that gotta go gotta go right you get to the front door
and you’re like oh my god I can’t get it and it’s gonna trip over my grocery bags
get into the bathroom well that’s not working for you right that’s not a fun
thing if you’re wetting your pants trying to get in somewhere or get into
the office and your zippers stuck so how can we work on that brain bladder
communication how can we kind of work on retraining that so that way you have
ways to control the bladder when that happens so you can not have leakage okay
you’re waking up frequently at night how can we train that bladder to allow you
to sleep through the night or wake up significantly less we know that urge
suppression techniques that you learn in physical therapy can improve your urge
incontinence and your overactive bladder symptoms sixty to eighty percent so
sometimes people think like well conservative management may not really
help my symptoms that much but overall physical therapy is around a fifty to
seventy-five percent improvement in urinary symptoms okay another technique
is called the nak technique essentially what you’re doing is if
different things cause increase in terminal pressure and that makes you
leak a little bit of urine then we want to start to actively tighten those
muscles before we do those tasks so learning to squeeze fast enough and
strong enough with our muscles to squeeze before you sneeze squeeze before
you call before you lift that baby that big bag
of dog food or mulch or groceries from your car so we’re starting to keep that
support there and also reduce leakage it’s been shown to be very effective
oftentimes women are maybe have public for a weakness or they might have a
strong pelvic floor they just can’t get the timing down so they’re just slow at
tightening it okay urinating frequently so that overactive
bladder can contribute to leakage it’s kind of a vicious cycle so the more
often you start to empty your bladder so that you don’t have leakage the more
your bladder says oh yeah she likes to empty me every 25 30 minutes so it
starts to send it so you’re kind of doing some of those things to yourself a
little bit the more you empty the more the bladder sends you the message and
that’s where you start to get that overwhelming urge you get to the
bathroom and you urinate and you say mmm that didn’t didn’t match up you thought
there would be a lot more urine than there really was okay so working on that
retraining they’re looking at those bladder training strategies it’s there
to help improve your bladders ability to hold in store yearn for normal amounts
of time anywhere from two to four hours depending on the individual okay hope
you two have less accidents wake up less at night and it’s been
shown to be about fifty to sixty percent improvement there
so overall conservative management can be highly effective at reducing your
symptoms and improving your quality of life
one thing that therapy has to offer is we can use biofeedback biofeedback is
where we use EMG sensors either in the vagina like a little tampon or
externally around the anus we use little tiny stickers so when you’re squeezing
your muscles relaxing your muscles we can show you what’s happening on a
computer so it’s nice to kind of get some training see okay that’s what it
feels like that’s what I need to do and then take that away you can go home and
practice come back let’s give you a pop quiz how was our practice where we
getting the outcome that we wanted to lots of women go home they think they’re
squeezing and holding their muscles and we see the way open when we hook you up
to the biofeedback that those muscles are relaxed and quite quite often prior
to like let’s say if you’re doing a 10 second
hold they might be relaxing at five seconds so you think you’re doing real
good at all this training and half the time you’re practicing your muscles are
just relaxed okay but you don’t feel what that feels like
so biofeedback can be very helpful and it’s individualized to each specific
patient when it passes off to Monica to talk about medications for overactive
bladder and urge incontinence hello everyone thanks for coming I probably
don’t need this I have a really loud voice anyway so okay so we have a lot of
medications to treat urge incontinence and remember the treatment modalities
are different for urge versus stress incontinence so I couldn’t give you a
medicine for stress incontinence it’s probably not going to work it’s not what
they’re designed to do there’s a little dysregulation there’s something’s went a
little haywire in the brain to bladder bladder brain communication and
medications work to try and regulate that a little bit medications that relax
the bladder we have a lot of different types so if one doesn’t work for you
another one might so don’t give up if somebody’s giving you one and though I
took it for two weeks of nothing I’m still running and crossing my legs and
