When, as a society, you are using more Poise pads than diapers, it might be a cue to take pelvic health seriously.

Leakage, urgency, prolapse and pain during intercourse... these are not minor irritants that women simply have to face as they age. Nor is a hysterectomy the automatic answer for every pelvic region disorder. Today, there are a number of options... both surgical and non-surgical... that help women improve their quality of life, pelvic health and sexual function.

Marcy Abel, MD, is a partner at Urology Associates, PC, a large practice featuring 28 urologists. Abel, who performs surgery at Baptist Hospital and Centennial Medical Center, is the only female urologist on staff at UA and one of only a handful in Tennessee. A non-functioning kidney as a child led to the interest in her specialty.

While she enjoys working with both men and women, nearly 80 percent of her patients are women. With her unique perspective, she has focused on... and embraced... pelvic health. The majority of her patients suffer from an assortment of bladder or pelvic dysfunction including overactive bladder, vaginal health and sexual health issues.

"The media has really gotten hold of male erectile dysfunction," she noted. "I always tell my patients, it takes two to tango. Upwards of 43 percent of women have sexual health problems."

She continued, "I encourage my internists to ask two questions... 'Are you sexually active, and are you having any problems?' I think there are two reasons why physicians haven't asked these questions. They think it's very time consuming –– which it is –– and two, there hasn't been anywhere to send them. There haven't been the resources, and now there is."

Abel was instrumental in opening the WISH Clinic –– Women's Institute for Sexual Health –– through UA nearly four years ago. Led by a certified nurse practitioner with expertise in the field of women's health, WISH takes a multidisciplinary approach to female sexual dysfunction addressing issues ranging from hypoactive sexual desire disorder to dyspareunia and vaginismus. Abel said the clinicians work not only with the patient but also the patient's gynecologist and primary care physician.

"Sexual health is very much connected to your overall health," she pointed out.

Of course sexual health complaints aren't the only pelvic function issues facing women. Abel said research studies have shown that more than 30 percent of women will have incontinence after giving birth. At least 10-15 percent of women develop prolapse, and greater than 40 percent of women will develop overactive bladder as they age.

Stress incontinence... leakage from jarring movements such as coughing, sneezing, laughing, or participating in sports... is not "normal," Abel stressed. However, fixing the problem hasn't always been easy.

"Fifteen years ago was not the time to have incontinence surgery," she stated. "The surgical advances have been enormous. The success rate of yesterday was often 60 percent, and within two years, it often came undone. Now we have a 30-minute, outpatient surgery with a success rate of 80-85 percent, and the days off work are minimal."

John W. Macey, Jr., MD, a partner at Nashville Ob-Gyn Associates – a division of Tennessee Women's Care, said what is different about pelvic floor surgeries today is the placement of graft material and the type used.

"It didn't take general surgery many decades to figure out that hernia repair is more effective when mesh is used to repair the defect," he pointed out. "Problems related to the pelvic floor are essentially hernias so repairing vaginal vault defects is likely to be more effective with the help of bolstering grafts."

Macey, a board certified ob-gyn who performs surgeries at Baptist Hospital and Centennial Medical Center, said urologists were among the first to use biologic grafts, such as fascia harvested from the patient or a cadaver, in pelvic reconstruction. "That use of grafts," he continued, "has morphed into use of various tissues from various sources including human cadavers, bovine or porcine."

Initially, urologists used the grafts primarily for urethra slings. "Now we are frequently using much larger grafts to support the entire vaginal surface," Macey said. He added the trend now is headed toward using polypropylene grafts, which are essentially plastic and cannot be broken down by the body like some biologic grafts.

He added the failure of a repair or recurrence of a pelvic floor defect frequently isn't due to the failure of the graft but rather a failure of sutures at the attachment site to pelvic structures. Many of today's polypropylene grafts come as kits with innovative advances in pelvic fixation, which facilitate reliable and secure attachments that are less likely to fail.

Macey agreed too many women are suffering from conditions such as incontinence needlessly and that techniques and outcomes have markedly improved over the years. However, he said it was important not to underestimate the complexity of these types of surgeries.

"Graft placement is not without risk. It's a very complicated surgery," he said. Macey added a difficulty in repairing pelvic support defects is the unusual configuration that must be fit in restructuring vaginal walls. "There is a high degree of plastic surgery in that there is reconfiguration and reconstruction of very distorted anatomy," he noted.

Another option is the use of a pessary, which is not dissimilar in look to a diaphragm and works by essentially taking up the space occupied by the hernia and pushing it back. "It's much less invasive... an office procedure that is nearly risk free," said Macey. However, he continued, "It's patient satisfaction rate is not as high as I would hope." He added that some women find it uncomfortable or difficult to utilize. "Some patients elect to use a pessary as a temporizing measure while planning or considering surgery," he continued.

In addition to surgical options, Abel and Macey both said the behavioral component is a major factor in improving outcomes for women. Macey did caution, however, that no amount of therapy is likely to fix gravity. Still, he said, for many conditions, physical therapy and behavior modification are a viable solution.

Abel noted that for years, women have been told to do Kegel exercises to strengthen pelvic floor muscles. The issue, she said, is that many women do them wrong undermining the benefit and, in some cases, worsening their condition. Done correctly, however, these exercises coupled with other behavioral modifications have proven to be very effective in postponing or avoiding surgical interventions while dramatically improving quality of life.

Working with trained physical therapists who have an understanding of the musculoskeletal system gives patients the best shot at maximizing these non-surgical options. Abel pointed to Saint Thomas Health Service's Life Therapies as an example of a focused program that utilizes highly skilled therapists.

Sara Underhill, DPT, is one of two physical therapists with STHS who devotes her entire workday to pelvic floor problems at Life Therapies. Patients often present with pelvic pain, incontinence and leakage of stool or urine caused by muscle weakness.

"A lot of women when they have leakage or pain, the last thing they think of is that it's a musculoskeletal problem, but their whole pelvis is filled with muscles –– you have huge, supportive pelvic floor muscles, abdominals and lower back muscles," she noted.

To strengthen what is weak, Underhill said they use manual manipulation including myofascial release, soft tissue release, trigger point work and joint mobilizations. Patient education is also a major component of Underhill's work.

"A lot of people have bad habits and don't know they are feeding them," she explained. For example, she continued, women who have frequent urination problems undergo behavior modification training not to give into every urge, which ultimately strengthens the muscle.

Posture is another key point. "A lot of patients come in, and I'll say, 'Change the way you stand. That's the first thing I want you to do,' and it changes their pain dramatically," Underhill said. "You'll see increased lumbar lordosis –– forward head, rounded shoulders. They let their belly hang, and they don't use their transverse abdominis at all. If you stand in that posture and sneeze, you'll leak. You have no stability."

In addition to surgical and therapy options to improve pelvic health, Abel also expressed a desire to see physicians and patients rethink an absolute avoidance of hormonal replacement therapy, particularly in light of newer local treatments that don't carry the same theoretical risks of systemic HRT.

"The hormonal stuff has really been a tragedy," she said. "The media said to get off hormones, but there is a consequence to a loss of estrogen. Estrogen nourishes vaginal tissue, as well as the bladder."

She added, "The studies we've had have been poorly designed and haven't given us the answers we need about hormone replacement."

What is evident is that there is more than one answer for pelvic dysfunction. Taking a multi-pronged approach optimizes a patient's chance to improve pelvic health, achieve significantly better outcomes and increase the quality of life.