doing the dance that nobody knows what you’re doing in the parking lot right
we’ve all trying to wait like this but so don’t give up if they take a while
you know six weeks typically to really get to a good state in the bloodstream
to evaluate is this the proper medication for you is it the right dose
do we need to adjust it in that type of thing um an estrogen my favorite thing
in the world we probably prescribe more estrogen cream than anyone on the planet
it’s a beautiful thing as postmenopausal women and I can speak from experience
there you know our ovaries stop producing estrogen all of this tissue
down here requires estrogen it lives and breathes and it needs it and we deprive
it once we go into menopause we don’t get it anymore it helps our urethra
close properly it helps our bladder function properly
it helps our external tissue not feel dry and uncomfortable we should not walk
around and be aware of this right it should just travel with us silently I
always say silent travel companion right just come along don’t talk nobody wants
to hear you right sex can become very very uncomfortable
because the tissue starts to thin over time with no estrogen I can’t tell you
how many women I’ve seen in my gang practice in the last 10 years that I say
to them and they’re 72 years old and their husbands sitting in the room with
them are you sexually active well yes like does it hurt yes finally
somebody has asked them it doesn’t feel good it hurts so I can fix it for you
comes back eight weeks later they’re both smiling everybody’s very very
available right so but from a pelvic floor standpoint incontinence standpoint
estrogen is huge and we use a ton of it and it’s a great so love estrogen cream
all right another treatment for stress urinary incontinence so we were just
talking about medications for urge incontinence stress incontinence besides
surgery and we’re gonna talk a little bit more about that later but we have
some non-surgical techniques you know Eliza works great with people with
stress incontinence to help strengthen some of those muscles to give you gain
some support back but we have these awesome little devices called pessaries
these are made out of silicone you don’t get a blue one when you come and see us
you’ll probably get a white on all right sorry little boring but they come in all
different shapes and sizes and they serve different purposes
some of them will provide some support for the urethra such as this one so we
talked about that muscle is not really supporting the urethra so it’s kind of
doing this and shaking like a hose and little squirts of urine are coming out
of it we can fit this in the vagina support the urethra and stop that little
tiny small little leaks throughout the day walking bending squatting all those
types of activities can cause that type of leak
and these work great for that once it’s put into the vagina you won’t even know
it’s there you won’t feel it silent little traveling companion again another
one another type we have some that are for prolapse which dr. Singh will talk
about later when things are kind of shifting downward we can put different
types of pessaries in to support those so there’s a lot of uses for these and
they work great all right did I talked about all that I think I
did yes all right moving in so this is a really interesting modality and we use
it a lot called posterior tibial nerve stimulation posterior tibial nerve is a
nerve and I can’t I have a dress on so it wouldn’t be good if me to lift my
legs up but eliza well nice so right here on the inside above that little
bone there called the medial malleolus your posterior tibial nerve runs there
and it goes up towards the bladder remember we talked about there’s a nerve
problem right the brain and the bladder are not communicating well if we take
this itty-bitty teeny-weenie acupuncture needle and it’s inside of this case and
if anybody wants to see them feel free to come up and I’ll let you take a peek
at them they’re so small I literally show my patients in office I take some
alcohol I wipe my leg and I just stick myself and they’re just looking at me
I’m like it really doesn’t hurt just so that they realize it’s not a terrible
thing we hook it up to a little monitor with a electrode a nice comfy recliner
for 30 minutes and it’s hooked up to this and we’ve put a timer on and you
can read a magazine and relax and this just sends a little nerve impulse to
that nerve you’ll feel a little tingling in your toes and in the bottom of your
feet and this goes up to the bladder and I have seen patients after 12 weeks you
come in you sit there for 30 minutes and we do this for 12 weeks in a row and at
the end I’ve had patients that tell me they’re doing fabulous great 90%
improvement sometimes it’s typically 60 to 70 percent I’ve seen patients get
that and I’ve seen patients get a lot more so it works fantastic and it’s a
nice nice option no medicine easy peasy come in for a half hour and then dr.
Singh is going to talk about Botox and some other options thanks for coming
everyone Thank You Liza and Monica okay so coming back to the surgical options
so as I had talked that you know there is conservative non-surgical options
which I assigned Monica really explained very well and coming back to the
surgical options so the surgical options are divided based on the type of
incontinence so for urge incontinence once we go in a
stepwise fashion we go to the conservative route pelvic floor
exercises medications and if you come back and things are not getting better
we have other options so I just send my patients if things are not working don’t
give up we have a lot of options we just have to go and step fights manner so we
go up the ladder and we have third-line management options and one of them is
support ox so it’s it’s the same botox which people put on their faces it’s the
same thing and what it does is basically it’s it’s it can be done as an in-office
procedure and this is basically right here that’s a bladder and what we do is
we put a camera into the bladder look into the bladder and inject very small
doses of that Botox all over the bladder muscle and what it does is that it
relaxes the bladder because that’s a problem right the bladder keeps on
spasming and you keep on leaking so it relaxes the bladder muscle and it works
great and it has been shown to achieve 30 30 % of women can be dry and it has
been shown to achieve 60 to 90 percent of improvement compared to you know
therapy so it works really great and it flies from typically 3 to 12 months I
would say on an average about more commonly 6 6 to 8 and it’s
but a lot of women by the end of 12 months they are more symptomatic well a
lot of them are like able to you know get themselves to the point that they
are not that much bothered by it and after 12 months they would be like okay
I think I might need just another treatment so they come back and get it
and they’re good for a year again so works really great and as I said it’s an
office procedure you go home the same day no I just local innocence can you do
great okay so the other treatment mortality for again overactive bladder
this is the second surgical option and it’s called sacral neuromodulation so as
we have been talking about that in overactive bladder there’s a problem
with the signaling from the brain and to the bladder so it’s also called a
bladder pacemaker it’s a surgical option where we go in and we put a bladder
pacemaker right into the back into the buttocks and basically the initial part
is a testing phase so the first two weeks we try to put an implant and just
to you know the testing to see if it works or not and if it’s working for you
then we go over and put this implant here right here and it connects and
stimulates a nerve that helps improve the bladder function and improves the
leakage it has been shown to be 60 to 70 percent shown to have 60 to 70 percent
of improvement okay coming back to the stress incontinence so we’ve talked
about urge stress incontinence the surgical options if you’ve done physical
therapy or you people have done Periyar some people don’t want to do pessary
they want definite a surgical option the option for stress incontinence is a
sling procedure or it’s all it’s what it basically does is that oops wrong one
okay so basically what it’s a tape so I’m gonna show you this it’s this is how
it is it’s mesh but not that same message you hear on TV and radio
it’s polypropylene okay and it’s it’s basically a hammock they need the
urethra so what happens is that the urethra the chief or maybe pee
it’s dipping down when you cough sneeze that it’s just gonna fold it up I an
analogy that I tell to my patient is that if you have a hose on mud you keep
on pressing on it it’s not gonna stop but if the horse is on concrete and you
push on it it’s gonna stop the flow and that is how it works it’s just meant to
support the urethra and prevent you from leaking due to coughing anything
laughing a little bit and so fine the and it can be done by two ways two
different techniques but basically is the same thing of providing I’ll touch
base a little bit about the mesh this is so far the best procedure for stress
incontinence you must have heard about mesh and TV and radio but this is not
the same as what you hear in TV and radio basically this has this procedure
it has been approved with FDA as dr. good was mentioning via urogynecologist
so we have special training for these procedures and these to treat these
disorders so our governing body American urogynecology codes Society has worked
extensively with FDA since 2009 when they were concerns for mesh and they’ve
done extensive research on women who’ve had mesh surgeries and they have come up
with the statement saying splaying this the mesh sling is the best procedure for
stress incontinence and should be offered to women with these issues it
has low complication rates and it has no complication rates and good outcomes up
to 90 percent successful and very reasonable and low comp less than five
percent complication rate the mesh that you hear doctor God is going to talk to
you it about more that is basically the there are two kinds of mesh that can be
used for prolapse and there’s one kind of prolapse procedure that was more
concerning for FDA so all the governing bodies in United States and all over the
world support the mesh link for stress incontinence as the best procedure and
we do spend a lot of time counseling our patients about it because we understand
that when everybody has mesh they are just concerned while mesh why mesh it’s
just plastic nobody’s allergic to mesh its polypropylene like plastic
everywhere it’s just the technique and the different procedures that you need
to know about it the other procedure that we talked about
is bulking it’s it’s also a procedure for stress incontinence and it’s
basically what what we do is that we just inject some material right here and
this is the urethra so it’s not working sorry but we just inject some calcium
like gel like material on the wall of the urethra to just close the opening so
that it can hold more urine and based on the patient’s risk factors and prior
surgical history this is also a good options for women who have stress
incontinence so right here it is it is typically last for one to two years it’s
an office procedure it again you go home the same day and people tolerate it
really well it does have lower success rate than material sling but mid races
thing is definitely the gold standard that we offer for two women with stress
incontinence all right I know what you doctor good thank you for coming okay
all right last but not least the last topic we’re going to discuss is pelvic
organ prolapse so again from I think about the vagina as a tube sock and it’s
not the sexiest thing to think about but it is so about half of women over 40
have some form of pelvic organ prolapse the real important detail here is are
you symptomatic do you feel it what does it feel like feels like you’re sitting
on a ball or a bowl which are you have an egg or when you sit something
scratching on your underwear that is what pelvic organ prolapse feels
like however some people don’t have those symptoms actually what they may
start to have is those urinary symptoms the doctor seeing was talking about
earlier and I analyzed that where you feel you gotta go and you’re finding
every bathroom and you know and target where they are you know in the hospital
that may be your initial symptom of prolapse so it’s important not to ignore
these symptoms because you may have something else going on and there may be
a lot of treatment mood out you’re seeing that we can offer you for
both problems at the same time so it’s important okay
pelvic organ prolapse and a me basics so like we talked about earlier the pelvic
floor those muscles rectum all go through they help hold up those pelvic
organs so from genetics having babies any weight losing weight coughing all
the time those put your pelvic floor stress on your pelvic floor those put
your public floor at risk for developing these problems as it progresses you’re
starting to feel a bulge to the tissue and you can have something called a
sistah seal or a rectus eel or uterine prolapse what is this so this to seal is
a term that means that the bladder wall which remember the front wall of the
vagina is attached to the bladder and the back wall of the vagina is attached
to the rectum here’s your tube sock so the tube sock is being pulled inside out
and the bladder is prolapsing or herniating a lot of people know what a
hernia is is herniating into the vagina so don’t start to feel a bulge in the
vagina and it’s the vaginal tissue being weighed down by the bladder not being
supported or the rectum not being supported and that’s called a rectus eel
it’s the posterior vaginal wall or the top of the vagina either if you have a
uterus or you don’t have a uterus can drop down just like turning your sock
inside out okay so what are the symptoms you may have pressure pressure heaviness
and all those other symptoms I talked about sitting on a ball feel like you
have a tennis ball between your legs all those types of things it may hurt when
you have sex because something may be hitting it when you’re having sex
you may feel a lump or a bump and again we talked about the urinary issues and
it also may go with constipation or diarrhea or irritable bowel because you
may have an organ that’s out of place so what are the treatments so we love
pessaries these are medical grade silicone devices as Monica pointed out
this one actually has two treatments it helps you with incontinence when you
cough and sneeze it helps that garden home to stay straight helps out your
throw straight stay straight and it also holds up your pelvic organs
so this is a two-in-one combination okay so we have pessaries and the most
important thing again is how much is this bothering you and how can we help
you feel better that is the most important thing out of all of this so we
start again with a stepwise approach conservative all the way up to surgical
treatments the very first thing is making sure you can do a Kegel because
you want to make sure that you can help hold those pelvic organs in place if you
can’t then Eliza what is your gal and she will help you learn how to contract
those pelvic floor muscles and then we will do a pessary and pessaries are easy
and we teach you how to use them okay this is a no brainer it’s just like
putting a tampon in that one instruction that your mom taught you when you were a
little girl we all get together and we show you how to use it most people it’s
just like putting on glasses in the morning okay you put your pessary in in
the morning take it out at night before you go to bed and you wash it and just
because part of your routine and I have women who love these and have been using
them for years and years and years I had a patient the other day who came in she
had one for 30 years and she loved it loved it okay so it’s up to you what you
want to do whether you want to use one of those or you want to use it as a
temporary measure the good news good news is if this helps your symptoms
surgery will fix your symptoms because this is surgery is a permanent version
of this okay so surgical options first of all it’s not for everybody and it
should be made together with your physician you and your physician to talk
about all the options and when you’re ready for surgery physically mentally
have the support at home that is the time that you can talk about all the
options okay so this is a decision you have to make with your healthcare
provider every situation is different whether you’re ready for surgery the
first time you visit or you’re ready for surgery five years from now that’s what
doctors seeing and I are here for we’re here to help make a team with you we are
a team to help you get to the point that you are happy and if you’re happy we’re
happy okay so there’s two main routes of pelvic reconstructive surgery it depends
on a lot of things there’s a list here but essentially it depends on how active
you are if you’re picking up your and kids if you’re out riding bites and
doing yoga on the weekend or that’s not just where you’re at in life anymore so
depending on how active you are depends on how old you are obviously if you’re
100 I’m not gonna offer you the same treatments if you were 40 okay so we
talked about all these risk factors and all of these components can have a kind
of a help you make a decision on where you are and where you’re gonna go with
surgery so there’s two main options and Gynaecologists for the mote art we are
the most minimally invasive surgeons there are and in fact we actually
develop the laparoscope for surgical techniques when it first came out but
there are two main routes in the first route nobody will ever know you had
surgery cuz it’s through the vagina that is the most minimally invasive surgery
there is no incisions on the belly and you’re good to go so we go up through
the vagina and sometimes we do a hysterectomy which means we remove the
uterus okay uterus and cervix so we don’t remove your ovaries unless that’s
another discussion that’s another topic unless that’s something that you want or
you need to have for another reason hysterectomy just means we remove the
uterus so once we remove the uterus we have access up into the vaginal cavity
up into the top of the vagina to your pelvis and we go further up to your
ligaments and reattach the vagina to the ligaments higher up in your pelvis so
what I like to explain to people is imagine that your ligaments oh the
connective tissues you have muscles but you also have connective tissues down
there the ligaments imagine over time they’ve become stretched like an old
rubber band on how many of you know what an overview looks like like rusty and
old and stretched out so what we do is we find that piece of tissue that’s a
healthier and that’s higher up in your pelvis then we reattach the vaginal tube
to those ligaments where it’s healthier and where it’s more anatomic again so we
can hold things up okay the vaginal route of surgery is very
successful it’s 60 to 80 percent successful and there are some really
good long-term studies is a fantastic treatment modality and again no
incisions on the belly the two treatment options we call are your sacral ligament
suspension and sakers – basically we use the toughest ligaments in the pelvis to
resuspend your vagina okay the second option is also minimally invasive and we
– brand-new robots here at the University of Florida Jacksonville one
here at the north and one downtown and dr. Singh and I both love to operate on
the robot it’s amazing we can see into your body and it’s almost like a 3d
picture of your body so what happens is we put a little camera in your belly
button and two tiny incisions on both sides of your belly and we use tiny tiny
instruments that go into your body and we sit at this console just like this
woman in the picture and we put our faces into the console and we can see
inside of your body and so we operate we operate the robot
the Oprah robot does not operate us we operate the robot and we fix your
prolapse abdominally so this is a new thing we don’t open you unless there’s
actually a reason to open you so with that treatment option we can do some of
those ligament surgeries as well but what we usually do is something called a
Sacro colpo PEC C it’s a fancy word and what it means is Sacro is your sacrum
that tail bone back here COPO is Latin for vagina and Pepsi means we put two
things together so what that means is we have a piece of mesh again we’re back to
the mesh topic and we could talk probably for another hour on mesh and
we’re not going to but this is type one propylene mesh this is a big sheet of it
and you can see everybody can see through it this is the same type of mesh
that used in abdominal hernias same type of mesh it we use for the mid urethral
sling and what you’ve seen on TV like dr. Singh has commented about is vaginal
mesh kits have had some challenges this is not the same thing as a vaginal mesh
kit this is placed airily into your abdomen and we use it I actually first
cut it and so I’ll show you what it actually looks like when I put it in
your body I’m an artist so I take this and I cut pieces to match the shape of
your vagina your spine and hold you straight it’s the strongest ligament in
your whole body okay so just like in this picture one piece goes on the front
one piece goes on the back and we attach it to the ligament that runs at burning
your spine this procedure is been around for 50 years it’s the
best surgery we have because with this graft augmentation
it is durable it is strong you can go back out ride your bike lift those
groceries lift your grandchildren this is this is to be the treatment for the
rest of your life to fix you for the rest of your life so it takes a lot of
skill which is why fellowship-trained urogynecologist are really the only ones
who offer this treatment and our skill to do this with the robot so this is a
fantastic treatment option for prolapse and by lifting the vagina back off the
bladder you would be surprised that your overactive bladder overactive bladder
sometimes may improve and your constipation may improve and other
issues that you’re having with a pelvic floor may improve as well okay more on
surgery so really again the conversation goes back to your treatment team even
starting with Eliza Eliza sometimes will tell us you know what there’s a patient
she’s doing really well however she really wants to be at that 95 percent
ninety or ninety percent success she wants to be treated and have some really
good goals here she might be a search a good surgical candidate does it mean
that she’s wasting her time it means that she’s learning how her pelvic floor
works she’s getting in there making the public floor healthier but we already
are thinking about the future and how to get you prepared for surgery if that’s
something you want you don’t want surgery and surgery scares you we still
want to take care of you if there are a lot of options for you to basically we
want to improve your quality of life not think about what’s going on down here
like Veronica said and make you feel sexy make you feel healthier make you
feel like you are feminine and that’s the goal with our for our profession and
we’re here to help you you and your two soccer must decide so
is this normal I think we all know at this point no and it’s not a normal part
of Aging so unfortunately because the conversation is so silent in our
community we suffer and we think oh this is just a normal part of getting older
it’s not it’s not it’s not a normal part of having babies either because guess
what two-thirds of your friends don’t have it so one-third ooh but two-thirds
don’t so that’s why we’re here to help so this is a fantastic patient website I
think there’s a flyer in your handouts ww Boise is for PFD org this is our
governing body like dr. Singh said the American uro gynecologic Society’s
website for patients so please spend spread the word there’s actually a
dialogue on there that you can blog and talk to other patients who are going
through the same thing so you can share your experiences and see what other
people have thought about this you can also if you’re not in our area or you
have a friend somewhere else you can find a provider who is like us in
another area bladder health month is coming up in November and we really want
to help you guys support this community so please check out this website it’s
been around for now seven years now does I mean it doesn’t feel like seven years
so it’s been out for seven years and people really love it and I love hot
pink so the whole website is full of hot pink
you are not alone that’s the most important thing if you’re suffering from
a pelvic floor disorder chances are we know what it’s like we’ve
all had babies and actually I’m postpartum so I just had a baby five
months ago we’ve been there we know what it’s what you’re like what it’s like
going through it and we we treat you as though you are our sisters our mothers
our friends we want to have that conversation with you so please have the
conversation with your friends share stories and get support be open with
your doctors oh I did again and thank you so much for coming we really really
appreciate you being here and I’m so lucky to work with these brilliant women
please take the time if you want to come and mingle and talk and ask questions if
you want to we can ask some questions out in the open and if you are don’t
want to talk and in the open we can talk afterwards as well and even have a
question raise your hand okay well okay I’ll go do you have an appointment well dr. singer I are happy to see you
at any moment but what you’re describing is actually called Noctor urea or
frequent nighttime voiding and urge incontinence on the way to the bathroom
and just like we went through there’s a stepwise approach to helping you as well
okay so starting with what are you drinking in that cup okay another cup no
I’m just kidding I’m not putting you on this I’m not I’m not trying to put you
on spon joking but you know what drinking what you’re eating when you’re
drinking when you’re going to bed all those types of things and learning the
techniques like Eliza talked about and maybe even going you may even make it to
the Botox level so there are lots of treatment options in a stepwise approach
and the other question that answer your question
basically you you basically we need to work with you as a team and that’s what
I always tell my patients the first visit is really a consult let’s hope we
let us tell you what your options are but we have to work together join
hand-in-hand to work in a stepwise fashion to help you
we’re here at the North we’re here all right at the first slide I kinda glaze
over that we are at the North dr. singers at the North I am at Southside
women’s health in the south at Emerson Street 95 and we both teach residents
OBGYNs how to be OBGYNs downtown at a street so we’re happy you at any of the
three locations depending on where you live
what is your access is yes ma’am yeah dr. sing practices it at the north and
I’m in the South and we both are downtown yes that’s the telephone number
yeah welcome so the first thing is make an
appointment we got we got about it we don’t have an hour to talk with nobody
no all in all seriousness it is a again it’s a team approach no it’s actually
retraining your bladder I have a three year old right now so I’ve been through
the potty training phase and it’s the same thing you know he saw the toilet
and he’s dribbling before he even gets his pants down so we retrain you and
reach retrain your bladder and it’s a combination of therapy medications
you know consultation working together evaluating we give you a three-day
voiding diary to see what you’re drinking how often you’re drinking what
your what your how much are peeing how often you’re leaking we evaluate that we
go through that we take a stepwise approach to figure out what’s going on
with your bladder and how they can fix it we all practice the same way that
helped so we don’t want you to put the keys in the doors our peen and we will
work on that we’ll work on that yes ma’am so that’s a complex question it’s a very
good question of women who do have hysterectomies can get prolapse as well
genetics has a huge component of who gets prolapse after a hysterectomy it
also is wear and tear on your body what you’ve been doing heavy lifting gaining
weight heavy exercise coughing all the time all those things have a play and if
you get prolapse after a hysterectomy gynecologic surgeons who do
hysterectomies for benign reasons meaning not cancer
you’re just bleeding too much or you hide those fibroids or whatever reason
it is if you had a hysterectomy for those reasons not cancerous they
incorporate those ligaments like I was talking about earlier into the top of
the vagina to help hold it up and be strong for you women who end up getting
pelvic floor disorders and prolapse later on is because there’s a weakness
so a lack of estrogen at menopause can help those symptoms become worse but the
truth is is that it’s probably a genetic component it’s a component of lifestyle
and it’s a component of you know have you ever done a Kegel do you know what a
Kegel is those are all those components together who gets prolapse does that
help answer the question go ahead so yes yes
so that’s overactive bladder that means your bladder is Mesquite’s and spasming
if it happened post hysterectomy I think it might be something which we note this
more it became worse but that’s a separate entity if you are asking if
it’s related to a hysterectomy I’m I am Not sure because if you have some
prolapse if somebody examines you if you have prolapse that can be contributing
to your overactive bladder symptoms so that’s why a lot of these pelvic floor
disorders they are they occur together so once you come for an examination if
you have some products that might be one of the explanations while you’re having
these overactive bladder symptoms but or Archer bladder is also a separate entity
women who do not have products can have a rapid pattern and that is what you
have well so I think I would yeah
but I think it’s more of maybe she what she means and of course I don’t know
what she means by that maybe that’s this has been going on for
her for a long time like I see busy 19 year olds 20 years old with this problem
it’s not just yes then there are a lot of things I mean if
you’re saying a small ladder there may be a lot of other complicated things
that might be going on and that is why we need to evaluate it but overactive
bladder as we said that you know here we discussed the more common things but
overactive bladder is when you’re Gladys starts you know going more and going you
know you go just two months or three ounces for ounces and you keep on going
but retraining it can working with Eliza can increase the bladder volume to ten
but you know I’m not denying that they might be something else going on but
being on a pair up so that’s why she needs further validation yes it’s a multimillion for our healthcare
system even reaching depends is of you know billion-dollar industry so your
healthcare insurance dollars will pay for all of this because they want you to
to have a better lifestyle they want you to feel better and spend less money on
depend spend less money on underwear some let’s spend less money on washing
your clothes they understand that so they 100% cover it as just they would
any other medical condition like you break your arm so we we just write in
our notes exactly what you need and it gets we have two great nurse care
coordinators who help you to get the care that you need and they’re fantastic
good said we are really good about you know when we place orders we have a
great team like Ashley and Lin and other reference card inators who makes sure
they run through your insurance and inform you about it so it’s not like you
know we just offered you something and it’s not you don’t have information go
ahead that applies to that I’m sorry so the
question she asked was that we talked about coffee and soda in all the fluids
that can irritate the bladder is that applicable to the mix the mixes that
come that you can add to the water like kool-aid it has artificial sweeteners in
it and that can irritate your bladder too there are other things which you
know water right in water which has sugar in it con syrup which is one of
the ingredients and a lot of these products and that can understate your
bladder too so that yes that’s right and what we usually
recommend is if you can’t stand to shrinking water on a tiny piece of fruit
like a slice of strawberry or lemon or lime a spice not for a whole lemon you
know into your water because then it becomes a bladder irritants well but put
a tiny bit of cucumber lemon lime strawberry and that will help flavor
your water but in general you know the conversation across the table in the
United States now is about chemicals and plastics and how we’re poisoning
ourselves and one of the things we’re doing very well is by drinking not water
out of plastic bottles and that’s irritating our bladders so trying to get
back to drinking water and drinking things that are good for you and at the
right times you don’t even have anything to it even gas and water can affect your
bladder so that’s something to be that you know about I usually go go back into the hospital
on Saturday so I get up three four times but I’m okay on times I gotta spell its
timing it’s choosing their lifestyle but telling you that never good sweet tea
again but it’s something that turns out these irritating your honor then you
have a choice Oh and it’s empowering you to know what you
can do to help yourself go ahead so then they talk about procedures any
procedures anywhere in any field when a surgeon consoles the patient’s about
procedures there’s always some risks benefits and complication rate for every
procedure and we talk to them about our patients extensively about the what are
the benefits what are the risks and what are the complications and what is the
risk part the percentage of complications and when we talk about
these procedures which are recommended by FDA our governing body to to improve
your quality of life the main thing is that these are procedures with good
outcomes with minimal complications or reasonable complications then as you
said that Botox are the mesh the procedures every surgical procedure has
some inherent benefit and complication which a surgeon sits down with you and
talk to you sensibly about it I like the toe I like to bring things that back to
like a different level with my patient so I say when I’m when I’m getting ready
for surgery it’s a very stressful time and if you’re not nervous then I’m
nervous so I like it when my patients come with questions and are nervous and
what I say is it’s like buying a car it’s a big big decision you have to make
sure is it in your budget is it something that you is really important
to you is it something that’s going to improve your lifestyle so you’ve made
the decision to buy the car you’ve made the decision to have the surgery so what
I tell people is when you drive off the lot all those thousands of papers you
just signed it’s all like for a loan or it’s all for your money right well we’re
signing papers because we’re explaining every little thing they can go wrong we
have a conversation like you’re my sister and we say this is what can
happen this is what you should expect to happen and this is why you come to
somebody like us because we do these every week twice a week all the time
this all we do but you go to somebody very skilled who does these all the time
but there are little things that can happen and usually we say that those are
less than 1% of the chance but when you buy a car they don’t make you sign
anything that says the sunroof could pop off and hit the person behind you you
could drive out a lot and get t-boned your seat belt may not work the airbags
may not deploy your radio may break in six months so we don’t talk
about anything and we spend a lot of money and spend a lot of time in our
luxury automobiles but we are always scrutinizing like oh there may be a
possibility of something happening during surgery we take care of you like
you’re a family member and if you don’t believe us you can ask any of the
patients we’ve taken care of before we take care of our team we have a
fantastic team who helps us all these ladies in the room we’re dedicating our
lives to taking care of review however like she said there are risk inherent
risks to anything you do just like driving your car and you have more
actually chances of getting in a car accident than anything bad happening to
you during surgery that brings it really back to reality so but you come to
somebody who’s skilled and who really wants to take care of you and that’s
what’s important thank you nope you sure don’t yep yeah we have our business cards and
information about us and pelvic floor disorders back there you can call our
referral coordinators and make an appointment
just like dr. Singh said yes yes yeah say anything about therapy you can call
for us and we refer you to therapy or you can go straight to therapy if that’s
something you’re interested in and all I can tell you about that yeah so just
somebody brought up insurance I just want to let you know that if your
insurance covers physical therapy any type of therapy let’s say for its neck
pain shoulder pain foot pain they also cover pelvic floor therapy so I just
happen to be a specialist we have women that are trained to do this at all of
our outpatient rehab locations here at UF health so we have somebody here at
the North somebody at Everson myself downtown I work closely with both dr.
Singh and dr. good and Monica in this team and also kind of mentor the other
therapists as well so we work well together there’s a flyer there and it’s
got all of our location information so if you’re not sure and you say you know
I just want to kind of dip my toe in the water and you might not want to get all
of the options yet you could always have your primary care send you to therapy
and we can have that conversation and if you’re ready to then go to the next step
I can get you set up with dr. Singh or dr. good or likes you said you can go
directly to them and then come to me we kind of pass our patients back and forth
to make sure that you get everything that you need okay any other you know I think just standing here
listening to the dialogue you can all see that this raises a lot of questions
and one leads to another to another to another we understand that this is very
sensitive information this is this is personal to you these are we get that
and at the end of the day I will tell you I can speak for everybody I feel
very privileged that you entrust us to give us the opportunity to try to help
you get a better quality of life this is not pleasant stuff at all and we always
say our patients are really complex and Dr Goode has mentioned multiple multiple
times this is a stepwise approach it is because I can’t would you come in you’ve
got a lot going on probably more than you realize and then we figure that out
and go you know what at the next visit we’re gonna do this and then we’ll see
it will keep going and at the end of the day the goal is to get you better and
you know there’s nothing more than I love seeing somebody come in three
months post-op and save you changed my life
thank you it’s pretty awesome so I feel really honored to be a part of that so I
hope you come into us because we can help you name

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